Elsevier Adaptive Quizzing Fundamentals Fall Semester 226

Which findings in the older client are associated with a urinary tract infection (UTI)? Select all that apply. 1 Fever 2 Urgency 3 Confusion 4 Incontinence 5 Slight rise in temperature

3, 4, 5 An older client with a urinary tract infection (UTI) is likely to appear confused. An older client may experience incontinence while a younger client may experience urgency. The older client may develop a slight rise in temperature. The classic symptoms of a UTI in a younger client are fever, dysuria, and urgency.

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 1 "I should serve food that is easy to eat." 2 "I should assist the client with eating." 3 "I should monitor weight and food intake once in a month." 4 "I should offer food supplements that are tasty and easy to swallow."

3. "I should monitor weight and food intake once in a month." The nurse should monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse should serve food that is easy to eat provide assistance with eating. The nurse should also offer food supplements that are tasty and easy to swallow.

A student nurse is listing the different aspects of the healthcare services pyramid. Under which type of healthcare services should the student nurse include sports medicine? 1 Primary care 2 Tertiary care 3 Preventive care 4 Restorative care

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A nurse preceptor is evaluating a nurse who is preparing to administer digoxin intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse doing what? 1 Checking the serum potassium level 2 Verifying the serum level of digoxin 3 Piggybacking the digoxin in an existing infusion 4 Administering the dose over a 5-minute time period

3 The nurse preceptor needs to stop the nurse because this action is unsafe. The manufacturer recommends that digoxin be infused alone, because there may be an incompatibility with other medications. A low serum level of potassium and the administration of digoxin can cause toxicity. An elevated serum level of digoxin and the administration of another dose of digoxin can result in toxicity. Digoxin IV is given over a 5-minute period through a Y-site connector.

Which nursing process involves delegation and verbal discussion with the healthcare team? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

4 The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? 1 "I will avoid the pooling of urine in the tubing." 2 "I will avoid prolonged clamping of the tubing." 3 "I will avoid draining urine from the tubing before ambulation." 4 "I will avoid raising the drainage tube above the level of the bladder."

3 Urine should be drained [1] [2] from the tubing into the drainage container before ambulation or exercise. Pooling of the urine in the tubing should be avoided because this action may increase the risk of infection. Prolonged clamping of the tubing should be avoided because intermittent clamping helps to maintain the bladder's capacity and tone. The drainage tube should not be raised above the level of the bladder; urine should flow freely by way of gravity.

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1 Private room 2 Semiprivate room 3 Room with windows that can be opened 4 Negative-airflow room

4 Tuberculosis is an airborne contagious disease that is best contained in a negative-airflow room. Negative-airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

Which subdimension would form a part for the caring process "doing for" according to the Swanson's theory of caring? Select all that apply. 1 Focusing 2 Protecting 3 Comforting 4 Seeking cues 5 Generating alternatives

2, 3 Protecting and comforting are the subdimensions of "doing for" according to the Swanson's theory of caring. Focusing is the subdimension of the caring process "enabling." The subdimensions of "seeking cues" and "generating alternatives" are appropriate for the caring process "knowing."

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? 1 It shows empathy. 2 It uses distraction. 3 It gives false reassurance. 4 It makes a value judgment.

3 A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1 Don an N95 respirator mask before entering the room. 2 Put on a permeable gown each time before entering the room. 3 Implement contact precautions and post appropriate signage. 4 After finishing with client care, remove the gown first and then remove the gloves.

1 A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? 1 The baby has a head lag when pulled to sit. 2 The baby can turn from the side to the back. 3 The baby can turn from the abdomen to the back. 4 The baby supports much of his own weight when he or she is pulled to stand.

1 A normal five-month-old infant should be able to sit up without a head lag. This finding should cause the nurse to conduct a further assessment. A baby should be able to turn from the side to the back by four months of age. At five months of age, the baby should be able to turn from the abdomen to the back. The baby should be able to support much of his own weight when pulled to stand by the age of five to six months.

*According to the most recent Diagnostic and Statistical Manual of Mental Disorders, which statement is correct? 1 Prevalence of gender dysphoria ranges from five to 14 in 1,000 natal males. 2 Prevalence of gender dysphoria ranges from three to five in 1,000 natal females. 3 Prevalence of transgender people is between one in 11,900 and one in 200,000 people. 4 Prevalence of invasive cancer of the cervix is the third most common cancer of the female genital system found in transwomen.

1 According to the Diagnostic and Statistical Manual of Mental Disorders ( DSM) prevalence of gender dysphoria ranges from five to 14 in 1,000 natal males. Prevalence of gender dysphoria in 1,000 natal females ranges from two to three as per the DSM. Prevalence of transgender people is between one in 11,900 and one in 200,000 people, but this data is not present in the DSM. According to the Centers for Disease Control and Prevention, not DSM, invasive cancer of the cervix is the third most common cancer of the female genital system after ovarian and uterine cancers. It is not specific to one transwomen population.

What can be inferred when a professional is said to have ethical sensitivity? 1 The professional has the ability to recognize ethical dilemmas. 2 The professional has the ability to take a morally correct action. 3 The professional has the ability to justify a well-reasoned action. 4 The professional has the ability to think critically to rank ethical obligations.

1 Ethical sensitivity helps to recognize if there is an ethical dilemma or issue. Ethical decision-making helps to take morally correct action through reasoning and justification. The ability to think critically to rank ethical obligations is called ethical reflection and analysis.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1 Orient the client to the unit environment. 2 Have a copy of hospital regulations available. 3 Explain that there is no reason to be concerned. 4 Reassure the client that the staff is available if the client has questions.

1 Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available and reassuring the client that the staff is available to answer questions are part of orienting the client to the unit. Explaining that there is no reason to be concerned may be false reassurance because no one can guarantee that there is no reason to be concerned.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? 1 Keeps the area free of microorganisms 2 Confines microorganisms to the surgical site 3 Protects self from microorganisms in the wound 4 Reduces the risk for growing opportunistic microorganisms

1 Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound apply to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

The nurse provides back massage therapy to a client complaining of back pain. The nurse then monitors the client on an hourly basis to check if the client is feeling comfortable. Which standard of practice does the nurse perform? 1 Evaluation 2 Consultation 3 Coordination of care 4 Outcomes identification

1 When the nurse evaluates progress toward attainment of outcomes, it is referred to as evaluation. When the nurse monitors the client on an hourly basis to check if the client is feeling comfortable after giving a back massage, this is considered evaluation. Consultation is when a nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change. Coordination of care is when a nurse coordinates care delivery with other team members. Outcomes identification is when a nurse identifies expected outcomes for a plan individualized to the client or the situation.

The registered nurse tells a nursing student, "In the nursing model, the registered nurse is responsible for all aspects of care for one or more clients during a shift of care and the care can be delegated." Which disadvantage would be most likely related to this nursing model? 1 The continuity of care is a problem. 2 The registered nurse doesn't spend enough time with the client. 3 The team leader needs to take time to delegate work. 4 The associate nurse cannot change a care plan without consulting the primary nurse.

1 When the registered nurse is responsible for the care aspects of one or more clients during a shift of care, the nursing model of total client care may come into practice. The lack of continuity of care is a disadvantage of this model. The registered nurse may not spend the time with the client as a team leader in the 'team nursing' model. Another disadvantage associated with this model is that the team leader may also require taking extra time to delegate work to the team. The primary nursing model does not involve the associate nurse changing the care plan without a discussion with the primary nurse.

A nursing student is listing the characteristics of various health models that are used in the healthcare setting. Which characteristics of the holistic health model are accurately described? Select all that apply. 1 "According to this model, clients are involved in their own healing process." 2 "According to this model, the natural healing abilities of the body are used." 3 "According to this model, therapy is used alone or in conjunction with conventional medicine." 4 "According to this model, each person has unique personal characteristics and experiences that affect subsequent actions." 5 "According to this model, self-actualization is the highest expression of one's individual potential and allows for continual self-discovery."

1, 2, 3 In the holistic health model, clients are involved in their own healing process. The natural healing abilities of the body are used in the holistic health model. Nurses use the holistic health model therapy either alone or in conjunction with conventional medicine. The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. According to Maslow's Hierarchy of Needs, self-actualization is the highest expression of one's individual potential and allows for continual self-discovery.

A nurse is caring for an obese client with diabetes mellitus. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called teamwork and collaboration? Select all that apply. 1 Engaging the physical therapist in managing the client's condition 2 Explaining the client's medication routine to the next shift nurse 3 Consulting with the dietician to help manage the client's condition 4 Consulting old records of similar client cases before preparing a care plan 5 Documenting in the electronic health record after administering every medication

1, 2, 3 To satisfy the Quality and Safety Education for Nurses (QSEN) competency called teamwork and collaboration, a nurse should be able to work effectively within the nursing and interprofessional teams by promoting open communication, mutual respect, and shared decision-making. The nurse should collaborate with the physical therapist to provide quality care. By communicating essential details of client care (such as the medication administration routine), the nurse satisfies the teamwork and collaboration competency. The nurse consults with the dietician to take a shared decision in the interests of the client. The nurse satisfies the evidence-based practice competency by integrating best current evidence with clinical expertise. In the given situation, the nurse integrates the result of case studies with the care plan to achieve optimal client care. Documenting the medications administered to the client n the electronic health record, for future reference satisfies the informatics competency.

What are the minor attributes that affect the quality of care provided for the client by the nurse? Select all that apply. 1 Timely care 2 Equitable care 3 Cost-effective care 4 Patient-centered care 5 Sound decision-making

1, 2, 4 Being equitable, being timely, and patient-centered care are the minor attributes that affect the quality of care. Equitability helps the nurse provide similar quality of care to all the clients irrespective of their gender, ethnicity, geographic location, or socioeconomic status. Being timely reduces the wait times and harmful delays in treatment. Patient-centered care helps nurses treat clients with respect and dignity and to make the client feel comfortable. Cost-effective care and sound decision-making are the major attributes that affect the quality of care.

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? Select all that apply. 1 Gloves 2 Gown 3 Mask 4 Goggles 5 Shoe covers 6 Hair bonnet

1, 2, 4 Standard PPE, which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. A mask would be necessary if the client had MRSA of the nares. Shoe covers and hair bonnet are not required for the client care situation described.

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply. 1 Providing meticulous skin care 2 Reducing shear forces and friction 3 Providing beverages and snacks frequently 4 Using a support surface base all the time 5 Avoiding pressure with proper positioning

1, 2, 5 Providing an older adult with meticulous skin care may reduce the risk of skin breakdown. Reducing shear forces and friction prevents the development of pressure ulcers. Pressure can be avoided with proper positioning. Beverages and snacks are frequently provided to clients who are hospitalized due to dehydration. A supportive surface base is used based on risk factors.

