ATI 152 Study Set

E. 1 In which way can nurses develop cultural self-awareness?

Objectively examine one's own beliefs, values, and practices

E.3 A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first?

Offer mother private time with the newborn

E.3 Cheyenne-Stokes reparations, an indication that the client is approaching death, are described as respirations that may consist of the following. Select all that apply

Periods of apnea Deep to shallow

E.4 The nurse is administering vaccines at county health immunization clinic. Which of the following clients should the nurse plan to administer the meningococcal conjugate (MCV4) vaccine?

an 11-year-old school age child

E. 2 A nursing student has taught a colleague that nursing practice is not limited to hospital settings, explaining that nurses are now working in ambulatory health clinics, hospice settings, and homeless shelters and clinics. What factor has most influenced this increased diversity in practice settings for nurses?

Shift of health care delivery into the community

E.4 The nurse is educating a client who is recovering from pneumonia about ways to fight new infections. What education can the nurse provide to this client?

Eat a balanced diet and get adequate fluid intake, rest, and exercise

E. 3 Which factors would alert the nurse to negative/dysfunctional family dynamics?

Intimate partner violence

E.4 A nursing interventions that helps with respiratory care measures for RSV is:

Placing the patient in semi-fowlers

E. 1 A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels,= with an oral agent alone. The nurse is preparing.a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain?

Demonstrating the technique for insulin self-injection

E. 1 A mother of a toddler want to learn how to do CPR. what teaching strategy would be most effective in helping her learn?

Demonstration

E. 1 Classification of illness can occur with cultural practice. What is an example of an unnatural illness?

Evil forces caused a client to develop schizophrenia

E.3 A nurse is using the family was context approach to provide care to a patient. What should the nurse do next?

Assess how much the family provides the patient's basic needs

E.4 Studying for the NCLEX-RN examination is an example of which type of stressor?

Actue, Time limited

E.3 A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? Select all that apply

Administer oxygen 2L/min via nasal cannula Perform mouth care every hour Administer artificial tears PRN Provide skin care with a moisture barrier cream

E.4 A toddler is diagnosed with acute otitis medication and prescribed antipyretics and numbing ear drops. Which instruction is most important to teach the parents about treatment?

How to administer the ear drops

E.3 The nurse asked the patine who lives with her and will be helping to care for her when she is discharged. The patient states she lives with her husband, two children, and her grandmother. The nurse recognizes this family form as

Extended

E. 1 A nurse diabetes educator is planning an initial visit to a home care client who was recently diagnosed with diabetes mellitus. Which skills would the nurse help the client learn?

Planning an appropriate and consistent diet Self-administration of medication Self-monitoring of glucose levels

E. 2 The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

Post- Traumatic Stress Disorder

E. 2 Which of the following health care insurance programs is most suitable for a client 68 years of age?

Medicare

E. 1 The nurse is admitting a new patient to the unit. The nurse notes that this patient would need an alternate meat choice when the menu specified pork for a meal. What cultural group would require an alternative meal choice?

Muslim

E. 2 The client is being seen by her primary health care provider (PHCP). During the visit, the client states that being a single parent who works is stressful, and because of this, she feels chronically fatigued. The client also states that she feels anxious because she cannot find consistent day care for her child. The nurse wants to help the client with community resources. Which resource would be best for the client?

Names of child care facilities

E. 1 Mrs. Dupree is a 55-year-old patient with end-stage renal failure (kidney disease) who has asked to be taken off dialysis. She now shares with the nurse that she has mistreated her only daughter in the past and would like to reconcile this before she dies. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people?

Need for foregiveness

E. 2 The nursing student is assessing a community in regard to safety and security. Which of the following would be inappropriate for the nursing student to include under this basic need category?

Parks and Swimming pools

E. 2 A home health nurse is doing an initial visit for a patient sent home that is a fall risk, but was not sent home with an assistive aid. The home health nurse assists the patient with getting a walker for the patient to use at home. Which role is the nurse demonstrating?

