Exam 3 PrepU's

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate? "You should try to make things right with your family." "It must be very difficult for you." "There's no need for anger." "I can't imagine how awful this is for you."

"It must be very difficult for you."

Which client statement, after a presentation about drug use, indicates to the nurse a correct understanding of the information presented? "Mixing alcohol and tranquilizers has legal implications and increases arousal." "Mixing alcohol and tranquilizers increase arousal and drug dependency." "Mixing alcohol and tranquilizers may cause physical impairment and helps wean people off drugs." "Mixing alcohol and tranquilizers may cause physical impairment and drug dependency."

"Mixing alcohol and tranquilizers may cause physical impairment and drug dependency."

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation? "In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops." "The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." "Palliative care is the gradual withdrawal of mechanical ventilation from a client with terminal illness and poor prognosis." "The client will have to go to an inpatient hospice unit in order to receive palliative care."

"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse? Sedate the client. Notify the family. Get written consent. Obtain a medical order.

Obtain a medical order.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross? Denial Anger Bargaining Acceptance

Anger

A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation? Meditation Guided imagery Biofeedback Anticipatory guidance

Anticipatory guidance

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death? The arms and legs are warm to touch. The client is calm and peaceful. The frequency of urination decreases. The client's breathing becomes noisy.

The client's breathing becomes noisy.

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws? Medical advice given to a neighbor regarding a child's rash A negligent act performed in an emergency situation Any emergency care given when consent is obtained Emergency care for a choking victim in a restaurant

Emergency care for a choking victim in a restaurant

The husband of a client with terminal cancer is afraid of hurting his wife during sexual intercourse. Which action by the nurse is likely to be most helpful in reducing this client's fears? Encourage discussion between the husband and wife regarding their intimacy needs Reassure the client's husband that he cannot hurt the client during sexual intercourse Inform the client's husband that the client cannot have sexual intercourse due to fatigue Suggest other ways the couple can spend time together, such as watching television together

Encourage discussion between the husband and wife regarding their intimacy needs

A nurse is developing a plan of care for an older adult to promote self-esteem. What intervention would be most appropriate to include? Explain that getting older is part of life and the client needs to start thinking about what will happen when he dies. Encourage the client to do activities that younger people do. Explain that his life experience will help to develop a plan of care. Explain that the younger generation is fast-moving and it's best to be around just those of the same generational age.

Explain that his life experience will help to develop a plan of care.

A nurse is preparing a presentation for a group of staff nurses about the rules affecting nursing practice and the parties involved. When describing the role of different sources for the rules, which issue would the nurse identify as being addressed specifically by state legislation? Select all that apply. Position statements related to medication administration Educational requirements of nurses Unprofessional conduct Clinical procedures Scope of practice

Scope of practice Educational requirements of nurses

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case? The client should be treated with antibiotics for pneumonia. The wishes of his family should be followed. The client should be resuscitated if he experiences respiratory arrest. Pharmacologic interventions should not be initiated.

The client should be treated with antibiotics for pneumonia.

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing? Unresolved grief Anticipatory grief Normal grief Inhibited grief

Unresolved grief

A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client? cocaine use alcohol use exercise projection

alcohol use

A client tells the nurse, "I am not the person I was yesterday, but I can draw on things from the past so that I can achieve in the future." The nurse interprets this statement as reflecting: body image. self-esteem. personal identity. role performance.

personal identity.

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to: specify the treatment measures that the client wants and does not want. make legal provisions for active euthanasia. dictate how the client wants his estate handled after his death, and by whom. give permission for organ donation.

specify the treatment measures that the client wants and does not want.

Which process evaluates and recognizes educational programs as having met certain standards? Accreditation Licensure Credentialing Certification

Accreditation

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care? Place a rolled towel under the head. Apply hairpins and clips. Avoid replacing dentures in the mouth. Cleanse drainage from the skin.

Cleanse drainage from the skin.

The hospice nurse is visiting the wife of a client who died 10 months ago. The wife states, "My life is meaningless since my husband died." The nurse recognizes that the client is in which stage of grief? Shock Disorganization Reorganization Protest

Disorganization

A nurse who obtains a license to practice nursing through self-misrepresentation is guilty of what tort? Assault Libel Slander Fraud

Fraud

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response? Hospice provides physical and psychological support; palliative care provides social and spiritual support. Hospice care focuses on quality of life while palliative care focuses on length of life. Hospice care differs from palliative care in its foundational philosophy. Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness.

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness.

Which question would provide the nurse with the information needed first when assessing self-concept? Do you like yourself? What are some of your personal strengths? What do you see yourself doing 5 years from now? How would you describe yourself to others?

How would you describe yourself to others?

A nurse is preparing to teach a 6-year-old with a broken arm and her mother about caring for the child's cast. Which statement reflects the best education plan for these clients? Separate the mother and child; teach the mother and let her teach the child. Provide the mother with written materials; teach the child about keeping cast dry. Focus mainly on the mother; ask the child a couple simple questions. Include the child in the education; ask questions of both mother and child.

Include the child in the education; ask questions of both mother and child.

