220 Final Practice Questions

A nurse wants to volunteer for a community group providing secondary prevention. What activity would the nurse attend? a. Stroke rehabilitation support group b. Blood pressure screening at the mall c. Bicycle safety class at the elementary school d. Drop by nutrition station at the grocery store

ANS: B Secondary prevention activities are aimed at early diagnosis and prompt intervention. Blood pressure screening events are a good example. Stroke rehabilitation is tertiary prevention. Bicycle safety classes and nutrition education are examples of primary prevention.

The nurse knows the one theory explaining the variation in response to stress among individuals is identified by which term? a. Stress appraisal b. Sense of coherence c. Allostasis d. Homeostasis

ANS: B Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious assessment of a demand or stressor. Allostasis is an alternative term for the stress response. Homeostasis is the tendency of the body to seek and maintain a condition of balance or equilibrium

The student nurse asks why spirituality is important in health care. What response by the registered nurse is best? a. "All people have a spiritual aspect to their beings." b. "Spirituality affects behavior, which also affects health." c. "Knowledge of it is needed to understand a patient holistically." d. "People who are less spiritual have worse outcomes."

ANS: B Spirituality affects behavior, which has a direct impact on health. Spirituality is a universal concept, but all people may not recognize it in themselves. Holistic knowledge is indeed based in part on spirituality, but that does not give the student information on a concrete link. Less spiritual people may or may not have worse outcomes.

The nurse understands state legislatures give authority to administrative bodies, such as state boards of nursing, to carry out what action? a. Create statutory laws. b. Establish regulatory laws. c. Try case law cases. d. Create laws based on social mores

ANS: B Statutory law is created by legislative bodies such as the U.S. Congress and state legislatures. Statutory laws are often referred to as statutes. State legislatures give authority to administrative bodies, such as state boards of nursing, to establish regulatory law, which outlines how the requirements of statutory law will be met. Judicial decisions from individual court cases determine case law. Case law was historically referred to as common law because it originally was determined by customs or social mores that were common at the time.

A nurse is a case manager for a home health care agency. The nurse often orders supplies for patients seen by the agency. What action by the nurse is best? a. Negotiate for cheaper prices from suppliers. b. Investigate what each patient's insurance will cover. c. Refer the patient to the closest supply source. d. Use the same supplier for all patients' needs.

ANS: B The case manager in home health care must be a well-versed financial steward and understand what each patient's insurance will cover to maximize the patient's benefit. The home health care nurse serves as a case manager (coordinator) of client care, needed services, and needed supplies in the home setting. The nurse must be well versed as a financial resource manager, who needs to be aware of what is or is not covered on the client's insurance plan.

The nurse identifies that The Code of Ethics for Nurses is defined in which terms? a. Like the Constitution and not revisable b. A succinct statement of ethical obligations c. Required by entry level nurses only d. A negotiable document dependent on individual conscience

ANS: B The current nursing code, the Code of Ethics for Nurses with interpretive statements, was published in 2015. The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession," the profession's "nonnegotiable ethical standard," and "an expression of nursing's own understanding of its commitment to society."

When the nurse measures the patient's blood glucose levels after an acute myocardial infarction (MI), the nurse knows this action is based on which rationale? a. Damaged muscle tissue releases glucose. b. Corticosteroids increase glucose. c. Myocardial infarctions are often seen in diabetics. d. All patients should have their blood glucose checked.

ANS: B The endocrine system responds to stress on the body such as what happens during an acute MI. Corticosteroids are important in the stress response because they increase serum glucose levels and inhibit the inflammatory response. Although MIs can be seen in diabetics, there is nothing to indicate this patient is diabetic. All patients do not routinely have their blood glucose checked regularly.

A nurse is interested in epidemiology. What work activity would best fit this role? a. Studying census data to determine common causes of death b. Researching population variables that contribute to disease c. Developing sanitary measures to prevent foodborne illness d. Designing research to determine the connection between pollution and cancer

ANS: B The epidemiologist works to develop programs to prevent the development and spread of disease. Studying census data, researching population variables, and designing studies do not fall in this field.

A young adult tells the nurse he has quit smoking cigarettes and now "vapes" (uses electronic cigarettes [e-cigarettes]). What response by the nurse is best? a. "Excellent! That is so much better for you than tobacco." b. "The health consequences of e-cigarettes are not known." c. "Using e-cigarettes actually is much worse for your health." d. "Tobacco or e-cigarettes ... doesn't matter. You need to quit."

ANS: B The health consequences of using e-cigarettes are not yet known because they are new products. The nurse educates the young adult to this fact.

The perinatal clinic nurse is going to teach a woman from a culture unfamiliar to the nurse about child-rearing practices. What action by the nurse is best before planning the education? a. Ensure the availability of written material to give the woman. b. Assess what practices are important to her cultural group. c. Determine if the woman is the primary family decision maker. d. Refer the woman to a prenatal educational class.

ANS: B The nurse must ensure he/she has a solid understanding of important child-rearing concepts in the woman's culture or risk that any teaching done will be irrelevant and perhaps in opposition to important beliefs. Since the nurse is unfamiliar with this culture, the first step is to assess. Written material is helpful if the patient can read and comprehend it. It would be important to determine if the woman is the decision maker, but this is not as much of a priority as learning about the culture. Referring the woman to an educational group may or may not be helpful.

The nurse administers a medication to a patient. Shortly afterward, the patient develops an itchy rash over the entire body and reports feeling very unwell. What is the priority action of the nurse? a. Leave the patient to notify the provider and the pharmacist. b. Determine if the patient is having any difficulty breathing. c. Document the reaction in the patient's chart. d. Obtain an order for hydrocortisone cream to relieve the itching

ANS: B The nurse must first determine if the patient is having any difficulty breathing, since the patient may be starting to have an anaphylactic reaction to the medication, which can lead to shortness of breath and airway swelling. After assuring that the patient is stable, the nurse can notify the appropriate personnel and request any treatments for the reaction.

The nurse sees a young child in the clinic whose mother has only a few weeks to live. The child has been misbehaving at school recently and is suspended after picking fights with other students and defying teachers. The nurse identifies which stage of grieving that the patient is experiencing? a. Denial b. Anger c. Bargaining d. Depression

ANS: B The patient is angry over the impending death of the mother and is acting out this anger at school by picking fights and defying his teachers. Denial is a temporary defense while processing the information. Bargaining is negotiation to change the predicted outcome. Depression includes crying and sadness.

. The nurse is caring for a patient with multiple chronic illnesses who is having difficulty remembering to take multiple medications at the correct times. Which is the appropriate Nursing diagnosis for this patient? a. Activity intolerance related to inability to take medications on time b. Impaired health maintenance related to complexity of medication schedule c. Risk for aspiration related to need to swallow many pills during day d. Powerlessness related to inability to figure out medication dose times

ANS: B The patient is not able to manage the prescribed medication regimen because of the complexity of the schedule, so Impaired health maintenance is an appropriate diagnosis. Activity intolerance does not relate to the ability to take multiple medications at once and manage medication times. The patient does not state any difficulty swallowing pills, so risk for aspiration is not applicable. Inability to figure out medication dose times does not constitute powerlessness.

The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The patient's urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse? a. Remove the urinary catheter and replace it with a new one. b. Gently irrigate the catheter using warmed sterile normal saline. c. Send a sample of the patient's urine to the laboratory for analysis. d. Call the provider and obtain an order for kidney and bladder ultrasound.

ANS: B The patient most likely has decreased urine output caused by clot formation that is blocking urine from draining through the catheter. The catheter should be gently irrigated using sterile technique and warmed sterile saline to loosen clots and facilitate urinary drainage. The catheter should not be removed. Ultrasound and urinalysis are not necessary.

The hospice nurse is caring for a terminally ill patient. The patient's son is distraught because the patient will probably die within the next few days and there is nothing he can do about it. What is the most appropriate nursing diagnosis for the patient's son currently? a. Chronic grief related to impending death of mother b. Death anxiety related to feeling powerless over situation c. Powerlessness related to progression of mother's terminal illness d. Complicated grieving related to desired avoidance of mourning

ANS: B The patient's son is experiencing death anxiety because he is unable to change the outcome of his mother's imminent death. The son makes no mention of religious beliefs, so impaired religiosity is not appropriate. Complicated grieving is applicable to individuals who have recently experienced a loss. Chronic grief is grief that continues for a long period of time.

The nurse carefully reviews the patient's medication list. Which observation about the list indicates the highest risk for serious drug-drug interactions? a. The patient has been taking the same medications for a long time. b. The patient is taking a large number of medications. c. Most of the drugs on the list are prescribed at high doses. d. The patient takes oral, injected, and inhaled medications

ANS: B The risk of drug-drug interactions increases when a patient takes many drugs. One of the most important ways to prevent adverse drug interactions is to minimize the number of drugs that the patient is taking. The other options do not show a high likelihood of drug-drug interactions

The nurse working in long-term care knows that there are multiple theories regarding aging. The one the nurse most identifies with proposes that the body's cells are leading to damaged organs and organ systems. This description is congruent with which theory? a. Cross-linking theory of aging b. Wear-and-tear theory c. Gould's theory on adult development d. Senescence theory of aging

ANS: B The wear-and-tear theory states that body cells are damaged from years of hard use. The cross-linking theory relates changes of aging to cross-linked and connected cells and systems become hardened over time, decreasing function. Gould's theory is a psychosocial one looking at tasks the adult completes, not physical changes. "Senescence" means biologic aging; there is no senescence theory of aging.

The nurse is caring for four patients. Which one should the nurse assess for spirituality needs as a priority? a. New mother, older child at home. b. Faces terminal diagnosis. c. Needs to change medications. d. Pleasant but quiet.

ANS: B There are many cues to alert the nurse that a patient might have unmet spiritual needs, including facing a terminal illness. The nurse should conduct spiritual assessments on all patients, but this one is the priority

. A home health care nurse notes a parent becoming irritated when his toddler repeatedly throws his rattle from the high chair to the floor. What action by the nurse is most appropriate? a. Teach the parent about age-appropriate discipline. b. Educate the parent on age-appropriate behaviors. c. Tell the parent to stop giving the rattle back to the child. d. Assess the child for signs of abuse or neglect

ANS: B Throwing an object down to watch someone else pick it up is a typical behavior for this age-group. The nurse should teach the parent about how this behavior relates to toddler growth and development. The other actions are not appropriate in this situation.

The nurse is preparing a teaching plan and is applying evidence-based practice. To promote involvement, the nurse must include which concept? a. Provide the latest professional literature to the patient. b. Ensure that the patient understands relevant information. c. Use only one teaching method to reduce confusion. d. Not review previously learned information.

ANS: B To promote involvement, nurses must ensure that patients understand the information relevant to their care. Nurses need to provide patients with easy-to-understand information and speak in a clear, distinct voice, using short sentences and understandable terminology. Multiple teaching methods should be used to meet the needs of all types of learners. Patient education sessions should be reassessed after two to three key points to ensure that the patient is still engaged in learning and ready to assimilate more information. Information taught at previous sessions can be reviewed before proceeding with new key points.

The student studying community health nursing learns that vulnerable populations can be best assisted by which activity? a. Researching their genetic risk for health problems b. Working with the community to decrease health risks c. Studying vital statistics to determine their causes of death d. Making sure the population maintains immunizations

ANS: B Vulnerable populations have some characteristic that puts them at higher risk for identified health problems. The nurse can best assist vulnerable populations by identifying and working with them to decrease their risks. Researching genetic risks, studying vital statistics, and improving immunizations are all part of the solution, but the overarching priority action is to help the community decrease its risks.

The nurse is caring for a patient who is in agonizing pain. All the following options are listed on the patient's medication order sheet to relive pain. The nurse knows which option that will provide the most rapid pain relief for the patient? a. Morphine (MSContin) 10 mg PO b. Hydromorphone (Dilaudid) 1 mg IV push c. Meperidine (Demerol) 75 mg IM d. Fentanyl (Duragesic) 50 mcg transdermal patch

ANS: B IV administration has the most rapid onset of action and will provide the patient with the quickest pain relief

The nurse is caring for a patient who will self-administer medication injections at home after discharge. How can the nurse best determine that the patient understands the technique and can administer the injections correctly? a. Provide written instructions about how to administer the injections. b. Watch the patient self-administer an injection. c. Call the patient the next day to ask if there is any difficulty with administering the injections. d. Ask the patient to express understanding as to how to administer the injections.

ANS: B The nurse should watch the patient self-administer an injection to make sure that the patient is doing it correctly. This will give the nurse an opportunity to point out and correct any mistakes and offer the patient reassurance about the technique.

The student of adult development learns that cognitive abilities improve during the young adult stage because of the influence of which experiences? (Select all that apply.) a. Physical growth of the brain b. Formal education c. Occupational training d. Overall life experiences e. Specific profession chosen

ANS: B, C, D Formal education, occupational training, and overall life experiences contribute to refining cognitive skills such as rational thinking and problem solving. Physical growth of the brain and specific profession chosen are not as directly related.

When teaching children, the nurse should include which concepts? (Select all that apply.) a. Exclude the children from teaching. b. Encourage parents or caregivers to be present. c. Use age-specific strategies. d. Consider the stages of development. e. Remember that parents are not the targets of the teaching.

ANS: B, C, D Patient education provided for children should be age specific. Effective patient education involving a child requires the presence of a parent or caregiver, who is likely the target of teaching. Children should not be excluded from the learning session unless exclusion is deemed appropriate by the parent or caregiver; a presentation using an age-appropriate strategy may complement the instructions reviewed with the adult. The stages of development should be explored as the foundation for the choice of educational materials.

The nurse knows when the body responds to the release of hormones during "fight or flight," that response includes which physiological signs? (Select all that apply.) a. Decreased respiratory rate b. Slowing of the digestive process c. Glucose being mobilized from the liver d. Pupils dilating e. Smooth muscles in the bronchi constricting

ANS: B, C, D The release of hormones increases the heart rate, resulting in increased cardiac output, and elevated blood pressure. There is an increase in the flow of blood to muscles at the expense of the digestive and other systems not immediately needed in the fight-or-flight response. Smooth muscles in the bronchi relax and dilate the bronchi and smaller airways, and the respiratory rate increases, allowing for an enhanced flow of well-oxygenated blood to muscles and other organs. The motility of the digestive tract is decreased, slowing digestive processes, but glucose and fatty acids are mobilized from the liver and other stores to support increased mental activities (alertness) and skeletal muscle function. Pupillary dilation produces a larger visual field.

When the nurse is caring for a patient receiving enteral feedings, which tasks can that nurse delegate to the UAP? (Select all that apply.) a. Verify tube placement b. Perform oral care c. Administer tube feeding d. Obtain vital signs and report results e. Measure oxygen saturation

ANS: B, C, D, E Administering an enteral feeding may be delegated, at the nurse's discretion, to UAP in accordance with state regulations and facility policies and procedures. The nurse should verify tube placement and assess the patient prior to delegating this procedure. The UAP can perform oral care and obtain vital signs, including oxygen saturation, and report results.

The nurse must provide patient education to a patient who has just been given the diagnosis of stage III cancer. The patient is complaining of chest and bone discomfort. Before providing the needed education, the nurse will complete which tasks? (Select all that apply.) a. Draw the curtain in the semi-private room. b. Medicate the patient to ease the pain. c. Place the patient in a private room if possible. d. Wait until later in the day. e. Attend to any other personal needs first.

ANS: B, C, D, E The location of patient education influences the outcome. The setting should be quiet, and the session should have minimal interruptions. Providing privacy is difficult in settings such as emergency rooms, outpatient surgery centers, and semi-private inpatient rooms, but the nurse should make every effort to ensure confidentiality. Environmental considerations such as good lighting and the availability of resources should be explored to enhance the outcome of patient education. The nurse should examine the patient's situation and comfort level before beginning teaching. For example, a postoperative patient who is rating pain at 7 of 10 will be much more receptive to learning after being medicated for pain. A patient who just received a diagnosis of metastatic cancer will learn and assimilate more information later in the day or perhaps the next day. The nurse must also take care of any other personal needs first, such as the need to use the bathroom.

The nurse working with older adults wants to support healthy coping strategies. What actions by the nurse are most appropriate? (Select all that apply.) a. Installing boxing equipment in the recreation room b. Provide reminiscing sessions for the adults to share personal stories c. Arrange for gentle yoga to be provided at the senior center d. Create activities designed to distract them from their losses e. Encourage the adults to eat frequent, healthy snacks

ANS: B, C, E To promote health coping in older adults, the nurse would provide reminiscing sessions, yoga, and would encourage small healthy snacks as this population frequently loses their appetite when stressed. Boxing equipment might cause the adults to focus on anger. Distraction can be a negative or positive coping mechanism.

The nurse knows that which attributes are characteristics of the young adult age-group? (Select all that apply.) a. The number of high school graduates going to college is decreasing. b. More than 88% of people aged 25 to 34 have completed high school. c. More males aged 20 to 24 were married than females in the same age-group. d. A significant percentage of those aged 25 to 34 has advanced degrees. e. Adult roles for the young adult are more diverse than for other age-groups

ANS: B, E More than 88% of people aged 25 to 34 have completed high school. Adult roles, which are influenced by many factors, are diverse and are not normed for this age-group. The number of high school graduates going to college is increasing. More females than males aged 20 to 24 are married. Only about 9% of those 25 to 34 have advanced degrees.

The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. The nurse knows which statements about screening examinations to be true? (Select all that apply.) a. Free or low-cost screening ensures patient screening. b. People may not screen due to fear of testing positive. c. Early screening ensures minimal treatment costs. d. Employment stability is enhanced by early screening. e. Treatment of disorders often means lost wages

ANS: B, E The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. Even if screening is free or low cost, the patient or family members may decline because of the potential for testing positive for a disease. Treatment of a disorder often requires time spent away from work, lost wages, and expensive drug therapies and diagnostic tests. The financial impact can be devastating to families or individuals who have a limited or fixed income and fear that employment stability may be compromised.