Which nursing interventions enhance comfort in an imminently dying client in the hospital? Select all that apply. 1 Frequently repositioning the client 2 Maintaining oral hygiene in the client 3 Limiting frequent visits of the family members 4 Measuring the vital signs of client frequently 5 Applying body lotion to the client's skin daily

1, 2, 5 The nurse provides comfort care to the client who is in the process of dying to ensure client comfort. Prolonged bed rest may cause back pain and skin issues; to reduce the pain, the nurse frequently repositions the client on the bed. Poor oral and skin hygiene may cause discomfort to the client, so the nurse carefully maintains the client's oral and skin hygiene. The nurse does not limit the visitation of family members because these visits may reduce the client's emotional stress. There is no need to measure the vital signs regularly in an imminently dying client, and doing so may increase discomfort in the client.

A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client's infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply. 1 Using informatics 2 Applying quality improvement 3 Using evidence-based practice 4 Providing patient-centered care 5 Working in an interdisciplinary team

1, 3, 4 According to the Institute of Medicine (IOM) competencies of the twenty-first century, the nurse should use informatics to provide better client care. This involves using information technology to communicate, manage knowledge, reduce errors, and support decision-making. The nurse in the given situation uses informatics to keep track of the client's recovery. A nurse should also use evidence-based practice to improve client care. This includes activities such as conducting research and integrating the best research with clinical practice and client values. The nurse in the given situation displays this competency by conducting extensive research about the client's condition to prepare the care plan. A nurse is required to provide patient-centered care. Relieving pain and suffering, coordinating continuous care, advocating for disease prevention and health promotion, and educating clients are examples of nursing activities related to patient-centered care. The nurse in the given situation performs this task by educating the client about hygiene maintenance.

While assessing the vital signs of an elderly alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. What other findings does the nurse expect to observe? Select all that apply. 1 Body temperature of 84.2 °F 2 Body temperature of 100.6 °F 3 Blood pressure of 100/62 mmHg 4 Respiratory rate of 12 breaths/minute 5 Respiratory rate of 16 breaths/minute

1, 3, 4 Alcohol acts as a vasodilator in the body; therefore, it causes dilation of surface blood vessels and results in hypothermia due to loss of body heat. However, the skin of the alcoholic client gives a false sensation of warmth, even while the client shows symptoms of hypothermia. Therefore the nurse finds the body temperature of the client is less than 86 °F. Cardiovascular collapse can result in clients with severe hypothermia. During severe hypothermic conditions, the blood pressure of the client decreases. Hypothermia lowers the respiratory rate; therefore, the client may have a respiratory rate of 12 breaths/minute. As the client does not have hyperthermia, he or she does not have a body temperature of 100.6 °F. The normal respiratory rate for elderly clients is in the range of 12 to 18 breaths per minute. Individuals with hypothermia may not have a normal respiratory rate of 16 breaths/minute.

What are the major attributes of quality health care? Select all that apply. 1 Safe 2 Timely 3 Effective 4 Efficient 5 Equitable

1, 3, 4 The attributes of health care can be major and minor. The major attributes are indispensable to maintain the quality of health care and include safe, effective, and efficient care. Health care is said to be of high quality if the care is safe and does not harm the client. Health care is effective in reaching its client goals. Health care should be efficient in terms of time, energy, and resources engaged in providing the care. The minor attributes of quality care include timely and equitable care. Timely care helps in preventing errors and avoiding complications. High-quality care is provided to all people who deserve it, irrespective of any discriminating factor.

What are the purposes of public health laws? Select all that apply. 1 Advocating for the rights of people 2 Prohibiting the purchase or sale of organs 3 Regulating health care and healthcare financing 4 Ensuring professional accountability for the care provided 5 Encouraging healthcare professionals to assist in emergencies

1, 3, 4 The primary purposes of public health laws are advocating for the rights of people, regulating health care and healthcare financing, and ensuring professional accountability for care that is provided. Public health laws help protect the health of the public. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. Good Samaritan laws are enacted to encourage health care professionals to assist in emergencies.

The mother of an 11-month-old infant reports that the baby has allergies. After an assessment, the primary healthcare provider also suspects anemia. Which questions would the primary healthcare provider most likely ask the mother? Select all that apply. 1 Do you use 2% cow's milk? 2 Do you breastfeed? 3 Do you use whole cow's milk? 4 Do you use alternate milk products? 5 Do you provide 18 to 21 ounces of breast milk per day?

1, 3, 4 The use of 2% or whole cow's milk in an infant younger than 12 months is not recommended because it may cause intestinal bleeding, anemia, and allergic reactions. Mothers should avoid using any alternate milk products because their use may cause complications in the infant. Breast feeding is recommended for the infant's nutrition because breast milk contains essential proteins, fats, carbohydrates, and immunoglobulins that help bolster the infant's ability to resist infection. An average infant of one month old should have 18 to 21 ounces of breast milk or formula per day.

A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give? Select all that apply. 1 "A nurse's documentation is the evidence of care that a client receives." 2 "Nurses' notes should not be given to attorneys in the event of a lawsuit." 3 "The nurse should note down assessments and significant changes in the client's health." 4 "In case an occurrence report is filed, nurses should enter the information the client's charts." 5 "Nurses should always document the primary healthcare providers' responses whenever they are contacted."

1, 3, 5 To perform risk management, nurses should always complete documentation in the appropriate manner. A nurse's documentation is considered to be an evidence of care received by a client. Documenting assessments and significant changes in the client's health are essential because this information helps to defend nurses in lawsuits. Nurses should document that the primary healthcare provider was contacted and document the provider's response to the situation at hand. Attorneys often review nurses' notes first if a lawsuit is filed. Nurses should never document that an occurrence report has been completed in a client's chart.

Which assessments should the nurse perform while assisting an older adult with housing needs? Select all that apply. 1 Assessing financial status 2 Assessing meaningful activities and interest 3 Assessing environmental hazards and support systems 4 Assessing long range plans such as wills and advance directives 5 Assessing access to public transportation and community activities

1, 3, 5 When assisting an older adult with his or her housing needs, the nurse should assess the client's financial status, environmental hazards, support systems, and access to public transportation and community activities. When an older adult is planning for retirement, the nurse should assess the client's meaningful activities and interest and long range plans including wills and advanced directives.

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. 1 Chemotherapy 2 Repositioning 3 Regular oral care 4 Blood transfusion 5 Radiation therapy

1, 4, 5 Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a client who is about to die and is receiving end-of-life care. End-of-life care comprises measures to make the client as comfortable as possible. It may include measures such as regular oral care and repositioning.

What purpose does block and parish nursing serve in preventive and primary care services? 1 Block and parish nursing provides services to older clients or those who are unable to leave their homes. 2 Block and parish nursing provides primary care to a specific client population that lives in a specific community. 3 Block and parish nursing provides nursing services with a focus on health promotion and education as well as on chronic disease. 4 Block and parish nursing provides services aimed at increasing worker productivity, decreasing absenteeism, and reducing the use of expensive medical care.

1. Block and parish nursing provides services to older clients or those who are unable to leave their homes.

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? 1 Sodium 2 Potassium 3 Calcium 4 Calcitonin

2 A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1 Discharge planning is not covered by insurance. 2 If the client cannot consent to the client's own surgery. 3 Postoperative complications occur that require additional treatment. 4 In case of the client's death, there will be directions about which of the client's belongings are to be given to family members.

2 Advance directives allow clients to designate another person to consent to procedures if the client is unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1 Evaluation 2 Assessment 3 Nursing interventions 4 Proposed nursing care

2 An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? 1 Binder 2 Ice bag 3 Elastic bandage 4 Warm compress

2 Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage on the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain. Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1 Anger 2 Denial 3 Bargaining 4 Depression

2 Denial includes feelings that the healthcare provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

While caring for a client dealing with pain, the nurse assesses the health status and prioritizes his or her needs. Which phase of the helping relationship is observed? 1 Working phase 2 Orientation phase 3 Termination phase 4 Preinteraction phase

2 During the orientation phase, the nurse assesses the health status of the client and prioritizes his or her needs. During the working phase, the nurse encourages and helps the client to set treatment goals. In the termination phase, the nurse evaluates the achievement of treatment goals with the client. In the preinteraction phase, the nurse reviews the client's medical and nursing history and talks to the caregivers.

Which statement defines the term family resiliency? 1 Family resiliency is the uniqueness of each family. 2 Family resiliency is the ability of the family to cope with stressors. 3 Family resiliency is the intrafamilial system of support and structure. 4 Family resiliency is the ability of the family to transcend.

2 Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.

A nurse understands that the effects of different variables on a client's health beliefs and practices can help healthcare providers to plan and deliver individualized care. Which statement made by the client should the nurse consider as an influence of the client's intellectual background on his or her health beliefs? 1 "Don't include seafood or ham in my diet because it is against my beliefs." 2 "Don't include eggs in my diet because eggs contribute to excess body heat." 3 "I do not smoke or drink because these intoxicants are major sins." 4 "I am not taking any of my prescribed medications because I recently lost my job."

2 If the client states that eggs should not be included in his or her diet because they cause excess body heat, this statement is an example of the influence of the client's intellectual background on his or her health beliefs. If the client states that seafood or ham should not be included in his or her diet because it is against his or her beliefs, this statement is an example of the influence of the client's cultural background on his or her health beliefs. If the client says that he or she does not smoke or drink because these drugs are a major sin, this statement is an example of spiritual factors influencing his or her health beliefs and practices. If the client says that he or she has stopped taking prescribed medications because he or she has recently lost their job, this statement is an example of the client's socioeconomic influence on his or her health beliefs and practices.

The nurse is getting ready to perform an initial assessment interview of a Chinese older adult who does not speak English. The client has a tibial fracture and is hard of hearing. Which should be available before starting the interview in order to minimize communication problems that may lead to health disparity? 1 Wheelchair and hearing aid 2 Hearing aid and interpreter 3 Interpreter and sphygmomanometer 4 Wheelchair and sphygmomanometer

2 In order to minimize communication problems leading to health disparities between the client and the nurse, a hearing aid and an interpreter should be available. A client with a broken leg will have limited mobility and may need a wheelchair, but this has no role in eliminating communication barriers. A sphygmomanometer is required to measure blood pressure, but it will not improve communication.