Which developmental consideration is a nurse assessing when determining that an 8-year-old boy is not equipped to understand the scientific explanation of his disease? Psychosocial development Motor development Emotional maturity Intellectual development

Intellectual development

A nurse talks with family members about an AIDS client from the clinic where the nurse works. Which tort has the nurse committed? Assault Slander Fraud Invasion of privacy

Invasion of privacy

What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women? Lecture/discussion Test taking Role play Demonstration

Lecture/discussion

A student nurse is preparing a care plan for a hospitalized school-age client focusing on ways to promote self-concept. Which intervention would not be appropriate? Limit visitation of friends. Teach parents about need for socialization. Allow for privacy. Provide age-appropriate activites.

Limit visitation of friends.

A withdrawn and isolated client is most likely suffering from what type of stressors on basic human needs? Love and belonging needs Self-esteem needs Safety and security needs Physiologic needs

Love and belonging needs

When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate? Short-term counseling Motivational counseling Long-term counseling Professional counseling

Motivational counseling

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers? Telling the mothers to avoid taking over-the-counter drugs while breastfeeding Advising the mothers to drink plenty of water Showing charts to the mothers that illustrate the types of breast milk Observing a mother expressing the breast milk

Observing a mother expressing the breast milk

The nurse provides education about physiologic stressors. The nurse recognizes the education to be effective when the client identifies which physiologic stressors? Select all that apply. Outside temperature of 100 degrees Upper respiratory infection Excessive protein in the diet Accidental death of a child Rheumatoid arthritis

Outside temperature of 100 degrees Upper respiratory infection Excessive protein in the diet Rheumatoid arthritis

The nurse is assessing for information about a client's self-concept. The information needed first is about which of the following? Sexual orientation Personal identity Body image Gender identity

Personal identity

The nurse completed education with a client. Which documentation entry is the most complete teaching plan? Start warfarin therapy initiated as prescribed; instructed to return to clinic for testing in 2 weeks. Discussed "Therapeutic Lifestyle Changes," printed materials reviewed, follow-up scheduled. Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled. Written and oral instructions given. Return demonstration performed accurately.

Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled.

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

Remain calm and conduct the teaching session in a quiet environment.

Which strategy should the nurse use when providing education to the older adult client? Avoid the use of colorful materials and keep the session short. Remain calm and conduct the teaching session in a quiet environment. Teach in a monotone voice in a quiet environment. Teach from books only and remain calm.

Remain calm and conduct the teaching session in a quiet environment.

A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in? Resistance Reflex pain response Exhaustion Alarm reaction

Resistance

A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case? The local press The plaintiff's lawyer A colleague The agency's risk manager

The agency's risk manager

A client asks about general adaptation syndrome (GAS). Which details provided by the nurse are correct? Select all that apply. There are three stages to GAS. The resistance stage usually lasts for less than a day. It can be a response to physiologic or psychological stress. GAS requires psychological hospitalization for treatment. The alarm stage of GAS can last from minutes to hours.

The alarm stage of GAS can last from minutes to hours. It can be a response to physiologic or psychological stress. There are three stages to GAS.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept? The nurse is the expert in the teaching-learning environment. Assimilation and application of psychomotor concepts is essential. The client and the nurse are equal participants. The nurse must be able to handle criticism during the process.

The client and the nurse are equal participants.

A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction? The client is a passive learner. The client is not interested. The client has a short attention span. The client belongs to a different culture.

The client belongs to a different culture.

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? The nurse informs the family about advance directives. The nurse informs the family about the living will. The nurse ensures that the client's family signs the consent form. The nurse ensures that the client signs the consent form.

The nurse ensures that the client's family signs the consent form.

A toilet trained toddler was admitted to the hospital for dehydration. Upon returing home, the toddler becomes incontinent of urine and stool. The parent is concerned regarding this return to previous behavior and calls the pediatric clinic. What is the nurse's best response to the parent? This behavior is sublimation. This behavior is called regression. This behavior is known as repression. This behavior is reaction formation.

This behavior is called regression.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report? To initiate litigation To improve quality of care To document everyday occurrences To document the need for disciplinary action

To improve quality of care

Which question would the nurse ask to assess a client's self-identity during a focused self-concept assessment? What do you like most about your body? Do you like being a teacher? What are your personal strengths? Who would you like to be?

What are your personal strengths?

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan? increased urinary output increased sensory stimulation decreased pain difficulty swallowing

difficulty swallowing

A client has experienced the loss of a loved one and is in the grieving process. The grief following this stressful event may be documented as what type of event? coping. chaos. distress. adaptation.

distress.

A young woman, who has recently suffered acute stress, asks the nurse why she seems to be more sensitive to stress than her husband. The nurse explains that a contributor to this phenomenon is: glucose. thyroid production. adrenal function. estrogen levels. cortisol.

estrogen levels.

During a health history, a client states, "Whatever happens, happens because of luck." The nurse interprets this statement as indicating: expectancy for success. self-efficacy. external locus of control. internal locus of control.

external locus of control.

A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform? transmits sensation of pain promotes coordinated movement heightens arousal and increases energy stabilizes mood and regulates temperature

heightens arousal and increases energy

A client's body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance.This process is known as: self-regulation. homeostasis. fight-or-flight response. stress.

homeostasis

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects: false imprisonment. defamation of character. invasion of privacy. professional negligence.

invasion of privacy.

