ADN 140 Concept Exam 3

An Appalachian male has been admitted to the unit for chest pain. A nurse told the family that they could not be with the client. The family became very upset and the client wants to leave. What is the most appropriate cultural response by the charge nurse?

"Would you feel more comfortable with your family with you?"

Why are health promotion and illness prevention a key responsibility of nurses?

Chronic illnesses are the leading health problem in the world

A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness?

Symptoms are not experienced

A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care?

Tertiary

In 2014, what percentage of older adults resided in long-term care facilities? a. 3% b. 2.5% c. 5.5% d. 3.5%

a. 3%

The nurse is providing discharge instructions to an elderly client. The nurse hands the client a paper about a new medication. The client cannot read. Learning does not occur. In this situation the nurse has failed to assess the a. Appropriateness of teaching techniques b. Client's social and cultural patterns c. Past experiences of the client d. Physical readiness of the client

a. Appropriateness of teaching techniques

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement? a. Assess the factors that the client believes contribute to the problem. b. Facilitate a change in the client's diet to ensure more carbohydrates at dinner. c. Obtain a p.r.n. order for a sedative-hypnotic from the client's physician. d. Educate the client on relaxation techniques and reduce noise levels on the unit.

a. Assess the factors that the client believes contribute to the problem.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? a. Hypothalamus b. Medulla c. Midbrain d. Cerebral cortex

a. Hypothalamus

The nurse develops a program of increased ambulation for a patient with an orthopedic disorder. This is an example of what component of the nursing process? a. Planning b. Implementation c. Evaluation d. Assessment

a. Planning

An 80-year-old client tells the nurse that he has been dizzy since starting to take an herbal remedy for arthritis in addition to prescribed medications. The nurse recognizes that the client may be experiencing the effects of which of the following? a. Polypharmacy b. Sleep disorder c. Cascade iatrogenesis d. Fluid volume overload

a. Polypharmacy

Research has shown that the incidence of chronic conditions is increasing. Which lifestyle factor is associated with chronic diseases? a. Smoking b. Exercise c. Eustress d. Gastrointestinal disease

a. Smoking

The home health nurse is making an initial assessment visit to a family that consists of two parents and twin 3-year-old boys. During the interview, the nurse is most concerned if the client makes which statement? a. The father states, "I don't discuss money matters with my wife because I don't want her to worry." b. The mother states, "We like to pay cash for the things we need." c. The mother states, "This house would be a mess if I didn't clean it every day." d. The father asks the nurse, "Do you mind if my little boy sits on my lap during the interview?"

a. The father states, "I don't discuss money matters with my wife because I don't want her to worry."

The new nurse is caring for a client of Asian descent. What should the nurse expect when caring for this client? a. This client will prefer the nurse to keep an arm's length distance. b. Maintain eye contact when communicating c. This client will touch the nurse during conversations. d. The nurse should sit close to the client.

a. This client will prefer the nurse to keep an arm's length distance.

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action? a. Wash her hands before and after the dressing change. b. Use sterile gloves to change the abdominal dressing. c. Apply extra gauze dressings to the wound to absorb the drainage. d. Change the abdominal dressing more frequently.

a. Wash her hands before and after the dressing change.

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: a. abandonment. b. neglect. d. emotional abuse. c. exploitation.

a. abandonment.

In Stage 4 sleep, the: a. pulse rate is slow b. temperature increases c. blood pressure is elevated d. respirations are irregular

a. pulse rate is slow

The nurse is administering a new medication to an elderly male client and begins instruction about the medication. The client states, "Tell my wife. She takes care of all this kind of stuff." The nurse replies a. "It is necessary that you learn about this medication." b. "When your wife comes in to visit, I will return and provide the information to both of you." c. "I will print the information about this medication and leave it with you to give to her." d. "I guess I will have to return when she arrives."

b. "When your wife comes in to visit, I will return and provide the information to both of you."