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what? 1 Double the intake of vitamin C. 2 Remove loose rugs from the environment. 3 Avoid taking showers until the cast is removed. 4 Increase weight bearing on the injured leg gradually.

2 Loose rugs can interfere with crutch walking and cause a fall; they should be removed to prevent further injury. Calcium rather than vitamin C is encouraged to enhance bone healing; vitamin C minimizes capillary fragility. It is not within the legal role of the nurse to encourage the client to increase the dose of any medication without a healthcare provider's prescription. The client may shower if the cast is protected from becoming wet. Decisions regarding weight bearing are a medical, not a nursing, responsibility.

A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? 1 Treat all clients equitably and fairly. 2 Act in ways to prevent harm to clients. 3 Tell the client the truth about their health. 4 Help the clients to make informed choices.

2 Nonmaleficence means to act in ways that prevent client harm or even the risk of harm. Telling the truth to clients about their health refers to veracity. Helping clients make informed choices promotes autonomy. Justice involves treating all clients equitably and fairly.

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1 Skin breakdown 2 Aspiration pneumonia 3 Retention ileus 4 Profuse diarrhea

2 Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

A nurse is caring for an older adult with dementia who has been admitted in the special ward for further treatment. Which situation should the nurse address to meet the safety and security needs of the client according to Maslow's hierarchy of needs? 1 "Since my teeth hurt when I eat, I drink fruit juices and prefer a liquid diet." 2 "I do not want to talk to any stranger as I fear that they might take away my things." 3 "My blood pressure level keeps on fluctuating, although I take medications regularly." 4 "Ever since my family members came to know about my problem they are trying to avoid me."

2 The nurse should attend to the safety and security needs of the client by addressing the client's fear of strangers. When the client says that he/she is on liquid diet, the nurse should consider this as a possible lack of nutrition. This is a physiological need. When the client says that his/her blood pressure level fluctuates, the nurse should consider this as an example of physiological needs. When the client says that his/her family members avoid him/her as he/she has dementia, the nurse should understand this to be a love and belonging need.

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1 "I don't mind it." 2 "You seem upset." 3 "This is part of my job." 4 "Nurses get used to this."

2 The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negates the client's feelings and presents a negative connotation.

A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent? 1 Clients with mental illness are not allowed to give consent. 2 Clients with mental illness have the right to refuse treatment. 3 Family members of the client need to give consent for all procedures. 4 Primary healthcare providers may perform procedures without consent.

2 The nurse should know that a client with a mental illness has the right to refuse treatment until a court rules that he/she is incompetent for making health related decisions for himself/herself. The nurse should also remember that even clients with mental illnesses have to give their consent for medical procedures. Family members may give consent only if they are the healthcare proxies of the client. Primary healthcare providers should not perform procedures without the consent of the client.

The quality analysis team has implemented the root cause analysis (RCA) tool in the hospital. The nurse recognizes that the tool will be useful in which case? 1 A client died after end-stage lung cancer. 2 A client died due to nosocomial infection. 3 A client was rescued while falling from the bed. 4 A client developed skin rashes after receiving medication.

2 The root cause analysis tool is used when a medical error resulted in death or serious harm to the client. Nosocomial or hospital-acquired infections usually occur due to the failure to maintain asepsis while providing care to the client. Therefore the RCA tool would be used to analyze the cause in this case. Death is an expected and normal consequence of end-stage lung cancer. This tool would not be used to assess the cause of death for this client. The client was rescued while falling off the bed. This is an instance of a near-miss event, which was not analyzed using the RCA tool. Skin rashes may be a normal side effect of a medication and is not caused by a medical error. Thus this case would not be analyzed using the RCA tool.

*The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? 1 "I should encourage fluid intake." 2 "I should provide conditional positive support." 3 "I should promote social interaction based on abilities." 4 "I should provide ongoing assistance to family caregiver."

2 When caring for cognitively impaired older adult, the nurse should provide unconditional positive support and respect. The nurse should encourage the client to drink fluids. The nurse should promote social interactions based on abilities. The nurse should provide ongoing assistance to family caregivers, educate them in nursing care techniques, and inform them about community resources.

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which activities should the nurse perform to meet the client's safety and security needs? Select all that apply. 1 Providing a cold bath to reduce the client's body temperature 2 Positioning the bed in a low position and keeping the side rails up 3 Monitoring vital signs, such as blood pressure to decrease the risk of falls 4 Observing a client who has suicidal tendencies to prevent adverse incidents 5 Collaborating with family members to provide emotional support for the client post-surgery

2, 3, 4 As per Maslow's hierarchy of needs, to meet the safety and security needs of the client, the nurse should position the bed in a low position and keep the side rails up to provide physical safety for the client. Monitoring vital signs, including blood pressure to prevent risk for falls is an example of a nursing activity that meets the client's safety and security needs. Observing a client who has suicidal tendencies to prevent adverse incidents is an example of a nursing activity that meets the client's safety and security needs. Providing a cold bath to the client to reduce body temperature is an example of a nursing activity that meets the client's physiological needs. Collaborating with family members to provide emotional support to the client post-surgery is an example of a nursing activity that meets the client's love and belonging needs.

What principal components are associated with a nurse's time management skill? Select all that apply. 1 Autonomy 2 Goal setting 3 Priority setting 4 Interruption control 5 Right communication

2, 3, 4 Goal setting, priority setting, and interruption control forms the principal components of time management. Autonomy is an important component in the decision-making process. Right communication is considered one of the rights of delegation.

What activities would the nurse state are involved in providing a secondary level of preventive care? Select all that apply. 1 Using specific immunizations 2 Preventing the spread of communicable disease 3 Providing facilities to limit disability and prevent death 4 Providing adequate treatment to arrest the disease process 5 Educating the public and industry to use rehabilitated individuals to the fullest possible extent

2, 3, 4 When providing secondary level of preventive care, the nurse would explain that preventing the spread of communicable diseases, providing facilities to limit disability and prevent death, and also providing adequate treatment to arrest disease process are key components. Specific immunizations are used when providing a primary level of preventive care. When providing a tertiary level of preventive care, the public and industry should be educated to use rehabilitated persons to the fullest possible extent.

Which statements are appropriate for a nursing instructor to include when teaching a group of students about high-quality health care? Select all that apply. 1 High-quality health care is expensive. 2 High-quality health care is competent. 3 High-quality health care meets the client's needs. 4 High-quality health care meets an established care standard. 5 High-quality health care involves the minimal use of hospital resources.

2, 3, 4 High-quality health care has different perspective for different people on the health care team. High-quality health care is competent enough to reach the desired client goals. The objective of high-quality health care is to meet the client's goals and, in meeting them, to maintain an established standard of care. High-quality health care is not expensive; it is cost-effective and involves the optimal use of hospital resources.

Which agencies have the power to implement Medicare and Medicaid reimbursement? Select all that apply. 1 Institute of Medicine (IOM) 2 The Joint Commission (TJC) 3 National Committee for Quality Assurance (NCQA) 4 Community Health Accreditation Program (CHAP) 5 Accreditation Commission for Health Care (ACHC) 6 The National Database for Nursing Quality (NDNQI)

2, 3, 4, 5 The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), Community Health Accreditation Program (CHAP), and Accreditation Commission for Health Care (ACHC) are the agencies that have the power to implement Medicare and Medicaid reimbursement. These agencies provide regulatory oversight and provide accreditation of health care organizations. The Institute of Medicine is an advisory body. It conducts studies and provides unbiased and authoritative advice to provide high-quality care and improve the nation's health. The National Database for Nursing Quality (NDNQI) provides research-based comparative data and helps the registered nurses in providing high-quality care to the clients. These two agencies are not the regulatory bodies and do not have the power to implement Medicare and Medicaid reimbursement.

A nursing student notes information regarding restorative care. Which points noted by the nursing student are accurate? Select all that apply. 1 The restorative healthcare team is an interdisciplinary group of health professionals. 2 Success depends on effective and early collaboration with clients and their families. 3 Clients and families follow treatment plans better when they are involved in restorative care. 4 Clients who are disabled or are suffering from terminal diseases need restorative care. 5 Restorative care is provided through home healthcare, rehabilitation, or extended care facilities.

2, 3, 5 Nurses who provide restorative care are required to understand that success can be achieved by collaborating with the client and caregivers from the early stages of providing care. Clients are able to reach optimal levels of health by following the treatment plans when they are involved in restorative care. Clients may receive restorative care through home healthcare, rehabilitation, and extended care facilities. The restorative healthcare team involves health professionals as well as the client and his or her caregivers in order to achieve best results. Clients who are disabled or suffering from terminal diseases need continuing care.

A nursing student is noting the characteristics of the secondary level of prevention. What points should the nursing student note? Select all that apply. 1 Secondary prevention activities are aimed at health promotion. 2 Secondary prevention focuses on individuals with health problems and illnesses. 3 Secondary prevention activities are directed at diagnosis and prompt interventions. 4 Secondary prevention helps in minimizing the effects of long-term disease and disability. 5 Secondary prevention includes screening techniques and treating diseases at early stages.

2, 3, 5 Secondary prevention focuses on individuals who are ill or have health problems and are in danger of developing further complications or worsening conditions. Secondary prevention activities are directed towards reducing the severity of illness through diagnosis and prompt interventions. This helps clients to return to normal level of health as soon as possible. Secondary prevention activities include screening techniques and treating diseases at their early stages. Primary prevention activities are aimed at health promotion of individuals who are considered physically and emotionally healthy. Tertiary prevention helps in minimizing the effects of long-term disease and disability through interventions that help to prevent complications and deterioration.

The nurse listens to and validates the feelings expressed by a confused older adult. Which elements does the nurse convey in this situation? Select all that apply. 1 Recalling 2 Respecting 3 Reassuring 4 Reinforcing 5 Understanding

2, 3, 5 Validation therapy is an alternative approach to communication with a confused older adult. By listening with sensitivity to the client and validating what the client is expressing, the nurse conveys respect, reassurance, and understanding. Recalling is related to reminiscence. Reinforcing is not related to validation.

What are the important points to be considered when imparting practical knowledge to nursing students about preventing complications in the hospital? Select all that apply. 1 Nursing students are not accountable if a client is harmed. 2 Nursing students should never be assigned any tasks they are unprepared for. 3 Nursing students are employees of the hospital and may act as witnesses to consent forms. 4 Nursing students can work as nursing assistants or nurse's aides when not attending classes. 5 Nursing students should notify the nursing supervisor in case they are delegated tasks they are not prepared for.