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

provide care transition at discharge for speech therapy

A nurse assisting a new mother in the act of breastfeeding is represented by which form of learning? affective simplistic psychomotor cognitive

psychomotor

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement? rationalization reaction formation regression repression

repression

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

return demonstration

An adolescent states, "I want to go to college and learn to be a chef." This is an example of: self-knowledge. social self. self-expectation. self-perception.

self-expectation.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse? "Have you discussed this with your health care provider?" "Once you've started treatment, it's important to continue." "Does your family agree with this decision?" "Can you tell me about why you've made this decision?"

"Can you tell me about why you've made this decision?"

When assessing a client, which statement indicates that the client is experiencing the anger stage of death and dying? "If I can just make it to Christmas, I'll be satisfied." "Now I can go in peace knowing everyone will be fine." "Maybe they made a mistake in my diagnosis." "I am a good person. Why did this happen to me?"

"I am a good person. Why did this happen to me?"

A Red Cross volunteer has recently returned from assisting families in the Northwest who survived a devastating forest fire. She is having trouble sleeping and has taken up smoking again. Which statement by her leads the nurse to suspect a nursing diagnosis of Caregiver Role Strain related to stress from disaster volunteer activities? "I guess the smoke in the air brought out my mental addiction to cigarettes." "I get so tired from working long hours at the site." "I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." "I need to get back to work here at home. That will get me back into a routine."

"I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes."

A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which statement? "We've all been talking to him about what school will be like; his brother had the same teacher and really liked her." "It's so hard to get them into a routine after summer break. I go through this every year with all my kids." "I am bringing him to the orientation so he can meet his teacher and some classmates." "I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."

"I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis? "I feel like I have absolutely no idea what to do next." "I haven't let my children out of my sight. I am afraid something will happen to them." "A lot of the time I'm terrified that I'm going to die the same way." "I had a good time at my class reunion. It was nice to be out with other people again."

"I feel like I have absolutely no idea what to do next."

A client presents with a flare of lupus. Which statement made by the client would cause the nurse to suspect a stress reaction? "I have a fever with this flare." "My joints hurt more with this flare." "My lupus typically flares twice a year." "I just had a baby 3 weeks ago."

"I just had a baby 3 weeks ago."

A young adult has come to the clinic for a routine visit, and the nurse is assessing her self-concept. Which statement by the client would the nurse interpret as reflecting the client's self-knowledge? Select all that apply. "I'm the child of parents who immigrated here from Russia." "I'm a 23-year-old who just graduated from college." "I'm going to be a national news reporter in a few years." "I think I'm an intelligent, generous person." "I'm strong and confident to face the world."

"I'm a 23-year-old who just graduated from college." "I'm the child of parents who immigrated here from Russia." "I think I'm an intelligent, generous person."

The psychiatrist is evaluating a client who has recently learned she has a terminal illness. Which statement indicates to the psychiatrist that the client is in the Kübler-Ross stage of bargaining? "Just let me go on vacation with my wife; then I'll be satisfied." "I know that my family will be taken care of. I am at peace." "Why is this happening to me—I quit smoking." "I waited years to see my grandchildren and now I won't see them."

"Just let me go on vacation with my wife; then I'll be satisfied."

The nurse is caring for Mrs. Grace, a 26-year-old woman who has just delivered a healthy baby girl. Mrs. Grace says she wants to be a good mother and help her child develop in the best way possible. She asks the nurse, "What kind of self-concept is a baby born with?" The nurse's best answer is: "The newborn has a beginning differentiation of self." "No self-concept is present at birth." "The sense of self is very consolidated at birth." "The differences between self and others are strong at birth."

"No self-concept is present at birth."

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death? "The duration of all stages is a few hours." "The process is the same from person to person." "Each stage of dying must be completed prior to moving to the next stage." "Sometimes a person returns to a previous stage."

"Sometimes a person returns to a previous stage."

The emergency department nurse suspects that an older adult client who fell and broke her hip is using a defense mechanism when the client states: "Does this mean I have to stay here in the hospital?" "They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight." "Can you call my next-door neighbor for me? I'm so worried that my cat, Clancy, won't have any food or water." "I'm so clumsy. I'm surprised it hasn't happened before this."

"They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight."

When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response? "This must be very difficult for you." "I'm sure you are angry and sad." "Have you talked with your spiritual leader about your fears?" "Yes, this is a terrible diagnosis you've received."

"This must be very difficult for you."

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states: "Why did this have to happen to me?" "I don't care about anything. I have no energy." "I do not believe I have this disease." "I just want to see my son have a family of his own."

"Why did this have to happen to me?"

A client is admitted to the oncology unit with a diagnosis of leukemia. Her sister comes to visit. The healthy sibling tells the nurse that her sister is sick because "I got mad at her and wished she would go away." Based on this information, the nurse would estimate the sister's age to be: 21 years 3 years 15 years 7 years

7 years

Upon arrival to the emergency room, the mother of a client involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? Moderate anxiety Severe anxiety Mild anxiety A panic attack

A panic attack

Which nursing interventions would be anticipated with hospice care? Select all that apply. Administer prescribed chemotherapy to treat invasive liver cancer. Insert a Foley catheter to prevent incontinence. Administer prescribed antiemetics to control nausea. Ease respiratory function by providing oxygen via nasal cannula. Administer prescribed morphine for pain control.

Administer prescribed morphine for pain control. Ease respiratory function by providing oxygen via nasal cannula. Administer prescribed antiemetics to control nausea. Insert a Foley catheter to prevent incontinence.