The nurse identifies which medications that are to be administered via parenteral routes? (Select all that apply.) a. Bisacodyl (Dulcolax) 10 mg suppository daily PRN constipation b. Prochlroperazine (Compazine) 10 mg IM q 6 hours PRN nausea c. Brimonidine (Alphagan) 0.1% solution 2 drops to each eye daily d. Proventil (Ventolin) inhaler 2 puffs as needed for shortness of breath e. Fentanyl (Duragesic) 50 mcg transdermal patch apply every 72 hours f. Insulin lispro (Humalog) insulin 15 units subcutaneously ac meals

ANS: B, F Parenteral medications are administered by injection into tissue, muscle, or a vein rather than through the gastrointestinal or respiratory route

A nurse assesses a 4-month-old infant and notes the baby does not follow a moving object with her eyes. What action by the nurse is best? a. Document the findings and continue the assessment. b. Refer the child and parent to a pediatric neurologist. c. Assess the child for other age-appropriate behaviors. d. Assess the child for signs of child abuse or neglect

ANS: C A 3-month-old child should be able to follow a moving object with his or her eyes. However, one single abnormal assessment finding does not necessarily mean that the child has a growth and developmental delay. The nurse should assess for other age-appropriate behaviors. Documentation should occur but is not the priority action at this point. A referral is not warranted nor is assessing for child abuse based on the data

The student learns that which is the best definition of a public health nurse? a. Works with the public. b. Works in public areas. c. Works with the greater community. d. Works with public funding.

ANS: C A public health nurse works with communities as a larger whole and is concerned with specific target or vulnerable groups within that community. The other options are inaccurate.

A patient asks the nurse to pray with him. The nurse is an atheist and uncomfortable with this request. What action by the nurse is best? a. Deny the request because of atheistic beliefs. b. Offer to call the chaplain instead. c. Agree to sit with the patient while he prays. d. Ask the patient if he will meditate instead.

ANS: C Although the nurse is uncomfortable with the request, the patient's needs (not the nurse's) come first. The nurse should attempt to honor the request while not imposing his/her ideas of religion and spirituality on the patient. The best option is to agree to sit with the patient while he prays himself. This is consistent with caring behaviors and fulfilling the patient's needs. Denying the request does nothing to address the patient's needs. The nurse can offer to call the chaplain in addition to sitting with the patient. Asking the patient to change his practices is unethical

The nurse identifies which goal to be appropriate for the nursing diagnosis of Difficulty coping? a. The patient will report an ability to remember discharge instructions. b. The patient's family will understand how to access respite care services. c. The patient will discuss possible coping strategies during weekly counseling sessions. d. The patient will attend an online support group weekly.

ANS: C An appropriate goal for Difficulty coping would be to discuss coping strategies. Remembering discharge instructions is an appropriate goal for Anxiety. Understanding how to access respite care services is an appropriate goal for Caregiver stress. Attending a support group is an appropriate goal for Difficulty coping.

The nurse recognizes which outcome statement to be appropriate for the nursing diagnosis Impaired swallowing? a. Patient will consume 50% of each meal. b. Patient will gain 2 lb a week. c. Patient will not show any signs of aspiration during meals. d. Patient will demonstrate using an assistive device to feed self.

ANS: C An appropriate goal statement for impaired swallowing is that the patient will not exhibit any signs or symptoms of aspiration during this hospitalization (e.g., lungs clear, respiratory rate within normal range for patient). Consuming 50% of meals and gaining weight are appropriate goals for Impaired nutritional intake. Using assistive devices is an appropriate goal for Impaired self-feeding

The nurse recognizes which goal to be appropriate for the nursing diagnosis of Anxiety? a. The patient will attend a weekly support group. b. The patient will discuss possible coping strategies during weekly office visits. c. The patient will report increased ability to concentrate on care instructions before discharge. d. The patient's family will use respite care once a week for the next month.

ANS: C Attending a weekly support group is an appropriate goal for Difficulty coping. An appropriate goal for Ineffective coping would be to discuss possible coping strategies during weekly visits. Using respite care once a week for the next month is an appropriate goal for Caregiver stress.

The nurse is providing education to an older adult around a healthy diet to support the challenges related to aging. Which statement indicates a need for further education? a. "I should choose foods that are nutrient dense." b. "High-fiber foods minimize the risk of constipation." c. "I should eat more calories to avoid malnutrition." d. "I can add spices to enhance the taste of food."

ANS: C Calorie needs change with aging because of more body fat and less lean muscle. Less activity further decreases calorie requirements. Eating whole-grain foods and a variety of fruits and vegetables and drinking water may minimize the risk of constipation. The challenge for older adults is to choose foods that are nutrient dense; these foods are high in nutrients in relation to their calories. Older adults may experience a decreased sense of smell or taste, so the addition of spices and herbs may enhance the taste of foods.

To help a hospitalized infant master the tasks in Erikson's stage of Trust versus Mistrust, which action by the nurse is best? a. Provide calming music during quiet time so the infant can sleep. b. Give the family food vouchers for the hospital cafeteria. c. Arrange to have a cot or small bed placed in the infant's room. d. Do not allow unlicensed assistive personnel to care for the infant.

ANS: C Caregiver consistency is vital to accomplishing this task. The nurse should provide the parent(s) a comfortable place to stay in the infant's room. Giving food vouchers is also a good intervention, but not as important as ensuring the parent(s) can stay with the child. Calming music is appropriate for a child this age but does not help the child master tasks in this phase. Sleep is important for any hospitalized patient but is unrelated to mastering the tasks in this phase

. The nurse correctly recognizes which one of the following illnesses to trigger the broadest range of emotional and behavioral responses? a. Ear infection b. Mild concussion c. Rheumatoid arthritis d. Influenza

ANS: C Chronic, debilitating disease such as rheumatoid arthritis and severe illness can produce a broad range of emotional or behavioral responses in patients and their families. A short-term, self-limited illness that is not life threatening does not evoke emotions or actions that cause fundamental changes in daily lifestyle. More often, illnesses such as the flu, ear infections, and sore throats are viewed as minor irritations or inconveniences. They usually require a short-term adjustment in daily routines, and treatment of symptoms is the priority so that the individual can continue with normal activities. The emotional and behavioral changes associated with non-life-threatening illness are usually minimal, and the individual quickly returns to the previous baseline level of emotional functioning.

The hospice nurse is caring for a several adult children shortly after the death of a parent. They have various reactions as they deal with their loss. The nurse recognizes which reactions to be in the cognitive domain? a. They let the house get filthy because they can't be bothered to clean it. b. They are tossing and turning all night and are unable to get a good night's sleep. c. They are easily distracted and often lose train of thought during conversation. d. They have lost their appetites and have no desire to eat anything.

ANS: C Cognitive deficits include the inability to concentrate and follow a conversation. Letting the house get filthy is a sign of apathy, which is in the behavioral domain. Insomnia falls within the behavioral and physical domains. Loss of appetite is within the physical domain.

The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate in a new chemotherapy trial. How would the nurse respond if working under the ethical principle of utilitarianism? a. "The patient should be allowed to decide." b. "As your nurse, I'll support your right to refuse." c. "You should do this because many could benefit from it." d. "If this is against your beliefs, you should not do it."

ANS: C Compared with deontology, utilitarianism is on the opposite end of the ethical theory continuum. Utilitarianism maintains that behaviors are determined to be right or wrong solely based on their consequences. Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions. Meeting the needs of patients while maintaining their right to privacy, confidentiality, autonomy, and dignity is consistent with the tenets of deontology. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. The remaining responses are examples of either deontology or autonomy.

The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation? a. "I can give the patient orange juice." b. "I can give the patient yogurt." c. "I can give the patient oatmeal." d. "I can give the patient milk."

ANS: C Full-liquid diets consist of foods that are or may become liquid at room or body temperature. Full-liquid diets include juices with and without pulp, milk and milk products, yogurt, strained cream soups, and liquid dietary supplements. Oatmeal is not considered part of a full-liquid diet.

The nurse recognizes that intentional behaviors to circumvent illness, detect it early, and maintain the best possible level of mental and physiologic function within the boundaries of illness is the definition of which term? a. Health promotion b. Self-actualization c. Health protection d. Self-transcendence

ANS: C Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness. Health promotion is behavior motivated by the desire to increase well-being and optimize health status. Maslow considered self-actualization the highest level of optimal functioning and involves the integration of cognition, consciousness, and physiologic utility in a single entity. In later years, Maslow described a level above self-actualization called self-transcendence. He refers to self-transcendence as a peak experience, in which analysis of reality or thought changes a person's view of the world and his or her position in the greater structure of life.

The nurse is caring for a patient who is undergoing a major cardiac procedure. When the patient complains of a racing heart and nausea, the nurse recognizes these complaints as part of what hormone response? a. Sense of coherence b. Stress appraisal c. Fight or flight d. Sympathoadrenal response

ANS: C In the "fight or flight" response, the corticotropin-releasing hormone (CRH) released by the hypothalamus stimulates the pituitary to release adrenocorticotropic hormone (ACTH). These hormones increase the heart rate, resulting in increased cardiac output, and the motility of the digestive tract is decreased, slowing digestive processes that could result in abdominal distress. Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious, assessment of a demand, or stressor. The sympathoadrenal response is a consequence of hypothalamic activation in sympathetic stimulation, which triggers epinephrine and norepinephrine release from the adrenal medulla.

The nurse is admitting a patient who has cystic fibrosis. During the admission interview, it is apparent that the patient is well versed in most aspects of his illness. When asked about where he learned so much, the patient responds, "I learned most of it myself. I looked things up on the Internet and read books. You have to know what's wrong with you to be sure that you're being treated right." The nurse knows this is an example of what type of education/learning? a. Formal education b. Psychomotor learning c. Informal education d. Affective learning

ANS: C Informal education is usually learner or patient directed. Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The nurse is developing a plan of care for a patient with a hip fracture. Which model would the nurse use to prioritize the patient's care? a. The Health Belief Model b. Pender's Health Promotion Model c. Maslow's hierarchy of needs d. The Holistic Health Model

ANS: C Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state. Holistic Health Models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind

The nurse needs to consider which approach when caring for patients with chronic illness? a. Help the patient face the reality that he will not get better. b. Emphasize to the patient that the illness is not his fault. c. Focus on improving quality of life through preventive behaviors. d. Acknowledge the limitations placed on the patient by his suffering.

ANS: C Nurses can help patients establish a daily routine of care by educating them about how to manage their care and the symptoms associated with the condition, including emergency or life-threatening situations. Emphasis is on improving quality of life through preventive behaviors. The attitude of being a victim, suffering with, or being afflicted by a chronic illness is viewed by nurses as a counterproductive behavior that needs positive intervention. Nurses can assist patients with strategies that help them cope with their chronic conditions and associated feelings of anger, frustration, and depression. Encouragement and positive support from a professional nurse can help individuals gain control over the alternating periods of health and illness and improve their quality of life

The hospice nurse is caring for a patient who is terminally ill. The patient's spouse is the primary caregiver, providing constant care and spending all his or her time meeting the patient's needs. The spouse says to the nurse "After my spouse dies, I will finally get that colonoscopy my provider has been bugging me about." What does the nurse understand about this statement? a. The spouse is looking forward to being freed from the caretaker role. b. The spouse has neglected his or her own physical needs for too long. c. The spouse is making some realistic plans for life after the death. d. The spouse is in denial that the patient is dying and the important role of caregiver will end.

ANS: C Often caregivers neglect their own needs while in the caregiver role. The spouse understands the patient will die soon and is being realistic in understanding his or her own physical needs have been neglected. This shows healthy coping

The nurse is attempting to open an occluded PEG tube. Which intervention by the nurse requires re-education? a. Flushes the tube with a small amount of air b. Flushes the tube using a 50- to 60-mL syringe and warm water. c. Reinserts the stylet to break up the clot. d. Flushes the tube with a special enzyme solution.

ANS: C Once the stylet is removed, it is never reinserted because it can puncture the intestine. If the tube becomes occluded, flush it with a small amount of air. If this is unsuccessful in removing the occlusion, flush the tube using a 30 to 60 mL syringe and warm water. If flushing the tube with water is ineffective, research now suggests using special enzyme solutions or declogging devices rather than carbonated beverages or juices

The nurse is seeing a patient during a follow-up visit after discharge in which the patient had a nursing diagnosis of Difficulty coping. Which statement by the patient would be a cause for concern? a. "I am sleeping better most nights." b. "I feel less anxious." c. "I do not need to do the relaxation exercises anymore." d. "I am continuing my exercises every day."

ANS: C Patients need to continue using the stress-reduction techniques to maintain a feeling of well-being. Once stress decreases, patients typically report feeling better, sleeping more soundly, and feeling less anxious. Continuing their positive activities such as exercising is good.

The nurse knows practicing nursing without a license is what wrongdoing? a. Misdemeanor b. Statute c. Felony d. Tort

ANS: C Practicing nursing without a license is a felony. A misdemeanor is a minor crime, such as stealing an item from a patient that does not have much value. A statute is a law created by legislative bodies. Torts are crimes committed against another person. An intentional tort example is assault and battery. Negligence and malpractice are examples of unintentional torts.

The nurse is caring for a patient who has been belligerent and is in 4-point "leather" restraints. When the patient continues to be verbally abusive and still tries to kick and punch staff even though he is restrained, the nurse should carry out which action? a. Do not attempt to meet patient needs until the patient has calmed down. b. Only provide care while security is in the room. c. Continue to attempt to meet the patient's needs. d. Inform the patient the police will be called if the patient's behavior does not stop.

ANS: C Provision 1.5 (of the Nursing Code of Ethics) states, "The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to the fair treatment of individuals, to integrity-preserving compromise, and to resolving conflict. The nurse should make all attempts to provide for the patient's needs. It is unrealistic to only provide care if security is present. Telling the patient that the police will be called is threatening.

A 40-year-old patient presents to her provider for a yearly physical. The provider notes a family history of breast cancer in the patient's mother. The provider schedules the patient for a mammogram. The nurse recognizes this as what level of prevention? a. Tertiary b. Primary c. secondary d. Holistic

ANS: C Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Holistic care is an approach to applying healing therapies. Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

During patient teaching led by the nurse with goals established through cooperation of the nurse and patient, the patient asks questions as needed and the nurse answers. The nurse understands that this is what type of teaching? a. Formal teaching b. Informal teaching c. Both formal and informal teaching d. Psychomotor teaching

ANS: C Some patient education sessions have formal and informal elements, because the nurse and patient may set goals together before the nurse formulates and implements the plan of care, and the patient is free to ask questions that may direct the session. The health care information is considered informal because it is situation and patient specific. Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. Informal education is usually learner or patient directed. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill.

The nurse concerned about a patient's spiritual needs can best address this by which action? a. Leaving a note on the chart for other professionals b. Calling the chaplain to come see the patient c. Collaborating during interdisciplinary rounds d. Informing the provider of the patient's needs

ANS: C Spiritual care must be multidisciplinary to be most effective. The nurse best addresses patients' spiritual needs by discussing them during interdisciplinary rounds.

5. A nurse has been told he has many obvious stereotypes about a specific cultural group. What action by the nurse is best? a. Ask to not care for members of this cultural group. b. Ask to take care of as many members of this group as possible. c. Begin to educate himself on aspects of this cultural group. d. Vow to not allow his stereotypes to show when providing care.

ANS: C Stereotypes are fixed ideas, often unfavorable, about groups of people. They occur because of being unwilling to gather all the information needed to make fair determinations. The nurse would benefit most from beginning to learn about this cultural group. Caring or not caring for members of this group will not help him obtain new information. The nurse should not let stereotypes show, but this is not the best option.

The nurse is providing education to a patient around anger management strategies. Which statement indicates a need for further education by the patient? a. "Exercise can help me deal with the anger." b. "I can use humor." c. "I can punch things." d. "I can take a time-out."

ANS: C Strategies should focus on nonviolent methods. Some anger management interventions include expressing feelings in a calm, non-confrontational manner; exercising; identifying potential solutions; taking a time-out; forgiving; diffusing the situation with humor; owning one's feelings; and breathing deeply.

The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable method to determine enteral tube placement? a. Auscultation of air bolus b. Measurement of pH of the aspirate c. Radiographic image d. Aspirate contents to visually inspect appearance

ANS: C Studies support the use of radiographic confirmation as the only reliable method to date of confirming enteral tube placement. Using only pH and the appearance of aspirate from the newly inserted tube is not a safe method of verifying proper gastric tube placement, especially in patients receiving antacid medications. Auscultation of an air bolus to assess tube placement is no longer recognized as a reliable source in determining gastric tube placement.

. A parent is concerned that her 16 year old is spending most of his time away from the family in his room and does not want to be involved in family activities he used to enjoy. What action by the nurse is best? a. Reassure the parent the teen is exerting independence. b. Ask the parent about the teen's friends and activities. c. Assess the teen for depression and possible suicide risk. d. Refer the family to the community depression support group.

ANS: C Teens typically begin to withdraw from the family to maintain privacy and exert independence, so this alone is not concerning. However, since the teen is not participating in activities he once enjoyed, the nurse should conduct a depression assessment. If the teen is depressed, the nurse should assess his suicide risk. If these screenings are normal, the nurse can reassure the parent. The teen himself is the best source of information about friends and activities, although the parent can be a good secondary source. A referral is not warranted without further assessment.

A nurse is orienting to a new job in a home health care agency and is told that most of her patients need tertiary prevention. What activity does the nurse plan to include in the daily routine? a. Household safety checks b. Well-baby checkups c. Antibiotic administration d. Monthly blood pressure assessments

ANS: C Tertiary care is aimed at people who are already experiencing a health alteration, such as those with an infection who need antibiotics. The other options are secondary prevention.

The nurse knows the World Health Organization defines health in which of the following terms? a. The absence of disease b. The lack of infirmity c. Complete well-being d. Being independent of fiscal responsibility

ANS: C The World Health Organization offers a definition for health: "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Nurses are responsible for helping patients reach their optimal levels of physiologic and mental health, but they also must provide health care in a system that requires cost containment and fiscal responsibility.

. The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient's belief system? a. "Do you engage in prayer to help you during times of stress?" b. "Do you go to church or other form of organized worship?" c. "Do you have certain beliefs that are helpful during times of stress?" d. "Do you want spiritual counseling while you are here?"