2, 4, 5

After reviewing a client's reports, the primary healthcare provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. 1 Peptic ulcer 2 Chronic renal failure 3 Cognitive impairment 4 Congestive heart failure 5 Chronic obstructive lung disease

2, 4, 5 Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore, these clients do not require palliative care.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? 1 Knowing 2 Enabling 3 Doing for 4 Being with

2. Enabling The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? 1 Apply abdominal girdle as needed. 2 Remove compression stockings for client ambulation. 3 Elevate the client's legs above heart level. 4 Keep the upper extremities elevated.

3

A client has the habit of staying up and watching movies till 4 a.m. on weekends. The nurse educates the client about the risks of not following a proper sleep routine. The client responds by saying, "I understand your point, but I haven't had any major problems yet." Which stage of health behavior change does the nurse recognize? 1 Action 2 Preparation 3 Contemplation 4 Precontemplation

3 A client who accepts the information provided by the nurse but still shows some ambivalence is probably in the contemplation stage of behavior change. A client in the action stage of behavior change may have implemented changes but is likely to find that old habits get in the way of new actions. In the preparation stage, the client understands that the benefits of the change outweigh its disadvantages and therefore seeks assistance to plan the changes. In the precontemplation stage, the client does not intend to enact a change in health behavior in the next 6 months and may reject the nurse's instructions or even become defensive.

*A nurse uses flow charts to determine the usefulness of bed-monitoring devices for checking on dementia clients. Which Quality and Safety Education for Nurses (QSEN) competency does the nurse comply with? 1 Safety 2 Informatics 3 Quality improvement 4 Patient-Centered care

3 According to QSEN competencies, quality improvement takes place when the nurse uses data to monitor the outcomes of care provided to improve the quality and safety of health care systems. In the given scenario, the nurse uses flow charts to determine the usefulness of applying bed-monitoring device for dementia clients in order to improve the quality of client care.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? 1 Increase fluids. 2 Increase fiber in the diet. 3 Wash hands with soap and water. 4 Wash hands with an alcohol-based hand sanitizer.

3 Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

A client with terminal pancreatic cancer says, "I am suffering so much because there are evil spirits in my body." Which religion might the nurse expect the client to practice? 1 Islam 2 Judaism 3 Buddhism 4 Christianity

3 Buddhists believe illness is due to the presence of nonhuman spirits, so this client might practice Buddhism. Muslims believe that time of death is fixed and cannot be changed. Jews and Christians do not believe that evil spirits cause suffering.

An octogenarian client tells the nurse, "Please do not give me dietary instructions post-surgery. I've had several surgeries in my lifetime and I know what to eat." Which variable influences the client's health beliefs and practices? 1 Emotional factors 2 Socioeconomic factors 3 Intellectual background 4 Perception of functioning

3 In the given situation, the client has acquired knowledge from past experiences. This shows the influence of the client's intellectual background on his or her health beliefs and practices. The manner in which a client handles his or her emotions when confronted with illnesses also influences health beliefs and practices. Social and economic variables also influence the client's health beliefs and practices. The way in which a client perceives physical functioning, also influences a client's health beliefs and practices. These factors are not influencing the client's decision in this case

A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform? 1 Do not administer the vaccine until checking with the healthcare provider. 2 Do not administer the vaccine due to pregnancy contraindication. 3 Administer the usual dose of the vaccine. 4 Administer half the usual dose of the vaccine.

3 Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. There is no need to check with the healthcare provider before administration. The seasonal flu shot has been given safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies. Flu shots are not contraindicated; however, the nasal vaccine is. There is no indication that dosages should be altered.

Which intrinsic factor is associated with the fall of an older adult? 1 Wet floors 2 Poor lighting 3 Deconditioning 4 Inappropriate footwear

3 Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? 1 Eating beef and veal is prohibited. 2 Consumption of fish with scales is forbidden. 3 Meat and milk at the same meal are forbidden. 4 Consuming alcohol, coffee, and tea are prohibited.

3 Jewish dietary laws prohibit any combination of milk and meat at the same meal. The Hindu, not Jewish, religion prohibits the ingestion of beef and veal; many Hindus believe that the cow is sacred. Fish that have scales and fins are considered clean, and therefore allowed in the diet. Seventh Day Adventists, Baptists, Mormons, and Muslims prohibit some or all of the beverages alcohol, coffee, and tea.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 30 degrees 4 Raised to 10 degrees

3 Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees, or at 10 degrees.

A nursing student is noting information about the National Database of Nursing Quality Indicators (NDNQI). Which point noted by the nursing student needs correction? 1 The National Database of Nursing Quality Indicators (NDNQI) was developed by the American Nurses Association (ANA). 2 The National Database of Nursing Quality Indicators (NDNQI) reports quarterly results on nursing outcomes at the nursing unit level. 3 The National Database of Nursing Quality Indicators (NDNQI) reports provide a database for individual hospitals to compare their performance against nursing performance internationally. 4 The National Database of Nursing Quality Indicators (NDNQI) was developed to measure and evaluate nursing-sensitive outcomes with the purpose of improving client safety and quality care.

3 National Database of Nursing Quality Indicators (NDNQI) reports provide a database for individual hospitals to compare their performance against nursing performance nationally. The American Nurses Association (ANA) developed NDNQI with the aim of bringing about quality improvement in client care. NDNQI reports quarterly results on nursing outcomes at the nursing unit level. NDNQI is used to measure and evaluate nursing-sensitive outcomes. This evaluation helps to improve client safety and quality care.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn disease 2 Cushing disease 3 End-stage renal disease 4 Gastroesophageal reflux disease

3 One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion? 1 The nurse shares constructive criticism with his or her team members. 2 The nurse meets with colleagues regularly to discuss work experience. 3 The nurse recalls, thinks, analyzes and learns from day-to-day work situations. 4 The nurse organizes or connects information in a way so the diverse information about a client forms meaningful patterns.

3 Reflective practice is a conscious process of recalling, thinking, analyzing, and learning from work situations. This practice may also include journaling work experiences for self-evaluation. Meeting with colleagues to share constructive criticism and discuss work experiences is an important part of critical skill development. The use of concept mapping requires the nurse to organize and collect the client's information in a way that forms meaningful patterns.

A primary nurse completes a nursing assessment of all assigned clients and develops a care plan for each client. Which element of decision-making does the nurse execute in this situation? 1 Authority 2 Autonomy 3 Responsibility 4 Accountability

3 Responsibility refers to duties and activities that an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given issue. Autonomy refers to freedom of choices and the responsibility for the choices. Accountability refers to individuals being answerable for their actions.

The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? 1 Chemically stimulate the loop of Henle 2 Diminish the thirst response of the client 3 Prevent reabsorption of water in the distal tubules 4 Cause fluid to move toward the interstitial compartment

3 Sodium absorbs water in the kidneys' renal tubules. When dietary intake of sodium is decreased, water is not reabsorbed and edema is reduced. A decrease in sodium will prevent the reabsorption of water. Furosemide stimulates the loop of Henle to inhibit the reabsorption of sodium and chloride at the proximal and distal tubules. Adequate hydration is the major factor that diminishes the thirst response. A low-sodium diet will help move fluid from the interstitial compartment to the intravascular compartment.

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which client statement indicates a need for further instruction? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the client's emotional well-being and care. Visitors who have been in contact with the client before and during hospitalization are a possible source of influenza for other clients, visitors, and staff.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1 "This is a decision you alone can make." 2 "Do not tell your partner unless asked." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."

3 The correct response promotes an exploration of the client's dilemma; it encourages further communication. Although the decision is for the client to make, this response is not supportive and abandons the client. It is inappropriate for the nurse to give advice.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? 1 Analysis 2 Evaluation 3 Explanation 4 Interpretation

3 The critical-thinking skill of explanation involves using knowledge and experience to provide client care. The nursing practice of assessing whether the obtained data is true is called analysis. Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions is an evaluation skill. The nursing practice of being orderly in data collection and looking for patterns to categorize data refers to interpretation.

A nurse is hired to work in a healthcare facility that has a completely computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says what? 1 "More medication errors are made when this system is used." 2 "It is disappointing that nurses are not allowed to use this system." 3 "Client information is immediately available when this system is used." 4 "I will have less time to provide direct care to my clients with this system."

3 The intent of these systems is to streamline documentation and recordkeeping for all appropriate health team members, including nurses. There is a reduction in medication errors with this type of system. Data are immediately available to appropriate health team members without the need to depend on record or chart availability. By streamlining documentation and recordkeeping, these systems increase opportunities for more direct client care by nurses.

A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home? 1 "I will change the dressing every day." 2 "I will recommend a physical therapy referral." 3 "I will provide you with a homecare service referral." 4 "I will not allow any family member to be present during dressing change."

3 The nurse provides a homecare service referral to help the client in changing the dressing. The nurse who is responsible for discharging the client never changes his or her dressing at the client's home. The nurse consults the primary healthcare provider to recommend a physical therapy referral to help the client in performing recommended exercises and provide strength training. The nurse should involve family members in the client's care to provide emotional support to the client.

A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? 1 The client is of Asian culture. 2 The client is of African culture. 3 The client is of North American culture. 4 The client is of Latin American culture.

3 The people who belong to United States and Western Europe culture possess individualistic characteristics. The people who belong to Asia, Africa, and Latin America do not possess individualistic characteristics; instead, they have a collectivistic approach. The new mother who belongs to any of these cultures other than the North American culture may depend on elder family members for child-rearing.

An adolescent who had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1 "I can ride my bike in about a week." 2 "I don't have to go to gym class for 3 months." 3 "I can't perform any weightlifting for at least 6 weeks." 4 "I can never participate in football again."

3 Weightlifting puts a strain on the incision and should be avoided for at least 6 weeks. Activities such as bike riding and physical education classes and football are contraindicated for approximately 3 weeks after uncomplicated surgery for an inguinal hernia. Refraining from these activities for this period of time prevents stress on the incision and promotes healing. However, the client should not participate in any of these activities until cleared by the surgeon.

Which terms might the nurse use to describe a client who was born a man but lives as a woman? Select all that apply. 1 Transvestite 2 He-she 3 Transgender 4 Transwoman 5 Transgendered 6 Transman

3, 4 A client who was born as a man but lives as a woman can be referred to as transgender or a transwoman. The nurse should also respect and use any other terminology the client prefers. The terms "transvestite" and "he-she" are insensitive and offensive. The term "transgendered" is outdated; using the suffix "-ed" is inappropriate. A client who was born as a woman but lives as a man can be referred to as a transman.