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which scenario would be an example of assisted suicide? Administering a lethal dose of medication Granting a client's request not to initiate enteral feeding when the client is unable to eat Neglecting to resuscitate a client with a "do not resuscitate" status Administering a morphine infusion

Administering a lethal dose of medication

A client was at home alone when a tornado struck and damaged the structure. What type of crisis does the nurse address in the care of this client? Situational Developmental Adventitious Maturational

Adventitious

Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults? Provide information in a structured format. Allow for long-term memory loss. Allow ample time for psychomotor skills. Keep the session at 2 to 3 hours.

Allow ample time for psychomotor skills.

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

Anticipatory guidance

Which statement regarding perceptions of death by children is accurate? Preschool-age children view death as a spiritual release. Toddlers perceive death as irreversible and unnatural. At about age 9, the child perceives death as irreversible. Adolescents tend to respond better than adults with death.

At about age 9, the child perceives death as irreversible.

When nurses become overwhelmed in their jobs and develop symptoms of anxiety and stress, they are experiencing what condition? Ineffective coping Culture shock Adaptation syndrome Burnout

Burnout

A nurse assessing children in a pediatrician's office would expect a child to achieve self-recognition at what age? By 6 years By 18 months At birth By 3 years

By 18 months

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action? Initiate a slow-code until the physician arrives. Consult with the charge nurse or nurse manager before calling the code. Call a code and begin resuscitating the client. Respect the client's wishes and avoid calling a code.

Call a code and begin resuscitating the client.

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief? Anger Depression Denial Bargaining

Depression

A female client, prominent in the local media, has had surgery for a colostomy. The client avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis. Altered Role Performance related to inability to cope with visitors Altered Self-Esteem related to colostomy and poor self-image Disturbed Body Image related to colostomy as evidenced by avoidance of colostomy Fear of Rejection by Others related to colostomy and altered self-image

Disturbed Body Image related to colostomy as evidenced by avoidance of colostomy

The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply. Systolic blood pressure which rose from 100 to 110 mm Hg A regular apical pulse of 90 beats/minute Cyanotic nail beds in hands and feet bilaterally Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago

Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago Cyanotic nail beds in hands and feet bilaterally

A nurse is assessing a dying client for realism of expectations and perception of condition. Which interview questions address this concern? Select all that apply. Have you had any previous experience with this condition before? What have you been told about your condition? How do you see the next few weeks playing out? How well do you think those around you are coping? What do you think may be happening in the midst of all of this? Do you know how to contact your doctor and get answers to your questions?

Have you had any previous experience with this condition before? How do you see the next few weeks playing out? What do you think may be happening in the midst of all of this?

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply. Decreased urine output Irregular heart rate Regular deep respirations Pale, cool skin Strong, bounding pulse

Pale, cool skin Decreased urine output Irregular heart rate

A teenage girl is discussing her recent breakup with her boyfriend. She tells the nurse she just stays in bed all day and cannot seem to feel any better. She says she is only relieved of the pain while sleeping. The nurse identifies this coping strategy as: adaptation. chronic stress. buffering. avoidance coping.

avoidance coping.

A nurse is reviewing a journal article about the development of the self. Place the stages listed below in their correct sequence from first to last that reflect the nurse's understanding of this development. 4 Self-awareness 1 Self-recognition 2 Self-concept 3 Self-definition

Self-awareness Self-recognition Self-definition Self-concept

Applying Engel's models of grief, place the phases below in the order in which they would occur from first to last. 1 Idealization 2 Developing awareness 3 Outcome 4 Restitution 5 Resolving the loss 6 Shock and disbelief

Shock and disbelief Developing awareness Restitution Resolving the loss Idealization Outcome

A nurse student states, "I feel good that I put an indwelling catheter in my client without any problem even though it was an emergency." This demonstrates which factor affecting self-concept? Inadequate coping Culture Stress tolerance Values

Stress tolerance

The nurse is providing instructions to a client about performance of breast self-examination. What outcome does the nurse evaluate regarding this education? The client will have restoration of breast function. The client will demonstrate self-efficacy and improved body image. The client will demonstrate improved coping skills. The client will use the self-examination for breast cancer detection and prevention.

The client will use the self-examination for breast cancer detection and prevention.

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation? The nurse should let the client go because the nurse cannot do anything. The nurse should warn the client that the client cannot come to the hospital again. The nurse should have the client restrained and call the physician. The nurse should call and inform the nursing supervisor of the situation.

The nurse should call and inform the nursing supervisor of the situation.

The hospice nurse is caring for a client with allow natural death (AND) orders. The nurse assesses that the client has a slow, irregular heart rate, has cooling of the extremities, and is agitated. Which interventions can the nurse implement? Select all that apply. Implement a slow code in the case of cardiopulmonary or respiratory arrest. Use medication to lower client consiousness to limit awareness of suffering. Do not perform cardiopulmonary resuscitation. Allow the client to stop drinking fluids. Administer a lethal dose of barbiturates.

Use medication to lower client consiousness to limit awareness of suffering. Allow the client to stop drinking fluids. Do not perform cardiopulmonary resuscitation.