ANS: C The nurse needs to obtain a knowledge base of the patient's culture as well as identify health beliefs and cultural values from the patient's worldview. Asking the patient specific questions about prayer or church or spiritual counseling is inappropriate until the nurse first understands what the patient's own beliefs and practices are

The nurse is caring for a patient who was just made NPO. The nurse is to administer carvedilol (Coreg) 25 mg PO to the patient for control of high blood pressure. What is the best action of the nurse? a. Crush the medication and administer it to the patient mixed with applesauce. b. Administer the medication to the patient with a small sip of water. c. Contact the patient's provider to clarify the order. d. Administer the equivalent medication dose through the patient's IV.

ANS: C The nurse should contact the patient's provider to clarify the order. Oral medications should never be administered to NPO patients without specific orders to do so from the provider. Not all medications can be administered intravenously.

The nurse knows which goal to be appropriate for the nursing diagnosis of Caregiver stress? a. The patient will report an ability to focus on discharge instructions. b. The caregiver will attend a coping skills class on a weekly basis. c. Caregiver will use respite care for the family loved one once a week for the next month. d. The patient will discuss strategies for coping with relationship violence within 24 hours.

ANS: C The patient will discuss possible coping strategies during weekly office visits is an appropriate goal for Difficulty coping. The patient will report an ability to focus on discharge instructions is an appropriate goal for Anxiety. Relationship violence is not related

The nurse is caring for a terminally ill patient who will probably die within the next 2 weeks. What is the priority nursing intervention? a. Encouraging the patient to limit fluid intake to minimize congestion b. Limiting the use of pain medications so that the patient can visit with family c. Helping the patient to identify and complete desired tasks and activities d. Completing funeral arrangements with the patient's next of kin

ANS: C The priority intervention for the nurse currently is to help the patient identify and complete desired tasks and activities while the patient is still able to do so. Pain management is a high priority at this time, so analgesics should never be limited unless requested by the patient. The patient can drink as much or as little fluid as desired.

The nurse is performing a physical assessment of patient who is undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress? a. Blood pressure of 120/84 b. Temperature of 99.5 °F (37.5 °C) c. Heart rate of 110 beats/min d. Respiratory rate of 10 breaths/min

ANS: C The release of hormones increases the heart rate, resulting in increased cardiac output and elevated blood pressure. A reading of 120/84 is a normal blood pressure, and temperature is elevated is indicative of an infection. The respiratory rate increases in stress not decreases

The nurse is assessing the patient's use of coping skills in response to stressful situations. The nurse identifies which question to be the most useful? a. "Have you been evaluated for stress?" b. "Do you have someone you can go to for help when you are stressed?" c. "How have you managed stressful situations in the past?" d. "Does stress cause you to experience muscle tension or headaches?"

ANS: C The use of open-ended questions assists in obtaining accurate information regarding the patient's stressors and coping skills. Questions that elicit yes/no answers will not allow the patient to provide as much information. Asking the patient about headaches and tension is asking about physical symptoms, not coping skills.

A community was devastated by a tornado several months ago. What nursing diagnosis would be most appropriate for the nurse to consider? a. Social isolation b. Deficient community resources c. Ineffective community coping d. Deficient community health

ANS: C This diagnosis considers those in a community who may be feeling helpless, hopeless, or frustrated because of an extraordinary event. Financial and physical resources may not be available for rebuilding. Social isolation refers to unacceptable social behavior. Deficient community resources is not an approved diagnosis. Deficient community health may become a problem if sanitary conditions lead to an outbreak of disease.

The nurse is educating the patient on the use of relaxation therapy. Which statement by the patient indicates a need for further education? a. "I should relax my muscles from head to toe." b. "I visual the relaxed muscle." c. "I should do this three times a week." d. "I focus on muscles that are tense."

ANS: C This technique should be done daily. Typically, relaxation progresses from head to toe. With practice, the patient visualizes an image of the relaxed muscles and will be able to relax muscles from the mental image. Progressive relaxation is implemented by having patient's focus on muscles that are tensed and then intentionally relax those muscle groups.

The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which action by the nurse indicates a need for further education? a. The nurse clears the tube with air prior to discontinuing. b. The nurse stops the tube feeding. c. The nurse instructs the patient to cough while pulling out the tube. d. The nurse clamps the tube while pulling it out.

ANS: C To remove the tube, instruct the patient to take a deep breath and hold it; pinch the tube, and pull it out smoothly and quickly. The nurse should stop any feedings, and suction and flush the tube with water and/or air as appropriate. The nurse should not ask the patient to cough while pulling out the tube. Coughing during tube insertion may indicate the tube is entering the patient's lungs.

When the nurse is caring for a patient who is receiving total parenteral nutrition (TPN), the nurse will change the tubing at which interval? a. Every 72 hours b. Every 48 hours c. Every 24 hours d. Every 12 hour

ANS: C Tubing should be changed every 24 hours, with aseptic technique used to minimize the risk of contamination, and the dressing over the site should be changed every 48 hours, with assessment for signs and symptoms of infection (redness, swelling, or drainage).

The nurse is caring for a patient on a medical-surgical inpatient unit when the patient tells the nurse he is very sad and is considering suicide. What is the first thing the nurse should do? a. Notify the health care provider. b. Make a referral to psychiatric services. c. Implement one-on-one observations. d. Document in the electronic medical record.

ANS: C Verbalization of suicidal ideation or a suicide plan must be taken seriously. In the case of a hospitalized patient, one-on-one observation should be implemented to ensure patient safety. Once the patient is under observation, the health care provider is notified to put in the referral; nurses generally do not put in the referral. Documentation is always done after the patient's safety is ensured.

The nurse makes a medication error. Which action will the nurse take first? a. Prepare an incident report. b. Explain to the patient that a medication error has occurred. c. Assess the patient for any adverse reactions. d. Document the medication given, the response, and corrective actions taken.

ANS: C When a medication error occurs, the nurse's priorities are to determine the effect on the patient and intervene to offset any adverse effects of the error. Actions include immediate and ongoing assessment, notification of the prescribing health care provider, initiation of interventions as prescribed to offset any adverse effects, and documentation related to the event. Error reporting is an essential component of patient safety and should be completed as soon as the patient is assessed and stable. The nurse should follow facility guidelines for medication error reporting.

The nurse is caring for a patient with a new diagnosis of diabetes type 2. Which statement indicates a negative coping response? a. "I will look up information on the Internet about diabetes." b. "I will join a support group." c. "I will only focus on learning to manage my medication first." d. "I will make changes slowly so I can adapt to each change."

ANS: C When the patient puts limits on learning by stating he/she will only learn about medication, he/she is using avoidance strategies to alleviate stress. Using strategies such as information gathering (seeking information about diabetes) is positive. Joining support groups and making changes slowly to adapt is also taking direct action by moving forward.

A patient, who is an adherent Muslim, is in a burn unit with severe burns. The patient has high caloric requirements but is refusing to eat during Ramadan. What action by the nurse is best? a. Insert a feeding tube and provide enteral feedings. b. Ask the provider about Total Peripheral Nutrition. c. Call the patient's religious leader for advice. d. Tell the patient he has to eat to get better.

ANS: C With permission, the nurse should consult with the patient's religious leader on this situation. There may be exceptions to the rule to fast during Ramadan for medical conditions. The other options ignore the patient's religious preferences, and both the tube feeding and parenteral nutrition have potential serious side effects.

The nurse is preparing to teach a 90-year-old patient. In teaching an elderly patient, the nurse realizes what information? a. Most elderly patients are highly literate. b. Cognitive abilities always decline with age. c. Sensory alterations often occur with aging. d. Teaching methods are the same as for the middle aged.

ANS: C Teaching should be tailored to elderly patients. Reports indicate that two-thirds of U.S. adults 66 years old and older have inadequate or marginal literacy skills, and 81% of patients 60 years old and older at a public hospital could not read or understand basic materials such as prescription labels. Although each patient must assessed individually, cognitive and sensory alterations often occur with aging, and the teaching materials should be adjusted accordingly.

. The student nurse learns the ANA's Scope and Standards of Practice for public health nursing include components? (Select all that apply.) a. Team membership b. Developing research c. Ethical behavior d. Responsible resource use e. Advocacy

ANS: C, D, E The ANA's Scope and Standards of Practice for public health nursing requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy like the standards of practice for all nurses. Team membership and developing one's own research are not included.

The community health nurse knows that which are standards of professional performance for home care nurses according to the ANA? (Select all that apply.) a. Collegiality b. Performance appraisal c. Ethical behavior d. Outcome identification e. Resource utilization

ANS: C, E The ANA's Public Health Nursing: Scope and Standards of Practice (2013) requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy similar to the standards of practice for all nurses.

The nurse is caring for a patient who is NPO with a new PEG (percutaneous endoscopic gastrostomy) tube. Which of the patient's medications can the nurse administer through the tube? (Select all that apply.) a. Zolpidem tartrate (Edluar) sublingual tablet 5 mg nightly at bedtime b. Ondansetron (Zofran) oral disintegrating tablet 8 mg q 8 hours PRN nausea c. Cefaclor (Ceclor) for oral suspension 250 mg q 6 hours d. Oxymorphone hydrochloride extended release (Opana ER) 40 mg q 12 hours e. Phenytoin (Dilantin) chewable tablet 100 mg q 12 hours f. Potassium chloride oral solution 20 mEq daily

ANS: C, E, F Extended-release, oral disintegrating, and sublingual tablets may not be administered through feeding tubes. Suspensions and oral solutions are ideal for feeding tube administration. Chewable tablets may be crushed and dissolved in liquid for administration through feeding tubes.

A nurse is conducting a preschool screening in the community. Which child would the nurse refer for further assessment? a. A 4 year old who throws a ball over-handed but better under-handed. b. A 4 year old who can skip across the room after being shown how. c. A 5 year old who is able to ride a bicycle with training wheels. d. A 5 year old who is unable to ride a tricycle without falling.

ANS: D A 3 year old should be able to ride a tricycle, so a 5 year old unable to perform this task needs further assessment. The other activities are appropriate for each child's age

9. An adult child brings his father to the emergency department and describes the sudden onset of a panic attack and aggressiveness. After ruling out an infectious process, what action by the nurse is best? a. Assess the patient for mental illness. b. Perform a mini-mental state exam on the patient. c. Ask about risk factors for delirium. d. Assess the patient for illicit drug use.

ANS: D Abuse of illicit drugs can cause many symptoms, including panic attacks and aggressive behavior. After assessing for an infectious process, the nurse should determine if the patient has used any recreational drugs. The other assessments are not as important and can be completed later.

A nurse is obtaining a history from a 37-year-old patient. What statement by the patient indicates that he has met the age-appropriate developmental task according to Gould? a. Patient describes moving out of his parents' house into an apartment. b. Patient reminisces about past life events and accomplishments. c. Patient questions his life choices such as profession and decision not to marry. d. Patient expresses satisfaction in having his own family and successful career.

ANS: D According to Gould, this patient is in the midlife decade, which occurs after the upheaval of entering the adult world and questioning one's decisions, but prior to reconciling one's life and becoming stabilized. The patient who has moved out of his parents' house is demonstrating activities seen in the early adulthood stage in which leaving the parents' world is paramount. Reminiscing about the past life occurs as part of the reconciliation stage, seen in an older person. Questioning and reexamining are typically seen in the stage for 28- to 34-year olds.

A nurse in the family practice clinic is assessing an older adult who has dementia. The adult daughter/caregiver expresses concern that the parent should no longer be left alone while the daughter is at work. What response by the nurse is best? a. Refer the family to a social worker. b. Encourage the daughter to look into nursing homes. c. Tell the daughter there are medications for dementia. d. Help the daughter explore adult day care options.

ANS: D Adult day care facilities offer care of the older person during the working hours. This might be a good option for the family. A social worker can help, but the nurse should be active in problem solving with the daughter. Medications are available for dementia, but dementia remains a progressive disorder, so this does not help solve the problem. A nursing home may not yet be needed.

The patient is reportedly well educated and employed as an engineer but is struggling to comprehend terms found in health-related literature given to explain his disease process. The nurse recognizes that this is evidence of what issue? a. Low literacy b. Psychomotor dysfunction c. Affective domain deficiency d. Low health literacy

ANS: D Although low literacy and low health literacy are related terms, they are not interchangeable. Low health literacy is content specific, meaning that the individual may not have difficulty reading and writing outside the health care arena. These patients may struggle to comprehend the complicated, unfamiliar terms and ideas found in health-related materials or instructions. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The home care nurse is caring for a terminally ill patient who states that he wants to set up a scholarship in his name at the local university before he dies. What is the best action by the nurse? a. Suggest that the patient think it over and wait a few days before contacting the school. b. Direct the patient to ask his family about the possibility of starting a scholarship. c. Assess the patient's mental status to ensure that he is competent to make the decision. d. Assist the patient to find the necessary information about endowed scholarships.

ANS: D As the patient's advocate, the nurse should help provide the necessary information for the patient to set up a scholarship if that is his decision. The patient does not need to discuss the subject with his family first, and assessment of the patient's mental status is not needed. The patient may not have the time to wait a few days before contacting the university.

When considering factors influencing health and the impact of illness, specifically age, the nurse would correctly identify which patient as having the greatest risk? a. 10-year-old girl b. 23-year-old woman c. 47-year-old man d. 85-year-old woman

ANS: D Assessment of the patient begins with risk factors that take into account the person's age and the associated level of immune system function. The very young, especially neonates and infants born prematurely, are more susceptible to infections because of the immaturity of their immune systems. Likewise, older adults have decreased immune system function because of the aging process. Older patients are at risk for opportunistic infections resulting from harmless organisms that become pathogenic and illness from the spread of community-acquired disease. Complications from comorbidities of chronic disease may also increase suffering in the aged population.

The patient asks the nurse to explain collaborative health care partnerships. The nurse gives a correct description when making which statement regarding collaborative care? a. Does not require participation of the patient. b. Is individual and cannot be mandated or legislated. c. Education needs are delegated to assistive personnel. d. Is designed to provide care to the patient as a whole.

ANS: D Collaborative health care partnerships are designed to deliver well-balanced care to the patient as a whole, rather than rendering fragmented care involving a single element of a disease process. Prevention is not solely the responsibility of the nurse; it involves active participation by the individual and the combined services of practitioners in a spectrum of health care disciplines as varied as nutrition, physical therapy, exercise physiology, and pharmacy. Collaborative preventive care can be mandated in the form of health care legislation, with rates for reimbursement of practitioners determined by the individual provider's ability to collaborate and develop innovative methods for delivering high-quality, cost-effective health care services. The role of the professional nurse is to collaborate and communicate health education to the patient and family, care provider, or surrogate. Patient education responsibilities are not delegated to assistive personnel or other members of the health care team and are considered a cornerstone of nursing care.

The nurse is caring for a patient who has had many admissions and readmissions. The nurse believes that the patient keeps coming to the hospital because the patient "wants his drugs," and is "non-compliant" at home with diabetic therapy. To reduce the risk of slander against this patient, the nurse should carry out which action? a. Write opinions in the medical record only. b. Never share observations. c. Make judgmental statements in private. d. Avoid making judgmental statements.

ANS: D Defamation of character occurs when a public statement is made that is false and injurious to another person. Oral defamation of character is slander. Slander is spoken information that is untrue, causing prejudice against someone or jeopardizing that person's reputation. The nurse should not make opinionated, slanderous comments about patients, orally or in writing. Written forms of defamation of character are considered libel.

The nurse is preparing to discharge a patient home. In providing instruction about the patient's medications, the nurse should make which statement? a. "Before taking Metoprolol, you need to take your BP and rate." b. "MS should be taken only when needed for pain." c. "Take 1 baby aspirin by mouth every morning." d. "Take your water pill bid and you should be fine

ANS: D Do not use abbreviations or medical terminology when providing patients with instructions.

The nurse frequently cares for patients who are nearing the end of life. The nurse identifies what strategy that is designed to prolong the time of death rather than restoring life? a. Establishing a do-not-resuscitate (DNR) order b. Adherence to living will requests c. Removal of extraordinary measures already in place d. Continuance of futile care

ANS: D Ethical dilemmas in end-of-life care exist regarding the establishment of do-not-resuscitate (DNR) orders, adherence to living will and organ donation requests, removal of extraordinary measures already initiated, and continuance of futile care (i.e., care that is useless and prolongs the time until death rather than restoring life).

The nurse understands "First, do no harm" defines what ethical principle? a. Beneficence b. Justice c. Fidelity d. Nonmaleficene

ANS: D First, do no harm is the colloquial definition of nonmaleficence. Unlike beneficence, which requires actively doing good, nonmaleficence requires only the avoidance of harm. In its simplest form, beneficence can be defined as doing good. To do justice is to act fairly and equitably. Keeping promises or agreements made with others constitutes fidelity.

The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. The nurse knows which goal to be most appropriate for this patient? a. The patient will be referred to medical social services for evaluation and counseling. b. The patient will be encouraged to describe previous stressors and coping mechanisms. c. Nursing staff support patient's coping attempts and encourage verbalization of feelings. d. The patient will use effective coping strategies with no alcohol consumption.

ANS: D Goals are met by the patient rather than nursing or medical staff. The patient's use of effective coping strategies without drinking alcohol is an appropriate goal. Referring the patient for counseling and encouraging the patient to verbalize stressors are interventions rather than goals.

The nurse understands who is ultimately responsible for explaining the content of the informed consent? a. The registered nurse b. The hospital social worker c. Educated family members d. The provider of the procedure

ANS: D Informed consent is permission granted by a patient after discussing each of the following topics with the physician, surgeon, or advanced practice nurse who will perform the surgery or procedure: (1) exact details of the treatment, (2) necessity of the treatment, (3) all known benefits and risks involved, (4) available alternatives, and (5) risks of treatment refusal.

The nurse is providing care to a patient experiencing pain. The nurse assesses the pain and promptly administers the ordered analgesics as promised to the patient. This nurse has applied what concept? a. Autonomy b. Accountability c. Confidentiality d. Fidelity

ANS: D Keeping promises or agreements made with others constitutes fidelity. In nursing, fidelity is essential for building trusting relationships with patients and their families. Following through on promises is a critical factor in establishing strong professional relationships with patients and their families. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions. Confidentiality is the ethical concept that limits sharing private patient information.

. After studying legal issues important to nursing, the student shows appropriate understanding with which statement? a. Laws change often, creating liability issues for nurses. b. Licensure laws are devised to protect the nurse. c. The nurse is not responsible for other disciplines' mistakes. d. Keeping current with changing laws can protect the nurse.

