Exam 1 - Semester 1

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. Arranging for home health care 2. Focusing on managing a single illness at a time 3. Communicating with one provider only to avoid confusion for the client 4. Allowing the client to teach a support person about the treatment regimen

1

Which is most appropriate when communicating with a transgender person? 1. Using identified pronouns 2. Using their first name to address them 3. Using pronouns associated with birth sex 4. Anticipating the client's needs and making suggestions

1

Which teaching method is most effective when providing health care instructions to members of specific populations? 1. Teach-back 2. Video instruction 3. Written materials 4. Verbal explanation

1

The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

1,5

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2. Active listening 3. Asking the client "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1245

Which notations indicate accurate nursing documentation by the nurse? Select all that apply. 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for measurement of vital signs. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

125

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

145

Which nursing action reflects implementation of systems level thinking? A. Conducting a skin assessment on a newly admitted client B. Documenting a pressure injury in the electronic health record C. Notifying the health care provider of a 2″ × 1″ pressure injury on the coccyx D. Participating in a quality improvement project about eliminating pressure injury occurrences

D

The nurse would plan which goals for the termination stage of group development? Select all that apply. 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with one another. 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation.

16

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take? 1. Report the observation to the pediatrician. 2. Move the objects in the child's direct field of vision. 3. Teach the child how to visually scan the environment. 4. Provide additional lighting for the child during play activities.

1

The parent of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse would tell the parent that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A jack set with marbles 4. A farm set with small animals

1

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse would provide which intervention for this client? 1. Monitor closely for harm to self or others. 2. Assist in completing an application for admission. 3. Supply the client with written information about their mental health problem. 4. Provide an opportunity for family members to discuss why they felt the admission was needed.

1

A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess our children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so that the children cannot get into the kitchen."

1

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially? 1. Contact the client's primary health care provider. 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.

1

A client experiencing disturbed thought processes believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would plan to tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble

1

A nursing student is preparing to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student would plan to explain to the group that which characteristic relates to the anal stage? 1. This stage is associated with toilet training. 2. This stage is characterized by oral gratification. 3. This stage is characterized by repression of sexuality. 4. This stage is associated with identification with the same-sex parent.

1

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the PHCP can be contacted. 4. Administer the recommended dose until the PHCP can be located.

1

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask Carol yourself." 3. "Only because you're worried about a friend, I'll tell you that Carol is improving." 4. "Being a friend, you know that Carol is having a difficult time and deserves privacy."

1

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse would implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Contact the nursing supervisor to update information regarding the fall. 4. Document in the nurse's notes that an occurrence report was completed.

1

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room

1

The nurse is completing the admission assessment of a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. The history 2. The physical assessment 3. The nursing plan of care 4. The medication reconciliation

1

The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 6 hours

1

The nurse is instructing a client on how to perform a testicular self-examination (TSE). The nurse would explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising

1

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

1

The nurse is preparing to provide instructions to new parents regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the parents to take which measure? 1. Allow the newborn infant to signal a need. 2. Anticipate all needs of the newborn infant. 3. Attend to the newborn infant immediately when crying. 4. Avoid the newborn infant during the first 10 minutes of crying.

1

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

124

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? 1. Have one of the client's family members interpret. 2. Page an interpreter from the hospital's interpreter services. 3. Have the triage receptionist who speaks the client's language interpret. 4. Obtain a translation dictionary in the client's language and attempt to triage the client.

2

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan specific to the facility. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.

2

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention would the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Determine whether a family member supervises medication administration. 4. Call the prescribing primary health care provider (PHCP) and report polypharmacy.

2

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action? 1. Refuse to float to the ICU based on lack of unit orientation. 2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. 3. Ask the nursing supervisor to review the hospital policy on floating. 4. Submit a written protest to nursing administration, and then call the hospital lawyer.

2

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the pediatrician. 4. Reassess the respiratory rate in 15 minutes.

2

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Notify the pediatrician. 4. Elevate the head of the bed to 90 degrees.

2

The nurse is preparing to initiate an intravenous (IV) line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.

2

The nurse is providing medication instructions to an older client with chronic heart failure who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1. Decreased absorption of digoxin 2. Increased risk for digoxin toxicity 3. Decreased therapeutic effect of digoxin 4. Increased risk for side effects related to digoxin

2

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse would implement which assessment technique to assess for muscle weakness in the eye? 1. Test the corneal reflexes. 2. Test the six cardinal positions of gaze. 3. Test visual acuity, using a Snellen eye chart. 4. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

2

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that two fingers can slide easily between the safety device and the client's skin

2

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next? 1. Check the client's temperature. 2. Isolate the client in a private room. 3. Check a complete set of vital signs. 4. Contact the primary health care provider.

2

The parent of a 3-year-old is concerned because the child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the parent? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. Allow the bottle during naps but not at bedtime.

2

Which car safety device should be used for a child who is 8 years old and 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

256

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A defect in the cochlea 2. A defect in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex

3

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "It sounds as if you are feeling angry that your family continues to hope for you to be cured." 4. "You are probably very depressed, which is understandable with such a diagnosis."

3

The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A. Dementia B. Relocation stress C. Urinary incontinence D. Presbyopia E. Obesity

D

The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.

234

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received

2345

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which action(s) to correct the error in the MAR? Select all that apply. 1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information.

2345

The nurse educator is preparing to conduct a teaching session about school-age children regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply. 1.Individuals move through all six stages in a sequential fashion. 2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5.In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

2346

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

235

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat

236

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. The parent reports that the child is having intermittent episodes of diarrhea. 4. The parent reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The parent reports that the child has recently been exposed to an infectious disease.