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means? eliminating all forms of medical and nursing care aggressive management of symptoms providing counseling related to the stages of death and dying treatment of the disease process

aggressive management of symptoms

While conducting the physical assessment of a client, the nurse notes an increase in the blood glucose level. Upon inquiry, the client discloses that lately he has been under a lot of stress at work. Which stage of stress is the client experiencing? tertiary stage alarm stage exhaustion stage resistance stage

alarm stage

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model? bargaining depression acceptance denial

bargaining

What is Kübler-Ross's third stage of grief? depression denial bargaining anger

bargaining

Family conflict around the care of a recently hospitalized woman has escalated to the point that crisis intervention may be required. This process should begin with: careful and objective analysis of different proposed options. clear identification of the relevant problem. presentation of clear, achievable, and evidence-based solutions. comparison of the family's situation to other similar situations.

clear identification of the relevant problem.

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario? projection sublimation compensation reaction formation

compensation

A client who responds to bad news concerning his lab reports by crying uncontrollably is handling stress by using: coping mechanism. defense mechanism. withdrawal behavior. adaptation technique.

coping mechanism.

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? resistance stage secondary stage exhaustion stage alarm stage

exhaustion stage

A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an): advance estate director. durable power of attorney. significant power. exemplary representative.

durable power of attorney.

A 65-year-old client has experienced the death of a parent and a family pet in the span of 1 month. Which action is a coping mechanism that demonstrates adaptation? joining the local garden club buying a new car deciding to no longer attend his family reunion picnic visiting a psychic

joining the local garden club

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? explain that family visits and support are important do not intervene and allow the client to work out the family issue tell the family they are causing too much stress limit the family visits to once daily

limit the family visits to once daily

A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms? obstructive sleep apnea type 2 diabetes moderate anxiety herniated lumbar disc

moderate anxiety

Asking a client to describe himself is one way to assess his: self-expectation. self-concept. self-knowledge. social self.

self-concept.

Which behaviors represent effective coping mechanisms? Select all that apply. taking a vacation sleeping 3 hours a night learning relaxation techniques denying responsibility for a DUI conviction setting limits with family members who upset you sleeping 14 hours a night

setting limits with family members who upset you learning relaxation techniques taking a vacation

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? a quiet environment a focus of attention soft music an open attitude

soft music

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress? endocrine system parasympathetic nervous system respiratory system sympathetic nervous system

sympathetic nervous system

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care? to improve the client's and family's quality of life to support aggressive treatment for cure to provide physical support for the client The client may develop a separate plan with each discipline of the health care team.

to improve the client's and family's quality of life

Palliative care is a structured system for care delivery. What is its aim? to give traditional medical care' to prevent and relieve suffering to bridge between curative care and hospice care to provide care while there is still hope

to prevent and relieve suffering

The nurse is working on an oncology unit and is visiting with colleagues about how to prevent burnout as a professional nurse. The nurse works on a checklist that will provide information about how well the nurse is meeting the need for positive self-concept. The checklist contains statements that are answered with a positive or negative. Which statements would be good to have on the list? Choose all that apply. "I cope effectively with change and loss." "I set very high goals and expectations for myself." "I always keep in mind how I need to improve." "I have good relationships with others." "I accept and feel good about myself."

"I cope effectively with change and loss." "I have good relationships with others." "I accept and feel good about myself."

A nurse is reviewing the health history of a client. Which statement documented in the history would lead the nurse to suspect that the client has a negative self-concept? Select all that apply. "I'm such a horrible person." "I feel like I'm so ugly." "Who would want to marry me now the way I look?" "What good am I?" "I like myself and my life."

"I feel like I'm so ugly." "What good am I?" "I'm such a horrible person." "Who would want to marry me now the way I look?"

A client is requesting that the nurse speak with the physician regarding alternate treatment options. What comment by the nurse would be most appropriate to help the client identify and use her personal strength? "You aren't helpless. When the doctor comes in you need to talk for yourself. I will stay with you while you talk." "I will discuss treatment options with your doctor and let you know what is decided." "I wonder if your husband would be willing to talk with the doctor for you? I will ask your husband for you." "I wonder why you want me to talk with the doctor? If you talk with them, you could hear all the treatment options firsthand. I will gladly stay with you while you talk to the doctor."

"I wonder why you want me to talk with the doctor? If you talk with them, you could hear all the treatment options firsthand. I will gladly stay with you while you talk to the doctor."

The nurse is providing care to a client who is recovering from mild myocardial infarction. The nurse determines that the client has an internal locus of control based on which client statement? "I'm just glad that the paramedics came so quickly when I called 9-1-1." "It was by chance that my sister, who is a nurse, was visiting me at the time." "I've been eating healthy and taking my medication. Otherwise, it could have been a lot worse." "Boy, I was really lucky that this was only a mild heart attack."

"I've been eating healthy and taking my medication. Otherwise, it could have been a lot worse."

Which statements made by a nurse would indicate to a nurse manager that the nurse requires further training? Select all that apply. "I am accountable for any task that I delegate." "If I make a mistake, I will not tell anyone." "I will have the supervisor fill out the incident report when I make an error." "The nursing plan of care must be accurate and must be followed. It is part of the client's permanent record." "When I document, I make sure it is factual, accurate, complete, and timely."

"If I make a mistake, I will not tell anyone." "I will have the supervisor fill out the incident report when I make an error."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse? "A living will can only be used in the state in which it was created." "We have it on file here, so any hospital can call and get a copy." "As long as your family knows your medical wishes, you will not need it." "Take it with you. It is recognized universally in the United States."

"Take it with you. It is recognized universally in the United States."