ANS: D Laws delineate acceptable nursing practice, provide a basis on which many health care decisions are determined, and protect nurses from liability in cases in which safe practice is maintained. Each state has a nurse practice act that establishes the standards of care required for legal nursing practice. Licensure, laws, rules, and regulations governing nursing practice are enforced to protect the public from harm. In many cases, the nurse is the last line of defense to prevent an error in medication administration or other types of patient care. Keeping current with changing laws related to nursing practice and technology can ensure safety for nurses and their patients

The nurse is caring for an emergency room patient who died because of a mishap with a loaded gun. The patient's body will be transported to the coroner's office for an autopsy. Which items will the nursing staff remove from the body before it leaves the hospital? a. Endotracheal tube b. Foley catheter and IV line c. Dentures d. Necklace and watch

ANS: D Medical devices and tubes are not removed from the body if an autopsy is to be performed. The patient's necklace and watch may be removed and given to the patient's family members before the body is transported to the coroner's office for autopsy. Dentures should be left in the patient's mouth.

The nurse is teaching a patient about the difference between mild anxiety and moderate anxiety. Which statement by the patient indicates a need for further education? a. "Mild anxiety can help me remember things." b. "Moderate anxiety will narrow my focus." c. "Mild anxiety will help me be creative." d. "Moderate anxiety will increase my perception."

ANS: D Moderate anxiety narrows a person's focus, dulls perception, and may challenge a person to pay attention or use appropriate problem-solving skills. Mild anxiety can be motivational, foster creativity, and increase a person's ability to think clearly

A nurse notes an older adult puts excessive amounts of salt on her food. What intervention by the nurse is best? a. Teach the adult how salt intake relates to hypertension. b. Ask the older adult why she puts so much salt on food. c. Encourage the older adult to use less salt on her food. d. Explore other herbs and flavor enhancers with the adult.

ANS: D Older adults tend to lose their sense of taste and smell. Food becomes less attractive to them and they may respond by adding salt. The nurse who understands this concept will help the older adult explore other flavor enhancers for food. Teaching about the relationship of sodium to hypertension is important but does not address the problem. Encouraging the adult to use less salt does not give her a strategy to do so. Asking "why" questions is a communication barrier that often causes people to become defensive.

The nurse working with older adults encourages them to stay healthy. What instruction by the nurse takes priority? a. Eat at least seven servings of produce a day. b. Get at least 8 hours of sleep a night. c. Get some exercise at least most days of the week. d. Stay away from people who are ill.

ANS: D One normal age-related change seen in the older adult is decreased immune function. The older adult should place high priority on avoiding illness by staying away from people who are sick and avoiding large crowds during peak communicable illness periods. The other instructions are also relevant but do not address this age-related change

When the nurse is preparing to provide preoperative teaching to a deaf patient, what action by the nurse is best? a. Use printed materials. b. Provide recorded materials. c. Use a family member to interpret. d. Provide an interpreter.

ANS: D Patients who are deaf or have low English proficiency are entitled to professional interpretation by federal law. Printed material may be helpful but not if the patient has low literacy/low health literacy. Recorded material may be an option is the patient has some hearing and the recordings are amplified. Family members are not used as interpreters.

The nurse knows that use of seatbelts and airbags in automobiles is an example of which term? a. Secondary prevention b. Tertiary prevention c. Holistic care d. Primary prevention

ANS: D Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Holistic care is an approach to applying healing therapies. Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

A school-aged child is scheduled for a minor procedure and is very nervous. What response by the nurse is best? a. Reassure the child the procedure is too minor to worry about. b. Read the child a pamphlet about what to expect during the procedure. c. Tell the child you will have the provider "put her to sleep" during the procedure. d. Explain the procedure and what to expect in simple terms.

ANS: D School-aged children benefit from simple explanations they can understand. Just telling the child not to worry is dismissive of the child's concerns. A school-aged child may not be able to read and/or understand a written pamphlet. Using phrases such as "put you to sleep" should be avoided since they can be misinterpreted.

Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. Which additional point does the nurse the nurse recognize as part of the definition of self-concept? a. If negative, self-concept will allow the patient to compensate for weaknesses b. If positive, self-concept will cause the patient to see challenges as devastating. c. Self-concept is a concept that is derived from the patient internally. d. Self-concept depends on relationships with family and friends.

ANS: D Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. It is a mental image of self in relation to others and the surroundings. If the image is positive, the person will develop strengths, compensate for weaknesses, and experience life in a healthy way. If the image is negative (e.g., frail), the person will find life's challenges devastating and sometimes insurmountable. The impact of illness on the self-concept of a patient and the patient's family members depends on how secure the parties' relationships are with one another.

A young nursing student is assessing an older patient. The student nurse questions if a sexual history needs to be taken. What response by the faculty is best? a. Since procreation is not an issue, you do not need to discuss this. b. Only discuss this topic if you are comfortable in doing so. c. Ask the patient if he/she wants to talk about sexuality. d. Sexuality is a basic human need and needs to be assessed.

ANS: D Sexuality is a basic human need. The faculty should tell the student to complete the assessment. Procreation is not an issue currently; however, this does not eliminate the need to discuss sexual issues. Asking permission may be an important part of taking a sexual history, but that response is implying the student can "get out of" the assessment if the patient is agreeable. The student needs practice to improve his/her comfort with this assessment.

The nurse is preparing a patient teaching plan and is seeking a way to determine the patient's readiness and motivation to act regarding lifestyle changes to best manage diabetes mellitus. Which model would be useful for this nurse? a. Maslow's hierarchy of needs b. Holistic Health Model c. Health Promotion Model d. Health Belief Model

ANS: D The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. Holistic Health Models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state.

The nurse is caring for a female patient who died a few minutes previously. The patient's family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse currently? a. Inform the patient's family that the body must be transported to the morgue. b. Instruct the patient's family that hospital staff will provide postmortem care. c. Obtain needed signatures for organ donation and autopsy. d. Offer to provide any needed supplies and provide privacy for the family.

ANS: D The most appropriate action of the nurse currently is to allow the family to wash the patient's body in accordance with their wishes and cultural values. The family may wish to participate in this procedure or may complete this procedure in private. Health care personnel should abide by their wishes as much as possible. Signatures may be obtained from the next of kin when washing is complete. The patient's body may be transported to the morgue or funeral home after washing is completed.

The nurse is caring for a patient who died a few minutes ago. The patient's family is at the bedside and very demonstrative in their grief, weeping loudly and holding on to the patient's body. What is the most appropriate action of the nurse? a. Inform the family that the patient's body must be taken to the morgue shortly. b. Ask the family members to step outside while postmortem care is provided. c. Obtain required signatures for the body to be taken to the funeral home. d. Provide privacy and allow the patient's family to grieve over the body.

ANS: D The nurse should allow the patient's family to grieve in private over the loss of their loved one. Some cultures favor free expression of emotions after death, and the nurse should respect this. Signatures can be obtained, postmortem care can be provided, and the body brought to the morgue after an appropriate time of grieving has been provided to the family.

The charge nurse overhears a new nurse telling a patient that he should no longer follow his vegetarian diet because his protein needs are so high and because "God made animals for us to eat." What action by the charge nurse is best? a. No action is necessary for the charge nurse to take. b. Reinforce the nurse's teaching on proper diet. c. Offer to call the dietitian to work with the patient. d. Privately speak to the nurse about this conversation.

ANS: D The nurse should not share opinions or religious edicts with patients when those beliefs contradict the patient's. The charge nurse should counsel the new nurse about this practice. The patient may hold deep convictions about being a vegetarian and may feel disapproval from the nurse, which will impact the nurse-patient relationship. The other options are not appropriate, although the charge nurse could suggest the new nurse collaborate with the dietitian and patient to determine high-protein foods the patient finds acceptable.

The nurse begins a shift on a busy medical-surgical unit and will be caring for multiple patients. Which patient does the nurse assess first? a. A patient who would like some acetaminophen (Tylenol) for a mild headache. b. A patient who has a question about her daily medications. c. A patient who needs discharge teaching about an antibiotic. d. A patient who just received nitroglycerin for chest pain.

ANS: D The nurse's first priority is always: ABCs—Airway, Breathing, and Circulation. This includes any patients who are having chest pain and/or difficulty breathing. The nurse needs to see this patient first to determine if the chest pain has been relieved or not and to determine if the patient is now stable or if additional interventions need to be done. The other patients' needs are less critical and can be met after this patient is assessed

The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse? a. Encourage oral fluid intake and administer a diuretic. b. Obtain a urine sample to test for culture and sensitivity. c. Calculate the patient's daily intake and output. d. Obtain an order to straight-catheterize the patient

ANS: D The patient who has not voided for 6 to 8 hours after urinary catheter removal and is complaining of suprapubic pain has acute urinary retention. The physician should be notified to obtain an order for straight catheterization to drain the bladder. A urine sample for culture and sensitivity is not ordered. Encouraging fluid intake and administering a diuretic will increase the amount of urine in the bladder and make the patient even more uncomfortable.

The preceptor is watching a nursing student care for a male patient who requires a condom catheter. Which action by the nursing student indicates that the procedure is performed correctly? a. Sterile gloves are donned before touching the catheter. b. Adhesive tape is applied securely around the base of the penis. c. Water-soluble lubricant is applied to the end of the catheter. d. The foreskin is returned to its natural position before the catheter is applied.

ANS: D The patient's penis should be cleaned with soap and water with the foreskin retracted prior to condom catheter application. The foreskin should then be returned to its natural position before the catheter is applied. Adhesive tape should never be applied around the base of the penis because circulation may be compromised. Sterile gloves and lubricant are not needed.

The nurse is working with a diabetic patient and is attempting to teach psychomotor skills. This is occurring when the nurse has the patient complete what action? a. Verbally describe his feelings about diabetes. b. Answer three of five true-or-false questions about diabetes. c. Identify three positive lifestyle changes to manage blood sugar. d. Draw up and self-inject insulin correctly.

ANS: D The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Learners in the cognitive domain integrate new knowledge through first learning and then recalling the information. They then categorize and evaluate, making comparisons with previous knowledge that result in conclusions related to the new content. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings,

A toddler has been hospitalized. The parents become upset when the toddler starts wetting his bed, saying that he has been potty trained for some time now. What response by the nurse is best? a. "Don't worry, this behavior will stop when he gets home." b. "Maybe he has a urinary tract infection; I'll get a urine sample." c. "I can call the Child Life Specialist for diversionary activities." d. "It is common for kids in the hospital to regress to earlier behaviors."

ANS: D The stress of hospitalization often causes toddlers to regress in their behaviors, and the nurse should provide this information to the parents. Stating that the behavior will stop, although accurate, does not provide an explanation. There is no need for a urine sample. Using Child Life is always a good idea for hospitalized children but is not related to the question.

When providing end-of-life care, the nurse knows it is essential to carry out which action? a. Tell the patient what he might like to hear to relieve anxiety. b. Begin making health care decisions for the patient. c. Provide the patient with the nurse's personal opinions. d. Offer unconditional support for the patient and family

ANS: D Two major roles of a nurse caring for a dying patient are: (1) providing accurate information regarding the disease process and treatment options and (2) offering support for the patient and family without interjecting personal opinions. An essential ethical concept is autonomy, which underscores the importance of allowing patients to make their own health care decisions. Limiting information to what will relieve anxiety, providing personal opinions, and making decisions for the patient do not demonstrate respect for patient autonomy.

The nurse has implemented a community-wide immunization program for seasonal influenza. Once the program has ended, what action by the nurse is best? a. Begin planning for next year's program. b. Send mail surveys to participants. c. Determine financial gains or losses. d. Evaluate the program and outcomes.

ANS: D The last step of the nursing process is evaluation. The nurse should evaluate the program to see if interventions had the desired effect. Evaluation could include surveys or looking at financial outcomes, but those are only limited aspects of the process. Planning for next year's event should not occur until after evaluation has been completed.

To teach effectively, nurses must recognize which concept? a. Age and socioeconomic status play a large role in understanding. b. 90% of Americans possess rudimentary literary skills. c. The ability to comprehend is a very new concept in health care. d. Most health care teaching is effective and understood.

ANS:A To teach effectively, nurses must recognize that patients of all ages come from diverse cultural and socioeconomic backgrounds. Each has a different ability to comprehend health care information. Results of the NAAL research indicate that among American adults, 30 million (14%) had below basic health literacy in English and 47 million (22%) had basic health literacy. This means that 77 million (36%) American adults possessed very rudimentary literacy skills that allowed them to read only short, simple printed and written materials. Although discussion of Nightingale's work often focuses on her efforts to distinguish nursing as a profession and address the impact of sanitation on health, she advocated exploring all aspects of the patient. She thought that patients needed care that is "delicate and decent" and that demonstrates "the power of giving real interests to the patient." Exploring patients' interests and abilities was an early acknowledgment that nurses must be aware of patients' ability to comprehend the health care information provided. Often, health care professionals assume that the explanations and instructions given to patients and families are readily understood. In reality, research has shown that these instructions are frequently misunderstood, sometimes resulting in serious errors.

In determining patient goals, the nurse should complete which action? a. Allow patients to identify what is most important to them. b. Take the lead and determine what is best for the patient. c. Focus on health promotion and staying healthy. d. Explain the importance of avoiding complications.

ANS: A As health care educators, nurses should allow patients to identify what is most important to them. If a newly diagnosed diabetic patient is interested in learning techniques of care that will allow discharge to home rather than to an extended care facility, the patient is more likely to be receptive to learning about self-monitoring blood sugar levels. After the learning goals related to the issues that the patient feels are a priority have been met, the patient may then be able to focus on health promotion and avoiding complications.

The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will the nurse take to facilitate this procedure? a. Obtain a Coudé catheter for insertion. b. Attach a leg bag to the catheter prior to insertion. c. Trim the pubic hair before cleaning the perineal area. d. Wait until the bladder is full to perform catheterization.

ANS: A A Coudé catheter is used when there is narrowing or constriction of the urethra, making insertion of a regular indwelling catheter difficult. The Coudé catheter has a special tip on the end that is designed to facilitate insertion of the catheter through the narrowed urethra caused by BPH. Coudé catheters may need to be placed using a metal wire introducer. Placement using an introducer typically is performed by a provider or the patient's urologist, to avoid damaging urethral tissue. Trimming the pubic hair will not facilitate catheterization. Attaching a leg bag to the catheter prior to insertion is not needed because a bedside collection bag will usually be used at first

A nurse working with a middle-aged adult is concerned that the adult is not meeting developmental tasks associated with Erikson's theory. What question by the nurse is most appropriate? a. Are there community organizations you would like to volunteer with? b. Do your children come to see you on a regular basis? c. Do you get at least 30 minutes of exercise most days of the week? d. How do you feel about reading for a leisure time activity?

ANS: A According to Erikson, this adult is in the Generativity versus Stagnation phase. Successful completion of the tasks associated with this stage includes reaching out to others beyond the nuclear family to community groups and society at large. Volunteering with an organization would be one way to meet the task. The other questions are related to individual-oriented behaviors.

A patient is diagnosed with pneumonia after an abrupt onset of fever, cough, and malaise. The patient is started on antibiotic therapy and is expected to improve in 2 to 3 weeks. Which statement by the nurse correctly identifies this illness? a. Acute b. Chronic c. Remission d. Exacerbation

ANS: A Acute illness is typically characterized by an abrupt onset and short duration (<6 months). Clinical manifestations of acute illness appear quickly. They may be severe or lethal, or they may soon resolve because they respond to treatment or are self-limiting. Chronic illness is characterized by a loss or abnormality of body function that lasts longer than 6 months and requires ongoing long-term care. Chronic health conditions may be controlled with lifestyle management or drug therapy, but they are considered to be irreversible. Chronic illness may be characterized by periods of wellness (i.e., remission) and exacerbation (worsening) of clinical manifestations, which can be life threatening. Individuals learn to adjust their lifestyles accordingly

The nurse knows which law protects health care professionals from charges of negligence when providing emergency care at the scene of an accident? a. Good Samaritan Act b. HIPPA c. Licensure d. Living wills

ANS: A All 50 states have enacted Good Samaritan laws offering protection for physicians and other health care professionals who provide emergency care at the scene of a disaster, emergency, or accident. Good Samaritan laws protect health care professionals from charges of negligence in providing emergency care if: (1) the care is within the professional's scope of knowledge and standards of care and (2) no fee is received or charged for services. The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect the privacy of health care information. Licensure and certification of nurses seek to ensure professional competence. The laws of each state require graduates of accredited nursing schools and colleges pass the National Council Licensure Examination (NCLEX) before beginning professional practice. A living will specifies the treatment a person wants to receive when he/she is unconscious or no longer capable of making decisions independently.

The public health nurse volunteers for a missionary group caring for Ebola patients in Africa. The nurse is reviewing the data using analytic epidemiology methods. What information does the nurse collect as the priority? a. Cultural norms in burial practices b. Genetic variables in disease acquisition c. Statistics related to incidence and prevalence d. Autopsy data on direct cause of death

ANS: A Analytic epidemiology hypothesizes why a disease is occurring in a community and looks at cultural practices, nutrition, and extrinsic factors such as the environment for links. Genetic variables and direct cause of death data are more related to epidemiology.

The nurse is caring for a patient whose family does not want the patient to be told about the new diagnosis of cancer because of the poor prognosis. Keeping this secret from the patient is in direct conflict with which ethical concepts? a. Autonomy and veracity b. Veracity and advocacy c. Justice and nonmaleficence d. Confidentiality and justice

ANS: A Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Truthfulness defines the ethical concept of veracity. Supporting or promoting the interests of others or to do so for a cause greater than ourselves defines advocacy. To do justice is to act fairly and equitably. First, do no harm is the colloquial definition of nonmaleficence. Unlike beneficence, which requires actively doing good, nonmaleficence requires only the avoidance of harm. Confidentiality is the ethical concept that limits sharing private patient information

A community nurse is working with a family that consists of a middle-aged adult, an older parent with dementia, and two school-aged children. Which assessment by the nurse is most important for this family? a. Stress-relieving methods b. Child care arrangements c. Functional ability of the older adult d. Knowledge of health screening needs

ANS: A Burnout can occur when caring for an older adult with dementia because their needs are great without lessening over time. Caring for both an older adult and school-aged children (often called the sandwich phenomenon or generation) adds even more stress. The priority assessment for this family is methods used to reduce stress

The nurse is caring for a terminally ill patient who is actively dying and refuses to eat anything other than a few bites of ice cream. The patient's family member approaches the nurse and requests that a feeding tube be inserted so that her loved one will not starve to death. What is the best response of the nurse? a. "Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea." b. "I will contact the provider to obtain an order to insert the tube and start tube feedings." c. "Intravenous fluids would be more comfortable for the patient than a tube feeding. I will call the doctor to get the order." d. "I will listen to the patient's abdomen to make sure that bowel sounds are present and try encouraging oral fluids."

