Foundations of Nursing Exam 1

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 this class? a. Programmed instruction b. Panel discussion c. Role-playing d. Role-modeling

c. Role-playing

A client expresses worry about upcoming surgery. Which response by the nurse is a cliché? a. "Do you want to cancel your surgery?" b. "Tell me what you are worried about." c. "Have you spoken to your family about your concerns?" d. "Don't worry, everything will be fine."

d. "Don't worry, everything will be fine."

When the preoperative client tells the nurse that the client cannot sleep because the client keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is: a. "You have a great surgeon. You have nothing to worry about." b. "It sounds as if your surgery is a pretty scary procedure." c. "You shouldn't be nervous. We perform this procedure every day." d. "The thought of having surgery is keeping you awake."

d. "The thought of having surgery is keeping you awake?"

Which client would be the best candidate for the nurse to engage in motivational interviewing? a. A 38-year-old client training to walk a half marathon b. A 44-year-old client who brought a food log to weight loss counseling c. A 66-year-old client who is showing improvement in range of motion d. A 28-year-old client with elevated blood glucose for 8 months

d. A 28-year-old client with elevated blood glucose for 8 months

Which learning domain is the focus for instruction when the nurse educates a new mother about the breast and its role in milk production for feeding the newborn? a. Psychomotor b. Behavioral c. Affective d. Cognitive

d. Cognitive

In a helping relationship, the nurse would most likely perform what action? a. Set up a reciprocal relationship in which both the client and nurse are giving and receiving help. b. Encourage the client to independently explore goals that allow the client's human needs to be satisfied. c. Establish goals for the client that are not set in a specific time frame. d. Establish communication that is continuous and reciprocal.

d. Establish communication that is continuous and reciprocal.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? a. PIE b. Narrative c. Exception d. FOCUS

d. FOCUS

While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse? a. "Use flash cards and writing pads." b. "Limit communication to avoid frustration." c. "Encourage family members to increase their vocal pitch." d. "Use words that begin with 'f,' 's,' 'k,' and 'sh' to communicate."

a. "Use flash cards and writing pads."

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment? a. "We reviewed your plans for your new diet and medications. Do you have any other questions?" b. "I think all went well with your physical, don't you?" c. "Will we see you in 6 months to see how your diet has progressed?" d. "Do you have any questions about all that was discussed during the exam?"

a. "We reviewed your plans for your new diet and medications. Do you have any other questions?"

A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf? a. A surrogate decision maker b. A church-appointed guardian c. A significant other d. A best friend

a. A surrogate decision maker

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply. a. Acknowledge the client's response to the medication b. Sign every entry c. Leave blanks in the charting e. Document in chronological order f. Identify the day and time for each entry

a. Acknowledge the client's response to the medication b. Sign every entry e. Document in chronological order f. Identify the day and time for each entry

A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information? a. "Are you allergic to any medications?" b. "Describe why people in glass houses should not throw stones." c. "Tell me about a time in your life when you were happy." d. "What do believe caused this current manic episode?"

a. "Are you allergic to any medications?"

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? a. "I will arrange access for you to review the record after you put your request in writing." b. "No, the physician will not give you access to review the records." c. "Only the client has the right to review the health care records." d. "Are you questioning the care of your child?"

a. "I will arrange access for you to review the record after you put your request in writing."

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 teaching? a. Blocking 30 minutes of time for skill teaching b. Ensuring the client's parents are present c. Using dolls to demonstrate psychomotor skills d. Giving stickers as a reward for task completion

a. Blocking 30 minutes of time for skill teaching

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory? a. Cognitive learning theory b. Adaptive learning theory c. Developmental learning theory d. Behavioral learning theory

a. Cognitive learning theory

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply. a. Documenting entries that are up to date and comprehensive b. Documenting entries that have unidentifiable writers' names and titles c. Using approved agency abbreviations d. Recording the date and time of all entries e. Documenting entries that are subjective

a. Documenting entries that are up to date and comprehensive c. Using approved agency abbreviations d. Recording the date and time of all entries

