Exam 1 Review Questions P2

The nursing student asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate? "A community is a group of individuals who live in the same geographic area." "A community provides resources and services that help to keep its members healthy." "The members of a community share some characteristic in common, such as cultural values." "Communities have few effects on the health of the individuals that live there."

"Communities have few effects on the health of the individuals that live there." The health of the residents of a community is affected by several factors, including the social support systems, the community health structure, environmental factors, and types of agencies providing assistance for those in need of shelter, housing, and food. The other three statements are true.

A client is completing a health history form and asks the nurse, "Why does this ask for my ethnicity instead of my race?" What is the appropriate nursing response? "Race and ethnicity are the same thing." "Race is based on physical characteristics, and ethnicity is specific to where you live." "Ethnicity is a social category that is being used to replace racial categories." "Ethnicity is a sense of identity with a collective cultural group."

"Ethnicity is a social category that is being used to replace racial categories." To answer the question, the nurse needs to address why the form asks for ethnicity instead of race. Ethnicity or ethnic group is being used to replace the term race, as race often has a negative connotation. Race and ethnicity are not the same thing. Race is based on physical characteristics; however, ethnicity is not specific to where one resides. Ethnicity is indeed a sense of identity with a cultural group; however, this answer selection does not answer the client's question.

A nurse has been asked to serve as an expert witness in a malpractice case in which an infant died in the newborn nursery. Which questions should the nurse consider prior to accepting this job? Select all that apply. "How much clinical experience do I have in the newborn nursery?" "Have I ever worked in this hospital system?" "How much education do I have about caring for newborns?" "How would I react if I was sued?" "How would I feel if my child died due to a nurse's malpractice?"

"How much education do I have about caring for newborns?" "How much clinical experience do I have in the newborn nursery?" The nurse who works on a case as an expert witness should have a solid education background and strong clinical experience comparable with those of the nurse defendant. Whether the nurse has worked in the hospital system, how the nurse would react if sued, and how the nurse would feel in similar situations should not be considerations as an expert witness.

The nurse is assigned to various clients on a medical unit. Which statement(s) made to a client by the nurse constitutes assault? Select all that apply. "I will withhold your cell phone until you pay full attention to these discharge instructions." "I am going to insert a catheter in you if you do not get up to go to the bathroom." "Give me your hand to hold, I can see you are upset by the bad news." "Hold still for these stitches; otherwise, I am going to have to hold you down." "Let me help you get your shirt off, so I can listen to your lungs."

"I am going to insert a catheter in you if you do not get up to go to the bathroom." "Hold still for these stitches; otherwise, I am going to have to hold you down." Assault is a threat or attempt to make bodily contact with a person without the person's consent. Threatening an intervention, such as a urinary catheter or restraint, when the client has not consented to it, is assault. Taking an object out of a client's hand without consent is battery. Holding a client's hand or helping a client remove clothing is not assault or battery unless the client has asked the nurse not to do so.

The nurse is planning the care for several clients. Which factor(s) should the nurse prioritize when planning to delegate care to unlicensed assistive personnel (UAP)? Select all that apply. "Is the UAP the right person for this task?" "Did the UAP follow directions correctly?" "Can the UAP assist the client with this task?" "Will the UAP complete this task without assistance?" "Did the UAP properly record the vital signs?"

"Is the UAP the right person for this task?" "Did the UAP follow directions correctly?" "Can the UAP assist the client with this task?" "Did the UAP properly record the vital signs?" There are five guidelines to delegation. They include the right task; right circumstance, right person, right directions and communication and right supervision and evaluation. The nurse should be available to provide assistance, if needed, especially if the individual chosen does not know how to complete the task. After teaching the individual how to perform the task, the nurse will be able to delegate the task in the future.

A client asks the nurse how cortisol works. What is the appropriate nursing response? "It strengthens lymphoid tissue." "It increases capillary permeability to prevent tissue swelling." "It suppresses the immune response." "It causes release of proinflammatory mediators."

"It suppresses the immune response." Cortisol suppresses the immune response, causes atrophy of lymphoid tissues, decreases capillary permeability to prevent tissue swelling, and prevents release of proinflammatory mediators. It does not strengthen lymphoid tissue, increase capillary permeability, or cause the release of proinflammatory mediators.

An older female client has just informed her family that she does not want to have surgery if the biopsy on a lung mass shows malignancy. Which statement(s), made by family members, violate the concept of feminist ethics? Select all that apply. "Of course you would have the surgery." "Daddy will want you to have the surgery." "You need to do what the doctor thinks is best for you." "Let's find out what your options are before making any decisions." "If it was me who was sick, you would want me to have the surgery."

"Of course you would have the surgery." "Daddy will want you to have the surgery." "You need to do what the doctor thinks is best for you." "If it was me who was sick, you would want me to have the surgery." Feminist ethics reflects a full commitment to full personhood for marginalized persons. Older adults, especially older females, are often marginalized. The family may wish to learn about the tumor and need for treatment prior to helping their mother make this decision. The other options infer that the woman is not able to make her own decisions about treatment.

The nurse cares for a client who is a member of a different culture from the nurse's. Which question is most important for the nurse to ask to assess the client's beliefs about treatment? "What are your expectations about being in the hospital?" "What do you eat for breakfast?" "How do you feel about being in the hospital?" "What do you believe about health care?"

"What are your expectations about being in the hospital? Culture is defined in many ways, but at the broadest level, it can be understood to be a shared system of beliefs, values, and behavioral expectations that provide social structure for daily living. It is important for the nurse to realize that people are individuals who may or may not ascribe to the norms of his or her culture. Asking what the client's expectations for treatment are specifically assesses beliefs. The client may not eat a diet from his/her culture.

A nurse has been named in a malpractice lawsuit. Prior to taking the nurse's deposition, the attorney explains that the case will be governed by common law. Which question by the nurse is indicated? "Why is this not a statutory case?" "Does that mean the findings of the case are not binding?" "Will this case be precedent setting?" "Will the board of health be involved?"

"Will this case be precedent setting?" Most law involving malpractice is common law. If a case is the first to set down a rule by its decision, a precedent will be set. Statutory law, such as state nurse practice acts, is enacted by the legislature. The findings of the case are binding in a common law case. The law establishing a board of health is known as administrative law.

A nurse researcher is reviewing the Privacy Rule under the Health Insurance Portability and Accountability Act (HIPAA) and finds information about handling protected health information (PHI). The nurse researcher would most likely find rules for which aspects of PHI? Select all that apply. Access Usage Documentation Revisions Sharing

Access Usage Sharing The Privacy Rule pertains to those who conduct research in that it outlines the rules for the use of, sharing of, and access to PHI when conducting research (NIH, 2007). Nursing researchers must familiarize themselves with HIPAA and the Privacy Rule to ensure that they are following federal guidelines, and must include with their IRB application the HIPAA form authorizing sharing of information. The Privacy Rule would not address how the nurse should document or revise protected health information.

The nurse receives a client assignment. Which client should the nurse see first? A client with right-sided heart failure with crackles in the lower lung bases bilaterally and 1+ pitting edema to the lower extremities A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90% A client with a history of stroke and right-sided weakness admitted for a new urinary tract infection A client admitted for chronic angina who is scheduled for an angiogram this afternoon

A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90% According to Maslow's hierarchy of needs, first-level physiological client needs are most important. These needs are those that are necessary to sustain life, such as breathing and eating. Using Maslow's hierarchy, along with airway, breathing, and circulation (ABCs), assists the nurse to prioritize care when given a client assignment. The client who is experiencing acute respiratory issues with pneumonia who is restless, diaphoretic, and exhibiting an oxygen saturation level of 90% requires priority assessment and intervention. The other clients listed are not currently in acute distress.

Which are examples of meeting self-actualization needs according to Maslow's hierarchy of needs? (Select all that apply.) A nurse attains a master's degree in nursing. A nurse refers a client's spouse to an Al-Anon group meeting. A nurse takes a course in communication to better relate to clients. A nurse raises the side rails on the bed of a client at risk for falls. A nurse administers insulin to a client with diabetes mellitus.

A nurse attains a master's degree in nursing. A nurse takes a course in communication to better relate to clients. The highest level on the hierarchy of needs is self-actualization needs (Level 5), which include the need for individuals to reach their full potential through development of their unique capabilities. A nurse referring a client's spouse to an Al-Anon group meeting would be an example of addressing self-esteem, Level 4. A nurse raising the side rails on the bed of a client at risk for falls would be Level 2, safety and security. A nurse administering insulin to a client with diabetes mellitus would be Level 1, physiological needs. Going to school to attain a higher degree and taking a class to improve communication skills are examples of meeting self-actualization needs, Level 5.