ANS: A Common physical symptoms at the end of life include anorexia and cachexia. Tube feedings will cause discomfort as the tube is inserted and nausea as the GI tract is given food that it cannot handle. Encouraging oral intake will lead to increased secretions and congestion as well as possible aspiration of fluids. Intravenous fluids will increase congestion and edema. The nurse would educate the family on this part of the dying process.

The nurse is providing patient care and pays special attention to meeting the needs of the patient while maintaining the patient's right to privacy, confidentiality, autonomy, and dignity. This nurse is applying what ethical theory? a. Deontology b. Utilitarianism c. Autonomy d. Accountability

ANS: A Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions. Meeting the needs of patients while maintaining their right to privacy, confidentiality, autonomy, and dignity is consistent with the tenets of deontology. Compared with deontology, utilitarianism is on the opposite end of the ethical theory continuum. Utilitarianism maintains that behaviors are determined to be right or wrong solely based on their consequences. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions.

Which nurse has committed a serious documentation error? a. The nurse who documents all medications for assigned patients prior to administration. b. The nurse who documents medication administration as the medications are given. c. The nurse who documents assessments as soon as they are completed. d. The nurse who documents meal intake as meal trays are picked up.

ANS: A Documentation must be accurate to provide a realistic view of a patient's condition. Serious documentation errors include: (1) omitting documentation from patient records, (2) recording assessment findings obtained by another nurse or unlicensed assistive personnel (UAP), and (3) recording care not yet provided. Nurses sometimes document that a patient has received medication before its administration; this is a serious violation of the law and becomes a medication error of omission if the nurse is distracted before administering the patient's medication.

A home health care nurse has been working with a patient who has the Nursing diagnosis Spiritual Distress. After a few weeks of implementing the care plan, what method is best for the nurse to determine if goals have been met? a. Ask the patient to what extent he/she feels goals have been met. b. Ask the patient to rate the distress on a scale of 1 to 10. c. Assess for objective data to support goal attainment. d. Determine if the patient thinks the interventions are helpful.

ANS: A For a diagnosis with a large subjective component, getting the patient's feedback on goal attainment is best. There may be no objective data the nurse can use to rate goal attainment. Using a scale can be a part of the evaluation, but the patient's determination is best.

The nurse has established a teaching plan including goals and identifies this type of education is termed by what term? a. Formal teaching b. Informal teaching c. Psychomotor teaching d. Affective teaching

ANS: A Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. Informal education is usually learner or patient directed. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The nurse is asked by the parent of a pediatric patient to explain the difference between growth and development. Which response by the nurse is best? a. "Growth is physical while development relates to physical, emotional, and cognitive function." b. "There is no difference between the two since they occur simultaneously." c. "Development refers to musculoskeletal and nervous system abilities and growth is a change in height and weight." d. "Both refer to an increase in abilities and functions of the child that occur sequentially over time."

ANS: A Growth relates to physical changes in height and weight. Development refers to changes in ability across several dimensions such as physical, emotional, and cognitive. Stating that the two are not different does not show understanding of this difference. Development is not related strictly to changes in specific body systems. Although both refer to increases in abilities and functioning over time, this answer is too vague to give the parent useful information

A young adult asks the nurse why she should participate in health screening and educational events. What response by the nurse is best? a. "Your choices now affect your future health." b. "It's free and full of good information." c. "Wouldn't you want to know if you had a problem?" d. "You can change bad habits now if you know about them."

ANS: A Health behaviors entrenched in the young adult stage impact future health and well-being. While these events are free and full of information and bad habits can be changed if the person has knowledge and motivation, those responses do not give the person useful information. Asking if the person wants to know about health problems sounds accusatory.

A nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best? a. Assess the patient's ability to read and understand. b. Determine if the patient wants to take written material home. c. Give the patient the same material as other patients get. d. Ask the patient if he/she has a need for written material.

ANS: A Health literacy in an important concept in health. If the patient cannot read or comprehend written material, it will be of limited use. The nurse first assesses the patient's ability to read and comprehend written material before choosing the material with which to send him/her home. Patients may or may not realize what they need for discharge, if anything. Giving the patient the same material other patients get does not acknowledge their need for holistic and individualized care.

A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift report, the nurse asks, "Why was the man convicted and imprisoned?" Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept? a. Beneficence b. Advocacy c. Confidentiality d. Autonomy

ANS: A In its simplest form, beneficence can be defined as doing good. Nurses demonstrate beneficence by acting on behalf of others and placing a priority on the needs of others rather than on personal thoughts and feelings. The ethical concept of beneficence necessitates providing care for the prisoner without reproach and provide compassionate care for all people in all circumstances. Supporting or promoting the interests of others or doing so for a cause greater than ourselves defines advocacy. Confidentiality is the ethical concept that limits sharing private patient information. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence

According to the Health Belief Model, which of the following patients would be most likely to change health behavior? a. The person who perceives that he is at risk for colon cancer b. The person who recognizes that colon cancer is easily cured c. The person who believes that behavior can change outcomes d. The patient who faces multiple social barriers

ANS: A In the three primary components of the Health Belief Model, six main constructs influence an individual's decision to take action about disease prevention, screening, and controlling illness. The model suggests that individuals are motivated to take action if they believe that they are susceptible to the condition (i.e., perceived susceptibility), that the condition has serious consequences (i.e., perceived severity), that taking action would reduce the susceptibility or severity of the condition (i.e., perceived benefit), that the costs of taking action (i.e., perceived barriers) are outweighed by the benefits, that those who are exposed to factors (e.g., media campaigns, postcard reminders, and advice from others) will be prompted to action (i.e., cues to action), and that those who have confidence in their ability to perform an action will do so (i.e., perceived self-efficacy).

A preschool-aged child got into the cookie jar and ate several cookies before dinner. When confronted by the parent, the child responds, "My pet horse ate them." What does the nurse teach the parents about this response? a. It is normal for children to have imaginary friends at this age. b. This vivid imagination will lead the child to misbehave later on. c. Lying is disobedient and should be punished consistently. d. The child is obviously afraid of the parents' response

ANS: A It is common for toddlers to have imaginary friends. They are especially important in allowing the child to express something unpleasant. The other responses are not appropriate

The nurse has been involved sexually with a patient. The nurse manages becomes aware of this situation and tells the nurse this behavior is a which type of crime? a. Malpractice b. Libel c. Slander d. Battery

ANS: A Malpractice may occur when a professional such as nurse acts unethically, demonstrates deficient skills, or fails to meet standards of care required for safe practice. Examples of these types of malpractice include engaging in sexual activity with a patient and administering penicillin to a patient with a documented penicillin allergy, resulting in the patient's death from a severe allergic (anaphylactic) reaction. Written forms of defamation of character are considered libel. Broadcasting or reading statements aloud that have the potential to hurt the reputation of another person is considered libel. Oral defamation of character is slander. Actual physical harm caused to another person is battery.

Several models exist that describe the relationship between health and wellness. Which model is used to understand the interrelationship between elements of basic requirements for survival and the desires that drive personal growth and development and is represented as a pyramid? a. Maslow's hierarchy of needs b. Health Belief Model c. Health Promotion Model d. Holistic Health Model

ANS: A Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state. Holistic health models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind.

The nurse caring for a patient with chronic pain uses guided imagery, therapeutic touch, and relaxation techniques as interventions for pain. The nurse is using what type of approach? a. Holistic b. Eastern holistic c. Risk factor reduction d. health protection

ANS: A Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence. Eastern holistic therapists have been using techniques such as acupuncture, yoga, and tai chi for thousands of years as methods of healing and, more recently, in conjunction with modern allopathic medical therapies. Risk factor reduction is step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease. Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness

The nurse recognizes the nursing goal for individuals and families seeking preventative care is to have those groups carry out which action? a. Take responsibility for their health and wellness. b. Abandon the use of electronic educational media. c. Make lifestyle changes after diseases occur. d. Use temporary changes until the danger has passed.

ANS: A Nursing goals for all individuals and their families seeking preventive care are improvement of quality of life through positive lifestyle choices and taking responsibility for health and wellness. Nurses can refer patients to a variety of personal health quizzes, located in the online version of Healthy People 2020, for risk assessments of their health status and lifestyle. The quizzes allow people to track their health and wellness status over a period of years and identify trends in disease risk factors that can be modified through lifestyle interventions or preventive measures before the disease occurs. The Healthy People 2020 initiative helps nurses provide educational materials for individuals, families, and communities, enabling them to lead healthier lifestyles and to make permanent changes in wellness habits.

The nurse understands ongoing evaluation of patient education occurs by which team member? a. Each member of the health care team who provides teaching b. The nurse who evaluates the patient's physical abilities c. The patient stating that he understands the instruction d. Not allowing review from the provider so the focus remains forward

ANS: A Ongoing evaluation of patient education occurs by each member of the health care team who provides teaching according to the patient's teaching plan. Having the learner repeat what has been learned can help the nurse evaluate the teaching plan and adjust the plan for future patient education sessions. Future sessions should review what was learned previously and continue to add to what has been taught. Health care team members can view documentation on the electronic health record (EHR) before beginning an education session to determine the patient's progress in meeting educational goals.

A patient who claims to be very involved in church is near death. What action by the nurse is best? a. Get permission to contact the religious leader. b. Allow the family to stay at the patient's bedside. c. Call the hospital chaplain to come to the bedside. d. Ask if the patient and family want to pray

ANS: A Organized religions use rituals to mark important life events such as birth, marriage, and death. This patient would most likely want end-of-life rituals as practiced in his/her church. The nurse's best action is to contact the religious leader (with permission) of that church or institution. Allowing the family to remain at the bedside is important but not the best option to care for the patient's spirituality needs. The hospital chaplain is a valuable resource, but the patient's own religious leader would be better. Praying with the family is always acceptable, but it is best to let the family take the lead in prayer.

When discussing immunizations for infants and children with new parents, the nurse should focus on which approach? a. Providing scientific evidence to parents b. Stressing that nonimmunization is a crime c. Acknowledging that immunizations are not needed d. Informing the parents that they have no choice

ANS: A Parents need to have scientific, evidence-based information about immunizations and their consequences before choosing to accept or reject immunizations for their children. The parent's ability to make an informed decision is the primary goal for nurses educating people about childhood immunizations.

When the nurse is preparing to teach a 5-year-old child postoperative care that will be anticipated after a tonsillectomy, the nurse would incorporate what concept? a. Use pictures and simple words to describe care to the patient. b. Teach the parents alone to reduce fear in the patient. c. Exclude the parents to reduce parental anxiety. d. Use clear simple explanations to convey information

ANS: A Patient education provided for children should be age specific. Use pictures and simple words for young children. Use clear, simple explanations for school-age children. The patient's age directly affects the instructional methods and materials used. Effective patient education involving a child requires the presence of a parent or caregiver, who is likely the target of teaching. Children should not be excluded from the learning session unless exclusion is deemed appropriate by the parent or caregiver; a presentation using an age-appropriate strategy may complement the instructions reviewed with the adult. The stages of development should be explored as the foundation for the choice of educational materials.

A patient has the Nursing diagnosis Spiritual Distress. What assessment by the patient best indicates that an important goal has been met? a. Observed praying quietly. b. Indecisive about treatment. c. Asks nurse if God exists. d. Executes living will.

ANS: A Patients may have spiritual distress when facing situations that threaten their meaning and purpose in life, such as in the face of a terminal diagnosis. Patients often express anger, frustration, neediness, or crying. The patient who has worked through this situation and is able to pray has best shown goal attainment. Indecision and questioning do not indicate the resolution of this diagnosis. Executing a living will may be an indication of pragmatism

The parents of a 4 year old express concern that the child is wearing the same size clothing as she did last year. What action by the nurse is most appropriate? a. Weigh and measure the child and compare with last visit. b. Reassure parents that their child is growing normally. c. Assess the child's eating and activity patterns. d. Encourage the parents to provide the child a multivitamin.

ANS: A Physical growth slows during the preschool years, with most children only gaining about 5 lb and 2 1/2 to 3 inches a year. The nurse should weigh and measure the child and compare the readings to those taken at the last visit. Showing the parents these results and educating them on expected growth will reassure them. Simply telling the parents their child is normal does not provide objective information and is dismissive of their concern. The nurse should assess each child's eating and activity habits. The child may or may not need a vitamin. This can be discussed with the provider.

The nurse is providing care for a patient who demands discharge from the hospital against the physician's orders. What action by the nurse is most appropriate? a. Have the patient sign an "Against medical advice" form. b. Follow the guidelines as presented in the code of Academic and Clinical Conduct. c. Review the ANA's Nursing Code of Ethics for guidance. d. Permit the patient to leave after an informed consent form is signed.

ANS: A Preventing patients from leaving a health care facility at their request may be considered false imprisonment. To prevent health care providers and institutions from being held liable if a patient chooses to leave a facility when physicians and nurses think that it is in the patient's best interest to remain hospitalized, the patient is asked to sign an against medical advice (AMA) form. A signed AMA form documents that the patient has chosen to leave the facility when leaving could jeopardize the patient's condition. The National Student Nurses Association adopted the Code of Academic and Clinical Conduct, in which students agree to "promote the highest level of moral and ethical principles" and "promote an environment that respects human rights, values, and choice of cultural and spiritual beliefs." This document does not apply to the issue at hand. The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession." While this is resource for nurses the described situation requires nurses to follow facility policy. Informed consent is permission granted by a patient after discussing each of the following topics with the physician, surgeon, or advanced practice nurse who will perform the surgery or procedure: (1) exact details of the treatment, (2) necessity of the treatment, (3) all known benefits and risks involved, (4) available alternatives, and (5) risks of treatment refusal. This does not apply to the stated situation.

A nurse is planning primary prevention activities. Which activity would the nurse include in this plan? a. Safer sex education for teens b. Mammogram screening c. Medication compliance d. Annual physical exams

ANS: A Primary prevention includes activities designed to prevent a disease or condition from occurring in the first place. Examples of primary prevention activities include vaccinations, wellness programs, good nutrition for health, and safer sex programs. Mammograms and physical exams are secondary prevention measures. Medication compliance would be tertiary prevention.

The nurse is caring for a patient that is actively trying to conceive a child but continues to drink alcohol. The patient states that she'll stop drinking once she is pregnant. What is the most appropriate response by the nurse? a. "Abstaining is best since most fetal development occurs before you realize you are pregnant." b. "Small amounts of alcohol are safe at any time during pregnancy." c. "Things will be okay if you quit drinking alcohol once you know you are pregnant." d. "Alcohol use should be avoided early in pregnancy but is acceptable past week 20."

ANS: A Rapid development occurs before many women know that they are pregnant, making alcohol consumption unsafe at any time during pregnancy.

The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient's family arrives to see the patient's body? a. Gently wash the body and provide perineal care. b. Remove the patient's dentures and jewelry. c. Ensure that the death certificate has been signed. d. Determine which funeral home will pick up the body.

ANS: A Release of bowel and bladder contents often occur at the time of death, and the perineal care is a priority before the family arrives. The body should be gently cleaned to remove blood and debris from the accident. The patient's dentures and jewelry should not be removed from the body. The death certificate does not need to be signed before the family arrives. The family can decide which funeral home will be used and notify the nurse after their arrival.

. An overweight, sedentary middle-aged smoker with a family history of cardiac disease has noticed a steady rise in resting blood pressure over a 3- to 4-year period. The patient is concerned about his slightly elevated blood pressure and begins walking 20 to 30 minutes in the evenings with his wife and reduces his pack-a-day cigarette habit to ten cigarettes a day. The nurse identifies these actions are the initial step of which behavior? a. Risk factor reduction b. Self-actualization c. Self-transcendence d. Health promotion

ANS: A Risk factor reduction is step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease. Maslow considered self-actualization the highest level of optimal functioning and involves the integration of cognition, consciousness, and physiologic utility in a single entity. In later years, Maslow described a level above self-actualization called self-transcendence. He refers to self-transcendence as a peak experience, in which analysis of reality or thought changes a person's view of the world and his/her position in the greater structure of life. Health promotion is behavior motivated by the desire to increase well-being (as opposed to preventing illness) and optimize health status

The nurse plans to develop a comprehensive screening tool to use with young adults, assessing their lifestyles and healthy living habits. What barrier must the nurse plan to overcome to make this screening successful? a. Young adults may not see a health provider regularly. b. Young adults are so diversified that a screening tool may not be appropriate. c. Young adults have too many risky lifestyle behaviors to make education relevant. d. Young adults are too busy with their lives to see a health care provider regularly.

ANS: A Since young adults are at the peak of their physical development and abilities, they may not see a health care provider on a regular basis. Screening tools can be used with any population. When riskier behaviors are demonstrated, the more education is needed. Time constraints are generally not the main reason young adults do not have regular medical care.

. When planning interventions for a community, what action by the nurse is best? a. Involve community leaders in planning. b. Create a plan of action addressing priorities. c. Determine what resources are available. d. Attempt to find funding for the plan.

ANS: A Stakeholders need to be involved in planning to ensure buy-in from the community. The stakeholders could be community or business leaders. The other actions are important, but if the community leaders are not committed to the plan, the plan is unlikely to work.

The nurse is providing care for a patient who has had a stroke recently and has multiple self-care deficits. The nurse is coordinating care with in-home agencies and arranging for the delivery of needed equipment. Which ethical concept is the nurse applying? a. Advocacy b. Confidentiality c. Autonomy d. Accountability

ANS: A Supporting or promoting the interests of others or doing so for a cause greater than ourselves defines advocacy. Confidentiality is the ethical concept that limits sharing private patient information. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions.

The nurse knows which statement indicates an appropriate understanding of ethical practice by the student nurse? a. "I will be held to the same ethical standards as professional nurses." b. "I will not be held ethically accountable until I graduate." c. "My nurse educators are responsible for my ethical standards." d. "Ethics are not important as a student."