The advanced practice registered nurse is the most independently functioning nurse. What are the specific functions of the nurse practitioner as an advanced practice registered nurse in a healthcare setting? Select all that apply. 1 A nurse practitioner focuses on teaching clients and family members to self-manage illnesses or disabilities. 2 A nurse practitioner is usually a certified diabetes educator or an ostomy care nurse and sees only a specific population of clients. 3 A nurse practitioner has the knowledge and skills necessary to detect and manage self-limiting acute and chronic stable medical conditions. 4 A nurse practitioner provides comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions. 5 A nurse practitioner may establish a collaborative provider-client relationship, working with a specific group of clients or with clients of all ages and healthcare needs.

3, 4, 5 A nurse practitioner is an advanced practice registered nurse who has the knowledge and skills necessary to detect and manage self-limiting acute and chronic stable medical conditions. A nurse practitioner provides comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions. A nurse practitioner may establish a collaborative provider-client relationship, working with a specific group of clients or with clients of all ages and healthcare needs. A nurse educator focuses on the teachings of clients and their family members so that they can self-manage illnesses or disabilities. A nurse educator is usually a certified diabetes educator or an ostomy care nurse and sees only a specific population of clients.

While obtaining the vital signs of a client, the nurse finds that the body temperature of the client is 98.6 °F. The nurse concludes that the client is experiencing what? 1 Hypothermia 2 Hyperpyrexia 3 Hyperthermia 4 Normothermia

4 A body temperature of 98.6 °F is normal. Therefore the nurse concludes that the client has normothermia. The client does not have low body temperature, or hypothermia. The client's body temperature does not exceed the normal range; therefore, the client does not have hyperpyrexia or hyperthermia.

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? 1 Encircle the drainage on the dressing. 2 Irrigate the suction tube with sterile saline. 3 Clean the drainage port with an alcohol wipe. 4 Compress the container before closing the port.

4 A portable wound drainage system (e.g., Jackson-Pratt, Hemovac) is compressed before closing the port to reestablish the negative pressure necessary for suction. Encircling the drainage on the dressing is not necessary; a portable wound drainage system usually removes excess drainage before it leaks onto the dressing. Portable wound drainage systems are not irrigated, because this would increase the risk of instilling microorganisms into the wound. The nurse should avoid touching the port, because it is sterile.

What principle must a nurse consider when caring for a client with a closed wound drainage system? 1 Gravity causes fluids to flow down a pressure gradient. 2 Fluid flow rate is determined by the diameter of the lumen. 3 Siphoning causes fluids to flow from one level to a lower level. 4 Fluids flow from an area of higher pressure to one of lower pressure.

4 A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Newton's law of gravity is not the physical principle underlying the functioning of a portable wound drainage system. Although fluid flow rate is determined by the diameter of the lumen and siphoning causes fluids to flow from one level to a lower level, they are not what cause the fluid to drain in a portable wound drainage system.

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking? 1 "The pain is usually present in my fingers and knees." 2 "I observed swelling and redness near the pain area." 3 "I feel the pain in each and every joint of my hands and legs." 4 "I run for 30 minutes every day; this exercise increases my pain."

4 A precipitating factor is an activity or factor that worsens the symptoms. If running for 30 minutes each day increases the client's pain, this action is a precipitating factor. By saying, "The pain is usually present in my fingers and knees," the client is providing information about the location. Swelling and redness are concomitant symptoms of pain. The quality factor indicates the description of the symptom; this is exemplified by the statement, "I feel the pain in each and every joint of my hands and legs."

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement made by the client meets the self-actualization need? 1 "I need help because I am having trouble breathing properly." 2 "I cannot afford health care because I am homeless." 3 "People always tend to criticize me, even if I do something good." 4 "I want to live because I want to be a good parent to my kids."

4 According to Maslow's hierarchy of needs, self-actualization is the highest expression of one's individual potential. When a client says that he or she wants to live because his or she wants to be a good parent to his or her kids, this statement indicates a need for self-actualization. When a client says that he or she is having trouble breathing, this statement indicates that the client has physiological needs. When a client says that he or she cannot afford health care because of homelessness, this statement indicates a deficiency in physiological needs. When a client says that people always tend to criticize him or her even if he or she does something good, this statement is an example of self-esteem needs.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? 1 Asking about what type of foods the client usually eats 2 Telling the client that the diet must be followed exactly as written 3 Telling the client that the intake of foods on the list must be limited 4 Asking about what the client knows about the diet that was prescribed

4 Asking about what the client knows about the prescribed diet may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.

What should a nurse recommend to best help a client during the period immediately after a spouse's death? 1 Crisis counseling 2 Family counseling 3 Marital counseling 4 Bereavement counseling

4 Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? 1 A column of water 20 cm high in the suction control chamber 2 75 mL of bright red blood in the drainage collection chamber 3 An intact occlusive dressing at the insertion site 4 Constant bubbling in the water seal chamber

4 Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and therefore the healthcare provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to do what? 1 Promote equalization of osmotic pressures 2 Prevent hypoxia associated with diaphoresis 3 Promote integrity of intracerebral neurons 4 Reduce brain metabolism and limit hypoxia

4 Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position

4 Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a healthcare provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, but will not prevent their accumulation.

The nurse notes that a client has mild hypothermia based on what body temperature? 1 29 °C 2 30 °C 3 33 °C 4 35 °C

4 Hypothermia occurs when the body temperature falls below 36.2 °C. Based on the severity, it is classified as mild, moderate, and severe. Mild hypothermia refers to a body temperature of 34 °C to 36 °C (93.2 °F to 96.8 °F). In this case, the client's body temperature is 35 °C, which indicates mild hypothermia. Moderate hypothermia refers to a body temperature of 30 °C to 34 °C (86 °F to 93 °F), and severe hypothermia refers to a body temperature below 30 °C (86 °F). The client does not have severe hypothermia; therefore, the client does not have a body temperature of 29 °C. The client does not have moderate hypothermia; therefore, the client does not have a body temperature of 30 °C or 33 °C.

The nursing supervisor assigns a nurse to care for five clients in the intensive care unit (ICU). The nurse notes that all the clients in the ICU are at a risk of developing serious complications at any time. What course of action should the nurse take to handle the situation? 1 Refuse to accept the assignment 2 Leave the ICU as a sign of protest 3 Notify the primary healthcare provider 4 Submit a written protest to the nursing administrator

4 If a nurse is given an assignment that appears to be unreasonable, the nurse should submit a written protest to the nursing administrator. Even though this does not relieve the nurse of responsibility, if a client is harmed due to inattention, it shifts some of the responsibility to the institution. If the nurse refuses to take up the assignment, it may be viewed as insubordination. The nurse should not leave the ICU unattended even if there is staffing shortage as he/she may be charged with client abandonment. The primary healthcare provider is the not appropriate person to be alerted regarding shortage of staffing.

Which action by a home care nurse would be considered an act of euthanasia? 1 Implementing a "do not resuscitate" order in the home health setting. 2 Abiding by the decision of a living will signed by the client's family. 3 Encouraging a client to consult an attorney to document and assign a power of attorney. 4 Knowing that a dying client is overmedicating and not acting on this information.

4 In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? 1 Suddenness of the change 2 Obviousness of the change 3 Extent of the change 4 Perception of the change

4 It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as-needed sedative. 4 Move the postoperative client to a room at the end of the hall.

4 Moving the postoperative client from the singing client's diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms, because they need to be monitored. The use of a sedative should not be the initial intervention.

The nurse is caring for a client diagnosed with a rare genetic disorder. Which domain of informatics would the nurse use to gather information about this condition to provide good quality client care? 1 Public health informatics 2 Clinical research informatics 3 Translational bioinformatics 4 Clinical health care informatics

4 Optimal health care can be delivered only if the clinician has in-depth knowledge of the client's condition. The nurse uses clinical health care informatics for gathering information about the client's condition. Clinical research informatics uses computer and information science to discover new knowledge relating to health and disease. Public health informatics uses information technology for improving the health of populations. Translational bioinformatics refers to the development of storage, analytic, and interpretive methods to assess the proactive, predictive, preventive, and participatory health of a population.

A visitor comes to the nursing station and tells the nurse that a client and a relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1 Ask the client if he or she is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe.

4 Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and ensured that any other people in the room are safe.

The nurse is caring for a client with breast cancer who is receiving chemotherapy. Which action performed by the nurse is in accordance with the rules of the Centers for Medicare & Medicaid Services (CMS)? 1 Checks the prescription before administering medications to the client 2 Refers the client to support systems and provides financial assistance 3 Teaches safety measures to the client in order to prevent the risk of infection 4 Enters symptoms and treatment provided to the client in the electronic health record (EHR)

4 The Centers for Medicare & Medicaid Services (CMS) specify how health care professionals should use electronic health records (EHRs) to receive Medicare and Medicaid payment incentives. The nurse should enter symptoms, treatments, and outcomes in the EHR because doing so helps to claim insurance. The CMS does not provide guidelines to prevent medication errors. The Joint Commission's National Client Safety Rules provides guidelines to prevent medication errors. Therefore checking the prescription before administering the medication is not in accordance with the rules of CMS. The CMS does not direct the nurse to refer the client to support systems or to provide financial assistance. The hospital's social worker provides information about support systems and financial assistance. The CMS does not provide guidelines to prevent infection in clients. The Centers for Disease Control (CDC) provides guidelines to prevent client infections. Therefore teaching safety measures to the client in order to prevent infection is not in accordance with the CMS.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

4 The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

A nurse working in an emergency department is concerned about a recent increase in malpractice claims against nurses. What is the best way for the nurse to prevent being named in a lawsuit? 1 Carry malpractice insurance. 2 Write vague incident reports. 3 Transfer to another department. 4 Attend professional development programs.

4 The best way to prevent professional negligence (malpractice) is to attend continuing education programs and improve practice; additional education is advisable when one is working in specialty areas, such as emergency departments or intensive care areas. Insurance is helpful after an incident, but it will not prevent malpractice claims. Writing vague incident reports is not professional; incident reports should be detailed. Preventing the issue by transferring to another department will not solve the problem. Each area of nursing practice requires expertise.

After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.

4 The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

What is the most important skill of the nurse leader? 1 Priority setting 2 Time management 3 Clinical decision making 4 Clinical care coordination

4 The most important leadership skill for a nursing student is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.

A nurse notices that a diabetic client is consuming chocolate brought by a family member. Which nursing action should a nurse perform to adhere to the principle of autonomy? 1 The nurse should ask if the client has a weakness for sweets. 2 The nurse requests that the client refrain from eating chocolates. 3 The nurse explains the consequences of eating chocolates to the client. 4 The nurse collaborates with a dietician to obtain a special diet chart for the client.