A nurse is demonstrating collegiality in professional practice. Which behaviors practiced by the nurse correlate with this standard of practice? Select all that apply. A nurse helps a colleague write a journal article. A nurse encourages a colleague to join the hospital journal club. A nurse encourages a colleague to quit smoking. A nurse encourages a colleague to join the American Nurses Association (ANA). A nurse helps a colleague complete a bed bath on a client.

A nurse helps a colleague write a journal article. A nurse encourages a colleague to join the hospital journal club. A nurse encourages a colleague to join the American Nurses Association (ANA). The ANA standard of collegiality refers to the nurse interacting with and contributing to the professional development of peers and colleagues. Examples include helping a colleague write a journal article, encouraging a colleague to join the hospital journal club, and encouraging a colleague to join a professional organization such as the ANA. Helping a colleague quit smoking does not contribute to the colleague's professional development. Helping a colleague complete a client bed bath indicates teamwork and collaboration, but does not help contribute to the colleague's professional development.

A nurse demonstrates the professional value known as altruism when caring for clients in a long-term care facility. What nursing action demonstrates this behavior? A nurse consults a client when planning care to determine priorities. A nurse researches the culture of a Muslim client when planning care. A nurse helps an older adult client fill out an informed consent form. A nurse promotes universal access to health care for underserved population

A nurse researches the culture of a Muslim client when planning care The professional value of altruism is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse's concern for the welfare of clients, other nurses, and other healthcare providers. It includes demonstrating an understanding of the cultures, beliefs, and perspectives of others. Altruism is demonstrated by the nurse researching the culture of a Muslim client when planning nursing care. Consulting a client when planning care to determine priorities and helping an older adult client fill out an informed consent form demonstrate the value of autonomy, which is the right to self-determination. Promoting universal access to health care for underserved populations demonstrates the value of social justice. Reference:

The nurse is managing the care for a postoperative client. How does the nurse demonstrate advocacy? Limiting visitors due to the client reporting pain Administering pain medication when the pain level reaches 9 on a pain scale of 0 to 10 Changing the channel on the television while providing care Turning and positioning the client every 4 hours

Administering pain medication when the pain level reaches 9 on a pain scale of 0 to 10 Advocating for clients is a nursing responsibility and is performed with the best interest and welfare of the client in providing safe, competent, and comforting care. Limiting visitors is an example of advocacy. The nurse recognizes that the client is in pain; therefore, limiting the visitors allows for the nurse to advocate for additional measures to allow the client to rest and recover. Administering pain medication and turning and the client every 4 hours are important and necessary interventions for a postoperative client, but this is not advocacy. Changing the channel on the television while providing care also does not promote advocacy.

The nurse is caring for a terminally ill client who immigrated from Mexico. Which nursing intervention regarding spiritual care is appropriate? Inquire if the client desires the Sacrament of the Sick. Ask the client if a spiritual leader is desired. Do nothing unless the client requests spiritual assistance. Call a Roman Catholic priest to visit the client.

Ask the client if a spiritual leader is desired. The appropriate response is to ask the client if a spiritual leader is desired, which is observant of the client's preferences. The nurse should not generalize that a Latino client is Roman Catholic, nor should the nurse refrain from inquiring about spiritual needs.

When providing care to a client, the nurse prioritizes the client's needs. Which intervention would the nurse employ to meet the client's physiologic needs? Select all that apply. Assessing the client's skin color Weighing the client Promoting a high-fiber diet Teaching the client about a procedure Including the client's spouse in the client's plan of care

Assessing the client's skin color Weighing the client Promoting a high-fiber diet Physiologic needs—for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. These needs are the most basic in the hierarchy of needs and the most essential to life, and therefore have the highest priority. Assessing skin color, weighing the client, and promoting elimination via a high-fiber diet are interventions focused on meeting the client's physiologic needs. Teaching the client about a procedure helps meet the client's emotional safety and security needs. Including the client's spouse in the plan of care addresses the client's love and belonging needs.

Which scenario is the best example of the nurse in the role of teacher/educator? Assessing whether the client is able to perform a dressing change Teaching a first-grader to read Communicating discharge status to a home care agency Conducting research on dressing changes

Assessing whether the client is able to perform a dressing change When in the role of teacher/educator, the nurse uses communication skills to assess, implement, and evaluate teaching plans to meet the learning needs of clients and their families. The nurse assessing whether a client is able to perform a dressing change is assessing the need for education on how to perform the dressing change. Teaching a first-grader to read is not within the scope of nursing practice. Communication of discharge status is an example of the nurse as a communicator. Conducting research is an example of the role of the nurse as a researcher.

Which activity by the nurse is an example of exercising professional standards of practice? Networking at a professional organization meeting Attending a conference for continuing education credits Mentoring a new nurse employee on the unit Referring to clients as "Mr." or "Ms."

Attending a conference for continuing education credits Professional standards of nursing practice are important, as they promote and guide clinical practice ensuring that care given is proficient and safe. These standards encourage nurses to maintain competence through experiences, evidence-based guidelines, and continuing education. As such, attending a conference for continuing education demonstrates the basic professional standard of maintaining competence in practice. Networking at a professional nursing organization meeting would help to connect with other members in the nursing profession but is not a standard of practice. Mentoring a new nurse is important for the successful transition of the new nurse from school to professional nursing but is not a professional care standard. Referring to clients as "Mr." or "Ms." is polite but not a care standard.

A client makes a decision to quit smoking and joins a smoking cessation class. This is an example of which of Dunn's processes that helps one know who and what one is? Being Belonging Becoming Befitting

Befitting Dunn defined processes that help one know who and what one is. These processes, which are a part of each individual's perception of his or her own wellness state, are being (recognizing self as separate and individual), belonging (being part of a whole), becoming (growing and developing), and befitting (making personal choices to befit the self for the future).

Identify the activities a nurse uses in the process of valuing. Select all that apply. Choosing Modeling Acting Rewarding Prizing

Choosing Prizing Acting Choosing, prizing, and acting are all activities one uses in valuing something. When one decides to value something, one chooses freely from alternatives after careful consideration of the consequences of each alternative. Prizing something one values involves pride, happiness, and public affirmation. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity. The other choices, modeling and rewarding, are approaches to transmitting values to others, not activities related to valuing.

Which are examples of ways that a nurse can use theories to guide client care? (Select all that apply.) Collect client data. Organize client information. Classify client data. Make client assignments on the unit. Analyze client situations.

Collect client data. Organize client information. Classify client data. Analyze client situations. Assignments on a clinical unit are made by using acuity systems or delegation rather than being based in nursing theory. The other choices are all examples of ways that theory can guide client care.

The unit where a nurse works is undergoing structural changes along with changes in client load and managerial style. The nurse feels disorganized and stressed and is having difficulty sleeping. The nurse wonders if these feelings are related to the changes at work. What next step should the nurse choose in the 4A plan to address this issue? Acting to make a change Committing to self-care Analyzing the risks and benefits of acting to reduce the distress Determining the severity of the distress

Committing to self-care In this scenario the nurse is Asking if the distress being felt is from changes at work. The next step is to Affirm that distress exists and commit to take care of self. The nurse affirms distress by validating feelings and perceptions with others. The third step is to Assess which includes determining the severity of the distress and analyzing the risks and benefits of acting on the distress. The fourth step is to Act which is implementing strategies to initiate changes to reduce distress.

Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs? Constipation related to decreased mobility Anxiety related to inability to cope with pending prognosis Impaired Social Interaction related to disturbed body image Risk for Falls related to unsteady gait following stroke

Constipation related to decreased mobility The most basic level in the hierarchy, physiologic need of elimination, is reflected by constipation related to decreased mobility. Risk for Falls identifies a problem related to the client's physical safety needs. Impaired Social Interaction identifies a problem with the love and belonging needs of the client. Self-esteem is reflected in the nursing diagnosis of Anxiety.

A nurse is reviewing a qualitative research study. Which aspects of this type of study would the nurse need to keep in mind? Select all that apply. Control or manipulation is rarely used. Reality is not viewed as a fixed entity. Objectivity is valued. Biases are controlled to avoid contamination. Intuition is used for analysis.

Control or manipulation is rarely used. Reality is not viewed as a fixed entity. Intuition is used for analysis. Qualitative research involves seeing reality not as a fixed entity but as existing in a context with the researcher rarely controlling or manipulating any aspect of the people/environment under study. Subjective interactions are viewed as the primary way to access understanding of the phenomena and intuition is used for analysis. Objectivity and control of biases are aspects of quantitative research.

Which term is most appropriate for describing a healthcare practitioner who is respectful of the healthcare traditions of other cultures? Culturally sensitive Culturally appropriate Culturally competent Culturally impositive

Culturally sensitive Culturally sensitive is defined as being respectful of other diverse cultures. Culturally impositive is the tendency for healthcare practitioners to impose their beliefs, practices, and values on people of other cultures. Culturally appropriate and culturally competent refer to the holistic care given by healthcare practitioners.