To ensure accurate charting, which actions should the nurse perform? Select all that apply. a. Documents interventions as close as possible to the time of execution Includes interpretations of client behavior b. Charts that the client is ingesting sufficient quantity of food and fluids c. Places a label with the client's name and identification number on each page of the client's chart d. Checks to make sure that the nurse has the correct chart prior to making an entry

a. Documents interventions as close as possible to the time of execution Includes interpretations of client behavior c. Places a label with the client's name and identification number on each page of the client's chart d. Checks to make sure that the nurse has the correct chart prior to making an entry

Which term describes a nurse who is sensitive to the client's feelings, but remains objective enough to help the client achieve positive outcomes? a. Empathic b. Competent c. Caring d. Honest

a. Empathic

Which are high-risk errors in documentation? Select all that apply. a. Failure to document completely b. Falsifying client records c. Charting in advance d. Inadequate admission assessment e. Batch charting

a. Failure to document completely b. Falsifying client records c. Charting in advance d. Inadequate admission assessment

A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report? a. Mental status b. Vital signs c. Further testing d. Client request

a. Mental status

The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply. a. Observation b. Telepathy c. Spoken words d. Touch e. Sight f. Intuition

a. Observation c. Spoken words d. Touch e. Sight

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship? a. Reviewing health changes b. Establishing trust and rapport c. Developing solutions that will be enacted d. Attending to physical health care needs

a. Reviewing health changes b

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

a. The client organizes materials needed and gives return demonstration.

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

a. To improve quality of care

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? a. Working phase b. Orientation phase c. Termination phase d. Evaluation phase

a. Working phase

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is afraid of waking up during surgery. The best response by the nurse is to: a. ask why the client thinks the client will wake up during surgery. b. state "everyone is afraid of that." c. ask the surgeon to come to the bedside to reassure the client. d. look directly at the client and state, "You are afraid of waking up during surgery."

a. ask why the client thinks the client will wake up during surgery.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: a. interpretation of data. b. relevant data. c. factual statement. d. important information.

a. interpretation of data.

When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed? a. Invasion of privacy b. Slander c. Fraud d. Assault

a. invasion of privacy

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be: a.aggressive. b.assertive. c.nurturing. d. passive

a.aggressive.

A client who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman." Which response would most likely encourage the client to expand on this and express concerns in more specific terms? a. Remaining silent b. "Feel like a woman . . ." c. "Do you want more children?" d. "Do you feel like you are not a woman?"

b. "Feel like a woman . . ."

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. a. "I will elaborate on the details on my entry in the clients' records." b. "I will use only agency-approved abbreviations." c. "I will draw a straight line through any blank space." d. "I will stay logged in on the computer until the end of my shift." e. "I will write, print, or type information legibly."

b. "I will use only agency-approved abbreviations." c. "I will draw a straight line through any blank space." e. "I will write, print, or type information legibly."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse? a. "Did you like the dinner yesterday?" b. "Is that a new shirt you're wearing?" c. "I guess you don't feel like talking today." d. "Did you sleep well last night?"

b. "Is that a new shirt you're wearing?"

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond? a. "Why do you think that the care team has made this recommendation?" b. "This must be very difficult for you to hear. How do you feel right now?" c. "What would help you accept that this is best for both of you?" d. "Do you understand that everyone here has your spouse's best interest at heart?"

b. "This must be very difficult for you a hear. How do you feel right now?"

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 the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? a. "Are you supposed to be out of the wheelchair?" b. "You have made an amazing recovery." c. "Those physical therapists work wonders. d. "Let me document that you can walk."

b. "You have made an amazing recovery."