4 The nurse adheres to the principle of autonomy by collaborating with other healthcare providers to pursue the best treatment plan for the client. In this case, the nurse should collaborate with a dietician to obtain a special diet chart for a diabetic client. As a communicator, the nurse enquires if the client has a weakness for sweets. As a caregiver, the nurse should request that the client refrain from eating chocolates. As an educator, the nurse should explain the disadvantages of eating chocolates to the client.

*The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need? 1 "The teachings of home self-care." 2 "A psychological episode of an anxiety attack." 3 "A physiological episode of an obstructed airway." 4 "The measures required to decrease postoperative complications."

4 The nurse leader should have the ability to set the priorities of the client depending on the client's need. Intermediate priority needs includes non-emergency, non-life-threatening needs. An example of this need would be measures that are required to decrease postoperative complications. The teaching of home self-care is a low priority need. High priority needs include addressing a psychological episode of an anxiety attack and addressing a physiological episode of an obstructed airway.

When providing preoperative teaching, what should the nurse focus primarily on? 1 Helping the client and family decide if surgery is necessary 2 Providing emotional support to the client and family 3 Giving minute-by-minute details of the surgery to the client and family 4 Providing general information to reduce client and family anxiety

4 The primary role of the nurse during preoperative teaching is to provide general information about the surgical experience and what to expect before and after surgery. Helping the client and family decide if surgery is necessary is not an appropriate intervention for the nurse. Emotional support is important and would be included as part of providing general information to reduce client and family anxiety. It is also not appropriate for the nurse to describe minute-by-minute details of the surgery unless the client and family request this information, at which time the surgeon should answer the questions.

The nurse is presenting information about hyperthermia to a group of nursing students. Which activities put a client at risk for this condition? 1 Snowmobiling 2 Skiing in the winter 3 Hiking Alaskan mountains 4 Performing strenuous activity in high humidity

4 When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

According to Benner et al., an expert nurse passes through five levels of proficiency when acquiring and developing generalized or specialized nursing skills. Arrange the order of level of proficiency from lowest to highest. 1. Expert 2. Novice 3. Proficient 4. Competent 5. Advanced beginner

Novice, advanced beginner, competent, proficient, expert A novice is a beginning nursing student who doesn't have any previous level of experience. An advanced beginner is a nurse who has had some level of experience. A nurse is said to be competent if she or he has been in the same clinical position for two to three years. A nurse is said to be proficient after three years of experience in the same clinical position. An expert is a nurse with diverse experience and who has an intuitive grasp of an existing or potential clinical problem.

Arrange the stages of Sigmund Freud's psychoanalytical model of personality development in its correct order. 1. Anal 2. Oral 3. Genital 4. Phallic or Oedipal 5. Latency

Oral Stage (0-1 year) Anal Stage (1-3 years) Phallic Stage (3 to 5 or 6 years) Latency Stage (5 or 6 to puberty) Genital Stage (puberty to adult) The first stage of Freud's theory is the oral stage starting from birth to 12 to 18 months. The anal stage is the second stage which starts from 12 to 18 months to 3 years of age. Children between the ages of 3 to 6 years are considered to be in the phallic or Oedipal stage. The latency stage lasts from 6 years to 12 years. The genital stage is the sixth stage; it starts from puberty and continues to adulthood.

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted? 1 These actions can be construed as assault and battery. 2 The problem was resolved with forethought and accountability. 3 Skin must be protected, and the actions taken were by a reasonably prudent nurse. 4 The nurse had tried to reason with the toddler and expected understanding and cooperation.

1 Assault is a threat or an attempt to do violence to another, and battery means touching an individual in an offensive manner or actually injuring another person. The nurse's behavior demonstrates anger and does not take into account the growth and developmental needs of children in this age group. Although the behavior (scratching) needs to be decreased, this can be done with mittens, not immobilization. A 3-year-old child does not have the capacity to understand cause (scratching) and effect (bleeding).

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1 Attention span 2 Primary language 3 Coping mechanisms 4 Activity and coordination

1 Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent? 1 Battery 2 Invasion of privacy 3 False imprisonment 4 Defamation of character

1 Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary healthcare provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.

*Which assessment finding is associated with depression? 1 The client has islands of intact memory. 2 The client has impaired recent and remote memory. 3 The client has impaired recent and immediate memory. 4 The client needs step-by-step instructions for simple tasks.

1 Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

Which organization has a publication that includes the objective, "Aiming to develop a system to clients who are lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)?" 1 U.S. Department of Health and Human Services (USDHHS) 2 The Centers for Disease Control and Prevention (CDC) 3 The Joint Commission (TJC) 4 The World Professional Association for Transgender Health (WPATH)

1 Developing a system to identify clients who are LGBTQ is a goal stated in the USDHHS's Healthy People 2020. The CDC's publications have goals that differ from this one. The TJC field guide lists the recommendations for health care agencies in designing a safe environment for LGBT client care. WPATH summarizes core principles that nurses and other health care providers should follow when caring for transgender clients.

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? 1 Shift of fluid into the interstitial spaces 2 Weakening of the cell wall 3 Increased intravascular compliance 4 Increased intracellular fluid volume

1 Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathologic reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? 1 Exploring 2 Reflecting 3 Refocusing 4 Acknowledging

1 Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.

How can a nurse best evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiologic responses

1 Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

On the second day of hospitalization, a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction, the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting

1 Focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. Exploring permits the nurse to delve deeper into the subject when the client tends to stay on a superficial level. Accepting is a technique used to understand and demonstrate regard for what the client stated.

Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself? 1 Focusing 2 Clarifying 3 Paraphrasing 4 Summarizing

1 Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take? 1 Initiate an agency incident report. 2 Report the fall to the state (provincial) health department. 3 Write a brief description of the incident to be kept by the nurse manager. 4 Determine that no documentation is needed because the visitor is not a client in the hospital.

1 Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event, along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.

*During follow-up visits, the client's child reports to the nurse, "I tell my parent every day about what may happen if medications aren't taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client's motivational level? 1 Not motivated 2 Intrinsically motivated 3 Extrinsically motivated with self-determination 4 Extrinsically motivated without self-determination

1 If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others.

Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? 1 Nurse 2 Pharmacist 3 Music therapist 4 Primary healthcare provider

1 In a palliative care setting, the health care team should comprise professionals of various disciplines to help achieve care outcomes. The nurse on the interprofessional team evaluates the physical, emotional, and spiritual needs of the client. The nurse also advocates for the client and provides referrals to other members of the team. The primary healthcare provider assesses the clinical manifestations of the client. The pharmacist supports the care of the client and the needs of the family. Music therapists help to increase the comfort of the client.

Which intervention reflects the nurse's approach of "family as a context"? 1 Trying to meet the client's comfort 2 Evaluating the client family's coping skills 3 Evaluating the client family's energy level 4 Trying to meet the client family's nutritional needs

1 In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

What does the nurse understand the term in-service education to mean? 1 It helps achieve an organization's required competencies. 2 It helps the nurse gain knowledge about traditional health care practices. 3 It is a one-way education program to promote and maintain current nursing skills. 4 It is focused on techniques and technologies that have been used successfully in the past.

1 In-service education helps achieve an organization's required competencies. Continuing education and in-service education help the nurse gain knowledge about the latest research and practice developments. Continuing education is a one-way education program to promote and maintain current nursing skills. In-service education is focused on new technologies.

What are the goals of care when working with families according to the family health system? Select all that apply. 1 To improve family health or well-being 2 To help the family prepare for later transitions 3 To assist in family management of illness conditions 4 To promote positive family behaviors to achieve essential tasks 5 To achieve health outcomes related to the family's areas of concern

1, 3, 5 When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? 1 Contact an interpreter provided by the hospital. 2 Contact the client's family member to translate for the client. 3 Communicate with the client using Spanish phrases the nurse learned in a college course. 4 Communicate with the client with the use of a hospital-approved Spanish dictionary.

1 Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

The professional obligation of a nurse to assume responsibility for actions is referred to as what? 1 Accountability 2 Individuality 3 Responsibility 4 Bioethics

1 Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession; this is referred to as accountability. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biologic and medical procedures and treatments.

Which nursing practice is associated with the self-regulation skill? 1 Reflecting on one's experience 2 Reflecting on one's own behavior 3 Supporting one's findings and conclusions 4 Clarifying any data that one is uncertain about

1 Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse? 1 The client's gag reflex has returned. 2 The client is confused due to anesthesia. 3 The client is nauseated and wants to vomit. 4 The client's airway is becoming obstructed.

1 The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not obstruct the airway.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 1 Tubing injection port 2 Distal end of the tubing 3 Urinary drainage bag 4 Catheter insertion site

1 The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

A client tells the nurse, "I keep reverting to my old habit of drinking soda, although I have stopped drinking as much." What stage of health behavior change has the client reached? 1 Action stage 2 Preparation stage 3 Maintenance stage 4 Contemplation stage

1 The client in this situation has reached the action stage of health behavior change. In this stage, old habits may get in the way of new behaviors. In the preparation stage, the client understands that the advantages of the health behavior change outweigh its disadvantages. In this situation, the client has already made changes in health behavior. In the maintenance stage, the client continues the health behavior change indefinitely. In the contemplation stage, the client may be ambivalent but is more ready to accept information regarding health behavior change.

What is the most important nursing action involved in caring for a client using medications to manage disease? 1 Administering the medications 2 Teaching about the medications 3 Ensuring adherence to the medication regimen 4 Evaluating the client's ability to self-administer medications

1 The most important part of the nursing practice regarding medication is administering the medications. Administering medications safely requires an understanding of the legal aspects of healthcare, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, ensuring adherence to the medications, and evaluating the client's ability to self-administer medications are responsibilities of the nurse performed before or after the administration of medicines.

The nurse manager working at a rehabilitation center for older adults notices an increase in the incidence of client falls. The nurse manager reprimands the nurses and staff responsible for the falls and places them on probation. Which statement best describes the nurse manger's leadership style? 1 The nurse manager exhibits autocratic leadership. 2 The nurse manager demonstrates shared leadership. 3 The nurse manger exhibits good clinical leadership skills. 4 The nurse manger demonstrates effective interprofessional leadership

1 The nurse manager in this scenario exhibits autocratic leadership. In an autocratic leadership style, all decisions are solely made by the leader. Autocratic leaders are more concerned about the task and may use the threat of punishment to accomplish it. The nurse manager is not involved in direct client care and so is not demonstrating clinical leadership. The nurse manger is not involving the staff in the decision-making process and thus is not demonstrating shared leadership. The nurse manger is not involving members of the health care team across disciplines in the decision-making process and thus is not exhibiting interprofessional leadership.