A nurse is visiting the home of a first-time mother and her newborn. The nurse is teaching the mother about the newborn's sleep needs. The nurse would inform the mother that newborns sleep approximately how many hours per day? a. 8 to 10 hours b. 14 to 20 hours c. 10 to 12 hours d. 18 to 22 hours

b. 14 to 20 hours

The nurse is evaluating a 42-year-old client who says that he is feeling stressed. Which of the following does the nurse know that could be a cause of stress for this age group? a. Retirement b. Being caught in the sandwich generation c. Losing driving privileges d. Social isolation

b. Being caught in the sandwich generation

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention? a. A narcotic medication b. Low-flow oxygen c. A hypnotic medication d. Warm milk

b. Low-flow oxygen

The nurse is caring for a client who perceives time differently. What action should the nurse take for this client? a. Have the client set all times for the interventions. b. Maintain flexibility when the client requests interventions at specific times. c. Set all interventions to be done at specific times. d. Perform interventions at random times during shift.

b. Maintain flexibility when the client requests interventions at specific times.

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative-hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation? a. The client is eating protein prior to bedtime. b. Most sedative-hypnotics lose their effect after 1 or 2 two weeks of administration. c. The client's daily activity is interfering with the drug. d. The nurse needs to administer another drug such as diphenhydramine for effectiveness.

b. Most sedative-hypnotics lose their effect after 1 or 2 two weeks of administration.

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patters? a. Newborns will nap two times per day. b. Newborns sleep 16 to 17 hours per day. c. Newborns have shorter periods of REM sleep. d. Newborns are inactive when awake.

b. Newborns sleep 16 to 17 hours per day.

In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which principle? a. The nurse should avoid performing health promotion education if this is not a priority in the client's culture. b. The client may have a very different understanding of health promotion. c. Health promotion is a concept that is largely exclusive to Western cultures. d. A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development.

b. The client may have a very different understanding of health promotion.

A man with Alzheimer's disease in a nursing home will follow directions for dressing and feeding better with one nurse than with other staff members. This factor is related to a. Health Belief Model b. Therapeutic Model of Interaction c. Empathy d. Aggression

b. Therapeutic Model of Interaction

A nurse is caring for a client diagnosed with pancreatitis. Which of the following is a priority need for nursing management? a. Depression due to recurrent symptoms b. Lack of self-confidence c. Acute pain in the abdomen d. Inability to take care of family

c. Acute pain in the abdomen

Which of the following is a nursing diagnosis related to health education? a. Altered nutrition, less than body requirements b. Self-esteem disturbance c. Ineffective health maintenance d. Ineffective airway clearance

c. Ineffective health maintenance

The nurse is preparing to administer prescribed medication to a client who is Native American/First Nations. The nurse enters the room and observes a shaman performing a healing ritual for the client. What action would be the most appropriate by the nurse? a. Administer the medication while the shaman continues the ritual. b. Ask the shaman to leave the room. c. Leave the room and return when the shaman is finished. d. Wait in the room until the shaman is done.

c. Leave the room and return when the shaman is finished.

The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to? a. Environmental b. Emotional c. Physical d. Intellectual

c. Physical

A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent? a. Acute b. Secondary c. Primary d. Tertiary

c. Primary

The nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. What level(s) of health promotion is this an example of? a. Chronic b. Tertiary c. Primary d. Secondary

c. Primary

Which is an example of tertiary health promotion? a. Immunizations b. Seat Belt Safety Class c. Rehabilitation d. Mammograms

c. Rehabilitation

A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client? a. Risk for Injury b. Relocation Stress Syndrome c. Sleep Deprivation d. Impaired Bed Mobility

c. Sleep Deprivation

A parent informs the nurse that immunizations are against her cultural and religious beliefs and she does not want her child to receive immunizations. The nurse proceeds to inform the parent that the child will be consistently ill and will not be allowed to start school unless immunized. The nurse also informs the parent that she had all of her children vaccinated. The nurse's behavior an example of: a. cultural conflict. b. stereotyping. c. cultural imposition. d. cultural blindness.

c. cultural imposition.

Which client would benefit from the nurse including interventions addressing their social health in the plan of care? a. client w/sexually transmitted infection b. new mother cradling her infant c. spouse and parent who is angry about no longer being able to work due to a spinal cord injury d. stressed client who is learning to using guided imagery for relaxation

c. spouse and parent who is angry about no longer being able to work due to a spinal cord injury

A nurse is planning education on self-administration of insulin to the client and his family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be? a. "Family members are at risk of developing diabetes mellitus in future." b. "Family members can take you to the hospital if any emergency occurs." c. "Family members are a point of contact and are able to check on your progress." d. "Family members are equally involved in planning and implementation of care."

d. "Family members are equally involved in planning and implementation of care."