Which statement describes the person who is likely the most motivated to learn? a. A 29-year-old male whose significant other is insisting on the client receiving the education b. A 70-year-old female who is the client's spouse and is learning the care so the client can come home c. A 52-year-old male who has been hired to drive the client home from the clinic d. A 25-year-old female who just completed a course of physical therapy

b. A 70-year-old female who is the client's spouse and is learning the care so the client can come home

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse? a. A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name. b. A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. c. A nurse describes a client on Twitter by giving the room number rather than the name of the client. d. A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo.

b. A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

Which nurse would most likely be the best communicator? a. A nurse who is bilingual b. A nurse who easily develops a rapport with clients c. An advanced practice nurse d. A nurse who is proficient in sign language

b. A nurse who easily develops a rapport with clients

An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action? a. Calling the health care provider about abnormal lab results b. Asking the LPN/LVN to teach a new diabetic client how to administer insulin c. Delegating oral medication administration to the LPN/LVN d. Obtaining vital signs on a newly admitted client

b. Asking the LPN/LVN to teach a new diabetic client how to administer insulin

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication? a. Provide paper and pencil for written communication b. Assess how the client would like to communicate c. Contact a person skilled in sign language d. Use facial and hand gestures

b. Assess how the client would like to communicate

When caring for a client, the nurse gives day-to-day examples to explain certain points of the health education. The nurse also notes the client's concentration level and educates when the client is active. Which aspect related to learning is the nurse targeting in this approach to teaching the client? a. Learning needs b. Attention and concentration c. Motivation d. Learning readiness

b. Attention and concentration

Which is a skill appropriate to use in therapeutic communication? a. Avoid the use of periods of silence. b. Control the tone of the voice to avoid hidden messages. c. Use cliches to enhance a client's understanding of information. d. Be precise and inflexible regarding the intent of the conversation.

b. Control the tone of the voice to avoid hidden messages.

The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement? a. Have the client repetitively choose appropriate foods from various menus. b. Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray. c. Ask a family member to do meal planning to alleviate the burden for the client. d. Provide brochures about low-sodium foods.

b. Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray.

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? a. Enlist support from nursing and nonnursing colleagues from the unit. b. Document the client's claims and the events surrounding the alleged incident. c. Consult with the hospital's legal department as soon as possible. d. Consult with practice advisors from the state board of nursing.

b. Document the client's claims and the events surrounding the alleged incident.

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique? a. Encouraging elaboration b. Giving false reassurance c. Seeking clarification d. Giving information

b. Giving false reassurance

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

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

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. a. Placing a note on the computer terminal with the client's name and information b. Informing the provider of the client's present heart rate of 116 beats/min c. Showing the provider the trends from baseline to present in blood pressure d. Faxing the results of blood chemistry levels to the provider's office e. Writing the hemocult result on a piece of paper and leaving it at the desk

b. Informing the provider of the client's present heart rate of 116 beats/min c. Showing the provider the trends from baseline to present in blood pressure d. Faxing the results of blood chemistry levels to the provider's office

Which is a drawback to the type of documentation known as charting by exception? a. Less interdisciplinary communication b. Issues related to high-quality care should a negligence claim arise c. Increased time required to document information d. Interference with standardized assessments

b. Issues related to high-quality care should a negligence claim arise

A new nurse is developing a teaching plan for an assigned client who has just started receiving chemotherapy. The nurse plans to teach the client about symptoms to report after chemotherapy. What is the priority action by the nurse? a. Find out what education has been provided to the client. b. Research information available in journal articles and other authoritative sources. c. Refer the client to online resources to learn about this topic. d. Ask other nurses what should be included in the content.

b. Research information available in journal articles and other authoritative sources.

Which information should the nurse include in a client's plan of care? Select all that apply. a. The minutes of the most current team conference meetings b. Routine care, such as the client's bath and mouth care c. The client's level of activity and current medical orders d. The client care assignment of the nursing and support staff e.,The client's problems, goals, and nursing orders

b. Routine care, such as the client's bath and mouth care c. The client's level of activity and current medical orders e.,The client's problems, goals, and nursing orders

The nurse has completed teaching. Which client behavior demonstrates understanding within the affective domain? a. Verbalizes key points of a brochure about diabetes that was read b. States, "I feel comfortable using my walker" c. Provides return demonstration of use of an inhaler d. Provides a description of how appropriate wound healing should look

b. States, "I feel comfortable using my walker"

Which observation during the nursing assessment of a client supports the documentation of low health literacy? a. The client complies with the medication regimen despite financial difficulties. b. The client avoids health care screenings and seeks care in the local emergency department. c. The client is provides a coherent health history. d. The client's health forms are complete.

b. The client avoids health care screenings and seeks care in the local emergency department.