Patient advocate

E. 2 A nurse caring for a client in a long-term health care facility measures the client's intake and output and weighs the client to assess water balance. These actions help to meet which type of need in Maslow's hierarchy of needs?

Physiologic

E. 1 A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent?

Primary prevention

E. 2 A nurse is collaborating with a team of community nurses to identify the vision and mission for community care. What is the central focus of community-based nursing?

Promoting and maintaining the health of individuals and families

E. 2 A man 75 years of age is being discharged to his home following a fall in his kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need?

Protecti9on from potential harm

E. 1 A nurse practitioner is teaching the student about sexual health and is evaluating the student's knowledge of sexual identity. The practitioner knows that the students understands when the student says which of the following?

" Gender role behavior is the behavior a person conveys about being male or female."

E.4 A nurse is assessing four clients for indications of general adaptation syndrome (GAS). Which of the following clients should the nurse monitor closely for GAS?

A 40-year-old client who has ulcerative colitis

E.3 A nurse on a medical-surgical unit is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grieving?

A client who is diagnosed with metastatic liver cancer

E.4 The nurse is caring for a client with an abscess on the back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physical will order to determine the type of bacteria present in the exudate?

A culture

E. 2 Which of the following is an example of a community factor that may affect health?

Air and water quality

E.4 What are classified as anti-invectives? Select all that apply

Antibiotics Antivirals Antifungals Antiprotozoals Anthelmintic agents

E.4 Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique?

Anticipatory guidance

E.4 Pneumonia is characterized boy all of the following except:

Caused by bacteria, viruses, and parasites

E.3 A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes Respiration's

E.4 A young adult client who has no significant prior health history has been prescribed antibiotics for the first time. What nursing diagnosis would be most appropriate for this client?

Deficient knowledge regarding drug therapy

E.4 The nurse is caring for a patient with a meningococcus infection.What type of precautions should be used for this patient?

Droplet

E. 1 A client has a cerebrovascular accident (CVA), resulting in flaccidity of the right side with aphasia. For this client, which interventions constitutes tertiary prevention?

Gait training and speech therapy

E. 1 The nurse is teaching a class of high school students about sexuality. After class the nurse is approached by Peggy, a 16-year-old female, who wvwntually discloses to the nurse that she has always had an inner sense that she was a male. The term for this is which of the following?

Gender Identity

E.4 The nurse is teaching a community group about emotions experienced with stress. What emotions will the nurse include in the teaching? Select all that apply

Helplessness Inadequacy Anxiety

E.3 A nurse is caring for a client who is 1 day postoperative following left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

Refusing to loot at the dressing or surgical incision

E.3 A senior college student visits the college health clinical about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress fActors. Which is the best response by the nurse?

" Give the freshman student this list of university and community resources."

E.3 A nurse is caring for a client who is experiencing grief following the unexpected death of his spouse. Which of the following statements by the client indicated he is experiencing maladaptive grieving?

" I have started smoking again."

E.4 A client on airborne precautions ask the nurse to leave the door open. What is the nurse's best reply?

" I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in."

E.3 A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?

" I just can't believe that this dialysis is going to ruin my whole life."

E.3 A nurse is leading a therapeutic group for clients at an outpatient mental health clinic. Which of the following client statements indicates a problem with role transition?

" I just can't seem to find any energy to take care of my children since my husband divorces me."

E. 3 A client has just been diagnosed with a brain tumor after recurring headaches prompted his physical to order a CT scan. The client may be experiencing the denial if he states:

" I really need to get back to my job because I'm falling behind on a lot of tasks."

E. 1 The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statements alerts the nurse to a need for clarification and further education?

" I will be doing well if I lose between 5 and 10 lbs per week."

E.4 A nurse is providing care for a client who seems anxious following a recent tragedy. Which of the following statements by the client reflects an maladaptive use of sublimation?

" I will work out in the gym every time I get mad about what happened."