A nurse is caring for a 79-year-old client who is new to a long-term care facility. Previously, the client lived in a rural community in a household consisting of the client and an adult child. The child is no longer able to care for the client. The client appears disoriented and reports being bothered by the "bright lights and constant activity." The nurse appropriately documents what condition in the chart? Culture assimilation Culture disorientation Culture blindness Culture shock

Culture shock Culture shock is a feeling a person experiences when placed in a different culture perceived as strange. Culture shock may result in psychological discomfort, or disturbances, as the patterns of behavior a person found acceptable and effective in his or her culture may not be adequate or even acceptable in the new culture. Cultural assimilation is a process in which a minority group begins to adapt their own cultural characteristics to the new culture in which they are living. Cultural blindness is when one ignores differences in another's culture and proceeds as though the differences do not exist.

A nurse manager receives negative survey results citing a decrease in the quality of client care. Which areas should the nurse manager research as causative factors in the decrease of quality care delivery? Select all that apply. Inadequate staffing patterns Increase in acuity of clients on the unit Nurses working 12-hour shifts Decreased satisfaction of nurses in the workplace Nurses working weekends

Decreased satisfaction of nurses in the workplace Inadequate staffing patterns Two of the chief reasons nurses cite for the declining quality of nursing care at their facilities are inadequate staffing and decreased nurse satisfaction. Nurses working 12-hour shifts and on weekends and increased acuity of clients are not cited in the literature as causes of declining quality of client care.

Which examples are considered acceptable cultural norms in health care? Select all that apply. Defining diabetes mellitus as a metabolic disorder characterized by elevated blood sugar Encouraging adult women to conduct self-breast exams once a month Arriving late for a scheduled appointment Documenting pain with every client assessment Following a specific regimen for cardiac rehab

Defining diabetes mellitus as a metabolic disorder characterized by elevated blood sugar Encouraging adult women to conduct self-breast exams once a month Documenting pain with every client assessment Following a specific regimen for cardiac rehab Standardized definitions of health and illness as well as maintenance and prevention of illness are considered acceptable cultural norms in the health care system. Thorough documentation is a cultural habit, as is using a systematic approach (such as cardiac rehab) to problem-solve. Tardiness is not an acceptable cultural norm in the health care system.

A recently licensed registered nurse is preparing to enter practice in an acute care facility and wants to practice within the guidelines of that state. When preparing to research the state nurse practice act, what information is important to obtain? Select all that apply. Content for the NCLEX The members of the state board of nursing Definition of legal scope of nursing practice Definition of important terms related to nursing Establishment of educational criteria

Definition of legal scope of nursing practice Definition of important terms related to nursing Establishment of educational criteria Nurse practice acts in each state are designed to regulate the practice of nursing within the state. The acts include the definition of important terms related to nursing, definition of the legal scope of nursing, and establishment of educational criteria. The practice acts do not dictate which content should be included on the NCLEX exam. The members of the state board of nursing are not important to know when researching scope of nursing practice in the state.

The nurse has developed a strong therapeutic relationship with an electrician who sustained severe burns while working on an industrial site. Which action by the nurse most directly addresses the client's self-actualization needs? Discussing the client's strengths and dialoguing about body image Encouraging the client to talk about previous accomplishments and goals for the future Reorganizing care and facilitating a day pass so that the client can spend Thanksgiving with family Encouraging the client's friends and family to take an active role in the client's care at the hospital

Discussing the client's strengths and dialoguing about body image Aspects of self-actualization include focusing on clients' strengths and fostering a positive body image. Addressing accomplishments and goals is likely to meet clients' self-esteem needs. Facilitating contact and connection between clients and their families is an action that promotes meeting love and belonging needs, as is reorganizing care and facilitating a day pass so that the client can spend Thanksgiving with family.

The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response? Explain to the client that the client is required to make all decisions related to the client's own health care. Document the client's request in the nursing care plan. Bring the client's spouse into the hallway to discuss surgical options for the client. Explain to the client that it is not a good idea to have the spouse in the room when discussing such a private matter.

Document the client's request in the nursing care plan. A culturally sensitive nurse is one who respects a client's requests while ensuring that the requests reflect safe medical practice. This client's request does not interfere with client safety. Thus, the request should be respected and communicated through documentation to other healthcare personnel. Telling the client that the client must make all health care decisions does not address the client's request. There is no need to move to the hallway to discuss the client's care with the client's spouse, and this would likely be offensive.

The nurse is caring for a very active, athletic adolescent recently diagnosed with multiple sclerosis. The client appears to be withdrawn and depressed when the nurse asks how the client is doing today. Using the health belief model, what step(s) will the nurse take to create a plan of care for this client? Select all that apply. Encourage the client to participate in as many activities as they can tolerate and provide information for health counseling. Review possible outcomes of the diagnosis with the client, allowing the client to express concerns while providing support. Assure the client that they will be able to live a full life, provide education on how to adjust to the new diagnosis, and include the family in any life-changing decisions. Conduct an in-depth interview of the client's previous health issues, how the client reacted to the illness, and what support system the client has. Assure the client that there is nothing to be worried about because many people are diagnosed with this disease, and alert the family to the possibility of depression.

Encourage the client to participate in as many activities as they can tolerate and provide information for health counseling. Review possible outcomes of the diagnosis with the client, allowing the client to express concerns while providing support. Conduct an in-depth interview of the client's previous health issues, how the client reacted to the illness, and what support system the client has. The health belief model is useful when educating individuals about health and illness because it allows nurses to assess a client's beliefs and then structure goals to meet individual health needs. It is important that the nurse validates the client's beliefs, but provide factual information so the client can evaluate health care beliefs and practices. In order to do so, the nurse must see how the client has handled disease in the past and what type of support system the client has. Offering false reassurance such as assuring the client they will be able to live a full life or simply encouraging the client to go on with a normal life is not always a healthy approach. Dismissing or belittling a client's beliefs does not build trust.

A client is to undergo surgery for removal of the gallbladder. Which action related to the client's informed consent falls within the nurse's scope of practice? Select all that apply. Ensuring the signed form is on the chart Acting as a witness to the client's signature on the form Answering questions about elements of the consent Explaining the details about the procedure to be done Identifying the risks and benefits associated with the procedure

Ensuring the signed form is on the chart Acting as a witness to the client's signature on the form Answering questions about elements of the consent Obtaining informed consent is the responsibility of the person who will perform the diagnostic or treatment procedure or the research study. This person is responsible for explaining the procedure along with any risks and benefits associated with it. The nurse's role is to confirm that a signed consent form is present in the client's chart and to answer client questions about the elements of the consent. Unless the nurse is obtaining consent for a nurse-prescribed and nurse-initiated intervention, the nurse signs the consent form as a witness to having seen the client sign the form, not as having obtained the consent.

When describing the concept of ethnicity, which statement would be most appropriate to use? Ethnicity is an alternative term that implies the same ideas as culture. Ethnicity allows people to define themselves and others to define them. Culture involves self-consciousness while ethnicity does not. Ethnicity is a present-oriented form of identity.

Ethnicity allows people to define themselves and others to define them. Ethnicity is a cluster of ways for people to define themselves and be defined by others. It involves the selection of certain shared cultural characteristics, such as symbols of a common group origin, history, or descent. Ethnicity is not culture. Ethnic identity is distinguished from culture in that ethnic identity is self-conscious about select symbolic elements that are taken as the emblem of group social identity. Ethnicity or ethnic identity refers to a self-conscious, past-oriented form of identity based on a notion of shared cultural (and perhaps ancestral) heritage, as well as current position within the larger society.

Which is the basic unit of human society? Individual Family Community Institution

Family Family is the basic unit of human society. An individual cannot survive alone and needs support. A community is a group of basic units of families. An institution is a type of community.

Which are factors that impact how a client defines health? Select all that apply. Family Culture Community Society Music

Family Culture Community Society Each client defines health in terms of the client's own values and beliefs. The person's family, culture, community, and society also influence this personal perception of health. Music does not affect how a person defines health.

What factor threatens to increase the number of people who are living at poverty level? Feminization of poverty Decreasing population of older people Increasing immigrant population Lack of health insurance

Feminization of poverty The feminization of poverty threatens to increase those at poverty level. This is caused by the increase in female-headed households through divorce, abandonment, unmarried motherhood, and changes in abortion laws. The older population is increasing. The immigrant population does not directly increase or decrease poverty level. Lack of health insurance is an issue for those who are in a poverty culture but does not increase those at the federal poverty level.