The nurse should consider which client aspect as nonverbal communication? a. The client's values and beliefs b. The client's tone of voice c. The client's accent d. The client's religious practices

b. The client's tone of voice

Which statement accurately describes the concept of feedback as it pertains to the process of communication? a. The receiver listens to the sender in an unassuming way. b. The sender and the receiver use one another's reactions to produce further messages. c. The sender's message is translated into a code, using verbal and nonverbal communication. d. The sender sends a clear message that is understood by the receiver.

b. The sender and the receiver use one another's reactions to produce further messages.

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others? a. Metacommunication b. Therapeutic communication c. Purposive communication d. Intrapersonal communication

b. Therapeutic communication

Which documentation by the nurse best supports the PIE charting system? a. Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg b. Vomiting 250 mL undigested food, antiemetic given, no further vomiting c. Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea d. States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given

b. Vomiting 250 mL undigested food, antiemetic given, no further vomiting

In the provision of care and the establishment of the therapeutic relationship, the nurse must first: a. avoid labeling clients. b. be aware of one's own personality. c. treat the client with dignity. d. understand the client's response.

b. be aware of one's own personality.

A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. In this case, the nurse plays the role in the process of communication of the: a. target. b. sender. c. decoder. d. receiver.

b. sender.

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed? a. "You are scheduled for surgery 4 hours from now." b. "I will need to draw blood from you before the operation." c. "Do you have any questions about your cholecystectomy?" d. "Can you remove your ring, or do you need help?"

c. "Do you have any questions about your cholecystectomy?"

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? a. "I am so sorry you are going through this. Can we talk?" b. "Can you please tell me why you are crying?" c. "I know this is hard for you. Is there any way I can help?" d. "Sitting in the dark is not going to cure your cancer. Let's open the curtains."

c. "I know this is hard for you. Is there any way I can help?"

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? a. "It seems like this client has fluid volume overload." b. "I am calling because the client receiving blood has developed dyspnea and had crackles." c. "I think the client would benefit from intravenous furosemide." d. "This client has a medical history of heart failure."

c. "I think the client would benefit from intravenous furosemide."

The daughter of an older adult client asks the nurse why a urine specimen was collected from the client earlier that morning. How can the nurse best respond to the daughter's query? a. "We want to do everything we can to get your mother healthy again." b. "Your mother's physician ordered a urine C&S to rule out a UTI." c. "We want to test the urine to make sure your mother doesn't have a urinary tract infection." d. "Sometimes sick urine can make the whole person sick, and this might be causing the fever."

c. "We want to test the urine to make sure your mother doesn't have a urinary tract infection."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? a. "The client was admitted today with a urinary tract infection." b. "The client's temperature has been 102°F (38.9°C) for the last 6 hours." c. "Will you prescribe a complete blood count to check the white blood cell count and a culture?" d. "I am concerned that the client might be exhibiting sepsis."

c. "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? a. Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients b. Yelling at staff members, dementia worse today, refused breakfast c. Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth d. Confused, belligerent, and uncooperative with care

c. Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth

A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting? a. Humility b. Sympathy c. Empathy d. Curiosity

c. Empathy

The nurse observing an interaction between a mother and daughter appropriately identifies the interaction as which communication zone? a. Personal b. Social c. Intimate d. Public

c. Intimate

The nurse is communicating with a client who begins to cry. The nurse places a hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client? a. Verbal b. Body language c. Kinesthetic d. Visual

c. Kinesthetic

Which situation is an example of battery that the nurse may witness while performing duties at the health care facility? a. Telling the client that the client may not leave the hospital b. Witnessing a procedure done on a client without the client's consent c. Performing a surgical procedure without getting consent d. Taking the client's photograph without consent

c. Performing a surgical procedure without getting consent

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. a. Obscuring identifiable names of clients and private information about clients on clipboards b. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards c. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public d. Making the names of clients on charts visible to the public e. Keeping record of people who have access to clients' records

c. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public d. Making the names of clients on charts visible to the public e. Keeping record of people who have access to clients' records

A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse? a. Why don't you want to do this? b. Most people are afraid of sticking themselves. c. Tell me what you know about these tests. d. Are you worried about the pain?

c. Tell me what you know about these tests.