25

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family.

3

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3

A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.

3

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the occurrence. 4. Call the laboratory, and ask for the name of the individual who sent the photograph.

3

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3

The nurse is caring for a client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment finding, if noted by the nurse, warrants a need for follow-up? 1. Reddened sclera of the eyes 2. Dry flaking noted on the scalp 3. A reddish-purple mark on the neck 4. A scaly rash noted on the elbows and knees

3

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid twitching of the eyeballs 2. A dorsiflexion of the great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim 3 times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."

3

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? 1. A person who has moderate hypertension 2. A person who has newly diagnosed cataracts 3. A person who has advanced Parkinson's disease 4. A person who has early diagnosed Lyme disease

3

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What would the nurse tell the AP about older clients with hearing loss? 1. They are often distracted. 2. They have middle ear changes. 3. They respond to low-pitched tones. 4. They develop moist cerumen production.

3

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the coworker in the medication room until help is obtained.

3

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond? 1. "Health care is very limited in the prison setting." 2. "Living in a prison isn't different than living at home." 3. "Living in a prison can predispose a person to different health conditions." 4. "Living in a prison is similar to living in a condominium complex or dormitory."

3

The parent of an 8-year-old child tells the clinic nurse of a concern that the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would plan to make which response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "At this age, children are developing their own personalities." 4. "You need to provide more praise to the child to stop this behavior."

3

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids

3

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway

4

The nurse working in a community outreach program for foster children plans care, knowing that which health conditions are common in this population? Select all that apply. 1.Asthma 2.Claustrophobia 3.Sleep problems 4.Bipolar disorder 5.Aggressive behavior 6.Attention-deficit/hyperactivity disorder (ADHD)

3456

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

356

A 16-year-old client is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read. 2. Encourage the parents to room in with the client. 3. Allow the family to bring in the client's favorite computer games. 4. Allow the client to interact with others in their same age group.

4

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse would ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which therapeutic response would the nurse make? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "It sounds as if you've been feeling like a failure for a while."

4

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The nurse plans to make which most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request."

4

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of six clients with the aid of an assistive personnel (AP). 4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.

4

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that they cannot leave the hospital 4. Observing care provided to the client without the client's permission

4

A parent arrives at a clinic with a toddler and tells the nurse how difficult it is to get the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the parent? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.

4

A parent brings a 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)

4

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention would the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4

An older client is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that a family member frequently hits the client if supper is not prepared on time when the family member arrives home from work. The nurse plans to make which most appropriate response? 1. "Oh, really? I will discuss this situation with your family member." 2. "Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends who can help you out until you resolve these important issues with your family member?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield

4

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care, anticipating which client behavior? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed toward others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan

4

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse would plan to tell the parent that which factor motivates good and bad actions for the child at the preconventional level? 1. Peer pressure 2. Social pressure 3. Parents' behavior 4. Punishment and reward

4

The nurse caring for a refugee considers which health care need a priority for this client? 1. Access to housing 2. Access to clean water 3. Access to transportation 4. Access to mental health care services

4

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly measurement of vital signs 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

4

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted their ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

4

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client would the nurse plan to care for first? 1. A client who is ambulatory, demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

4

The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4

The nurse is caring for an older client in a long-term care facility. Which action does the nurse plan that will contribute to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the AP to find out when the last pain medication was given to the client. 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, must be addressed first? 1. Blood pressure 154/72 mm Hg 2. Visual acuity of 20/200 in both eyes 3. Random blood glucose level of 206 mg/dL (11.77 mmol/L) 4. Complaints of pain associated with numbness and tingling in both feet

4

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance. 2. Exert coercion on the AP. 3. Provide a positive reward system for the AP. 4. Confront the AP to encourage verbalization of feelings regarding the change.

4

The nurse planning care for a military veteran needs to prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. Hypertension 2. Hyperlipidemia 3. Substance abuse disorder 4. Post-traumatic stress disorder

4

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which therapeutic response would the nurse make? 1. "Really?" 2. "Why haven't you been able to sleep?" 3. "Sometimes I have trouble sleeping too." 4. "Tell me more about your sleep over the past few nights."

4

The visiting nurse observes that an older client is confined by their child to the room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my child needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the child, "Confining your parent to their room is inhumane." 2. Suggest to the client and child that they consider a nursing home for the client. 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4. Suggest appropriate resources to the client and child, such as respite care and a senior citizens center.

4

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute.

4

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs

4

How will the experienced nurse explain systems thinking to a new nurse? A. Reading a journal article to enhance one's understanding of a specific disorder B. Providing patient-centered care to each individual, recognizing his or her uniqueness C. Engaging in a professional development activity to earn continuing education credit D. Using information from individual client care to improve outcomes at a macro level

D

The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? A. "It is important to provide care consistent with the client's expectation." B. "I will always consider my client's cultural preferences when delivering care." C. "I have been comparing our rates of infection with other units in the hospital." D. "I will look for the policy about family visitation to show my client."

C

The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A. Situation B. Background C. Assessment D. Recommendation

A

Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? A. Diabetes mellitus B. Hypotension C. Osteoarthritis D. Peptic ulcer disease

A

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A, B, C, D, E

The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply. A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." C. "Be sure to take a laxative every day to clean out your bowels and prevent toxins." D. "Exercise several times a week to keep our bowels working for regular elimination." E. "Drink at least 3 caffeinated beverages every day to keep your bowels stimulated." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

A, B, D, F

The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A. Quality Improvement B. Ethics C. Health Care Disparities D. Systems Thinking E. Teamwork and Collaboration

A, D, E