A nurse is completing a family assessment during a routine home health visit. The parents have a child with special needs, along with six other children, and the older siblings help out with the younger. Which theory would best help the nurse understand this family's functioning? General Systems Theory Adaptation Theory Developmental Theory Maslow's Theory

General Systems Theory Systems theory is described as studying relationships between a whole and identifying how parts interact and behave. This family has adjusted to the size and configuration of the family with a special needs child by manipulating the individual roles of the family members. Adaptation theory is based on an understanding of humans and their interaction with the environment. Developmental theory is based on growth and maturation of humans. Maslow's hierarchy presents basic human needs in the order in which people generally attempt to meet them. These three theories would not be as appropriate as the general systems theory, as adaptation, human development, and basic human needs are not the topic of interest; rather, the interaction among components (individual family members) of a system (the family) is the topic of interest.

What type of nursing program would allow a student with a 4-year degree in psychology to enter and complete a baccalaureate degree in nursing, take the NCLEX examination, and transition into a Master of Science in nursing (MSN) program? Baccalaureate program Graduate entry program Advanced degree program Continuing education program

Graduate entry program Students in a graduate entry program possess a baccalaureate degree in a field other than nursing. These students can track directly into a master's or doctorate in nursing program after successfully passing the NCLEX-RN. Baccalaureate programs are for those with none or lower level college background. Advanced degree programs provide a specific track to move from one degree within nursing to another. Continuing education allows those with an active license to earn professional continuing credit hours to maintain or advance their licensure or certification.

Which teaching statement best exemplifies cultural competence in relation to time for the American culture? It is a sign of respect to be late for your health care appointments. It is important to be on time for your health care appointment. It is important to be future-oriented when considering your appointment time. It is important to arrive within 20 minutes of your scheduled appointment time.

It is important to be on time for your health care appointment. In the United States, being on time and completing a job promptly are the expectation. This expectation is not the same in all cultures. It should be included when explaining cultural practice that timeliness is important. Being late for an appointment is considered disrespectful in the American culture.

The nurse and a student are discussing entry into the profession of nursing. Which statement should the nurse use to describe a diploma program? "It is obtained by a 36-month program at a community college." "It is obtained through a 2-year program at a university." "It is obtained by a 36-month program at a hospital." "It is obtained by a 4-year program at a university."

It is obtained by a 36-month program at a hospital." Diploma programs are obtained through a hospital program and take 36 months. Associate degrees are obtained through a community college and take 2 academic or calendar years. Baccalaureate degrees are obtained through a 4-year degree at a senior college or university.

The nurse is assessing a client who is unresponsive. To obtain information about the client's culture, the nurse interviews a person who has native knowledge about the client's culture. Which technique is the nurse using? Key informant Explanatory Ethnographic Open-ended

Key informant The key informant technique is a method in which the interviewer looks for, locates, and interviews people who have expert or native knowledge about a culture. A willingness to discuss this knowledge and rapport with the interviewer are critical. The optimal key informant about a client is the client, but medically or culturally compromised clients (i.e., those who are unable to function optimally in the culture) might not be able to fill the role. The explanatory model is similar to the ethnographic interview. Given that the client is the expert on the client's own multicultural identity, questions are posed by the nurse to understand the client's beliefs about the client's health, or the explanation for the client's condition. The ethnographic interview is a structured way to elicit the respondent's concepts and understandings. The nurse interviewer asks questions, the client answers, and the nurse interviewer asks for clarification of the client's responses, if needed. A variety of techniques are used in open-ended interviewing to elicit responses from the interviewee that are as free from influence by the interviewer's comments as possible. Open-ended questions require that the respondent use the respondent's own words to answer.

A nurse is part of an orientation team for a group of newly hired nurses. The nurse is to prepare a presentation for the group about different cultural groups common to the facility. As part of the presentation, the nurse is planning to describe how culture is communicated to provide a foundation for culturally competent care. Which methods of communication would the nurse include? Select all that apply. Language Behavior Symbols Implicit beliefs Lifeways

Language Behavior Symbols Culture is communicated through language, behavior, and symbols. Implicit beliefs and lifeways are components of culture.

The nurse offers a client two possible times to ambulate, as prescribed by the health care provider. The nurse is acting in which nursing role? Communicator Client advocate Manager and coordinator Caregiver

Manager and coordinator While the nurse is acting in many roles, the nurse is managing and coordinating the care for the client by giving choices for when care may be implemented. The nurse is not acting simply as a communicator, advocate, or caregiver.

Which aspects of nursing make it recognizable as a subculture? Select all that apply. Manner of dress Language used Rituals Talent for planning Sensitive use of time

Manner of dress Language used Rituals Nurses are recognizable as a subgroup in numerous ways: their legally sanctioned, authoritative stance vis-à -vis clients and the general public; manner of dress; language ("nurse-ese" includes a large vocabulary of acronyms specific to healthcare professions as well as its own subcultural lingo); and the rituals and ritualized behaviors into which nurses are socialized as nurses. Talent for planning and sensitivity to the use of time are values of nurses that reflect the dominant group.

A nurse is providing care to a client and has enlisted the help of a trained interpreter to assist in communicating with the client. Which action would the nurse do first? Meet with the interpreter alone before a combined meeting with the client. Tell the interpreter what the nurse wants to learn from the client. Explain what messages the nurse wants to convey to the client. Discuss any concerns about how to communicate with the client.

Meet with the interpreter alone before a combined meeting with the client. The nurse should first meet with the interpreter before they meet with the client. During this meeting, it would be appropriate to tell the interpreter what the nurse wants to learn from the client and what messages the nurse wants to convey to the client. Also, the nurse should discuss any concerns about how to communicate with the client, and ask for feedback on how to help the interpreter reach a mutual understanding with the client.

What is the central theme of Florence Nightingale's nursing theory? Humans are in a constant relationship with stressors in the environment. Meeting the personal needs of the client within the environment. Nursing is an art. Nursing is a therapeutic, interpersonal, and goal-oriented process.

Meeting the personal needs of the client within the environment. Florence Nightingale believed in meeting the personal needs of the client within the environment. Hildegard Peplau believed nursing is a therapeutic, interpersonal, and goal-oriented process. Nursing is an art is the theory of Ernestine Wiedenbach, while Betty Neuman's nursing theory states that humans are in a constant relationship with stressors in the environment.

Which is the goal of tertiary prevention of illness? Preventing disease or illness Providing prompt treatment Improving general well-being Minimizing complications

Minimizing complications The goal of tertiary prevention of illness is to minimize complications and maximize function. Prevention of illness or disease, and improvement of the general well-being of a client, is a goal of primary prevention. Providing prompt treatment is a goal of secondary prevention.

The nurse is explaining to a nursing colleague why there should be only one entry into the profession. What is the best statement by the explaining nurse? "Multiple methods of preparation increase the number of nurses." "Increasingly, there is opportunity for educational advancement." "Multiple methods of preparation are confusing to consumers." "State laws recognize both the LPN and RN as nursing credentials."

Multiple methods of preparation are confusing to consumers." Educational preparation for the nurse has become a major issue in nursing; the multiple methods of preparation are confusing to employers, consumers of health care services, and nurses themselves. Proponents of multiple preparations for nurses have stated that it increases the number of nurses, which is important due to nursing shortages. State laws do recognize both the LPN and RN as nursing credentials, but this is confusing to consumers. Increased opportunity for educational advancement does not support the argument that there should be only one entry into the profession.

Which national nursing organization serves as a primary source of research data about nursing education, and is the professional organization for nurse educators? National League for Nursing (NLN) American Nurses Association (ANA) Sigma Theta Tau International American Association of Colleges of Nursing (AACN)

National League for Nursing (NLN) The NLN serves as the primary source of research data about nursing education, conducting annual surveys of schools and new RNs. The NLN's objective is to foster the development and improvement of nursing services and nursing education, and it serves as the professional nursing organization for nurse educators. The ANA is the professional organization for RNs in the United States, and it establishes standards of practice, encourages research to advance nursing practice, and represents nursing for legislative actions. Sigma Theta Tau International is the honor society for nursing. AACN is the national voice for baccalaureate and higher-degree nursing education programs and provides accreditation for collegiate nursing programs

A nurse is conducting a community health assessment for high risk families. What risk factors should the nurse identify? Select all that apply. New sibling was introduced two months ago. Family does not have health insurance. Home is located in an area with gang violence. Nearest acute care facility is 45 minutes away. Family adheres to a strict vegetarian diet.

New sibling was introduced two months ago. Family does not have health insurance. Home is located in an area with gang violence. Nearest acute care facility is 45 minutes away. A new sibling can cause stress to a family with child care issues and financial burdens. A family without health insurance is at higher risk of developing disease-related conditions and less likely to seek medical attention. If the home is in an area with violence, the family is opened to safety-related scenarios and possible risk for injury. Safety is a priority for families. If the nearest care facility is 45 minutes away, the family has limited health care accessibility. Vegetarian diets can provide adequate nutrition for the family.