E.3 A nurse is providing palliative care to a client whose partner asks why music therapy might help her. Which of the following responses should the nurse make? Select all that apply

" Music therapy works as a distraction and can help alleviate her pain." "Music therapy can help facilitate movement in some clients who have mobility limitations."

E.3 A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

" The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."

E. 1 A client is admitted to the hospital and the nurse is attempting to complete an admission assessment. The client reports that the spiritual healer will be coming in soon and is upset by the admission questions. What is the most appropriate response by the nurse?

" We can wait for your healer to come and then work together to answer these questions."

E.3 A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the clients family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?

" What do you think your spouse would have wanted?"

E. 3 The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family?

" You're hesitant about changing the dressing like I was before I was shown an easier way; would you like to see?"

E.4 A child diagnosed with acute otitis media has been given a prescription for benzocaine. The nurse is correct when she makes which statement?

"Benzocaine drops should be placed in your eat to numb it and reduce pain."

E.3 A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?

"Can you tell me the reason you get upset each time I go to the mall?"

E.3 A nurse is caring for a client who has cancer nadir receiving palliative care. Which of the following statements by the client indicated they understand this type of treatment?

"I am hoping this will limit my discomfort."

E. 1 The nurse is providing home care for a patient who traditionally drinks herbal tea to treat an illness. How should the nurse respond to a request for the herbal tea?

"Let me check with the doctor to make sure it is okay to drink the tea with your medications."

E.4 The nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?

"Make sure your family has all their childhood immunizations."

E.4 The nurse has been talking to a client who has had difficulty coping with a new situation. The nurse has met with the client a number of times but each time the client is reluctant to talk about the situation of the feelings associated with it. Which statement by the nurse would be most helpful to the client in this situation?

"Many people who have difficulty talking about a situation are able to write about it. I would suggest spending some time each day writing about your feelings."

E.3 A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?

"Respite care allows the primary caregiver time away from day-to-day care responsibilities."

E. 1 A nurse is trying to encourage a client with paraplegic who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate?

"What do you know about support groups?"

E. 1 A client from a minority culture has been hospitalized for 6 days for postoperative infection. The client's weight is decreased each day, and the nutrition intake is declining. Which nutritional assessment questions is most appropriate?

"What type of food do you eat at home?

E.3 The nurse planning to assess the structure of a family should ask which question?

"Who does the grocery shopping?"

E.3 A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statement should the nurse make?

"You may hold your baby as long as you want."

E.4 A toddler has been diagnosed with otitis media with effusion. The parents tell the nurse, " We really don't understand what that diagnosis means." How should the nurse respond?

"the diagnosis means unwanted fluid is within the middle ear space, and there may not be an infection present."

E.3 A nurse is caring for a group of clients on a mental health unit. Which of the following should the nurse recognize as a maladaptive defense mechanism?

A client forgets to schedule needed appointments when fearing chemotherapy

E. 2 A nurse demonstrates understanding of Healthy People 2030 by supporting which statement?

A client's health is affected by social, economics, and political factors

E.3 The nurse understands the single-parent family form includes all of the following scenarios except

A grandmother caring for her grandchild

E. 2 Which statement best describes health disparity:

A specific difference that is closely linked to social, economic, and/or environmental disadvantage

E.4 A nurse is caring for a 4-year0old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

A video game

E. 2 Which factors are most likely to affect health care access and health outcomes? Select all that apply.

Access to transportation Environmental safety Access to edcuation Familial support

E.1 A nurse is caring for a client who is upset after being told about a diagnosis of cancer. The clients asks the nurse to take a minute to pray, but the nurse is not a very religous person. What is the best action for this nurse?

Agree to pray with the client and stand in silence by the bed

E. 3 Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family?

Alternative

E.4 A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client.

An isolation room three doors from the nurse's station

E. 3 The nurse is providing discharge teaching for an older- adult patient who will need tube feedings at home.The spouse is the only source of care and states " I will not be able to perform the feedings due to arthritis." Which action should the nurse take?