While at a coworker's house, a nurse discusses with the coworker a client whom the nurse suspects of physically abusing the client's child. The next day, the client is moved to another nursing unit after a surgical procedure and comes under the care of the coworker, who is also a nurse. The coworker confronts the client about the alleged physical abuse. The client is shocked and angered by the accusation and denies it categorically. What would be the charge if the client were to file a suit? a. The second nurse could be charged with libel. b. No charges are valid because the revelation took place during off-duty hours and off-site. c. The first nurse could be charged with slander. d. No charges are valid because both nurses are involved in the client's care.

c. The first nurse could be charged with slander.

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. Which expectation should the nurse have when developing the relationship? a. The nurse and client will have a social relationship. b. The relationship will occur spontaneously. c. The nurse is accountable for the outcome. d. The relationship is based on the needs of the nurse.

c. The nurse is accountable for the outcome.

A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach? a. "It's your choice about the surgery. What do you understand about the situation?" b. "If you don't have the surgery you may not live. Your family needs you." c. "Your grandchildren would be very upset if they lost their grandfather." d. "Surgery is your only option. You need this operation."

d. "Surgery is your only option. You need this operation."

Before starting the education process, the nurse should determine the preferred learning style, age and developmental level, capacity to learn, motivation level, readiness to learn, and learning needs of the client. How does this help the nurse in the client's health education? a. By assisting the client's learning b. By fulfilling the client's requirements c. By reducing chances of any miscommunication d. By implementing effective teaching

d. By implementing effective teaching

When the newly diagnosed client with insulin-dependent diabetes reports never having received instruction on the administration of injections, an appropriately stated nursing diagnosis for the client is: a. Knowledge Deficit related to lack of knowledge about injections. b. Ineffective Health Care Maintenance related to diabetic instructions. c. Self-care Deficit related to lack of knowledge about injections. d. Deficient Knowledge of Injection Administration as verbalized by the client, related to the lack of instruction and experience.

d. Deficient Knowledge of Injection Administration as verbalized by the client, related to the lack of instruction and experience.

The nurse is performing an admission assessment on a client who was just transferred from the emergency department. The client has an elevated temperature and a wound infection. The client's sensorium is decreased, but the client is responsive. When should the nurse initiate teaching for this client? a. When the family is not present b. When the client's infection is improving c. At the time of discharge d. During the admission assessment

d. During the admission assessment

A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments? a. Slander b. Malpractice c. Negligence d. Libel

d. Libel

Which client characteristic is important to assess when using the health belief model as the framework for education? a. Developmental level b. Family support c. Source of information d. Motivation to learn

d. Motivation to learn

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? a. Releasing the client's entire health record when only portions of the information are needed b. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information c. Disclosing client health information for research purposes after obtaining permission from the client's physician d. Submitting a written notice to all clients identifying the uses and disclosures of their health information

d. Submitting a written notice to all clients identifying the uses and disclosures of their health information

A nurse is educating an older adult client with diabetes and family members about the importance of a nutritious diet. What outcomes does the nurse hope to achieve in the process of educating the client and family? Select all that apply. a. The nurse will be able to diagnose the client's illness earlier. b. The nurse will be well-informed about the client's care. c. The nurse will be more aware of the client's health. d. The client will achieve optimal health. e. The client will cope with alterations in health status.

d. The client will achieve optimal health. e. The client will cope with alterations in health status.