A nurse is caring for a hospitalized client. Which nursing actions demonstrate a caring and compassionate attitude? Select all that apply. Leaving the room promptly once care is completed Notifying the client before leaving for lunch Offering snacks and beverages to visiting family Explaining all nursing procedures clearly Listening to the client tell stories about past experiences

Notifying the client before leaving for lunch Offering snacks and beverages to visiting family Explaining all nursing procedures clearly Listening to the client tell stories about past experiences One of the best methods for avoiding lawsuits is to administer compassionate care. Notifying the client before leaving for lunch, offering snacks and beverages to visiting family, explaining all nursing procedures clearly, and listening to the client tell stories are examples of a caring and compassionate attitude. Leaving the room promptly once care is completed does not demonstrate care or compassion.

A nurse manager is attempting to switch the medical records in an orthopedic office to a computerized format. The nurse asks questions about the accuracy and efficiency of the current record keeping system by using the PICO format. Which statements illustrate the components of this process? Select all that apply. P: The nurse purchases computers from a computer store. P: The nurse chooses the population involved (orthopedic clients). I: The nurse considers interventions to make the plan work. C: The nurse calculates the cost of the new program. C: The nurse compares the written records to the computerized records. O: The nurse determines the occurrence of problems in the systems.

P: The nurse chooses the population involved (orthopedic clients). I: The nurse considers interventions to make the plan work. C: The nurse compares the written records to the computerized records. The PICO format is a format used to ask a clinical question. The "P" stands for patient, population, or problem of interest. The "I" stands for intervention of interest. The "C" stands for comparison of interest. The "O" stands for outcome of interest. The nurse choosing the population of orthopedic clients is a correct example of the "P" component. The nurse considering interventions to make the plan work is an example of the "I" component. The nurse comparing the written records to the computerized records is an example of the "C" component. The nurse purchasing computers from a computer store is not an example of the "P" component. The nurse calculating the cost of the new program is not an example of the"C" format. The nurse determining the occurrence of problems in the systems is not an example of the "O" component.

The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take? Reorient the client to person, place, and time. Notify the physician. Position the client in a side-lying position. Document the type of seizure in the client's health record

Position the client in a side-lying position. The need for oxygen is the most essential of all physiological needs. Aspiration is a risk for the client after a seizure because of lethargy and increased oral secretions. The client needs to be positioned on the side to allow the secretions to drain from the mouth. Immediately following a seizure, the client experiences postictal confusion, which usually resolves in 1 hour unless complicated by a head injury or hypoxia. Notifying the physician and documenting the type of seizure are good interventions after the client's airway is secure and breathing is normal.

A Native American/First Nations client comes to a new clinic. The client has been to multiple clinics. The client uses peyote as part of the client's religion. Past care providers have dismissed the client's health concerns as being imaginary. What is the priority nursing diagnosis? Social isolation related to living in a tribal unit that is decreasing in size Ineffective management of therapeutic regimen related to mistrust of traditional healthcare personnel Powerlessness related to the inability to make health care providers understand the client's symptoms Situational low self-esteem related to the repeated use of peyote

Powerlessness related to the inability to make health care providers understand the client's symptoms Peyote is a hallucinogenic drug that is legal when used as part of religious ritual. Use of the drug does not warrant dismissing the client's health concerns. The priority diagnosis is powerlessness, as the client feels as though no one will listen. The other options are not related to the given situation.

The nurse is assessing an infant of Asian descent and notes dark blue spots on the infant's lower back. What action should the nurse take next? Press lightly on the pigmented area and observe the infant's reaction. Ask the parents to leave the room and conduct a thorough assessment. Contact the health care provider. Document and report the findings to authorities.

Press lightly on the pigmented area and observe the infant's reaction. Mongolian spots are a type of hyperpigmentation that results in dark blue areas on the lower back, abdomen, thighs, and arms. To differentiate Mongolian spots from a bruise or injury, the nurse should press on the Mongolian spot. Mongolian spots do not produce pain when pressure is applied. The nurse will not ask the parents to leave the room as they are the legal guardians of the infant and should be present for the assessment. This action is only taken if suspicion of abuse is readily apparent. The nurse should assess before calling the health care provider. The nurse needs to complete the assessment before documenting it. Because this is not an ominous finding warranting further investigation, the nurse would not contact the authorities.

The nurse strives to uphold human dignity when providing care to clients. Which behaviors by the nurse would best exemplify this value? Select all that apply. Protects the privacy of the client Maintains confidentiality Promotes universal health care Provides culturally competent care Demonstrates accountability

Protects the privacy of the client Maintains confidentiality Provides culturally competent care Human dignity is defined by the right of a person to be valued and respected for one's own sake, and to be treated ethically. The nurse is exemplifying this by protecting privacy, maintaining confidentiality, and providing culturally competent care. Promoting universal health care would better exemplify the value of social justice and, in any case, would not be appropriate an appropriate action when providing care to clients. Demonstrating accountability is not a human dignity issue but is a core concept in the overall nursing care of a client.

What are the primary purposes for conducting research in nursing? Select all that apply. Decrease the number of illnesses in the population Improve NCLEX pass rates Provide a basis for best practice guidelines Provide a resource for evaluating care Develop new ways to improve assessment and diagnostic skills

Provide a basis for best practice guidelines Provide a resource for evaluating care Develop new ways to improve assessment and diagnostic skills The nursing profession uses research findings to develop innovative methods to sharpen assessment and diagnostic skills; establish future standards for developing client goals, client outcomes, and nursing interventions in the planning stage; and provide the latest knowledge to enhance nursing practice. Reviews of clinical research also provide a basis for best practice guidelines and serve as another excellent resource for nurses in evaluating care. Primary purposes of nursing research do not include decreasing the number of illnesses in the population (which is more the goal of medical research) or to improve pass rates on the NCLEX.

The nurse is caring for a client who was recently diagnosed with diabetes mellitus. Which action demonstrates that the nurse is using the Basic Needs theory? Watching the client test the blood glucose level daily Teaching the client about disease management Providing foot care for the client Helping the client cope with the new diagnosis

Providing foot care for the client Believing that the setting in which a person learns has an effect on patterns for living things is part of Virginia Henderson's Basic Needs theory, as evidenced by the nurse providing foot care. The other actions support different nursing theories.

All members of the health care team are encouraged to read and contribute to the individual plans of care for their clients. Which health care provider develops the plan of care? the RN the LPN or RN the physician any licensed member of the health care team

RN To serve as evaluation criteria and meet the standards of The Joint Commission (2010), the plan must be developed by a registered nurse, it must be documented in the client's health record, and it must reflect the standards of care established by the institution and the profession. It may be countersigned by members of the interdisciplinary team who provide care for the client.

A client has recently immigrated and is exhibiting symptoms of culture shock. The client reports feeling unaccepted in the new culture. The client states, "I can't do anything right here." What is the priority nursing diagnosis? Powerlessness related to the loss of familiar cultural practice Situational low self-esteem related to culture shock and feelings of fear and incompetence Spiritual distress related to low self-esteem Social isolation related to culture shock and feelings of low self-worth

Situational low self-esteem related to culture shock and feelings of fear and incompetence The client is experiencing low self-esteem, which is often associated with culture shock. It is situational in nature and will likely improve with cultural assimilation. The client does not indicate powerlessness, spiritual distress, or social isolation.

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family? Socialization Physical Reproductive Affective and coping

Socialization Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. Incorporating religious beliefs, values, and attitudes is an example of socialization. Physical functions of the family include providing a safe, comfortable environment necessary for growth and development, rest, and recuperation. The reproductive function of the family is raising children. The affective and coping function of the family involves providing emotional comfort to family members.

A nurse is caring for a client who has breast cancer. The client tells the nurse: "I don't know why this happened to me, but I'm ready to move on and do whatever I need to do to get healthy again." This client is in which stage of acute illness? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3 When a person becomes ill, certain illness behaviors may occur in identifiable stages (Suchman, 1965). These behaviors are how people cope with altered functioning caused by the disease. They are unique to the person and are influenced by age, gender, family values, economic status, culture, educational level, and mental status. By the statement the client made above, the client is in stage 3 of acute illness, assuming a dependent role. This stage is characterized by the client's decision to accept the diagnosis and follow the prescribed treatment plan. Stage 1 is experiencing symptoms. Stage 2 is assuming the sick role. Stage 4 is achieving recovery and rehabilitation.

The nurse caring for several clients on a surgical unit notes that one of the clients is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action? Stereotyping Racism Honoring rituals Transcultural nursing

Stereotyping Although the nurse was trying to be thoughtful (as with transcultural nursing), the action would be considered stereotyping because the nurse assumed this ritual was part of the client's practices. Without validation from the client, this cannot be considered to be honoring the client's religious dietary ritual. Racism involves negative thoughts or feelings toward a specific group of people.