ANS: A The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual (not just nurse educators) who enters the nursing profession," the profession's "nonnegotiable ethical standard," and "an expression of nursing's own understanding of its commitment to society." This is a powerful mandate for all nurses to communicate and act professionally to prevent inflicting physical or emotional pain on others while pursuing nursing education and engaging in nursing practice.

A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting? a. Praying five times a day b. Having privacy c. Personal cleanliness d. Giving alms e. Maintaining modesty

ANS: A The five pillars of Islam are: believe in one God, pray five times a day facing Mecca, giving alms to the less fortunate, fasting during Ramadan, and making a pilgrimage to Mecca. The nurse is best able to help the patient maintain the practice of praying five times a day while hospitalized.

The nurse recognizes which concept that correctly completes the definition of the genetic vulnerability of an organism (risk of disease expression based on genotype)? a. It is involuntarily passed from biologic parents to offspring. b. It is totally unrelated to environmental factors. c. It is nonresponsive to alteration by way of lifestyle modification. d. It is not a factor in mental illness because it is behavioral.

ANS: A The genetic vulnerability of an organism, or risk of disease expression based on genotype, is involuntarily passed from biologic parents to their offspring. Societal attitudes about testing and management of high-risk populations depend on the potential for expression of genetic disorders that may be triggered by environmental factors. Controlling factors that place stress on physiologic function can reduce pathologic genetic expression and susceptibility to disease. For example, a person with a family history of hyperlipidemia and atherosclerosis is at risk for developing cardiovascular disease later in life. Lifestyle-modifying factors, such as weight reduction, daily exercise, and balanced nutritional intake, can help reduce the likelihood that the genetic risk factor for heart disease will be expressed. Diabetes, cancer, mental illness, and renal disease also have genetic components and are amenable to interventions that reduce risk.

The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the highest priority for the patient? a. Impaired skin integrity r/t localized skin irritation from liquid stool b. Social isolation r/t potential leakage of stool from ostomy appliance c. Lack of knowledge r/t care and maintenance of ostomy appliance d. Disturbed body image r/t presence of stoma and altered elimination

ANS: A The highest priority Nursing diagnosis for this patient is impaired skin integrity because the liquid stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can lead to bacterial infection and significant discomfort for the patient. In addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing skin breakdown. The other nursing diagnoses are appropriate for this patient but are not the highest priority

The nurse is caring for a patient who is having difficulty coping after being in a motor vehicle crash in which her brother was killed. The patient was driving the car and blames herself for the accident. What is the priority nursing intervention of the nurse? a. Check to make sure that the patient does not want to hurt or kill herself. b. Educate the patient about available support systems for grief resolution. c. Enhance the patient's coping skills to alleviate depression and anxiety. d. Encourage the patient to meet with a spiritual leader for guidance.

ANS: A The highest priority for the nurse is to ensure the safety of the patient, so assessment of potential suicidal tendencies is paramount. The other interventions can take place once the nurse is confident that the patient will not try to hurt or kill herself.

The nurse is caring for a patient who lost her husband 1 year ago after 55 years of marriage. The patient no longer takes care of herself or cooks and rarely eats, stating she has no appetite. The nurse determines that the Nursing diagnosis of complicated grieving applies to the patient. Which is the priority goal for the patient? a. The patient will shower every other day and eat at least two meals a day. b. The patient will identify personal strengths that will increase coping ability. c. The patient will discuss the meaning of her loss with a family member or friend. d. The patient will be provided with phone numbers for local community resources.

ANS: A The highest priority goal of this patient is self-care including showering and eating in order to protect her health and safety. The other goals are lower priority after the patient's necessary activities of daily living are addressed. Goals should also reflect what the patient accomplishes; so the goal of being provided with phone numbers is actually something for the nurse to do.

A nurse is providing anticipatory guidance to a new mother about the Erikson stage of trust versus mistrust. What education should the nurse provide to the mother to help her child successfully master this stage? a. Consistently provide your child with food and attention. b. Ensure someone is able to feed your child on a schedule. c. Allow unrestricted crawling and exploring as the child develops. d. Provide firm guidelines for behavior and activities.

ANS: A The most important item needed for a child to master this stage of development is a consistent caregiver who provides food and attention. If the caregiver is inconsistent or unable to meet these needs, the child will develop mistrust of those around him. Ensuring that someone feeds the child is not providing consistency. Allowing exploration within limits (setting boundaries) is important to master initiative versus shame and doubt

A nurse has assessed a community and has found many areas in which health can be improved. As a result, the nurse has multiple ideas for programming. What action by the nurse is best? a. Determine what the community thinks is most important. b. Use vital statistics to determine which is most important. c. See what other communities are focusing programming on. d. Choose the easiest problem to address first.

ANS: A The nurse's priorities may be very different from the community's. For programming to be successful, there must be buy-in from members of the community. Unless programming addresses a need the community thinks is important, it is unlikely to be successful.

The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. The nurse identifies which term that best describes the activity of the patient's children? a. Anticipatory grieving b. Bereavement c. Caregiver role strain d. Death anxiety

ANS: A The patient and her children are experiencing anticipatory grief as they prepare for the expected death of the patient. Reminiscence and life review are used to assist those experiencing anticipatory grief with the realization that death is approaching.

The nurse is caring for a patient who suffered a miscarriage at 24 weeks of pregnancy. The patient is devastated by the loss but her husband minimizes her grief by stating, "Quit crying. It's not like you lost a real baby." What term best describes the anguish felt by the patient? a. Disenfranchised grief b. Delayed grief c. Moral distress d. Masked grief

ANS: A The patient is experiencing disenfranchised grief because she cannot share the pain of her loss with her husband. The husband is not willing to support his wife as she mourns the loss of her pregnancy or recognize the grief that she is going through. Delayed grief is suppression of the grief process. Moral distress occurs when people cannot act according to their moral values. Masked grief occurs when a person's bereavement behaviors interfere with his or her life, but the person does not notice this.

The hospice nurse is caring for a terminally ill patient who will probably die within the next hour or two. The patient's daughter is keeping a vigil by the bedside and asks what she can do to help her father at this time. What is the appropriate response of the nurse? a. "Just let him know you are here, talk to him, and let him know that you love him." b. "You can try to feed him a few bites of ice cream to keep his mouth from getting dry." c. "You can take this time to ensure that arrangements are set with the funeral home." d. "You should let me know when your father's breathing pattern changes."

ANS: A The patient's daughter should be encouraged to spend the last moments of her father's life with him, reassuring him with her presence. The daughter should be encouraged to continue talking with him because the patient may still hear her even if his eyes are closed and he does not speak. The nurse is responsible for monitoring the patient for breathing changes. Oral intake will lead to nausea and/or aspiration. This is not the time to make arrangements with the funeral home.

The nurse is caring for a patient who is terminally ill with metastatic bone cancer. The patient tells the nurse that he is not afraid of death but does not want to be in pain and suffer before he dies. Which intervention by the nurse will be most appropriate to meet this patient's wishes? a. Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain. b. Assist the patient to reminisce and review his life, spending as much time as possible with loved ones. c. Use therapeutic touch, guided imagery, and soft music to put the patient at ease and relieve anxiety. d. Encourage the patient to participate in prayer and meditation along with preferred religious practices

ANS: A The patient's primary wish is to die without pain, and the best intervention to meet this goal is administration of pain medication around the clock with extra doses for breakthrough pain. The other interventions may make the patient more comfortable but will not address his primary desire for adequate pain management.

A nurse is wondering if home health care nursing is a good fit. What characteristic or ability does the experienced home health care nurse suggest is most important? a. Clinical reasoning b. Organization c. Assessment skills d. Time managemen

ANS: A The role of the registered nurse in home health care is essentially autonomous in that the nurse must be highly proficient in health assessment (physical and psychosocial), be well versed in complex technical and clinical skills, possess strong critical-thinking and clinical reasoning abilities, and demonstrate excellent organizational skills. All choices are important characteristics or abilities of home health care nurses. However, since the nurse working out in the community may not have the resources (personnel or materiel) available in an acute care facility and often must improvise, clinical reasoning would be the most important of the choices provided.

The nurse understands the unique ability of the patient to understand and integrate health-related knowledge is known by which term? a. Health literacy b. Formal patient education c. Informal patient education d. Primary education

ANS: A The unique ability of a patient to understand and integrate health-related knowledge is known as health literacy. Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. Informal education is usually learner or patient directed. Many health care consumers begin receiving information as children through their primary education. Handwashing, proper dental care, and nutrition are examples of early instructions.

A nurse is concerned about not consistently meeting the spiritual needs of patients. What action by the nurse is best? a. Care for own spiritual needs. b. Begin a meditation practice. c. Consult the chaplain. d. Read books on the subject.

ANS: A To avoid burnout and a decreased ability to attend to the spiritual needs of patients, nurses must take care of their own spiritual needs first. This may include meditation, consultations, and reading, but other activities can guide the nurse into a reflective practice that will allow better spiritual care.

The nurse is preparing to teach a patient for the first time and needs to evaluate the health literacy of the patient. The nurse uses the VARK assessment to gather what information? a. Assess the learning styles of the patient. b. Find the one method that the patient uses to learn. c. Be sure that the patient is a unimodal learner. d. Reduce the need for creating a collaborative learning plan

ANS: A Tools have been developed to help health care workers evaluate the health literacy of their patients. One such tool is the VARK (verbal, aural, read/write, kinesthetic) assessment of learning styles of people who are having difficulty learning. Individuals typically learn through more than one method. For example, a patient's VARK assessment may indicate learning through VAR or ARK. When the use of more than one style facilitates learning, the individual is considered a multimodal learner, meaning that the person does best when more than one teaching strategy is used or that the person is able to adapt to a variety of teaching strategies on the basis of what is being presented. Understanding how patients learn best makes collaborative learning plans most effective. It is good practice to provide multiple means of learning, because most individuals learn through more than one style and repetition enhances learning.

The nurse is to teach an 84-year-old Spanish-speaking patient newly diagnosed with diabetes how to self-administer insulin. The patient has hearing and visual impairments. To be effective as a teacher, the nurse should carry out which tasks? (Select all that apply.) a. Assess reading level and learning style. b. Determine readiness to learn. c. Use family members as interpreters. d. Provide written instruction in English. e. Place the patient in group classes.

ANS: A, B Before health care teaching sessions for adults, assess reading level, learning styles, and readiness to learn. Family members should not be used as interpreters of specific medical information to maintain the patient's right to privacy and to avoid possible misinterpretation of medical terminology. Access to interpretation or translation for deaf and limited English proficiency (LEP) patients is required by Title VI of the Civil Rights Act of 1964, which mandates equal rights for people regardless of race, color, or national origin. Use photos, drawings, or video to enhance understanding. A patient whose cultural beliefs and values are considered is more likely to demonstrate compliance. Patients with learning disabilities or cognitive alterations need individualized instruction geared to their special needs.

Health care providers are required to supply patients with written information regarding their rights to make medical decisions and implement advance directives, which consist of three documents. The nurse knows which items are considered "advanced directives"? (Select all that apply.) a. Living will b. Durable power of attorney c. Health care proxy d. Patient's Bill of Rights e. The Uniform Anatomical Gift Act

ANS: A, B, C Advance directives consist of three documents: (1) living will, (2) durable power of attorney, and (3) health care proxy, commonly referred to as a durable power of attorney for health care. The Patient's Bill of Rights informs consumers of health care about specific privileges of which they should be aware. Patients should expect: (1) excellent care, (2) a safe environment, (3) participation in planning their care, (4) privacy, (5) help with discharge arrangements, and (6) assistance with fulfilling financial responsibilities. The Uniform Anatomical Gift Act was approved to allow people over the age of 18 to donate their bodies or body parts after death for transplantation, deposit in tissue banks, or research

Which recommendations would the nurse identify as appropriate screening guidelines? (Select all that apply.) a. Women ages 21 to 29 should have a Pap test every 3 years. b. Self-breast exams should be addressed with male and female patients. c. Adolescent males should perform monthly self-testicular exams. d. Women ages 30 to 65 should receive Pap tests every 10 years. e. After a total hysterectomy, Pap testing should be more frequent

ANS: A, B, C All women should begin cervical cancer screening at the age of 21 years. Women between the ages of 21 and 29 years should have a Papanicolaou (Pap) test every 3 years. A priority assessment task for nurses in a variety of care settings is to ask female and male patients about breast self-examination. An adolescent male should be assessed for testicular self-examination habits, and older males should have an annual prostate examination. Women between the ages of 30 and 65 years should have a Pap test plus a human papillomavirus (HPV) test (i.e., co-testing) every 5 years. Women 65 years of age or older who have had normal results for previous Pap tests should no longer be screened. Women who have had a total hysterectomy (i.e., removal of the uterus and cervix) should not be tested, unless the surgery was done as a treatment for cervical cancer or pre-cancer.

On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. The nurse recognizes that diagnoses specifically related to patient education include which responses? (Select all that apply.) a. Deficient knowledge b. Readiness for enhanced knowledge c. Noncompliance d. Pain e. Alteration in elimination

ANS: A, B, C On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. Diagnoses specifically related to patient education include deficient knowledge, readiness for enhanced knowledge, and noncompliance.

The home health care nurse educates patients on which goals of hospice care? (Select all that apply.) a. Relieve suffering. b. Support the patient and family. c. Provide grief support. d. Keep patients out of the hospital. e. Lower medical expenses.

ANS: A, B, C The goals of hospice care include relief of suffering, supporting the family and patient, and providing grief support after the patient dies. Goals do not include keeping patients out of the hospital or lowering medical costs.

In addressing patient education, the nurse recognizes that patient education is a process involving what components? (Select all that apply.) a. Assessment b. Diagnosis c. Planning d. Implementation and evaluation e. Reliance on evidence-based practice (EBP)

ANS: A, B, C, D Assessment of health literacy occurs with each patient encounter. On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. After working with the patient or caregiver to determine the appropriate nursing diagnosis, the next step is developing the patient education plan. In all patient education situations, a return demonstration by the patient (i.e., repeating what has been taught) helps the nurse to assess the level of learning that has taken place. Although evidence-based practice is important, it is sometimes insufficient when making patient care decisions.

The nurse explains to the patient that which services will be covered under Medicare? (Select all that apply.) a. Infusion therapy b. Ostomy management c. Renal dialysis d. Chemotherapy e. Grocery shopping

ANS: A, B, C, D Medicare will reimburse for professionally rendered services provided by a licensed health care provider. Grocery shopping would not be covered. If homemaker services are provided to a patient also receiving skilled care, then they too are reimbursed.

The nurse is completing documentation after feeding a patient with aspiration precautions. Which items should the nurse document? (Select all that apply.) a. Episodes of coughing or gagging b. Hesitation or fear of eating C. Amount eaten d. Aspiration protocol used e. Respiratory status

ANS: A, B, C, D, E It is important to document thoroughly the patient's experience during the feeding so the other nursing staff will be aware of patient's needs including any episodes of coughing, gagging, or choking; respiratory status; hesitancy or fear of eating; and occurrences of nausea, vomiting, regurgitation, and/or reflux symptoms. The nurse would document the amount the patient ate, but this is not part of the required documentation for aspiration precautions.

The nurse manager of the unit is implementing a program to assist the nursing staff in managing compassion fatigue. Which interventions will be the most successful? (Select all that apply.) a. Support group that nurses can participate in that meets on the unit b. Exercise competitions to encourage nurse to exercise and log their time c. Organized break times so nurses can get off the unit for breaks and lunches d. Quiet area on the unit where the nurses can go during break e. Promotion of work-life balance

ANS: A, B, C, D, E To care most effectively for others, nurses must first take time to care for themselves. Many of the stress reduction interventions incorporated into patient care plans can be effective in addressing the stressors faced by nurses. Exercise, balanced nutrition, and mindfulness therapy have been shown to help health care professionals in coping with the demands of patient care. Interventions designed specifically to prevent nurse burnout and address compassion fatigue include mentoring programs, quiet areas on a nursing unit for relaxation, availability of pastoral care, the sharing of feelings with trusted colleagues, and promotion of work-life balance.

The nurse is caring for a patient who has just died. Which assessment findings by the physician and nurse are used to confirm that death has occurred? (Select all that apply.) a. The patient was incontinent of bowel and bladder. b. The patient's pupils are fixed and dilated. c. The provider does not hear a heartbeat. d. The patient's extremities are cool and mottled. e. The patient has no palpable peripheral pulses. f. The patient's face is relaxed and the mouth is open.

ANS: A, B, C, E Assessment findings that confirm death has occurred include lack of pulse/heartbeat and fixed dilated pupils. Cool, mottled extremities, relaxed muscles, and incontinence of bowel and/or stool are common assessment findings in patients who are dying

The nurse manager of a busy oncology unit is concerned about compassion fatigue among the nursing staff. Which signs and symptoms would alert the nurse to this problem? (Select all that apply.) a. Nurses become very emotionally upset without an apparent cause. b. Nurses start to avoid caring for certain patients. c. Nurses start to call in sick more often. d. Nurses begin working more overtime. e. Nurses have difficulty showing empathy for patients.

ANS: A, B, C, E Compassion fatigue occurs when deeply caring and empathetic nurses become overwhelmed by the constant needs of patients and families. Symptoms include mood swings, avoidance of working with some patients, frequent sick days, irritability, reduced memory, poor concentration, and a decreased ability to show empathy.

When does the nurse assess patients' spirituality? (Select all that apply.) a. Upon admission b. New diagnosis c. Life-changing diagnosis d. When the chaplain makes rounds e. When facing treatment decisions

ANS: A, B, C, E There are many times at which a spiritual assessment is necessary. All patients should have their spirituality assessed upon admission at a minimum. Other assessments should be conducted at times when the patient is at risk for spiritual distress. Assessment should be done based on patient need, not when the chaplain is available.

The nurse tells the student that which disorders are related to the presence of free radicals? (Select all that apply.) a. Cancer b. Cataracts c. Glaucoma d. Arthritis e. Liver disease

ANS: A, B, D Free radicals are naturally occurring chemicals that can cause cellular damage. They are implicated in such diseases as cancer, cataracts, and arthritis. They are not implicated as a causative factor in glaucoma and liver disease.