The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse? a. "I will leave the questionnaire here. Please fill it out when your spiritual healer arrives." b. "These questions need to be answered so we can provide you with the best care." c. "I can wait until your spiritual healer arrives, but you are the only one who can answer these questions." d. "We can wait until your spiritual healer arrives and work together to answer these questions."

d. "We can wait until your spiritual healer arrives and work together to answer these questions."

Which client requires priority intervention when providing care on a medical-surgical unit? a. A newly admitted client who is upset due to new cancer diagnosis b. An older adult client who is yelling and angry with family members c. A client with a blood pressure of 98/40 mm Hg who needs to ambulate to the bathroom d. A postsurgical client who is feeling dizzy with a heart rate of 45/bpm

d. A postsurgical client who is feeling dizzy with a heart rate of 45/bpm

You are the nurse caring for a patient newly diagnosed with diabetes and you are developing a holistic plan of care. You know that for this plan of care to be successful it must what? a. Take into account the cost of care. b. Connect families, friends and the environment. c. Provide a connection between medicine and nursing. d. Address the disease but also incorporate the mind, body, and spirit.

d. Address the disease but also incorporate the mind, body, and spirit.

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include? a. Maintain open communication b. Strengthen the marital relationship c. Maintain a supportive home environment d. Adjustment to retirement

d. Adjustment to retirement

You are the community-based nurse who acts as case-manager for a small town about 60 miles from a major health care centre. What is the most important factor of community-based nursing for you be knowledgeable about? a. Eligibility requirements for services. b. Transportation costs to the health care centre. c. Possible charges for any services provided. d. Community resources available to patients.

d. Community resources available to patients.

Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? a. Arranging for social services to assist with meals for a homebound client b. Counseling a client who complains of being depressed c. Providing entertainment for a client on bedrest d. Encouraging a client to have regular checkups

d. Encouraging a client to have regular checkups

An older adult client with mild hypothermia has been admitted to the health care facility. What should the nurse do to provide an appropriate environment to an older adult client? a. Raise the side rails of the bed. b. Use a bright light at night for safety. c. Keep an attendant with the client. d. Ensure that the environment is warmer.

d. Ensure that the environment is warmer.

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include? a. Advise parents that waking from nightmares or night terrors is common during the adolescent stage. b. Teach parents of infants to report any eye movements, groaning, or grimacing by their infant during sleep periods. c. Inform parents about the preschool child's awareness of the concept of death possibly occurring and encourage parents to help alleviate the child's fears. d. Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

d. Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

Which behaviors demonstrated by the client would the nurse consider as reflection of the client's pride in ethnicity? Select all that apply.

requesting native cuisine listening to folk music and dance asking to wear person unique clothing

The school nurse informs the mother of a second-grade student that lice were found in the child's hair. The mother explains to the nurse that she has another child to pick up and cannot stay to receive education related to the treatment of lice at this time. The mother reassures the nurse that she will "look up treatment options on the Internet and take care of the child." What would be the best action of the school nurse in this situation? a. Perform hand hygiene and notify the second-grade teacher to wash down the classroom b. Notify the social worker of suspected child neglect and make a referral to child protective services c. Instruct the mother to treat the other child for lice in the same manner as the second-grade child d. Provide the mother with a list of credible websites related to the treatment of lice

d. Provide the mother with a list of credible websites related to the treatment of lice

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family? a. The family members vacation together every year at a beach resort. b. The family consults their rabbi and synagogue members during times of stress. c. The family celebrates Hanukkah and Passover with special meals. d. The father is an engineer and the mother is an elementary school teacher.

d. The father is an engineer and the mother is an elementary school teacher.

Which are stressors that affect the health of the family? a. Many job opportunities with adequate income. b. Public transportation present throughout the community. c. Family members who live in the same geographic location. d. Well-funded school systems and inadequate childcare services.

d. Well-funded school systems and inadequate childcare services.

A nurse is caring for a 55-year-old man from Thailand. The client has bacterial pneumonia and a temperature of 104°F (40.0°C); yesterday his temperature was 102°F (38.9°C). The physician on call prescribes cool compresses for the client to help lower the fever. However, the client insists that the nurse bring him warm blankets because they will help him recover more quickly. The nurse recognizes that the client's request is an example of: a. cultural competence. b. ethnocentrism. c. cultural stereotyping. d. cultural ritual.

d. cultural ritual.

Nursing students are socialized into the: a. diagnostic process. b. nursing specialties. d. health care culture. c. caring paradigm.

d. health care culture.