A couple with adolescent children is most likely to focus on which developmental task? Strengthening the marital relationship Establishing a mutually satisfying marriage Adjusting to retirement Coping with loss of energy and privacy

Strengthening the marital relationship The couple in a family with adolescents and young adults likely has a developmental task to strengthen marital relationships. Establishing a mutually satisfying marriage and coping with the loss of energy and privacy are tasks for a couple with young children. Adjusting to retirement is a developmental task for older adults.

The nurse is educating a client with diabetes on how to better control blood sugar levels and recognize the symptoms associated with both hyperglycemia and hypoglycemia. The client is frequently admitted to the hospital due to elevated blood sugars. This education is an example of which level of health promotion? Primary Secondary Tertiary Chronic

Tertiary Tertiary health promotion and illness prevention begin after the illness is diagnosed and treated, with the goal of reducing disability and helping to rehabilitate to a maximum level of functioning. Educating a client with diabetes on how to recognize areas of risk for the disease is one such example of tertiary promotion. Primary promotion is focusing on educating the client to potential risks. Secondary promotion is screening. There is not a chronic promotion component.

A nurse is applying a care-based approach to an ethical dilemma. When integrating this approach, which concept should the nurse keep in mind? Select all that apply. The caring relationship is essential to the approach. Clients are people and are to be respected. Attention is needed to focus on each person's individual situation. Autonomy and beneficence guide any action. Benefits to one client typically are benefits to another.

The caring relationship is essential to the approach. Clients are people and are to be respected. Attention is needed to focus on each person's individual situation. The nurse-client relationship is central to the care-based approach, which directs attention to the specific situations of individual clients viewed within the context of their life narrative. The care-based approach is essential to person-centered care. Other aspects include the promotion of the dignity and respect of clients as people, and attention to the particulars of individual clients. Autonomy and beneficence reflect the principle-based approach. When applying a principle-based approach, the nurse needs to understand that a benefit to one person may be considered a harm to another.

The nurse has an ethical conflict regarding the client's use of marijuana to control symptoms of advanced cancer. Which argument(s) regarding this conflict reflect a utilitarian approach? Select all that apply. Marijuana is not legal in the client's state of residence. The client experiences significant reduction of cancer symptoms when using marijuana. The client is homebound and will not be driving. Specific dosages of marijuana have not been determined. There is little opportunity for any other persons to divert or use the marijuana the client obtains.

The client experiences significant reduction of cancer symptoms when using marijuana. The client is homebound and will not be driving. There is little opportunity for any other persons to divert or use the marijuana the client obtains. Utilitarian arguments are those that determine rightness or wrongness of an action based on the action's consequences. In this case, that the client experiences reduction of symptoms, that the client will not be driving, and that there is little opportunity for diversion all reflect an utilitarian approach. Deontologic arguments are based on a rule such as legality or specific dosages.

A 13-year-old client with cystic fibrosis who is being discharged confides in the nurse that her parents argue a lot. Sometimes, her mother has too much to drink and starts throwing things at people. At times she gets scared her mom will hurt someone. She feels as if she is causing her parents to fight and her mom to drink because she is always in the hospital. She also worries about getting a bad grade in school due to her many absences and not getting into a good college. According to Maslow's hierarchy of human needs, which issue should take priority when caring for this client? The client feels as if she is the cause of her family's dysfunction. The client's parents argue a lot. The client feels scared that her mother will hurt someone. The client is worried about getting a bad grade in school..

The client feels scared that her mother will hurt someone. According to Maslow's hierarchy of human needs, physiologic needs come first, followed by safety (threatened by the mother throwing things), then love and belonging (threatened by the parents constantly arguing), then esteem (threatened by a sense of guilt over feeling like the cause of family dysfunction), and then self-actualization (threatened by making a bad grade).

A nurse receives a report for a client who is going to surgery in the morning. The nurse is informed that the client is Jehovah's Witness. What education is needed for this particular client? The client needs to be informed that blood may be given if needed in an emergency situation so informed consent can be obtained. The client should be informed that surgery is not an option because blood will need to be transfused. The client should be informed that he or she can discuss the possible need for blood with a spiritual counselor prior to surgery to make an informed decision. The client needs to have a discussion with the health care team about blood product preferences.

The client needs to have a discussion with the health care team about blood product preferences. Although the client is Jehovah's Witness, the nurse needs to initiate a discussion with the client about administration of blood and blood products. The nurse should not stereotype and assume the client will refuse all blood products. The client should be informed about choices and given options prior to surgery. These options should be provided without judgement or personal opinion. If the client chooses to refer to a spiritual counselor, this should be provided, but this is not education needed.

A nurse is assessing a client for potential variables that influence the client's health. When assessing the client's self-concept, which area should the nurse include? Select all that apply. The client's feelings about self as a person The client's view of self physically The client's educational level The client's cultural background The client's degree of interaction with family members

The client's feelings about self as a person The client's view of self physically Self-concept incorporates both how people feel about themselves (self-esteem) and the way they perceive their physical self (body image). Educational level, culture, and family interaction are not components of self-concept.

A nurse is caring for a family consisting of three middle-aged adults. Which examples describe developmental tasks of this type of family structure? Select all that apply. The family must adjust to the cost of family life. The family must maintain ties with younger and older generations. The family must prepare for retirement. The family must adjust to loss of spouse. The family must support moral and ethical family values. The family must cope with loss of energy and privacy.

The family must maintain ties with younger and older generations. The family must prepare for retirement. Developmental tasks of this type of family structure would include maintaining ties with younger and older generations and preparing for retirement. The other options are not developmental tasks of this type of family structure. A couple and family with young children would have the developmental tasks of adjusting to the cost of family life and coping with loss of energy and privacy. A family with adolescents and young adults would have the developmental task of supporting moral and ethical family values. A family with older adults would have the developmental task of adjusting to the loss of a spouse. also middle aged is around 40 to 60

Nursing is described in various ways. The focus of all nursing interventions should involve which factor? Select all that apply. The human experience and responses of individuals, families, and groups Curing the illness in individuals The birth, health, illness, and death of individuals Focus on the spiritual dimension of the client Advanced through the use of evidence-based practice to ensure the best care

The human experience and responses of individuals, families, and groups The birth, health, illness, and death of individuals Advanced through the use of evidence-based practice to ensure the best care The focus of all nursing interventions is on the human experience and responses of individuals, families, and groups to birth, health, illness, and death as well as utilizing EBP to provide the best possible care for each client. Focusing on curing each illness is not possible, as some illnesses cannot be cured. If the nurse focuses on the only the spiritual dimension of the client, it will also limit the many ways in which a nurse can assist the client as the spiritual aspect is only part of the holistic nursing process. It leaves out the physical and mental aspects which also need addressing..

An adolescent informs the nurse at the clinic, "I do not know what is happening to me, my skin is turning very white in spots all over my hands." The nurse assesses hypopigmented areas on the hands and documents the finding. Following evaluation by the health care provider, what education will the nurse provide to the client? Using a pigmented cream will help to even the skin tones. The hypopigmented areas will be confined to the present location. There may be a slight stinging sensation when washing the hands. This is due to sun exposure, so your pigmented areas should be covered in sunscreen.

Using a pigmented cream will help to even the skin tones. The adolescent is experiencing hypopigmentation, which is called vitiligo and can affect clients of any ethnic group. Vitiligo may be embarrassing for the person affected. A pigmented cream can be used to cover the area and make the skin tones more evenly blended. There are no physical symptoms such as stinging, and the disorder is not caused by sun exposure. The condition may affect different areas of the body and is not necessarily confined to the present area.

x A nurse working on a busy acute care unit is planning care for a group of clients. Which nursing action best exemplifies the primary focus of the nurse's role? The nurse adjusts the environment of the client to facilitate provision of care. The nurse concentrates on the health status of a client. The nurse focuses on the procedures being performed for clients that day. The nurse comforts a client who received bad results from a diagnostic test

The nurse comforts a client who received bad results from a diagnostic test. The focus of nursing is promoting health and wellness in partnership with individuals, families, communities, and populations. With this in mind, the nurse would comfort the client who received bad results from a test. By focusing on this intervention of the four listed, the nurse is providing physical, emotional, and spiritual support for the client. The nurse would not concentrate on the health status of the client. The nurse would not focus on the procedures to be performed for clients that day. The nurse would not adjust the environment of the client to facilitate provision of

A nurse seeks to incorporate the principle of bioethics known as nonmaleficence when caring for clients in a long-term care facility. Which nursing action(s) exemplify this principle? Select all that apply. The nurse performs regular client assessments for pressure injuries. The nurse follows "medication rights" when administering medicine to clients. The nurse provides information to clients to help them make decisions about treatment options. The nurse arranges for hospice for a client who is terminally ill. The nurse keeps promises to provide diligent care to clients. The nurse acts fairly when allocating time and resources to clients.