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate? "I would like you to demonstrate how to change the dressing on your leg." "I notice that you do not have the dressing secured. Place a piece of tape on the wrap." "Tell me about what signs of infection you will report to the health care provider." "Let's see how you irrigate the wound with saline."

"Tell me about what signs of infection you will report to the health care provider."

A 56-year-old executive meets with the nurse for education about recently diagnosed atrial fibrillation. He verbalizes concerns about the time he will spend away from his work, and that he is not sure it is necessary to have blood tests every week. He feels it is a waste of time when he does not have any symptoms. Which is the best motivational statement by the nurse for this client? "You have to take your warfarin and go to the clinic every week for a blood draw. It's not the most convenient way to live, but you have to do it." "Atrial fibrillation is when your upper heart beats ineffectively and blood clots can go to your brain. Would you like some printed information about this?" "Your doctor wants you to take your warfarin every day, go to the clinic every week to have blood drawn, and then wait for any dosage change. Do you understand?" "The medicine and blood work for atrial fibrillation can help prevent blood clots that have the potential to cause debilitating strokes. What have you heard about warfarin therapy?"

"The medicine and blood work for atrial fibrillation can help prevent blood clots that have the potential to cause debilitating strokes. What have you heard about warfarin therapy?"

A new mother of twins is struggling with role performance issues related to balancing the demands of motherhood with working outside the home. What question would be most appropriate to help the client move forward with a positive self-concept? "What new behaviors might be necessary to help modify your current roles?" "What do you think makes this struggle that you feel?" "Why do you think it is so hard to raise two babies?" "Would it be an option for you to quit your job and stay home?"

"What new behaviors might be necessary to help modify your current roles?"

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my parent understands what to do?" What is the appropriate nursing response? "I will have you bring your parent back next week to see how things are going." "When 15 minutes have passed, I will ask your parent to show me how to instill the drops." "We can never be completely sure that your parent understands instructions." "After I demonstrate it once, your parent will be able to do it."

"When 15 minutes have passed, I will ask your parent to show me how to instill the drops."

Which statements by a nurse to a charge nurse indicate that the nurse requires further training? Select all that apply. "When a client is having surgery, it is my responsibility to get the consent." "I must make sure I give the client all necessary information about the procedure before I have the client sign the consent form." "My signature as a witness indicates the consent is signed and I saw the client sign it." "In the event of an emergency that threatens a client's life or health, consent is not needed." "When I sign the consent form as a witness, I am saying that the person knows all the risks and benefits of the procedure."

"When I sign the consent form as a witness, I am saying that the person knows all the risks and benefits of the procedure." "I must make sure I give the client all necessary information about the procedure before I have the client sign the consent form." "When a client is having surgery, it is my responsibility to get the consent."

The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left him immobile. As the nurse enters the home, the client braces his hands on the arms of his chair to rise and uses crutches to walk across the room. What is the best response by the nurse? "Let me document that you can walk." "You have made an amazing recovery." "Are you supposed to be out of the wheelchair?" "Those physical therapists work wonders.

"You have made an amazing recovery."

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document? Proof of health care power of attorney A proxy directive A living will A will

A living will

Which scenario is an example of certification? An education program that meets standards of the National League for Nursing A graduate of a nursing education program who passes NCLEX-RN A nurse who demonstrates advanced expertise in a content area of nursing through special testing A hospital that meets the standards of the Joint Commission

A nurse who demonstrates advanced expertise in a content area of nursing through special testing

Which nursing student would most likely be held liable for negligence? A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home. A nursing student performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound. A nursing student completes an incident report after administering a medication to a client who then experienced an adverse reaction to the medication. A nursing student reports that insulin was not administered to the client by the nurse on the previous shift.

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

Which action constitutes battery? An older adult client refuses an intramuscular injection, but the nurse administers it. While bathing a client behind pulled curtains, two nurses discuss a different client. The nurse threatens to restrain a client if the client does not take a medication. The nurse tells a client that the client cannot leave the hospital because the client is seriously ill.

An older adult client refuses an intramuscular injection, but the nurse administers it.

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor? Assault Defamation of character Battery Fraud

Battery

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met? Breach of duty Proximate cause Damages Duty

Breach of duty

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process? Accreditation Certification Litigation Licensure

Certification

Which statement about providing client education before discharge is most accurate? A client's beliefs and culture can hinder the success of education. Client education focuses on identified home needs. Standardized plan of care is emphasized in client education. Client education opens up communication with the community.

Client education focuses on identified home needs.

A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education? Cognitive, affective, and psychomotor Cognitive, pedagogical, and psychomotor Gerogogical, cognitive, and andragogical Gerogogical, andragogical, and pedagogical

Cognitive, affective, and psychomotor

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? Describe how the walker can improve the client's quality of life. Fully discuss the rationale for using the walker. Tell the client how to move the walker as he ambulates. Explain how the walker supports the client's lower extremities.

Describe how the walker can improve the client's quality of life.