What should the nurse teach the young mother about the nutritional needs of the newborn? 1 The newborn should be breastfed for the first twelve months. 2 The newborn should be given 2% cow's milk if breast feeding is not possible. 3 The newborn should receive solid food in addition to milk starting from the fourth month. 4 The breastfed newborn should receive iron supplements during the first four months.

1 The nurse recommends breastfeeding for the first 12 months. After the first year, the infant may change to whole cow's milk. If breast feeding is not possible, the newborn should be fed on iron-fortified commercially prepared formula. Whole milk, 2% milk, or alternate milk products should not be given to an infant below 12 months of age because these products can cause intestinal bleeding, anemia, and increased incidence of allergies. Solid foods are not recommended for infants under six months of age because the extrusion reflex pushes the food out of the mouth. The breastfed infant absorbs adequate iron from breast milk during the first four to six months of life. After six months iron-fortified cereal may be given to the infant.

What should the community nurse teach about the risk of adolescent pregnancy? 1 Risk for premature birth 2 Risk for having a large baby 3 Risk for chromosomal defects 4 Risk for increased weight gain

1 The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nursing student is listing the different aspects of the healthcare services pyramid. Under which type of healthcare services should the nursing student include family planning? 1 Primary care 2 Continuing care 3 Restorative care 4 Secondary Acute care

1 The nursing student should include family planning under primary care. Family planning is not a part of continuing care, restorative care or secondary acute care healthcare services.

*What are the elements of discovery of a lawsuit? Select all that apply. 1 Experts 2 Medical records 3 Proof of negligence 4 The depositions of witnesses 5 Petition-elements of the claim

1, 2, 4 Experts, medical records, and the depositions of witnesses are elements of discovery of a lawsuit. Proof of negligence is a part of a trial. Petition and elements of the claim are a part of the pleadings phase.

What steps should a nurse take when caring for a client to prevent nursing malpractice? Select all that apply. 1 Be alert about common sources of client injuries. 2 Gain knowledge regarding current nursing practices. 3 Refrain from speaking falsely about a client's medical condition. 4 Communicate with the client regarding tests and treatment plans. 5 Refrain from divulging medical information to unauthorized persons.

1, 2, 4 To avoid nursing malpractice, the nurse should ensure that the care provided to clients meets the recommended standards of care. The nurse should pay attention to the common sources of client injury, such as falls and medication errors. The nurse is also required to stay updated by gaining knowledge about the current nursing literature in the nurse's area of practice. The nurse should explain in detail about tests and treatment plans to clients and listen to their concerns. In addition, the nurse should also document that the appropriate explanation has been provided. To prevent slander and defamation of character, the nurse should avoid speaking falsely about a client's medical condition. In order to prevent invasion of privacy, the nurse should refrain from divulging medical information to unauthorized persons without obtaining the client's consent.

*Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. 1 Interventions to restore tissue integrity 2 Interventions to optimize neurologic functions 3 Interventions to manage restricted body movements 4 Interventions to promote comfort using psychosocial techniques 5 Interventions to provide care before, during, and immediately after surgery

1, 2, 5 Interventions such as restoring tissue integrity, optimizing neurologic functions, and providing care before, during, and immediately after surgery are classified under physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy [1] [2]. Interventions to manage restricted body movements are classified under the simple physiologic domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.

What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. 1 Assess the client for pain before teaching. 2 Take down notes while talking to the client. 3 Ensure the client is not preoccupied or anxious. 4 Teach one concept at a time according to the client's interest. 5 Teach a family caregiver if the client does not respond quickly.

1, 3, 4 The nurse must assess the client for pain and ensure that the client is physically well enough to learn. The nurse must begin teaching after determining that the client is not preoccupied or too anxious to comprehend the material. The nurse must postpone teaching if the client appears disinterested. The nurse should sit facing the client so that the client is able to view the nurse's expressions and lip movement. The nurse should refrain from taking down notes during the teaching because this action conveys a lack of interest. Because older adults process information more slowly than young people, the nurse should allow the client to take some time to respond to the nurse's queries.

What are external barriers that can prevent a nursing professional from making morally correct actions? Select all that apply. 1 Inadequate staffing 2 Lack of assertiveness 3 Perception of powerlessness 4 Lack of organizational support 5 Poor relationships with colleagues

1, 4, 5 When faced with dilemmas, external and internal barriers may prevent a professional from acting in a morally correct way. This may cause moral distress. External barriers include inadequate staffing, lack of organizational support, and poor relationships with colleagues. These factors are present in the organizational environment and can lead a person to act in a particular manner. Internal barriers are factors within a person that prevent one from acting in a morally correct way. These include lack of assertiveness and perception of powerlessness.

A nurse is recalling the various levels of preventive care to promote health, wellness, and to prevent illness. Which scenario is a perfect example of primary prevention? 1 An infant receives rotavirus vaccination in the hospital setting. 2 An adult in the early stages of Parkinson's disease is advised to perform adequate exercise. 3 An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. 4 An older adult with Parkinson's disease is administered carbidopa-levodopa to slow the progression of the disease.

1. An infant receives rotavirus vaccination in the hospital setting. Primary prevention consists of all health promotion efforts and wellness education activities. An infant receiving the rotavirus vaccination is an example of primary prevention. An adult in the early stages of Parkinson's disease is advised to perform adequate exercises; this is an example of secondary prevention. An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. This is an example of tertiary prevention. An older adult with Parkinson's disease is administered carbidopa-levodopa to slow the progression of the disease. This is an example of secondary prevention. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

*What does a nurse understand by the Quality and Safety Education for Nurses (QSEN) competency called informatics? 1 A nurse should ensure that the risk of harm to clients and healthcare workers is decreased by improving professional performance. 2 A nurse should use information and technology to communicate, manage knowledge, mitigate error, and support decision-making. 3 A nurse should integrate best current evidence with clinical expertise and client preferences and values to deliver quality health care. 4 A nurse should use data to monitor the outcomes of health care processes and implement improvement methods to design and test changes to improve quality of health care.

2 According to informatics, a nurse should use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. According to the Quality and Safety Education for Nurses (QSEN) competency called safety, a nurse should ensure that the risk of harm to clients and healthcare workers is decreased by improving professional performance. The QSEN competency called evidence-based practice states that a nurse should integrate best current evidence with clinical expertise along with client preferences and values to deliver quality healthcare. The QSEN competency called quality improvement states that a nurse should use data to monitor the outcomes of healthcare processes and implement improvement methods to design and test changes to improve quality of health care.

A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage? 1 The nurse is learning about the profession through a specific set of rules and procedures. 2 The nurse is able to identify the basic principles of nursing care through careful observation. 3 The nurse is able to understand the organization and specific care required by certain clients. 4 The nurse is able to assess the entire situation and transfer knowledge gained from multiple previous experiences.

2 According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia 2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios

2 Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image.

What is a characteristic of the primary nursing model? 1 Care can be delegated. 2 Care is provided by the registered nurse to the client during a stay in a facility. 3 The registered nurse is responsible for all aspects of care for one or more clients during a shift of care. 4 The registered nurse leads a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

2 The primary nursing model includes one primary registered nurse who provides care to the same client during their stay in a facility. According to the total client care model, the care can be delegated. Total client care also involves the registered nurse being responsible for all the aspects of care for one or more clients during a shift of care. The team nursing model requires the registered nurse to lead a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? 1 "You do not need to wear them while you are awake, but it is important to wear them at night." 2 "You will need to apply them in the morning before you lower your legs from the bed to the floor." 3 "If they bother you, you can roll them down to your knees while you are resting or sitting down." 4 "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

2 Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

*Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems? 1 Educator 2 Counselor 3 Change agent 4 Case manager

2 As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. A nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.

A nurse is recalling common terms that are used in health ethics. What does beneficence in health ethics refer to? 1 Beneficence refers to the agreement to keep promises. 2 Beneficence refers to taking positive actions to help others. 3 Beneficence refers to the ability to answer for one's actions. 4 Beneficence refers to avoiding harming or hurting an individual.

2 Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Accountability refers to the ability to answer for one's actions. Nonmaleficence refers to avoiding harming an individual. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing? 1 Place the dressing in the bedside trash can. 2 Place the dressing in a red bag/hazardous materials bag. 3 Contact Environmental Services personnel to pick up the dressing. 4 Transport the dressing to the laboratory to be placed in the incinerator.

2 Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; thus, the dressing should be placed in a red bag or hazardous materials bag. The soiled dressing should not be placed in a single bag and left in the trash can. Infection control is every healthcare worker's responsibility, not just Environmental Services'. The lab is not responsible for disposal of hazardous wastes that occur as a result of normal nursing activities.

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. Which statement by the UAP would the nurse recognize as providing false reassurance? 1 "I agree; I think you should get a divorce." 2 "Everything will be fine; just wait and see." 3 "You should be glad that you have such a loving family." 4 "In the scheme of things, you do not have a major problem."

2 Saying that everything will be fine provides false hope. Agreeing with the client is an example of offering approval. Commenting on how a client should feel is an example of being judgmental. Implying that the problem is minor is an example of minimizing.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? 1 Sharing hope 2 Sharing humor 3 Sharing empathy 4 Sharing observations

2 Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction? 1 The nurse records the vital signs and leaves the room. 2 The nurse adjusts the bed and asks if the client is comfortable. 3 The nurse leaves the door of the room open while attending to the client. 4 The nurse tells the client that the primary healthcare provider will visit soon.

2 The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse's willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse should close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary healthcare provider's imminent visit. Test-Taking Tip: The professional nurse must provide nursing care with empathy and compassion.

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 1 Justice 2 Autonomy 3 Beneficence 4 Paternalism

2 The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others. Justice means to be righteous, equitable, and to act or treat fairly. Beneficence relates to the state or act of doing good and being kind and charitable. It also includes promotion of well-being and abstaining from injuring others. Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities.

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations

2 The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed form birth to 2 years. During this stage, the child learns about himself and his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

*A health care worker is collecting data on the quality of health care provided in a health care center. The health care worker finds that too many nurses are attending to a single client. What does the health care worker conclude from this? 1 The nursing team is not providing safe care. 2 The nursing team is not providing efficient care. 3 The nursing team is not providing effective care. 4 The nursing team is not providing patient-centered care.