When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners? a. The adult learner is not as concerned with the immediate usefulness of the material being taught as with the quality of the material. b. As clients, adults are the least likely to resist learning because of preconceived ideas about the teaching-learning process. c. As an adult matures, self-concept becomes more dependent; therefore, this client must be made aware of the importance of reducing stress. d. The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

d. The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

When communicating with a client, the nurse uses reflection for which purpose? a. To investigate the situation to help problem solve b. To determine the sequence of events in the conversation c. To keep the client on the topic of concern d. To have the client elaborate on thoughts and feelings

d. To have the client elaborate on thoughts and feelings

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

nursing through special testing

a. To assist the client to identify and achieve goals

a. To assist the client to identify and achieve goals

The nurse makes a contract with the client during which phase of the nurse-client relationship? a. Termination Phase b. Working Phase c. Orientation Phase d. Intimate Phase

c. Orientation Phase

The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education? a. The client will demonstrate improved coping skills. b. The client will demonstrate self-efficacy and improved body image. c. The client will have restoration of breast function. d. The client will be able to perform proper breast self-examination for breast cancer detection and prevention.

d. The client will be able to perform proper breast self-examination for breast cancer detection and prevention.

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

d. slander

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic? a. "All of the people got themselves out of the car?" b. "Did a police officer take a report at the accident scene?" c. "Was there any cracking of the windshield?" d. "Were there any fatalities in the other vehicle?"

a. "All of the people got themselves out of the car?"

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information? a. "Could you tell me more about how you are feeling right now?" b. "Did you take any medication when you had the pain?" c. "I have had chest pain before, and it is really scary!" d. "Have you ever had chest pain prior to this admission?

a. "Could you tell me more about how you are feeling right now?"

A nurse is assessing a client who has come to the clinic for a follow-up appointment. The client was diagnosed with asthma several months ago and has missed several appointments since that time. The client also has not been following the medication plan and has not kept the appointment for allergy testing. The nurse suspects that the client may be experiencing problems with health literacy. The nurse teaches the client about the condition and prescribed treatment. Which question from the nurse would help to assess the client's health literacy about the condition? a. "How are you supposed to take your medication?" b. "Are you having trouble getting your medications filled?" c. "Do you understand what asthma is?" d. "Do you have any questions about what you are supposed to do?"

a. "How are you supposed to take your medication?"

A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning? a. "I'm starting to see how my lifestyle has caused me to end up here." b. "I understand why they're not letting me eat anything for the time being." c. "I can see how things could have been much worse if I hadn't gotten to the hospital when I did." d. "My intravenous drip will keep me from getting dehydrated right now."

a. "I'm starting to see how my lifestyle has caused me to end up here."

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply. a. "Is there any chance you might be pregnant?" b. "Do you smoke cigarettes?" c. "Are you ready to get out of bed?" d. "Does it hurt when I touch you here?" e. "What sorts of things do you do for fun?" f. "What plans do you have after you are discharged?"

a. "Is there any chance you might be pregnant?" b. "Do you smoke cigarettes?" c. "Are you ready to get out of bed?" d. "Does it hurt when I touch you here?"

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy? a. "Just take your time. I am listening." b. "It is difficult when family members are ill. It helps if you take some time for yourself." c. "I know how you feel. I was the primary caregiver for my father when he was dying." d. "It's okay to cry. Sometimes that helps us to feel better."

a. "Just take your time. I am listening."

A nurse and client are working together to help the client make lifestyle changes to promote improved health. The nurse is having the client sign a contractual agreement for the work they will do together. Which statements by the nurse reflect the proper purposes of such agreements? Select all that apply. a. "Our goals are defined, as are ways to meet them." b. "With this contract, we show that we are both dedicated to improving your health." c. "Because you signed this contract, you agree to follow the contract forever." d. "This is a formal, legally binding document." e. "When you sign this agreement, you must meet all goals."

a. "Our goals are defined, as are ways to meet them." b. "With this contract, we show that we are both dedicated to improving your health."

A charge nurse has implemented staff education on nursing values. The nurse would determine that further education is required when which statement(s) are overheard? Select all that apply. a. "The gonorrhea test was positive. That's what the client gets for sleeping around." b. "Smoking has been shown to be a risk for many illnesses, including heart disease and cancer." c. "If you are going to have extramarital sex, please protect yourself by using a condom." d. "If that was my mother, I sure wouldn't agree to a no-code." e. "I can't believe the client is giving that precious baby up for adoption."

a. "The gonorrhea test was positive. That's what the client gets for sleeping around." d. "If that was my mother, I sure wouldn't agree to a no-code." e. "I can't believe the client is giving that precious baby up for adoption."