Arrange for home care

E. 1 The nurse is assessing an older adult who immigrated at the age of 3 years. The client speaks the dominant language and lives in a neighborhood with many households from the country of origin. Which action by the nurse is most appropriate?

Ask the client about special cultural beliefs or practices

E. 2 The community nurse receives a call about a client who has been wandering the neighborhood alone and has been returned home by neighbors. On arrival the nurse observes pets in the home, cluttered floors, and the client is disheveled and confused. Which of the following is the nursing priority?

Ask what day, year, and month it is

E. 2 A homeless mother brings her 1-year-old child to an emergency clinic. The nurse caring for this child understands that children affected by homelessness are most at risk for which problems? Select all that apply.

Asthma Anemia Ear infection Diabetes Mellitus

E. 2 A home health nurse is preparing to make the initial visit to a new patient's home. When planning educational interventions, what information should the nurse provide to the patient and his or her family?

Available community resources to meet their needs.

E. 2 All of the following are factors to consider when caring for a clients with limited income. Which is the most important?

Basic human needs may go unmet

E. 2 A client is experiencing social isolation. Using Maslow's hierarchy of needs, identify the level that would correspond to this need?

Belongingness and affection

E.3 While at the bedside, the patient's family came to visit. During her introduction of her family members, the patient stated "this is my son Craig and my daughter Hope, and this is my bonus daughter Amanda!" The nurse recognizes this family core as which of the following

Blended

E. 1 A nurse is educating a 4-year old client about case care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?

Blocking 30 minutes of time for skill teaching

E.4 A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of Both legs. Which of the following conditions is the client displaying?

Bradykinesia's sign

E. 2 The nurse is performing an initial home visit on an elderly client in the community. Which observation of the client requires immediate attention?

Cluttered and unsanitary home

E.1 A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can give myself insulin." What domains of learning does the nurse identify for this client as having being successfully addressed by education?

Cognitive, affective, and psychomotor

E. 2 Which of the following statements accurately describes a characteristic of a community?

Communities are formed by the characteristics of people and other factors.

E. 2 Which statement best describes social determinants of health:

Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality or life outcomes and risks

E.2 Which of the following nursing activities will be most effective to help achieve the Healthy People 2020 guideline to eliminate health disparities among clients?

Conducting blood pressure screenings in an underserved area.

E. 1 Which term describes the tendency to impose one's cultural belief, values, and patterns of behavior on a person from a different culture?

Cultural imposition

E.4 A client is diagnosed with an infection. What would the nurse anticipate being used to determine the best drugs to treat infection?

Culture and sensitivity (C&S)

E. 3 A nurse ia caring for a client in the emergency department who had a traumatic amputation of his left arm in a industrial accident. The nurse should expect the client to be experiencing which of the following of Kubler-Ross's stages of grief?

Denial

E. 2 The nurse is discharging a client from the hospital following orthopedic surgery with a referral for home health. What action by the nurse would be performed during the entry phase of the home visit for this client? Select all that apply.

Develop rapport with the client and family Make an initial and thorough assessment Negotiate time for the next home visit

E. 2 Which statement best describes a vulnerable population

Disadvantaged subsegment of a community requiring utmost care, specific ancillary considerations, and augmented protection in research; includes those living in poverty, women, children, older adults, rural and inner-city residents, new immigrants, the homeless, mentally ill patients, and people with disabilities and special health care needs.

E.4 In children with otitis media, a procedure known as myringotomy may be performed. Which statement is most accurate regarding this procedure?

During this procedure, small tubes are inserted into the tympanic membrane

E. 2 A nurse is assessing a child that is homeless and lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely related to risk factors of homelessness?

Ears

E. 2 A nurse is performing a home visit for a client who lives alone with a history of being non-compliant for follow up visits and treatment in the community. During the visit what is the most important step the nurse should take?