The nurse recognizes which personality factors that have been shown to buffer the impact of stress? (Select all that apply.) a. Resilience b. Sense of coherence c. Gender d. Hardiness e. Coping style

ANS: A, B, D Personality factors such as resilience, hardiness, and sense of coherence can buffer the impact of stress, reducing the negative consequences. Gender is not a personality factor. Coping style refers to a pattern of measures taken to relieve stress but is not a personality factor.

The nurse working in a family practice clinic has very limited time to assess patients for health concerns. When working with middle-aged patients, which problems does the nurse assess for as the priorities? (Select all that apply.) a. Heart disease b. Cancer c. Sexually transmitted diseases d. Stroke e. Functional abilities

ANS: A, B, D Specific health concerns for this age-group include cardiovascular disease and cancer. The nurse should assess for heart disease, stroke, and cancer. Sexually transmitted diseases can occur in any group but is more a priority for the young adult. Functional abilities are more a priority for the older adult.

A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.) a. Vaccination compliance b. Family structure c. Communication patterns d. Roles for women e. Education

ANS: A, B, D, E Income, education, health literacy, where people live or work, early childhood development, social exclusion, family structure, the status and role of women, and vaccination adherence are just some of the social determinants of health recognized worldwide. Communication patterns often are important to assess in culturally diverse individuals, families, and communities, but this is not considered a social determinant of health care.

The nurse is assessing hospitalized older adults for risk factors that could lead to delirium. For which patients does the nurse plan extra care to prevent delirium? (Select all that apply.) a. A 95 year old b. On multiple pain medications c. Is blind d. 2 days postoperative e. Intractable pain

ANS: A, B, D, E There are several risk factors for developing delirium, including advanced age, polypharmacy, pain, surgery, and hospitalization. Being blind is not a risk factor.

In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, what additional actions should the nurse take to practice within the law? (Select all that apply.) a. Maintain confidentiality. b. Follow legal guidelines for sharing information. c. Block document once per shift. d. Change nursing procedures according to latest journal articles. e. Meet licensure and continuing education requirements

ANS: A, B, E In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, nurses should follow guidelines to practice legally and avoid charges of malpractice, maintain confidentiality, follow legal and ethical guidelines when sharing information, document punctually and accurately, adhere to established institutional policies governing safety and procedures, comply with legal requirements for handling and disposing of controlled substances, meet licensure and continuing education requirements, and practice responsibly within the scope of personal capabilities, professional experience, and education.

A nurse is planning a community education event for parents on the topic of school-aged children and the risks of too much social media time. What topics should the nurse plan to include? (Select all that apply.) a. Increased bullying b. Decreased physical activity c. Decreased understanding of spatial relationships d. Weight loss and malnutrition e. Increased aggressiveness

ANS: A, B, E Some of the risks associated with social media include bullying, decreased physical activity with resultant obesity, and aggressiveness

The nurse is caring for a patient who just died after a lengthy illness. Which portions of postmortem care may be delegated by the nurse to the nursing assistant? (Select all that apply.) a. Gently washing the body and closing the patient's eyes b. Offering support and empathy to the patient's family members c. Documenting the patient's time of death in the medical record d. Notifying all of the patient's consulting providers of the patient's death e. Removing the patient's hospital ID band, IV lines, and urinary catheter f. Gathering the patient's belongings so they may be taken home by the family

ANS: A, B, F The nurse assistant can gently wash the patient's body, close the patient's eyes, and gather the patient's belongings. Offering support and empathy to the patient's family members would be done by all of the involved members of the nursing staff. Documenting the time of death in the chart and notifying all of the patient's providers is performed by the nurse. The nurse assistant can remove the patient's IV lines and urinary catheter if allowed by policy, but the hospital ID band would be left in place

The nurse is teaching parents about actions to assist in developing a critical skill in the concrete operations phase of Piaget's developmental theory. What activities does the nurse suggest the parents participate with their child in? (Select all that apply.) a. Separating a collection of toy horses into functions each type performs. b. Exploring a space and astronomy museum and planetarium together. c. Making a scrapbook of leaves sorted by color or type of tree. d. Having the child explore how common objects can be used for different purposes. e. Asking the child to describe an event from several different points of view.

ANS: A, C In the concrete operational stage of Piaget's theory, seriation is an important task. This task includes separating or sorting objects using specific criteria. Separating toy horses by functions and arranging a leaf album by color or tree type are examples of seriation. Exploring museums does not contribute to seriation. Learning how objects can be used for unusual purposes and describing other points of view are part of the formal operations stage.

The nursing student learns which facts about religion and spirituality? (Select all that apply.) a. Spirituality focuses on the meaning of life to people. b. Religion and spirituality are mutually exclusive. c. Religion implies an organized way of worship. d. Religion provides the structure by which to understand spirituality. e. Spirituality is an individual practice that does not include others.

ANS: A, C, D Spirituality focuses on the meanings of life, death, and existence. Religion is an organized and structured method of practicing or expressing one's spirituality, so they are interconnected and not mutually exclusive. Religion provides the structure for expressing spirituality. Spirituality can be expressed through relationships with others.

. A nurse wants to create a community action plan for health problems related to air pollution from a nearby factory. Which stakeholders does the nurse consult as the priority? (Select all that apply.) a. Factory owners b. Stock shareholders c. Community residents d. Local health care providers e. Factory employees

ANS: A, C, D Stakeholders have a significant interest in a topic. The priority stakeholders the nurse would want to consult for this project include the factory owners, community residents, and health care providers. The stockholders would probably not be consulted. The employees could be a significant stakeholder if the action plan affected employment.

The nurse is conducting a windshield survey. What items does the nurse assess? (Select all that apply.) a. Types of housing available b. Cars seen in parking lots c. Recreational facilities d. Health care facilities e. Places of worship

ANS: A, C, D, E A windshield survey is a type of community health assessment. The nurse walks or drives through a neighborhood and notes the type of housing available, the presence and condition of recreational facilities, the presence of health care facilities, and places of worship among other items. Types of cars noted in the neighborhood are not one of the assessments

In preparing to teach the patient, the nurse must consider which concepts? (Select all that apply.) a. Background b. Race c. Pain level d. Emotional status e. Readiness to learn

ANS: A, C, D, E Consideration must be given to the patient's background, readiness to learn, and current condition before education can occur. A patient's ability to read, write, and comprehend health care materials enhances health literacy. Race, by itself, is not a factor.

. The nurse is planning an educational workshop on health risks for the young adult. What topics does the nurse plan to include as priorities? (Select all that apply.) a. Sexually transmitted diseases b. Falling c. Responsible alcohol use d. Intimate partner and sexual violence e. Distracted driving

ANS: A, C, D, E Health risks for this population include sexually transmitted diseases, alcohol and illicit drug use, violence, and distracted driving. Fall prevention is more appropriately directed toward an older audience

Which actions by a nurse constitute spiritual care? (Select all that apply.) a. Baptizing a critically ill child per the parent's request b. Leaving the room, giving the patient and family privacy for prayer c. Considering developmental stage when planning care d. Notifying the hospital chaplain of a patient's request e. Praying with patients and families when requested

ANS: A, C, D, E Many activities fall into the realm of spiritual nursing care, including baptizing an infant in an emergency, notifying the chaplain or other religious leader of patient requests for service, and praying with the patient and family. The nurse always considers the patient's developmental level when planning or providing any type of care. The patient and/or family may or may not want privacy for prayer; the nurse should assess the situation and not just leave.

Which statements by the nurse are correct regarding informed consent and someone who requires an interpreter? (Select all that apply.) a. A professional interpreter is needed. b. A family member may interpret when convenient. c. Detailed medical information remains a priority. d. Professional interpreters are not effective in providing medical information. e. If necessary, family members can make decisions regarding informed consent.

ANS: A, C, E If a patient is illiterate or requires an interpreter, the method of obtaining informed consent must be adapted appropriately. Use of a professional interpreter rather than a family member is essential to provide detailed medical information accurately. A patient whose culture prefers to allow other family members to make final health care decisions is inconsistent with nursing's ethical belief in autonomy. However, in this situation, the method of obtaining informed consent may need to be adapted to meet the patient's beliefs within the scope of the law

According to the Healthy People 2020 initiative, health information and the associated access issues have become more complicated. There are many considerations when determining whether an individual has proficient health literacy. The nurse acknowledges that the patient should be able to do what actions? (Select all that apply.) a. Read and identify credible health information. b. Recognize abnormalities on an x-ray. c. Navigate complex insurance programs. d. Evaluate EKG findings. e. Advocate for appropriate care.

ANS: A, C, E The patient should be able to exhibit certain competencies such as reading and identifying credible health information, understanding numbers in the context of the patient's health care, making appointments, filling out forms, gathering health records and asking appropriate questions of physicians, advocating for appropriate care, navigating complex insurance programs (Medicare or Medicaid, and other financial assistance programs), and using technology to access information and services. Interpreting EKGs and X-rays is beyond this scope.

The nurse knows that when patients are experiencing stress, which physiologic changes can be seen in their signs and symptoms? (Select all that apply.) a. Increase in heart rate b. Flaccid muscles c. Pupil dilation d. Decrease in blood pressure e. Increase in respiratory rate

ANS: A, C, E The physiologic response to stress, whether physical or psychological, is activation of the autonomic nervous system, resulting in an increase in heart rate, blood pressure, and respirations along with pupil dilation and muscle tension and decreased blood flow to the skin.

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions can the nurse delegate to the nursing assistant? (Select all that apply.) a. Gently cleaning the stoma with warm water and a washcloth b. Assessing the stoma and incision for signs of infection or ischemia c. Obtaining needed supplies from the clean utility room d. Teaching the patient how to care for the ostomy after discharge e. Determining which type of ostomy appliance to use f. Application of skin protectant to the area surrounding the stoma

ANS: A, C, F The nursing assistant can gently clean the stoma with warm water and a washcloth, obtain needed supplies, and apply skin protectant. The nurse is responsible for assessment, teaching, and determining which ostomy appliance to use.

The nurse is caring for a male patient who will be performing intermittent self-catheterization at home. Which actions by the patient indicate the need for additional teaching about this procedure? (Select all that apply.) a. Patency of the balloon is tested prior to insertion of the catheter. b. The catheter is inserted another 2 inches after urine is seen in the tubing. c. The catheter is carefully secured to the leg to prevent accidental removal. d. The foreskin is returned to its natural position after the catheter is removed. e. Catheterization is performed regularly before the bladder becomes distended. f. Water-soluble lubricant is generously applied along the length of the catheter.

ANS: A, C, F Only 5 to 8 inches of the catheter tip are covered with water-soluble lubricant. Patency of the balloon is only checked when indwelling catheters are inserted. Intermittent catheters need not be secured to the patient's leg because they will be removed after the bladder is drained. The other actions are correct.

A nurse is assessing a 12 month old at a well-baby visit. For what developmental milestones does the nurse assess this child? (Select all that apply.) a. Attempting to walk with help b. Transferring objects from one hand to the other c. Ability to roll around on the floor holding a bottle independently d. Searching for objects that are out of sight e. Moving from lying on abdomen to sitting unassisted

ANS: A, D, E A 12 month old should be attempting to walk with help, hold a bottle independently and move from lying on abdomen to sitting up unassisted. Transferring objects from one hand to the other and rolling from front to back are milestones seen around 7 months of age and holding a bottle independently occurs at 4 to 6 months.

The nurse identifies which factors that center on the childhood stress related to school experiences? (Select all that apply.) a. Goal achievement b. Family dissolution c. Life changes d. Test anxiety e. Competition

ANS: A, D, E Childhood stress related to the school experience centers on competition, goal achievement, and test anxiety. Family dissolution and life changes are not related to the school experience.

The nurse recognizes which of the following to be a benefit of regular physical exercise? (Select all that apply.) a. Enhances the immune system. b. Decreases bone density. c. Limits joint mobility. d. Improves mental health. e. Helps to prevent type 2 diabetes

ANS: A, D, E Exercise is essential for the prevention of illness and promotion of wellness. Physical exercise is any bodily activity or movement that enhances or maintains physical fitness levels and overall health. Exercise strengthens muscles, improves cardiovascular performance, hones athletic skills and endurance, and reduces or maintains weight, and it is performed for enjoyment (Powers and Howley, 2012). Regular physical exercise enhances the immune system, builds and maintains healthy bone density, increases joint mobility, and helps to prevent cardiovascular disease, type 2 diabetes, and obesity. Exercise also improves mental health and helps to prevent depression through the release of endorphins and other neurotransmitters that are responsible for exercise-induced euphoria (Powers and Howley, 2012).

A nurse is studying intrinsic factors that influence the development of asthma in a community. What factors does the nurse assess? (Select all that apply.) a. Socioeconomic status b. Genetics c. Pollution in the area d. Water cleanliness e. Immunization status

ANS: A, E Host, or intrinsic factors are individual variables such as genetics, age, gender, ethnic group, immunization status, and human behavior that impact a person's health. The other options are all extrinsic factors, which pertain to environmental characteristics.

A nurse reads on a patient's chart that she has sarcopenia. What assessment does the nurse perform to confirm this? a. Mini-mental state exam b. Tests of muscle strength c. Gait and balance d. Vision and hearing

ANS: B "Sarcopenia" means loss of tissue. Muscle tissue and muscle mass both tend to decrease starting in the 30s. The nurse assesses muscle strength to get information about possible sarcopenia in this patient. Tests of cognition, gait and balance, and sensory perception are not related

The nurse realizes that a medication error has been made. The nurse then reports the error and takes responsibility to ensure patient safety despite personal consequences. This nurse has exhibited what ethical concept? a. Autonomy b. Accountability c. Justice d. Advocacy

ANS: B Accountability is the willingness to accept responsibility for one's actions. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Supporting or promoting the interests of others or doing so for a cause greater than oneself defines advocacy. To do justice is to act fairly and equitably.

The nurse recognizes that starting an intravenous (IV) infusion line on a patient against his will may be classified as which wrongdoing? a. Assault b. Battery c. Felony d. Misdemeanor

ANS: B Actual physical harm caused to another person is battery. Battery may involve angry, forceful touching of people, their clothes, or anything attached to them. Performing a surgical procedure without informed consent is an example of battery. Actions much more subtle, such as inserting an intravenous catheter or urinary catheter against the will of a patient, also may be classified as battery. Assault is a threat of bodily harm or violence caused by a demonstration of force by the perpetrator. A feeling of imminent harm or feeling of immediate danger must exist for assault to be claimed. A misdemeanor is a crime of lesser consequence that is punishable by a fine or incarceration in a local or county jail for up to 1 year. A felony is a more serious crime that results in the perpetrator's being imprisoned in a state or federal facility for more than 1 year

A nurse is planning a community event in which participants will be assessed for their risk of having a stroke. Which site does the nurse choose to access the highest risk population? a. Community elder center b. African American church c. Synagogue in a rural area d. Asian American grocery store

ANS: B African Americans have a higher rate of stroke death that do white Americans, even at younger ages. The nurse chooses the African American church for stroke screening. The other places will not have as large of a high-risk population.

The nurse is performing wellness checks at a community center for older adults. Which person would the nurse evaluate as having the highest risk of stroke? a. Caucasian, 55 years of age, BP 148/92 mm Hg b. African American, 70 years of age, BP 150/100 mm Hg c. Asian American, 40 years of age, BP 146/78 mm Hg d. Caucasian, 74 years of age, BP 150/82 mm Hg

ANS: B African Americans have a higher rate of stroke than whites at any age. Hypertension is also a risk factor for stroke. Stroke risk also increases with age overall. Therefore, the person with the highest risk of stroke is the older hypertensive African American

The nurse is caring for an Islamic patient who has just died. The family is traveling from overseas. Which action is the priority for the nurse to take right after the patient dies? a. Arranging for embalming to preserve the body until burial b. Rearrange the furniture so the bed can face Mecca c. Arranging for transportation of the body to the crematorium d. Bringing in fruit for the patient's journey to the other world

ANS: B After death, a patient's body can be turned to face Mecca which is the holy site for Muslims. The nurse would need to find out which direction that is. The family will work with the funeral home to determine when and where burial will take place. Buddhists often bring fruit when someone dies.

Which statement by the nurse indicates comprehension of ethical issues? a. Ethical issues are rare occurrences but take a great deal of time to resolve. b. Ethical issues have required The Joint Commission to mandate ethics committees. c. Ethical issues most frequently lead to legal intervention in patient care matters. d. Ethical issues lead to ethics committees made up entirely by nurses

ANS: B All nurses are faced with ethical decisions each day in practice, and some choose to obtain further education and experience in the field of bioethics and participate on institutional ethics committees along with physicians, ethicists, attorneys, and academicians. Ethics committees are required by The Joint Commission to respond to ethical challenges related to patient care requiring consultation. The work of the ethics committees in health care institutions helps to prevent unnecessary legal intervention in patient care matters. Ethics committee members come from all areas of health care, not just nursing. If acceptable resolutions are not achieved through consultation with the ethics committee, patients, families, and health care providers, the legal system may become involved.

During discharge teaching, the nurse is to give the patient a signed, dated, and timed prescription from the physician for medications to be taken at home. Which prescription drug order needs to be corrected before it is given to the patient? a. Warfarin (Coumadin) 5 mg PO daily before dinner b. Methotrexate (Trexall) 8 tablets PO once weekly on Saturdays c. Levothyroxine (Synthroid) 137 mcg PO daily before breakfast d. Zolpidem (Ambien) 5 mg PO at bedtime as needed for slee

ANS: B All prescriptions must have the name of the drug to be administered along with dosage, route, and frequency. The methotrexate order does not contain a dosage for the drug, just the number of pills to be taken. The other orders are complete.

The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information? a. Alternative therapies can include relaxation techniques. b. Alternative therapies are used in conjunction with medical therapies. c. Alternative therapies can be used when patients are experiencing stress. d. Some alternative therapists require certification.

ANS: B Alternative therapies are used in place of medical treatment. These types of interventions are useful when patients are experiencing physiologic and psychological responses to stress. Some complementary and alternative therapies such as therapeutic touch, Reiki, biofeedback, and massage therapy require additional certification and training, whereas muscle relaxation and guided imagery do not.

