Basics of Nursing Practice EAQ
What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 1 Achievement of a personal philosophy 2 Adaptation to the children leaving home Correct3 Attainment of a sense of worth as a person 4 Adjustment to life in an assisted-living facility
3 Attainment of a sense of worth as a person Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth . Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.
When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty Correct4 False imprisonment
4 False imprisonment False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.
To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) Correct1 Encourage ambulation 2 Give sips of ginger ale Correct3 Auscultate bowel sounds 4 Provide a straw for drinking 5 Offer an opioid analgesic
1 Encourage ambulation 3 Auscultate bowel sounds Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) 1 Difficulty in swallowing Correct2 Diminished sensation of pain 3 Heightened response to stimuli Correct4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat
2 Diminished sensation of pain 4 Impaired hearing of high-frequency sounds Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affect an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.
Considering Erikson's developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with: 1 Mastering his environment 2 Identifying with the male role Correct3 Developing meaningful relationships 4 Differentiating himself from the environment
3 Developing meaningful relationships Developing meaningful relationships is the young-adult task associated with intimacy versus isolation. Mastering his environment is a toddler's task associated with autonomy versus shame and doubt. Identifying with the male role is a preschool-age child's task associated with initiative versus guilt. Differentiating himself from the environment is a toddler's task associated with autonomy versus shame and doubt.
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? Correct1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications
1 Encouraging daily physical exercise Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. Correct2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.
2 Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 diminished. 2 normal. Correct3 full. 4 bounding.
3 full. The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected/normal pulse, and a 4+ rating is a bounding pulse.
A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.) Correct1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" Correct4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?"
1 "What is diabetes?" 4 "Can you tell me how the glucose monitor works?" Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.
A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1 Arrangements will be made by the client and the client's family. Correct2 The plan is formulated and implemented early in the client's care. 3 The rehabilitation is minimal and short term because the client will return to former activities. 4 Arrangements will be made for long-term care because the client is no longer capable of self-care.
2 The plan is formulated and implemented early in the client's care. To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the health care system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. Correct3 Cause the device to pull away from the skin. 4 Tear the ileal conduit.
3 Cause the device to pull away from the skin If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine , or tear the ileal conduit .
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. 2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. Correct3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.
3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.
A nurse preparing to apply restraints to a client should understand which of the following principles? 1 The law prohibits restraining clients until a written prescription is obtained. 2 Charges of felony may be leveled against nurses who use restraints improperly. 3 Nurses are not obligated to report institutions that use restraints unlawfully. Correct4 Charges of assault and battery may be leveled against nurses who use restraints improperly.
4 Charges of assault and battery may be leveled against nurses who use restraints improperly. Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid healthcare provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint orders may differ from state to state and in different settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to report institutional misuse of restraints since this may constitute false imprisonment and abuse.
A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? 1 Advising the client to join a support group immediately after discharge. 2 Assuring the family that staff members will take care of the client's needs. 3 Reminding the client to keep medical follow-up appointments after discharge. Correct4 Conducting a multidisciplinary staff conference early during the client's hospitalization.
4 Conducting a multidisciplinary staff conference early during the client's hospitalization. Collaboration of all team members involved in the client's care early during hospitalization will allow for efficient planning of care and help prepare for discharge. The client may or may not be ready to join a support group at that time. Assuring the family that staff members will take care of the client's needs may promote dependence. The client should be encouraged to assume self-care gradually. Although this should be done eventually, it is not the priority at this time.
What are the best ways for a nurse to be protected legally? (Select all that apply.) 1 Ensure that a therapeutic relationship with all clients has been established. Correct2 Provide care within the parameters of the state's nurse practice act. 3 Carry at least $100,000 worth of liability insurance. Correct4 Document consistently and objectively. Correct5 Clearly document a client's non-adherence to the medical regimen.
Correct2 Provide care within the parameters of the state's nurse practice act. Correct4 Document consistently and objectively. Correct5 Clearly document a client's non-adherence to the medical regimen. Malpractice or negligence must be proven legally. If a nurse is providing the best possible care under the circumstances, and within the scope of nursing practice, it would be difficult to prove allegations of malpractice. It is unrealistic that the nurse will have a therapeutic relationship with all clients. Liability insurance protects the nurse if found guilty and a monetary award is made, but it does not reduce the possibility of litigation. Consistent, objective, and clear documentation also support practice within legal parameters.