Ensure the client understands the risks of noncompliance

E.4 When the rate of a disease spread beyond the normal level, it is known as a(n) ________. When the disease spreads from one continent to another it is known as a(n)___________.

Epidemic, pandemic

E. 2 A nurse uses Maslow's hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful?

Establishing priorities of care

E. 3 A nurse is working with a patient. When the nurse asks about family members, the patient states that it includes my spouse, children, and aunt and uncle. How will the nurse describe the type of family?

Extended

E. 3 The nurse is caring for an older adult patient who has no apparent family. Then questioned about family and the definition of family, the patient states, "I have no family. They're all gone." When asked, "Who's prepares your meals?" The patient states, "I do, or I go out." Which approach should the nurse use for this patient?

Family as context

E. 3 A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nursing using?

Family as system

E.3 The nurse's caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the needs for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using?

Family as system

E.3 The nurse is assessing the family unit to determine the family's ability to adapt to the change of a member having surgery. Which area is the nurse monitoring?

Family resillency

E.4 The nurse is assessing a 16-year-old client who acknowledges a high level of stress at both school and work. The client does not have many friends and is very shy. Which strategies can the nurse use to help the client with coping skills? Select all that apply

Give the client unconditional acceptance Teach the client a few problem-solving skills Provide the client with positive responses

E. 1 As the nurse enters the room to teach the client about self-care at home, the client states, " I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have the client rate pain level, and reschedule the teaching session

E. 4 A client who has had a traumatic experience states that he has no lasting effects from this experience. His wife disagrees. Which of the following will the nurse assess if the wife is correct about the tasting stress?

High blood pressure, palpitations

E. 2 A nurse is working as part of a team developing a community-based care program for the local homeless population. Which of the following would be important to keep in mind when developing the program? Select all that apply.

Homeless people often have no or insufficient health insurance Health problems are often related to a person's living situation. Ill homeless people often deteriorate more rapidly than those who are not homeless

E.4 Which are considered internal stressors? Select all that apply

Hormonal change Fear Illness

E.4 If a nurse assessed the vital signs of a person who ws in the initial alarm reaction stage (shock phase) of the general adaption syndrome, what would be the expected findings?

Hypertension

E.4 Culture and susceptibility tests are performed prior to the prescription of antimicrobial drugs. What Is the specific purpose of the culture test?

Identifies the organism causing the infection

E.3 A nurse is caring for a client who is experiencing a normal grief reaction following the loss of her spouse. Which of the following findings should the nurse expect?

Insomnia

E.4 The nurse is caring for a child who has conductive hearing loss. What is true regarding this type of hearing loss?

It is caused by chronic otitis media or another infection

E.1 A nurse is caring for a client who is preparing to undergo a left mastectomy. As the nurse performs the physical assessment, the client informs the nurse that she is unable to accept blood products as treatment due to her religion. The nurse interprets this as a belief of which religion?

Jehovah's Witnesses

E.4 A client comes to the clinic and reports frequent headaches and daily fatigue that is interfering with normal functioning. During collection of psychological history, the nurse notes a stressor sequence that may be caused the physical deviations. Which series of events represents a stressor sequence?

Job loss, bankruptcy, and loss of house

E. 1 Personal space and distance is a cultural perspective that can impact nurse-patient interactions. What is the best way for the nurse to interact physically with a patient who has a different cultural perspective on space and distance than their patient?

Know the patient's cultural personal space preferences.

E. 2 The nurse is preparing a talk on health issues in the LGBT population. Which statistics would the nurse include?

LGBT youth are 2 to 3 times more likely to attempt suicide.

E.3 A nurse is assessing a parent who lost a 12 year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?

Leaves the child's room exactly as it was before the loss

E.4 An adolescent describes a dysfunctional home life to the nurse and reports smoking marijuana to help cope with the situation. How will the nurse identify this form of coping?