The nurse is providing care to a client whose condition has progressively declined. The nurse assesses and makes appropriate interventions as well as notifies the health care provider. Despite the nurse's efforts, the client expires. What element of liability has the nurse demonstrated? Duty Causation Damages Breach of duty

Duty

A client has suffered an amputation of the right leg due to a motor vehicle accident. What would be an example of a maladaptive response? Expressing they will never be a whole person again Talking to the family about the motor vehicle accident Learning to ambulate with a walker or a cane Asking the nurse about a prosthetic device

Expressing they will never be a whole person again

An 18-year-old says that it was just bad luck that he got in a motor vehicle accident and broke his arm. What is the client demonstrating by saying this? Internal locus of control Control reasoning Expectancy External locus of control

External locus of control

A client with cancer has a family who is emotionally supportive of the client. Having a supportive family is which type of resource? Internal resource Financial resource Professional resource External resource

External resource

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse? Have client rate pain level and reschedule the teaching session. Assess client understanding of self-care and administer medication. Redirect client to learning about self-care and begin education. Give written materials to client and retrieve pain medication.

Have client rate pain level and reschedule the teaching session.

Which question would the nurse include on a self-concept assessment related to body image? Do you like who you are? Who influenced you the most growing up? How do you feel about any physical changes you noticed recently? Who would you most like to be?

How do you feel about any physical changes you noticed recently?

An older adult female client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. She is tearful and verbalizes that she feels lonely and abandoned in the hospital unit. The nurse noticed that family visits daily and that there are flowers and cards in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client? Dysfunctional Family Processes; family contact daily. Altered Mobility; able to tie shoes. Impaired Walking; unilateral neglect. Ineffective Coping; verbalizes support systems.

Ineffective Coping; verbalizes support systems.

A nurse asks a coworker about the condition of the nurse's next-door neighbor, who has been admitted to the unit. If the coworker shares the neighbor's client information with the nurse, the coworker could be held liable for committing which act? Defamation of character Invasion of privacy Negligence Assault

Invasion of privacy

An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed? Negligence of duty Defamation of character Invasion of privacy Unintentional tort

Invasion of privacy

Which nursing action helps to maintain a sense of self for clients? Maintaining the privacy of the client's room number Assessing weight and overall nutritional status Offering a simple explanation before initiating any procedure Asking the client to refrain from negative expressions

Offering a simple explanation before initiating any procedure

When a nurse asks a client to describe her personal characteristics and traits, the nurse is most likely assessing the client for what self-concept factors? Body image Role performance Self-esteem Personal identity

Personal identity

A client started a nursing program and is trying to balance going to school full-time, a part-time job, and spending time with family. The client states, "I am trying to do everything and doing nothing well." Which role problem is this client experiencing from this role transition? Role agreement Role strain Role conflict Role ambiguity

Role strain

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into her class? Panel discussion Programmed instruction Role-playing Role modeling

Role-playing

A 24-year-old man is suffering from depression. He has come to the clinic today for a follow-up visit with his provider and the nurse has been asked to provide some client education on the antidepressants he has been prescribed. When the nurse asks him how he is feeling today, he responds that he is feeling down because he feels as if he is a failure. This scenario best describes which dimension of self-perception? Self-evaluation Social self Self-knowledge Self-expectation

Self-evaluation

A nurse is assessing a client's self-perception. Which dimension is reflected by the client's statement, "I want to use my skills to become the best artist I can be"? Self-knowledge Social self Self-evaluation Self-expectation

Self-expectation

A child lists his favorite sports figures and tells the nurse he is going to be just like them. How does the nurse identify this human need? Self-evaluation Self-knowledge Self-expectations Self-actualization

Self-expectations

A nurse may attempt to help a client solve a situational crisis during what type of counseling session? Long-term counseling Motivational counseling Short-term counseling Professional counseling

Short-term counseling

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? Libel Slander Negligence Malpractice

Slander

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case? The Good Samaritan law will provide absolute exemption from prosecution. The Good Samaritan law will not protect the nurse because the nurse did not accept compensation. The Good Samaritan law will provide legal immunity to the nurse. The Good Samaritan law is not applicable to health care workers.

The Good Samaritan law will provide legal immunity to the nurse.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? The client describes signs and symptoms of hypoglycemia. The client prepares the skin for the administration of an insulin injection. The client demonstrates proper technique for injecting insulin. The client expresses a desire to improve his nutritional intake and lose weight.

The client describes signs and symptoms of hypoglycemia.

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, what best represents that the client has learned a new skill? The client nods when asked about process and assists with cleanup. The client states understanding and passes a written test. The client organizes materials needed and gives return demonstration. The client verbalizes items needed and how to perform skill.

The client organizes materials needed and gives return demonstration.

A nurse is educating a client about smoking cessation. The nurse determines that the client has high self-efficacy. Which outcome would the nurse expect to occur? The client will refrain from participating in trying to quit. The client will voice reasons for not being able to quit. The client will focus on another activity. The client will be able to stop smoking.

The client will be able to stop smoking.

After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances? The nurse must document that float staff, nurses on overtime, and part-time staff were contacted in an effort to fill the gaps in care. The nurse is legally held to the same standards of care as when staffing levels are normal. The nurse is legally obliged to refuse to provide care when understaffing creates the potential for unsafe conditions. Understaffing constitutes an extenuating circumstance that creates a temporarily lower expectation for care for the nurse.

The nurse is legally held to the same standards of care as when staffing levels are normal.

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation? The nurse should write the order and implement it. The nurse should remind the physician later to write the work order. The nurse should ask the physician to come back and write the order. The nurse should inform the client of the change in medication.

The nurse should ask the physician to come back and write the order.