The nurse performs regular client assessments for pressure injuries. The nurse follows "medication rights" when administering medicine to clients. The concept of nonmaleficence refers to the avoidance of causing harm. Examples of nonmaleficence include the nurse performing regular client assessments for pressure injuries. Nonmaleficence would also include the nurse following "medication rights" when administering medicine to clients. Providing information to clients to help them make decisions about treatment options demonstrates the ethical principle of autonomy. Arranging for hospice care for a client who is terminally ill demonstrates the ethical principle of beneficence. Keeping promises to provide diligent care demonstrates the ethical principle of fidelity. Acting fairly when allocating time and resources demonstrates the ethical principle of justice.

The nurse is using Leavell and Clark's Agent-Host-Environment Health Model to help plan nursing interventions for clients in a hospital setting. Which examples of nursing actions to prevent hospital-acquired infections (HAIs) best illustrate the principles of this model? Select all that apply. The nurse should assess the clients for risk factors for infection when planning nursing care. The nurse should assess client's ability to fight off infection by using a graduated scale with high-level wellness on one end and death on the other. The nurse should consider the client's family history and age when assessing risk factors for infection. The nurse should consider client's past behavior when determining goals for recovery. The nurse should assess what the clients believe to be true about themselves and their illnesses when developing a nursing plan to prevent HAIs. The nurse should examine environmental stressors in clients' lives to see how these stressors might affect their recovery and ability to ward off infection.

The nurse should assess the clients for risk factors for infection when planning nursing care. The nurse should consider the client's family history and age when assessing risk factors for infection. The nurse should examine environmental stressors in clients' lives to see how these stressors might affect their recovery and ability to ward off infection. The Agent-Host-Environment model of health and illness, developed by Leavell and Clark (1965), views the interaction between an external agent, a susceptible host, and the environment as causes of disease in a person. It is a traditional model that explains how certain factors place some people at risk for an infectious disease. These factors are constantly interacting, and a combination of factors may increase the risk of illness. The nurse assessing the clients for risk factors for infection when planning nursing care helps to illustrate this model. The nurse assessing the client's family history and age when assessing risk factors for infection helps to illustrate this model. The nurse assessing environmental stressors in clients' lives is another example to illustrate this model. The other options are not examples illustrating the Agent-Host-Environment health model.

A nurse is writing a letter to a U.S. congressman to support the promotion of health care issues. Which guidelines would ensure a properly written letter? Select all that apply. The nurse should state the purpose of the letter briefly and clearly in the first paragraph. The nurse should name the city and state where the nurse lives and votes. The nurse should avoid using specific examples from the workplace to support the position. The nurse should restate exactly what the legislator should do at the end of the letter. The nurse should write a longer email and shorter letter. The nurse should address the letter to as many legislators as possible.

The nurse should state the purpose of the letter briefly and clearly in the first paragraph. The nurse should name the city and state where the nurse lives and votes. The nurse should restate exactly what the legislator should do at the end of the letter. Writing a letter to a U.S. congressman should be in the format of a formal letter, stating the nurse's concerns in a way that best relays this information. The formal letter should state the purpose of the letter briefly and clearly in the first paragraph, state the city and state where the nurse lives and votes, and restate exactly what the legislator should do at the end of the letter. The nurse should cite specific examples from the workplace to support the position. The letter should be kept to one page. The letter should be addressed to one legislator only, not a group of individuals.

The nurse is performing an assessment for a Native American/First Nations client who is hesitant to answer questions related to psychosocial history. What action by the nurse will facilitate communication between the nurse and the client? Wait to write down notes or put the information in the computer until after the interview, if possible. Have another family member with the client to answer questions that the client will not respond to. Inform the client that the questions must be answered for the client to receive the health care needed. Instruct the client that the interview is quick and answers should be brief.

Wait to write down notes or put the information in the computer until after the interview, if possible. A Native American/First Nations client may be very private and not feel comfortable discussing personal situations with the nurse, considering these questions to be intrusive. The client may opt not to answer questions asked. The family member should not be asked the questions if the client does not choose to answer the question since this may also be determined as disrespectful. The client should not be made to feel pressured to answer questions with the threat of treatment withheld since this is not a valid or therapeutic response. The nurse should be patient when awaiting a response from the client after asking a question and not rush through the interview. Waiting to write down or input the conversation into the computer will facilitate a more trusting and respectful relationship between the nurse and the client.

Which questions should the nurse include in a cultural assessment? Select all that apply. "What do you think is causing your illness?" "What religion do you belong to?" "What do you do to promote good health?" "Do have a particular name for this illness?" "What do you think about religions other than your own?"

What do you think is causing your illness?" "What religion do you belong to?" "What do you do to promote good health?" "Do have a particular name for this illness?" Transcultural assessment encompasses a number of considerations surrounding illness, such as causation, naming, prevention, and health promotion. In addition, it is significant and appropriate to ask what religion or religious group a client identifies with. However, it is likely unnecessary and possibly inappropriate to elicit the client's views of those who belong to other religious groups.

A nurse is orienting a group of nurses who will be helping to collect data for the nurse's research study. The nurse is explaining the study's theoretical framework, likening it to: an architectural blueprint. the exact model of what the nurse is studying. a step-by-step procedure. a summary statement about the study's focus.

an architectural blueprint. Often, a theoretical framework is likened to an architectural blueprint. These renderings, although not exact models of vision, help the user move from vision to reality. They help nurses further construct theories and distinguish nursing from other disciplines. The theoretical framework is not an exact model, a step-by-step procedure, or a summary statement.

The emergency department nurse is preparing a care plan for a young child who has suffered a fractured arm after a bicycle accident. Which factor should the nurse consider including in the care plan for this child to best address this issue? applying for Children's Health Insurance Program (CHIP) schedule visits from home health nurse assess nutritional needs update immunizations

applying for Children's Health Insurance Program (CHIP) This child may be at risk of not being covered by medical insurance. CHIP is a government funded health care option which can help pay for these expenses as well as provide coverage for future health needs. Update immunizations and assessing nutritional needs would be handled after assuring the client is receiving appropriate care for the fracture. Visits from a home health nurse would not necessarily be a priority or necessity.

A nursing student is engaging in a conversation with a nursing instructor whom the student intensely dislikes. Which nursing student behavior is consistent with reaction formation? imitating the speech of the nursing instructor accusing the nursing instructor of being prejudiced being extremely nice to the nursing instructor developing stomach pain during each conversation with the nursing instructor

being extremely nice to the nursing instructor Reaction formation involves acting just the opposite of one's true feelings; thus, being extremely nice to the nursing instructor is the opposite of what the student feels. Imitating the speech of the nursing instructor is consistent with identification. Accusing the nursing instructor of being prejudiced is consistent with projection. Developing stomach pains when talking with the nursing instructor reflects somatization.

Nursing is described in various ways. The focus of all nursing interventions should involve which factor(s)? Select all that apply. human experience and responses of individuals, families, and groups curing the illness in individuals birth, health, illness, and death of individuals pyschosocial dimension of the client use of evidence-based practice to ensure the best care

birth, health, illness, and death of individuals pyschosocial dimension of the client use of evidence-based practice to ensure the best care human experience and responses of individuals, families, and groups The focus of all nursing interventions is on the human experience and responses of individuals, families, and groups to birth, health, illness, and death as well as utilizing evidence-based practice to provide the best possible care for each client. Focusing on curing each illness is not possible, as some illnesses cannot be cured. The nurse can assist the client's psychosocial needs as part of the holistic nursing process, as long as the physical aspect is also addressed.

Healthcare facilities that sponsor health promotion activities only in affluent areas are considered: culturally sensitive. culturally blind. culturally affluent. culturally different.

culturally blind. Cultural blindness is a process of ignoring cultural differences and proceeding as if they do not exist. It can also reflect a lack of capacity to reach out effectively to minorities or culturally stigmatized groups. Cultural sensitivity is an awareness of and respect for the differences between one's own culture and another. Healthcare facilities are not described as culturally different or affluent.

The nurse is caring for two clients with the same ethnic background. The nurse notices some differences between the two in the religious practices and the slang used for communicating. What is most likely the etiology of these differences? cultural norms cultural relativity ethnicity ethnocentrism

ethnicity Ethnicity or ethnic identity refers to the differences among a group who share the same cultural and/or ancestral heritage. Cultural norms are the actions that are expected by others within the culture. Cultural relativity refers to the differences between cultures in the meaning of various behaviors. Ethnocentrism is the belief that one's own practices are the only correct practices.