Maladaptive

E. 1 Mr. Field is a 45- year-old man who has suffered a myocardial infarction (heart attack). Mr. Field provided for his family by working in the construction industry, which he will no longer able to do. He tells his nurse that he fears he will be of no use to anyone now. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people?

Need for meaning and purpose

E.4 Which area of nursing epeceriences the highest level of stress in the work setting?

New graduate nurses

E.1 A nurse is providing care to a client who is from a different culture. Which aspect about culture would be most important for the nurse to integrate into the client's care?

Not all members of the same culture act and think alike

E. 2 All of the following are examples of community factors affecting health except:

Number of colleges and universities

E.4 The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority deception should healthcare providers receive?

Performing hand hygeine

E.2 According to Maslow's basic human needs hierarchy, which needs are the most basic?

Physiologic

E.4 A client admitted with bacterial meningitis must be t6ranspirted to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, mask, and eye protection during suctioning, and then apply a mask to the client's face for transport

E. 1 Which statement best conveys the relationship between race and ethnicity?

Race denotes physical characteristics, while ethnicity is rooted on a common heritage

E.4 The client is a child age 5 years hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the denfense mechanism of:

Regression

E. 1 A nurse caring for a client of the Jewish faith knows the importance of asking about any food preferences when discussing diet. This is important for which reason?

Religios practices and beliefs can directly influence a client's self-care practices

E. 1 Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session inn a quiet environment

E. 2 The nurse should plan to take which action next after assessing a homeless pediatric client who is a victim of abuse?

Report signs of abuse and document it.

E.1 The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurses appropriate response?

Reteach the length of time to take the prescription

E.1 A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?

Return demonstration

E. 1 A nurse is providing client care on a rehabilitation unit that has an increasingly diverse population. What nursing actions would be appropriate when providing care to clients? Select all that apply.

Review available information and health practices of the common cultures in that area. Ask the client if they require any special diet or interventions while they are in the hospital. Keep in mind that clients may be members of multiple religious or cultural groups at the same time.

E.3 Family functioning can be threatened by structures that are

Rigid

E. 1 The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?

Role-playing

E. 2 A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make?

Safety of the immediate environment

E.4 A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to identified as the causative factor?

Staphylococcus aureus

E. 1 When a labor and delivery nurse tells a coworker that an Asian client probably dod not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as

Stereotype

E.4 The student nurse asks the nursing instructor to explain why stress an increase the risk of infection. The instructor explains:

Stress causes the body to release cortisol, which can increase the risk of infection

E.4 Selye's general adaptation syndrome (GAS) is a theory of adaptation to biologic stress. Selye compared the GAS with the life process: childhood, adulthood, and later years. What would occur during "adulthood" in the GAS?

Stressful events occur and resistance or adaption occurs

E. 3 When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding which aspect of the family?

Structure

E.4 A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

Sudden pain relief

E.4 The fight-or- flight response is a manifestation of the stress reaction caused by which part of the nervous system?

Sympathetic

E.3 A client is admitted with post-traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism?

The client begins reading a book when he experiences hand tremors in response to loud noise

E.3 A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief?

The client has help his partner's closet untouched since her death

E.3 A nurse scaring for a 48-year-old client who us grieving following the death of her husband seven months ago, The client reports that she has lost 30 lb. and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?

The client's husband died seven months ago

E. 2 The nurse is working in a very busy outpatient clinic that cares primarily for uninsured clients. The nurse plans care knowing that the most likely reason for this clinic being so busy is which factor?

The clients lack access to preventive health care.

E. 2 Based on a community assessment, the nurse has set the following outcomes. Which outcome reflects Maslow's level of safety and security needs?

The community will establish an effective wastewater disposal system by January 22.

E. 2 What is the best example of community-based nursing?

The nurse visits a mother and her newborn baby to ensure satisfactory bonding,

E.3 A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lbs in the past 2 months

E. 1 A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone the teaching session? Select all that apply

The patient is hurting The patient is fatigued The patient is febrile (high fever)

E.4 After teaching a group of parents about ear infections in children, which statement indicated that the teaching was successful?