A patient has recently been given a terminal diagnosis. When family members offer to help, the patient snaps and yells at them, but then angrily accuses them of not helping. The patient's spouse is frustrated and asks the hospice nurse what to do about this situation. What response by the nurse is best? a. "Don't worry. Your spouse will get over this phase soon." b. "Anger is an expected part of the grieving process." c. "Would your spouse be open to professional counseling?" d. "This diagnosis is difficult to handle; just be patient."

ANS: B Anger is one of the stages of grief as identified by Elizabeth Kubler-Ross. The nurse would first explain this to the spouse. Telling the spouse the patient will get over the phase soon or that the diagnosis is difficult to handle is false reassurance and dismissive of the concerns. It is too early to consider counseling although the patient may need it later. This is also a yes/no question which is not therapeutic.

The nurse understands that as the health care community explores the concept of health literacy, many organizations recognize what concept? a. Consumers need to understand has no governmental support. b. Improvements are dependent on developing operational definitions. c. Low literacy and low health literacy are interchangeable terms. d. Interest in effective patient education is unique to the United States

ANS: B As the health care community explores the concept of health literacy, many organizations recognize that before improvements can be made, operational definitions are imperative. The realization that consumers need to be able to understand the medical information delivered by health care providers has gained recognition at many governmental levels. The Healthy People 2020 publication describes a national movement that addresses the priorities of prevention and public health in the United States. Health literacy with its impact on this initiative is being recognized and has become a key component of the project. Although low literacy and low health literacy are related terms, they are not interchangeable. Low health literacy is content-specific, meaning that the individual may not have difficulty reading and writing outside the health care arena. Interest in effective patient education is not a phenomenon unique to the United States. The Institute of Medicine Roundtable on Health Literacy held a workshop in 2012 focused on international health literacy.

A home health care nurse is working with the family of a patient who has Alzheimer disease and requires 24-hour care. What assessment by the nurse indicates the family is meeting an important goal for caregiver role stress? a. Family eats dinner together every night. b. Family uses respite care one night a week. c. Family investigates research trials for patient. d. Family verbalizes exhaustion from caregiving.

ANS: B Caregiver role stress can occur when the caregiver(s) is unable to meet obligations or unable to take care of personal needs. Using a respite caregiver once a week gives the family a little time off to accomplish needed tasks. The other observations are not tied to this diagnosis.

A father expresses frustration that his school-aged child is suddenly "sick all the time." What action by the nurse is best? a. Encourage the father to give the child a multivitamin each day. b. Explain that illness is frequent in this age-group because of exposure to others. c. Encourage the father to discuss testing the child's immunity with the provider. d. Make sure the parents are washing their hands frequently in the home.

ANS: B Children in this age-group tend to have a higher incidence of minor illnesses because of exposure to others. The nurse can reassure the father by explaining this. No other action is needed at this point.

The nurse recognizes which action by the nursing student would be considered uncivil? a. Prompt arrival to class b. Texting during class c. Attentive listening d. Active participation in class

ANS: B Civility (i.e., acting politely) is essential in all interactions among faculty and nursing students. Respectful interaction between students and faculty members establishes professional communication patterns and affects the way in which students interact with patients. Texting in class is disrespectful and is an example of incivility. Arriving on time, listening attentively, and participating in class all show respect and civility.

A nursing faculty member is contrasting culture and ethnicity to students. Which statement is most accurate? a. Culture is biologically determined; ethnicity is chosen. b. Culture is socially transmitted; ethnicity is identification with a group. c. Culture is a chosen identity whereas ethnicity is biologically based. d. Culture and ethnicity are similar constructs used interchangeably.

ANS: B Culture refers to the learned, shared, and transmitted knowledge of values, beliefs, and ways of life of a group that generally are transmitted from one generation to another and influence the individual person's thinking, decisions, and actions in patterned or certain ways. Ethnicity is the person's identification with or membership in a racial, national, or cultural group and observation of the group's customs, beliefs, and language. The words may be used interchangeably by some people, but this is not correct.

An adult caregiver for an older adult reports the adult is doing well other than sleeping more frequently and for longer periods. What response by the nurse is best? a. Assess the older adult for exercise habits. b. Perform a screening for depression. c. Reassure the caregiver that this is normal. d. Ask the older adult to provide a sleep diary

ANS: B Depression is common in the older adult population and is frequently overlooked or misdiagnosed. People may think withdrawal and excessive sleeping are normal age-related changes, but they are not. The nurse should assess the older adult for depression. Other assessments can follow because they are not the priority for this patient.

The nurse is preparing to insert a nasogastric (NG) tube in a patient. Which step in the process indicates a need for further education? a. The nurse lubricates 4 inches of the tube prior to insertion. b. The nurse marks the length of the tube with a marker for insertion. c. The nurse measures the length of tube needed using the nose-earlobe-xiphoid process. d. The nurse applies clean gloves for the procedur

ANS: B Document the length of the tube to be used if the tube has a preprinted measurement scale. For any tube (with or without a preprinted scale), mark the measurement on the tube using a small piece of tape to ensure proper placement of the tube; fold the ends of the tape for easy removal. Do not use a permanent marker to mark the tube at this point of the procedure. When placement of the tube is confirmed as correct, then remove the measurement marking tape, mark the exit location on the tube with permanent marker, and proceed with the ordered treatment. Lubricate 4 inches of the tube tip with a water-soluble lubricant. For an NG tube, measure the length of tube needed for the patient by placing the tip of the tube at the tip of the patient's nose and extending it to the patient's earlobe and then to the patient's xiphoid process. Clean gloves are used.

The nurse has delegated the feeding of a patient who has recently had a stroke to the UAP. Which procedure that the UAP performs would demonstrate a need for further education? a. Uses thickened liquids. b. Puts the bed at 25 degrees. c. Encourages slow eating. d. Has the patient alternate between food and sips of fluid

ANS: B During feeding, the head of the bed needs to be elevated at 30 to 45 degrees or higher. Liquids are thickened, and patients are encouraged to use slow-eating habits and to alternate between bites of food and sips of fluids to facilitate swallowing

A nurse is assessing an adolescent female who began menstruating 2 years ago. She has grown 1/2 inch in the last 2 years but has not gained any weight. What action by the nurse is most appropriate? a. Ask the teen to provide a 24-hour diet recall. b. Talk to the teen about healthy dietary practices. c. Reassure the teen she will have a growth spurt soon. d. Collaborate with the provider for endocrine testing.

ANS: B During the adolescent growth spurt, teens achieve approximately 20% to 25% of their final height. This occurs during the time span ending about 2 years after the onset of menses. Since this teen has already reached that mark with little growth, the nurse should assess the teen's knowledge and practice of healthy eating. Poor eating habits are common with this age-group. A 24-hour diet recall can be utilized but the nurse's assessment should encompass more than just the recall. The teen most likely will not have another growth spurt later. Endocrine testing is not warranted at this point.

The nurse identifies which patient would most likely need to have adjustments made to the education plan for discharge because of role function? a. A 67-year-old married female who lives with her retired husband b. A 32-year-old single mother of a toddler following hysterectomy c. A 13-year-old who lives at home with his parents after appendectomy d. A 50-year-old married mother with two children in college and teenager at home

ANS: B Exploration of the patient's roles is an important task that must be done before development of a patient education plan. For example, a 32-year-old, single mother of five young children who has just undergone a hysterectomy may require a different perspective in her discharge instructions than that in the instructions of a 67-year-old female living with her husband who recently retired after 35 years as a family practice physician. The first patient may have less support and less flexibility regarding rest, lifting limitations, and cost of prescriptions than the second. It is important not to stereotype and assign roles but rather to develop a plan in collaboration with the individual. The patient's support system should be taken into consideration when the nurse plans patient education.

The student nurse learning about ethics expresses good knowledge when making which appropriate statement? a. "Ethics are internal values developed outside the influence of societal norms." b. "Ethics are influenced by many variables including family and friends." c. "Ethics are societal in nature and do not involve personal influences." d. "Ethics are totally independent from a person's character."

ANS: B Family, friends, beliefs, education, culture, and socioeconomic status influence the development of ethical behavior. The study of ethics considers the standards of moral conduct in a society. Personal ethics are influenced by values, societal norms, and practices. Behaviors that are judged as ethical or unethical, right or wrong, reflect a person's character.

The nurse is providing discharge instructions for a patient with multiple sclerosis. Which discharge instruction is aimed at preventing a future exacerbation? a. Engage in some form of exercise as tolerated. b. Avoid highly stressful situations. c. Check your skin regularly for pressure sores. d. Eat a diet with lots of fiber.

ANS: B High stress levels are known to exacerbate multiple sclerosis and other autoimmune diseases. Exercise helps keep muscles loose and helps with balance. Assessing skin for pressure sores and eating a diet with high fiber prevents complications from multiple sclerosis.

Which statement by the patient indicates to the nurse that it may be an appropriate time to consider hospice care rather than further aggressive measures to treat his terminal illness? a. "I am praying every day that this last round of chemotherapy will work." b. "I want to spend what time I have left at home with my grandchildren." c. "I need to meet with my financial planner to make sure my life insurance is all set." d. "I am concerned that my wife won't be able to live on her own after my death."

ANS: B Hospice care is provided to patients who are terminally ill and wish to have no further aggressive treatment in attempt to cure the disease. The patient's statement that she just wants to be home with her grandchildren indicates a readiness for hospice care.

A nurse works in a pediatric oncology unit and is feeling depressed and discouraged. What initial action by the nurse is best? a. Apply for a job transfer to another unit. b. Consult with the hospital chaplain. c. Make an appointment with Employee Assistance. d. Ask other nurses how they deal with the stress.

ANS: B Hospital chaplains are great resources for nurses experiencing burnout, moral distress, or spiritual distress. The nurse can take all options, but a consultation with the chaplain is the best place to start to see if the issue can be resolved. The chaplain has a wider range of perceptions and tools than do the other staff nurses.

The nurse knows that when coordination between multiple health care disciplines is needed, which role should be utilized? a. Pastoral care b. Case manager c. Social worker d. Dietitian

ANS: B If coordination of care between multiple health care disciplines is needed, a case manager is used. Pastoral care plays a significant role in addressing stress and anxiety issues when the patient has a preferred religion or strong faith background. A social worker identifies appropriate services and resources. A dietitian can provide education regarding dietary needs and food choices.

The patient is asking about using the Internet for resources regarding lifestyle behaviors and benefits of modification. What is the best response that the nurse should provide the patient? a. Information on lifestyle behaviors is not available on the Internet. b. The patient should use websites that are easy to understand. c. Most websites are designed for health care providers only. d. Only negative outcomes are evaluated on the Internet.

ANS: B Information on lifestyle behaviors that lead to disease is available at research-sponsored websites that have peer-reviewed material and expert analyses. Website content should be easy to read and understandable for the general population. Most sites that discuss the latest information about health risks, lifestyle behaviors, and outcomes have separate information specifically for health care providers. Research that evaluates positive and negative lifestyle-behavior outcomes is constantly evolving as discoveries are made about the physiologic changes bodies experience with disease and illness

The nurse is to administer 1 mL of prochlorperazine (Compazine) 10 mg IM to an adult patient. Which syringe will the nurse select to administer the medication? a. 1 mL tuberculin syringe with 27 gauge, 1/2 inch needle b. 3 mL syringe with 23 gauge, 1 1/2 inch needle c. 1 mL syringe with 27 gauge, 5/8 inch needle d. 3 mL syringe with 18 gauge, 1 inch needle

ANS: B Intramuscular injections for adults are usually administered with a 3 mL syringe and a 1 to 3 inch, 19 to 25 gauge needle. Tuberculin syringes are typically used for subcutaneous injections. The inch needles are too short for intramuscular injections into adults. The 18 and 27 gauge needles are too small for adult intramuscular injections.

The nurse is implementing a patient teaching plan regarding diabetes mellitus. One of the short-term goals of the plan is that the patient will be able to verbalize three symptoms of hypoglycemia. The nurse recognizes that this is what type of teaching? a. Psychomotor teaching b. Cognitive teaching c. Affective teaching d. VARK teaching

ANS: B Learners in the cognitive domain integrate new knowledge through first learning and then recalling the information. They then categorize and evaluate, making comparisons with previous knowledge that result in conclusions related to the new content. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes. Tools have been developed to help health care workers evaluate the health literacy of their patients. One such tool is the VARK (verbal, aural, read/write, kinesthetic) assessment of learning styles of people who are having difficulty learning.

The nurse working with an adult population knows that many age-related declines in function begin occurring at what age? a. 20 b. 30 c. 50 d. 70

ANS: B Many age-related functions peak before age 30 and begin to decline after that.

A nurse is assessing a middle-aged adult for cognitive skills. The patient has difficulty with seriation tests. What action by the nurse is most appropriate? a. Document the findings and continue the assessment. b. Perform another test for fluid intelligence. c. Consult with the provider about dementia screening. d. Ask the patient about family medical history.

ANS: B Middle-aged adults (especially younger ones) often have trouble with math processing (fluid intelligence) because of the prevalence of calculators and computers and dependence upon them to do work formerly done by the individual. The nurse should conduct other tests for fluid intelligence. The findings should be documented, but this is not the only action needed. Dementia screening is not indicated with one test result. Family medical history should be part of all screenings but is not directly related to this issue.

The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse? a. "The insurance company will not pay for chemotherapy at this stage." b. "The focus right now needs to be on keeping your loved one comfortable." c. "I will call the provider and relay your wishes." d. "The patient needs to get stronger first before chemotherapy can be administered."

ANS: B Nurses advocate for patients to ensure that they are aware of their options for care that include interventions, treatments, anticipated outcomes, as well as risk and benefits of any decision made concerning medical care. The nurse must function as the patient's advocate and encourage what is in the best interest of the patient. Chemotherapy will not extend the patient's life when death is expected within the next few days and will only make the patient suffer needlessly when it is administered. The patient will not get stronger over the next few days, and this criterion for chemotherapy will never be met

A nurse is completing an OASIS assessment on a patient. What data would be most important for the nurse to assess? a. Presence of grocery stores nearby b. Safety concerns within the home c. Number and kind of pets d. Proximity to a health care facility

ANS: B OASIS (Outcomes and Assessment Information Set) is a data set of outcome measures for adult home health care clients that is used to track outcome-based quality improvement. Factors that could potentially affect patient safety in the home are particularly important. The other options are not included in this assessment.

A home health care nurse is making a well-baby visit to the home of a new mother who has an infant. What assessment finding leads the nurse to provide further anticipatory guidance and teaching to the mother? a. Mother states she does not breastfeed but uses a recommended formula. b. Crib has colorful blankets and pillows for the baby to cuddle. c. A mobile is hanging well above the crib playing soft music. d. Several rattles and plush toys are available in different textures.

ANS: B Objects such as pillows and blankets pose a suffocation hazard to infants and should be kept out of cribs. The other items are appropriate for a newborn.

A nurse has referred a patient to a community agency. When talking to the patient later, he states that he did not find the agency helpful. What action by the nurse is best? a. Determine what the patient would find helpful. b. Review the agency's mission and scope. c. Make another appointment with the agency. d. Warn the patient that nonadherence affects payment.

ANS: B One of the most important aspects of a community health nurse's role is to be familiar with referral agencies. Awareness of the scope of an agency's influence and services helps the community nurse to pinpoint which agencies are best able to address specific needs. The nurse may have sent this patient to an agency that did not meet his needs. The nurse should ask the patient's opinion about what services are needed. Making another appointment without ensuring that this is the right agency for the patient will not solve the problem. Telling the patient that payment might not be ensured for nonadherence is not therapeutic communication.

The nurse is assessing a patient's environment and its impact on outdoor activity and notes that the child rarely plays outside. Which is true regarding the indoor environment? a. Indoor environments protect the patient from toxics chemicals. b. Indoor activity is sometimes a result of unsafe outdoor conditions. c. Indoor activity decreases the risk of respiratory illness. d. Indoor lifestyles reduce the risk for sedentary behaviors.

ANS: B Outdoor environments affect individual health in the areas of sanitation and waste disposal, water quality, air quality, and safety. Children living in areas where there are safety issues related to gang activity, sexual predators, or heavy traffic are less likely to engage in outdoor play activities. Their limited access to safe outdoor play space increases their risk for sedentary behaviors, excessive calorie intake, and obesity. Indoor environments may harbor toxic household cleaning agents, chemicals (e.g., radon, carbon monoxide, unused drugs), tobacco smoke, and energy sources (e.g., microwave ovens). Exposure to mold, household pests (e.g., dust mites, spiders), and unsanitary living conditions in an enclosed space increases the likelihood of respiratory illness and skin disorders.

The nurse is caring for a terminally ill patient who appears to be calmly having a conversation with someone even though there is nobody else in the room. The patient reaches out and appears to take something out of thin air and hold it close. Which is the appropriate action of the nurse? a. Reorient the patient and reassure that nobody else is in the room. b. Be present but quiet and let the patient continue the conversation. c. Carefully assess the patient's mental status and level of attention. d. Obtain a set of vital signs and check the patient's pulse oximetry.

ANS: B Patients who are near death sometimes have a special communication with loved ones who have already died. It is important to recognize that these experiences can be comforting to the dying patient, and nurses would not contradict or argue with the person. It is imperative to simply be present with the person, listen, and be open to any attempts to communicate. It is acceptable to ask gentle questions such as "What are you seeing?" or "How does that make you feel?" Having an open discussion with the family while describing what is occurring may provide further insight to the nurse as the health care provider, as well as promoting a sense of understanding and acceptance for the family. As long as the patient is calm and content, the best action of the nurse is to be present but let the patient continue the conversation undisturbed.

A patient died suddenly in the emergency department. Which action by the nurse best provides the family connection with others? a. Offering the family written information on grief support groups. b. Asking the family if there is someone the nurse can call for them. c. Having the hospital social worker or chaplain sit with the family. d. Offering to stay with the family during this difficult time

ANS: B Promoting connectedness means recognizing that family and friends are providing at least some of the patient's spiritual care. The nurse best assists when offering to call someone for the patient or family. The other options may be appropriate but are not directly related to connectedness

What does the nursing student learn about race? a. It is biologically based. b. It is a social construct. c. It is chosen by the person. d. It helps establish superiority

ANS: B Race is often thought to be inherited and biologically based, but this is not true. Race is a social construct that is used to group people together based on common physical characteristics, heredity, or common descent. People are placed into racial categories by the larger society. One race is not superior to any other.