2 Too many nurses attending to a single client indicates that the work that can be performed by a few nurses is being performed by many nurses. This indicates that the nursing team lacks efficiency. The inability of the nursing team to avoid injuries in the client indicates that the nursing team is unable to perform safe care. The inability to address the problems of the vulnerable groups indicates that the nursing team is unable to provide effective care. The inability to address all the problems of the client while providing care indicates that the nursing team is unable to provide patient-centered care.

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? 1 Colitis 2 Stomatitis 3 Paralytic ileus 4 Gastrocolic reflux

3 After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

A nursing student lists the preventive and primary care services available in schools, primary healthcare provider's offices, occupational health clinics, community health centers, and nursing centers. Which service provided by these centers is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

3 Disease management is the most expensive service provided by community health centers. Running errands is inexpensive, and if the person walks or rides a bike, can be used as a health promotion activity. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

The nurse is providing care in a multi-specialty hospital. Which nursing action is indicative of a failure to provide equitable care to clients? 1 The nurse treats all male and female clients alike. 2 The nurse maintains direct eye contact while talking to clients. 3 The nurse provides preferential treatment to clients from low economic status. 4 The nurse asks a female nurse to attend to the client according to the client's wishes.

3 Equitable care refers to providing care without any bias in terms of religion, ethnicity, or socioeconomic status. The nurse believes in providing treatment first to people from low socioeconomic background. This indicates that the nurse is biased toward poor people and has failed to provide equitable health care. Treating both males and females alike indicates that the nurse is providing equitable care. Maintaining firm eye contact indicates that the nurse is exhibiting therapeutic communication with all clients. The nurse asks another female nurse to attend to the client according to the client's wishes. This indicates that the nurse respects the client's decision and tries to implement it.

*What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare? 1 A proxy is a legal document that prohibits the purchase or sale of organs. 2 A proxy is a legal document that ensures the client has the right to refuse medical treatment. 3 A proxy is a legal document that designates a person or persons to make health care decisions on behalf of the client. 4 A proxy is a legal document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition.

3 Healthcare proxies enable another person or persons to make healthcare decisions on the client's behalf when the client is no longer able to make decisions on his or her own. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. This act is not related to healthcare proxies. The ethical doctrine of autonomy ensures the client's right to refuse medical treatment. A living will is a written document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition.

Which definition is involved in the caring process called knowing according to Swanson's theory of caring? 1 Being emotionally present for the other 2 Sustaining faith in the other's capacity to get through an event 3 Striving to understand an event as it has meaning in the life of the other 4 Facilitating the other's passage through life transitions and unfamiliar events

3 In Swanson's theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? 1 Ensuring the client's skin integrity 2 Reviewing the preoperative instructions 3 Administering general anesthetic to the client 4 Placing the client in the correct position on the operating table

3 Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? 1 Relieve bronchial spasms 2 Increase depth of respirations 3 Loosen pulmonary secretions 4 Expel carbon dioxide from the lungs

3 Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.

Which component of decision-making refers to the duties and activities an individual is employed to perform? 1 Authority 2 Autonomy 3 Responsibility 4 Accountability

3 Responsibility refers to all duties and activities an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? 1 Picks up the walker and carries it for short distances 2 Uses the walker only when someone else is present 3 Moves the walker no more than 12 inches (30.5 cm) during use 4 States that a walker will be purchased on the way home from the hospital

3 Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates? 1 A depressed immune system 2 An active tuberculosis infection 3 A previous exposure to the organism 4 An imminent tuberculosis infection

3 The presence of antibodies indicates past exposure to or infection with an organism that may be presently dormant. A positive response does not indicate the status of the immune system. A positive response does not necessarily indicate active TB infection; a purified protein derivative (PPD) test administered to an individual with active TB may cause a severe reaction. A positive PPD test does not predict forthcoming exposure or infection; it only indicates past exposure to the organism.

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what? 1 Libel 2 Negligence 3 Breach of confidentiality 4 Defamation of character

3 The release of information to an unauthorized person or gossiping about a client's activities constitutes a breach of confidentiality and an invasion of privacy. Libel occurs when a person writes false statements about another that may injure the individual's reputation. Negligence is a careless act of omission or commission that results in injury to another. Defamation of character is the publication of false statements that injure a person's reputation.

*A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? 1 Decrease peristalsis 2 Minimize electrolyte imbalance 3 Decrease bacteria in the intestines 4 Treat inflammation caused by the malignancy

3 To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.

How should the nurse prevent footdrop in a client with a leg cast? 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.

3 To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? 1 Exempt from any lawsuit because of the doctrine of respondeat superior 2 Totally responsible for the obvious negligence because of failure to report defective equipment 3 Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client 4 Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

3 Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the adequate functioning of equipment. The hospital shares responsibility for safe, functioning equipment.

A nurse is caring for a client with pain after surgery. The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. Which standard of practice does the nurse perform? 1 Planning 2 Diagnosis 3 Assessment 4 Implementation

3 When a nurse collects comprehensive data relevant to the client's health or the situation, it is considered assessment. In the given scenario, the nurse is assessing the client to minimize pain. Planning refers to instances when a nurse develops a plan to attain expected outcomes. Diagnosis refers to instances when the nurse analyzes the assessment data to determine the diagnoses or issues. Implementation refers to instances when the nurse implements the identified plan.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial

4 A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

According to Avedis Donabedian, which is the most important validator of quality and effectiveness of health care in a hospital? 1 The number of clients admitted in a hospital 2 The values and goals presented by the hospital 3 The number of health care workers in the hospital 4 The client outcomes achieved by the care provided

4 Avedis Donabedian was a physician and founder of the Donabedian model of care. According to him, the client outcomes obtained by health care delivery determines the quality and effectiveness of the health care. The number of clients admitted to a hospital does not indicate the quality of the health care delivered in the hospital. The values and goals presented by the hospital define the quality of the medical system. Similarly, the number of health care workers in the hospital does not determine the quality or effectiveness of the health care system.

An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. The nurse's best response is: 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

4 For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

A nursing student is recalling information about hospice care. What is hospice care? 1 Hospice care is a resident's temporary or permanent home, where the surroundings have been made as homelike as possible. 2 Hospice care offers an attractive long-term care setting with an environment akin to the client's home, which offers the client greater autonomy. 3 Hospice care is a service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult. 4 Hospice care is a system of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness.

4 Hospice care is a system of family-centered care that allows clients to remain at home in comfort while easing the pain of terminal illness. A nursing center is a resident's temporary or permanent home, where the surroundings are made as homelike as possible. Assisted living offers an attractive long-term care setting with an environment that is like the client's home and offers the client greater autonomy. Respite care is a service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult.

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? 1 Holding a pencil 2 Showing hand preference 3 Placing objects into containers 4 Transferring objects from hand to hand

4 Infants of aged 6 to 8 months may be able to transfer objects from hand to hand. Infants of aged 10 to 12 months may be able to hold a pencil. Infants of aged 8 to 10 months may show a hand preference. Infants of aged 10 to 12 months may be able to place objects into a container.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse? 1 "You must keep up a strong appearance for him." 2 "I think he'd have difficulty dealing with that now." 3 "Don't you think he knows that without you telling him?" 4 "You should share your feelings with him while you can."

4 It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him," impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now," denies that this is a time for closeness and honesty. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? 1 Prioritize psychosocial needs over physical needs. 2 Use the Nursing Outcomes Classification (NOC) only. 3 Use nursing knowledge to plan outcomes and disregard client and family desires. 4 Set priorities and outcomes using the client's and family input.

4 Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

A nursing student is listing examples of active and passive health promotion strategies. Which strategy is an example of a passive health promotion strategy? 1 Weight-reduction program 2 Smoking-cessation program 3 Drug abuse prevention strategy 4 Fluoridation of municipal drinking water

4 Passive strategies of health promotion help people benefit from the activities of others without direct involvement. The fluoridation of municipal drinking water is an example of a passive health promotion strategy. Active strategies of health promotion require clients to adopt specific programs for improving health. Weight-reduction programs, smoking-cessation programs, and drug abuse prevention strategies are examples of active health promotion activities. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses

Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? 1 Instruct the client to position one arm on each shoulder of the nurses. 2 Direct the client to extend the legs and remain still during the procedure. 3 Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. 4 Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

4 Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.

A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with? 1 Safety 2 Quality improvement 3 Patient-centered care 4 Evidence-based practice

4 The QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. What is it important for the nurse to inform the client of? 1 That the client is acting irresponsibly 2 That this action violates the hospital policy 3 That the client must obtain a new primary healthcare provider for future medical needs 4 That the client must accept full responsibility for possible undesirable outcomes

4 The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for the illness and possible injury or undesirable outcomes. Healthcare professionals have a responsibility to inform the client and, if possible, have the client sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current primary healthcare provider will refuse to provide care to the client in the future.

*What does a nurse understand by the quality improvement competency, according to Quality and Safety Education (QSEN)? Incorrect1 Using information and technology to communicate, manage knowledge, mitigate errors, and support decision-making 2 Integrating best current evidence with clinical expertise along with client and family preferences and values for the delivery of quality healthcare 3 Functioning effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care 4 Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

4 The quality improvement competency states that a nurse should use data to monitor the outcomes of healthcare processes and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems. According to the competency called informatics, a nurse should use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. As per the competency called evidence-based practice, a nurse should integrate best current evidence with clinical expertise and client and family preferences and values for the delivery of quality healthcare. According to the competency called teamwork and collaboration, a nurse should function effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care.

A registered nurse is explaining the term "just culture" to the student nurse. Which explanation provided by the registered nurse is accurate? 1 "It refers to the agreement to keep promises." 2 "It refers to taking positive actions to help others." 3 "It refers to the ability to answer for one's actions." 4 "It refers to promoting open discussion whenever error occurs without fear of recrimination."

4 The term "just culture" refers to the promotion of open discussion whenever errors occur without fear of recrimination. Fidelity refers to the agreement to keep promises. Beneficence refers to taking positive actions to help others. Accountability refers to the ability to answer for one's actions.

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? 1 Time available for care 2 Validity of the problem 3 Method for providing care 4 Effectiveness of the interventions

4 When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

*Why does the nurse establish "moderately hard" client-centered goals? Select all that apply. 1 To decrease the cost of treatment during therapy 2 To decrease the number of follow-up visits by the client 3 To achieve the goal in a shorter period of time with less effort 4 To prevent the client from quitting before the goal is achieved 5 To prevent the client from losing motivation toward achieving the goal

4, 5 Healthcare providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.

Which of the following legal defenses are the most important for a nurse to develop? A. Activity theory B. Continuity theory C. Disengagement theory D. Gerotranscendence theory

D. Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.