The short and wider Eustachian tubes of an infant increase the risk

E.3 A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? Select all that apply

The shoulders droop The facial muscles relax The pulse is within the expected range

E. 1 A client scheduled for complex heart surgery had been reading the Bible for hours each day, cries often, and is not sleeping well. What might these observations cur the nurse about the client?

These behaviors are signs of spiritual distress

E.3 The nurse is interviewing a patient who is being admitted to the hospital. The patient's family went home before the nurse's interview. The nurse asks the patient, "Who decides when to come to the hospital?" Wha is the rationale for the nurse's action?

To assess the family structure

E. 1 A diebetes nurse educator is teaching a client, newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education?

To help the client develop self- care abilities

E.4 The nurse is preparing to perform hand washing. Place the following steps in the correct order

Turn on the faucet and adjust force and temperature of the water Wet the hand and wrist areas Apply soap Wash the palms and backs of the hands for at least 15 seconds Pat hands dry with paper towel Turn the faucet off with a paper towel

E. 2 The nurse is caring for diverse population groups at a health clinic. Which of the following patients demonstrates a potential health disparity group?

a 30-year-old immigrant who does not speak English

E.4 A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

confusion

E.1 When providing patient teaching it is essential for the nurse to incorporate what action so that learning can be optimized?

include teaching strategies that encourage patients to be active participants

E. 2 A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community?

it offers access to health care services

E. 1 A public health nurse administers influenza vaccines to a group of individuals during a community vaccination clinic. The nurse understands that this action is considered primary prevention due to which statement?

the vaccination focuses on health promotion and prevention of illness

E. 1 Which group of terms best defines spiritual distress?

Alienation, despair

E. 1 A client who does not speak the dominant language is admitted to the hospital. Which cultural intervention would be most appropriate by the nurse?

Call for an interpreter who is familiar with health care

E. 1 A 20-year-old client newly diagnosed with type 1 diabetes needs to learn how to self - administer insulin.g When planning the appropriate educational interventions and considering variables that will affect the client's learning, the nurse should prioritize what factor?

Client's culture

E. 2 A community nurse goes to visit an elderly client living alone. The client's spouse passed away 6 months ago and since then the client has had a 20 lb weight gain and reports the inability to cook and eats out a lot. Further assessment reveals the client has not seen a provider in 2 years, is on a limited income, and does not participate in any social activities. The nurse understands that Mr. Thomas would benefit most from which of the following?

Consultation with a provider

E. 1 You are caring for Carol, a hospice patient, who tells you that she is worried about how she has treated a younger sister. She asks you how to make things right. You recognize this as which of the following spiritual needs?

Foregiveness

E. 1 The nurse is preparing a talk on health issues in the LGBT population. Which statistics would the nurse include?

LGBT youth are 2 to 3 times more likely to attempt suicide. Lesbians are more likely to get preventative services for cancer

E. 2 Although the life expectancy has increased, Healthy People 2020 will focus on the older adult's need for:

Maintainance of independent lifestyles

E. 1 Which nursing activity reflects secondary prevention?

Making a referral for a mammogram

E. 3 A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient's family. Which action should the nurse take to help relieve stress?

Provide education

E. 2 The nurse is working in a poverty-stricken neighborhood and sees several adolescents in the practice. What are possible consequences for the adolescents living in this area? Select all that apply.

To be a victim of ciolence Use tobacco prodicuts Drink alcohol Engage In sexual behaviors with multiple partners

E. 2 Nursing interventions when caring for the homeless are aimed at evaluating the health care needs of people who live in shelters and attempting to obtain health care services for those who are homeless.

True

E. 2 A transgender client is following up with the primary health care provider (PHCP). The nurse caring for this client recognizes the best way to deliver care is to employ which approach?

Use the client's preferred pronoun to address him or her.

E. 2 Which group represents a growing proportion of those who are homeless?

Women with children