A 65-year-old Asian American female has been brought to the emergency department accompanied by her spouse with a fractured femur. The health care provider has prescribed a Foley catheter be inserted. Which action(s) should the male nurse, who has been assigned to the provide care to this client, prioritize to best care for this overly anxious client? Select all that apply. explain the situation to the client request the client's permission to insert the Foley catheter allow the spouse to stay in the room during the insertion find a female nurse to insert the catheter inform the attending health care provider of the client's fear

explain the situation to the client request the client's permission to insert the Foley catheter allow the spouse to stay in the room during the insertion Traditionally, Southeast Asians believe the area between a female's waist and knees is particularly private and should only be touched by the spouse. Before doing so, the male nurse can relieve the client's anxiety by offering an explanation, requesting permission and allowing the client's spouse to stay in the room. Asking a female nurse to complete this task may not be an option depending on the client load and how busy the unit is. There is no need to report this to the health care provider; however, a note can be put in the client's medical record to note this situation.

The client experienced a stroke with left-sided weakness. The case manager determines that the client no longer requires acute care but currently is unable to return to the home environment. Which health care environment will be the appropriate referral option for this client? primary care secondary care tertiary care extended care

extended care The client who is unable to return to the home environment but no longer requires acute care will be referred to an extended care facility to meet the rehabilitation needs after a stroke. Primary care is delivered in an office or clinic setting with a health care provider. Secondary care is a referral made from the primary care provider for specialty consultation or additional testing. Tertiary care is the environment from which the client is being released that provides acute care.

As the staff reports for duty, each nurse and unlicensed assistive personnel (UAP) checks the assignment board (above) to see what he or she will be responsible for during that shift. Which method of nursing is this facility utilizing to provide care to the clients? functional nursing case method team nursing primary nursing

functional nursing This method is referred to as functional nursing. Each member is assigned a specific task or function. The case method is a pattern in which one nurse manages all the care for a specific client(s) for a designated period of time. Team nursing involves a specific team of nurses working together to provide care for a specific group of clients. The team leader coordinates and delegates tasks to the various team members. Primary nursing occurs when the admitting nurse is responsible for planning client care and evaluating the client's progress. The nurse may delegate the client's care in his or her absence but remains responsible until the client is discharged.

The nurse is developing a plan of care for a client. Which nursing action is defined as an activity(ies)/intervention(s)? Select all that apply. holding the client's hand starting an IV educating clients reading an x-ray diagnosing a medical condition

holding the client's hand starting an IV educating clients Nursing care involves a wide range of activities, from carrying out complicated technical procedures to something as simple as holding a client's hand. It includes inserting an IV, holding a client's hand, and educating clients. Reading an x-ray and diagnosing a medical condition are completed by health care providers.

Which action by the nurse is the best indication that the nurse is incorporating the quality and safety education for nursing (QSEN) competency of teamwork and collaboration in the plan of care for a client? including the client in the morning rounds of the health care team keeping up all four side rails for a confused client to prevent falls using a new client positioning technique described in research to prevent pressure injuries asking a client about his or her personal goals for rehabilitation following a stroke

including the client in the morning rounds of the health care team The QSEN competencies include client-centered care, teamwork and collaboration, quality improvement, safety, evidence-based practice, and informatics. The competency of teamwork and collaboration is best indicated by including the client in the morning rounds of the health care team, which fosters open communication, mutual respect, and shared decision making among team members. Keeping the side rails up on the bed of a client who is confused is an example of the competency of safety. Using a new technique for client care based on the latest research is an example of the competency of evidence-based practice. Gaining input from a client regarding personal goals for rehabilitation is an example of the competency of client-centered care. Reference:

After passage of the Affordable Care Act (ACA) the nurse was able to suggest a new option for health insurance to the clients who were previously uninsured due to the high costs. Which option could the nurse now recommend to the clients? marketplace Medicare Medigap Tricare

marketplace Health insurance marketplaces are state organizations that provide a means for individuals or certain employers to purchase affordable private health insurance under ACA provisions. This insurance lowered premiums and out-of-pocket expenses for people with low or modest incomes by providing financial assistance subsidies. Tricare is a plan available for individuals in the military. Medigap is an additional plan to help with costs not covered by Medicare. Medicaid is a federally-funded, state-run insurance program for low-income individuals.

A 35-year-old client was admitted to the hospital following an automobile accident with a fractured leg. Which action should the nurse prioritize after learning this client's family is of Italian descent? monitor hemoglobin and hematocrit for possible anemia daily aspirin is prescribed to prevent blood clots monitor diet to avoid dairy products monitor blood glucose levels

monitor hemoglobin and hematocrit for possible anemia People with Mediterranean or African heritage commonly lack the enzyme G-6-PD which helps red blood cells metabolize glucose. This deficiency makes red blood cells vulnerable during stress, which can result in the destruction of red blood cells at a much greater rate than in unaffected people. If the production of red blood cells cannot match the rate of destruction, anemia develops. The use of aspirin is contraindicated with this disorder, because it can increase the rate of red blood center destruction. Individuals with lactase deficiency must avoid dairy products. Monitoring blood glucose is not a priority in this situation.

A comprehensive definition of family is that it is a social group with members who share common values, interact over time, and: occupy specific positions. participate in religious rituals. evolve psychologically over time. maintain order and safety.

occupy specific positions. The family is a social group whose members share common values, occupy specific positions, and interact with each other over time. A group need not participate in religious rituals, evolve psychologically over time, or maintain order and safety to be defined as a family.

A nurse who admitted a client and performed the necessary admission tasks, notes the comments from the night shift nurse and updates the client's nursing care plan. Which type of nursing care is this facility utilizing? primary nursing functional nursing team nursing case method

primary nursing Primary nursing is the process in which the admitting nurse assumes responsibility for planning client care and evaluating the client's progress. The primary nurse may delegate the client's care to someone else in his or her absence but the primary nurse is consulted when new problems develop or the plan of care requires modifications. The primary nurse remains responsible and accountable for specific clients until they are discharged. Functional nursing is the process where each nurse on the shift is assigned a specific task, such as passing medications or performing wound care. Team nursing involves a team of nurses working together to provide care to a specific group of clients. One nurse is the team leader and responsible for delegating the care to the rest of the care unit and ensures the clients receive appropriate care. The case method is most often used in home health, public health and community mental health nursing. In this group one nurse manages all the care of a client or group of clients' needs for a designated period of time. Nurses involved in this type of care are often referred to as case managers.

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention? provide care transition at discharge for speech therapy assess blood pressure every 4 hours conduct mental status assessment every 2 hours discuss family history of hypertension

provide care transition at discharge for speech therapy Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors.

Which nursing actions will increase efficient management of client care and decrease the ramifications of the nursing shortage? (Select all that apply.) pursuing postlicensure education becoming cross-trained in another area of the hospital taking early retirement implementing evidenced-based clinical pathways coordinating health care services before client discharge

pursuing postlicensure education becoming cross-trained in another area of the hospital implementing evidenced-based clinical pathways coordinating health care services before client discharge Pursuing postlicensure education, becoming cross-trained in other hospital areas, implementing evidenced-based clinical pathways, and coordinating health care services prior to client discharge are ways in which client care can be efficiently managed, decreasing the ramifications of the nursing shortage. Taking an early retirement is not one of the factors that can increase efficient client management or address nursing shortages.

Christine Grady is a nurse ethicist that proposed a framework for evaluating ethics. Grady suggested that a independent review is needed for ethical research. This principle is correctly defined as: enhancements of health or knowledge must be derived from the research. individuals should be informed about the research and provide their voluntary consent. scientific objectives, not vulnerability or privilege, and the potential for and distraction of risk and benefits, should determine communities selected as study sites and the inclusion criteria for individual subject. unaffiliated individuals must review the research and approve, amend, or terminate the research.

unaffiliated individuals must review the research and approve, amend, or terminate the Informed consent means that "individuals should be informed about the research and provide their voluntary consent." Independent review suggests that unaffiliated individuals must review the research and approve, amend, or terminate the research. Fair subject selection suggests that scientific objectives, not vulnerability or privilege, and the potential for and distraction of risk and benefits, should determine communities selected as study sites and the inclusion criteria for individual subject. Value suggests that enhancements of health or knowledge must be derived from the research. Favorable risk-benefit ratio is correctly defined as "within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks." Fair subject selection suggests that scientific objectives, not vulnerability or privilege, and the potential for and distraction of risk and benefits, should determine communities selected as study sites and the inclusion criterial for individual subject.

A student nurse is preparing a poster for a health fair which will compare the various types of methods used to pay for health care. Which factor(s) should the student include in the managed care section? Select all that apply. uses resources efficiently provides education to reduce risk of disease bargains with providers for reasonably priced quality care implements Diagnostic Related Groups (DRGs) for all hospital stays offers providers a preset fee schedule

uses resources efficiently provides education to reduce risk of disease bargains with providers for reasonably priced quality care Managed care uses several techniques including using resources efficiently, providing education to reduce risk of disease, and bargaining with providers for reasonably priced quality care. Medicare instituted the DRG technique. Capitation is the process of the insurance company providing the health care provider a set amount per member whether the services are used or not.