A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care? The nurse withholds the medication, retakes the heart rate, and gives the medication at a later time. The nurse administers the medication and reassesses the client after 30 minutes. The nurse withholds the medication and notifies the health care practitioner. The nurse administers the medication after reviewing the client's serum potassium level.

The nurse withholds the medication and notifies the health care practitioner.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report? To provide information to local, state, and federal agencies To determine the nurse's fault in the incident To evaluate the immediate care provided by the nurse to the client To evaluate the quality of care provided and assess the potential risks for injury to the client

To evaluate the quality of care provided and assess the potential risks for injury to the client

A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal electrocardiogram waves, indicating atrial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which describes the nurse's legal liability? Tort Defamation Slander Felony

Tort

Which are examples of a nurse appropriately protecting a client's privacy? Select all that apply. During a bed bath, the nurse exposes the client's upper torso while washing the client's face. Because the facility is a teaching facility, the nurse allows a nursing student to photograph a client for a care plan. The nurse questions the client about the client's social life even though it does not affect care planning. The nurse moves the client from the emergency department waiting room to a private area to collect assessment data. With the client's permission, the nurse explains the client's diagnosis to the client's spouse.

With the client's permission, the nurse explains the client's diagnosis to the client's spouse. The nurse moves the client from the emergency department waiting room to a private area to collect assessment data.

Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature? A single witness is sufficient for a will. A beneficiary to a will is allowed to act as a witness. Witnesses to a signature do not need to read the will. Witnesses do not need to observe the signing of the will and can sign it at a later time.

Witnesses to a signature do not need to read the will.

Which statement best describes the client most motivated to learn? a 70-year-old female; learning care so spouse can come home a 52-year-old male; hired to drive client home from clinic a 29-year-old male; significant other insisting on education a 25-year-old female; just completed a course of physical therapy

a 70-year-old female; learning care so spouse can come home

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is: a will. a standard of care. an advance directive. a license.

an advance directive.

The nurse is assisting a male client 55 years of age to understand the anatomy and physiology of the heart following a heart attack. What type of learning is taking place? affective pedagogy psychomotor andragogy

andragogy

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's education? ensuring the client's parents are present using dolls to demonstrate psychomotor skills blocking 30 minutes of time for skill teaching giving stickers as a reward for task completion

blocking 30 minutes of time for skill teaching

The nurse must instruct a 35-year-old client with Down syndrome about use of an albuterol rescue inhaler. Which of the following demonstrates individualization of the education plan for this client? client's understanding of health assessed, questions answered on age-appropriate level, television on in room developmental stage is adult at age 35, information given in short sentences, motor skills not assessed lesson focused for client of school-age developmental level, authoritarian style, client taught at meal time client understanding of illness, motor skills and developmental stage assessed, clarification provided

client understanding of illness, motor skills and developmental stage assessed, clarification provided

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which of the following learning domains does the client's learning style fall? psychomotor domain affective domain cognitive domain interpersonal domain

cognitive domain

A nurse is assessing a client and suspects that the client is experiencing a dysfunction in self-concept based on which behavioral findings? Select all that apply. intensive eye contact social withdrawal taking on of additional responsibility difficulty making decisions inability to discuss a change in body function

difficulty making decisions inability to discuss a change in body function social withdrawal

An infant who was born with Down syndrome, gastrointestinal anomalies, and cardiac defects has required nearly continuous hospitalization in the neonatal intensive care and pediatric care units of the hospital during her first year of life. To counteract the negative effects of prolonged hospitalization, the nurse should: give the parents details about their infant's daily routines. facilitate as many opportunities as possible for infant-parent attachment. remind the parents that their infant's circumstances are just as nurturing as a home environment. educate the parents about the fact that the infant is less emotionally vulnerable than an infant with no cognitive deficits.

facilitate as many opportunities as possible for infant-parent attachment.

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce his risk for cancer, improve his respiratory status, and enhance the quality of his life. The nurse also shares her story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses his feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client? motivational counseling developmental counseling situational counseling long-term counseling

motivational counseling

Mrs. Shields is a 46-year-old obese woman diagnosed with hypertension and type 2 diabetes. She tells the nurse that she knows she needs to lose weight. She recently visited her local fitness club, obtained a membership and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is Mrs. Shields in related to her weight loss? contemplation precontemplation maintenance preparation

preparation

When caring for a diabetic client, the nurse notes that the client learns better when he practices the self-administration of the insulin injection by himself. In which learning domain does this client's learning style fall? cognitive domain affective domain psychomotor domain interpersonal domain

psychomotor domain

A nurse is overheard in the hospital cafeteria making false, derogatory comments about a client. The nurse is guilty of: invasion of privacy. slander. libel. assault.

slander

A client with a diagnosis of colon cancer has required the creation of an ostomy following bowel surgery. Which factor is most likely to influence the client's adjustment to this change? the specific location of the ostomy the client's knowledge of a peer who also has an ostomy the coping mechanisms that the client possesses the prognosis of the client's cancer after the surgery

the coping mechanisms that the client possesses

The nurse is caring for a middle-age client who is admitted after taking an overdose of benzodiazepines. The client states, "I lost my job and I am just a failure at everything." The nurse is aware that potential causes of poor self-concept at this age can be related to which factors? Choose all that apply. failure to accept role responsibility inability to resolve child versus adult roles unsatisfying career choice failure to develop meaningful goals inability to accept bodily changes

unsatisfying career choice failure to accept role responsibility failure to develop meaningful goals