The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing? a. "You are hoping to figure out the cause of your extreme fatigue during this hospital stay." b. "You are unsure of what helps or prevents your fatigue." c. "You are frustrated because you are too tired to perform normal activities." d. "You have been having a great deal of fatigue for the last 3 months."

a. "You are hoping to figure out the cause of your extreme fatigue during this hospital stay."

A client states to the nurse, "I understand that I need a mastectomy for the treatment of my breast cancer, but I am fearful of learning about the drains I will need to empty." When responding to the client, the nurse will need to address which type of learning? a. Affective b. Psychomotor c. Behavioral d. Cognitive

a. Affective

The nurse is providing education to a group of clients with diabetes about the benefits of healthy food choices. What type of learning is the nurse using with this client group? a. Affective b. Psychomotor c. Technical d. Cognitive

a. Affective

Which is a characteristic of a person-centered or helping relationship? a. An unequal sharing of information b. The accountability of the person being helped for the outcomes of the relationship c. Spontaneous occurrence with random individuals d. A focus on the needs of the helping person

a. An unequal sharing of information

The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client? a. As the client is sitting quietly, reading a book b. At the time of pain medication administration c. Immediately before discharge to home d. When the meal tray arrives

a. As the client is sitting quietly, reading a book

A nurse drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication? a. Ask the care provider to come and assess the client. b. Provide the client's most recent vital signs. c. Ask whether the care provider is familiar with this client. d. Provide the most likely diagnosis of the problem.

a. Ask the care provider to come and assess the client.

A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? a. Assertive b. Aggressive c. Nonassertive d. Therapeutic

a. Assertive

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate? a. Assess for cultural differences. b. Replace one-on-one teaching with written materials. c. Delegate the health education to a colleague. d. Boost the morale of the client.

a. Assess for cultural differences.

A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client? a. Assessing importance b. Evoking change talk c. Prioritizing d. Eicit-provide-elicit

a. Assessing importance

According to Rosenstock, which health beliefs are critical for client motivation? Select all that apply. a. Clients believe there are actions they can take to reduce the probability of contracting the disease. b. Clients view the disease as a serious threat. c. Clients view themselves as susceptible to the disease in question. d. Clients view themselves as victims of the disease in question. e. Clients believe that the risks of taking these actions are greater than the risks posed by the disease itself.

a. Clients believe there are actions they can take to reduce the probability of contracting the disease. b. Clients view the disease as a serious threat. c. Clients view themselves as susceptible to the disease in question.

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning? a. Cognitive b. Psychomotor c. Developmental d. Interpersonal

a. Cognitive

The nurse is preparing discharge teaching for a client with diabetes. Which information should the nurse include? Select all that apply. a. Community resources b. Appropriate use of a glucometer c. Meal planning d. Instructions to follow up with the health care provider e. Ways to pay for hospitalization and outpatient care charges

a. Community resources b. Appropriate use of a glucometer c. Meal planning d. Instructions to follow up with the health care provider

A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent at this point, which element of informed consent would be violated? a. Competence b. Voluntariness c. Comprehension d. Disclosure

a. Competence

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan? a. Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique. b. Lecture provided about infection, and client stated understanding what infection is. c. Discussed wet-to-dry dressing changes, and client stated understanding. d. Spouse taught to flush feeding tube before and after medication. e. Denied further instruction needed.

a. Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique

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? a. Describe how the walker can improve the client's quality of life. b. Fully discuss the rationale for using the walker. c. Tell the client how to move the walker as the client ambulates. d. Explain how the walker supports the client's lower extremities.

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

The nurse has performed the following activities during the shift. Which activities are violations of client privacy and/or confidentiality? Select all that apply. a. Discussing the client's HIV status over lunch with a friend, a nurse on another team located on the same nursing unit b. Answering questions from a client's visitor before verifying the visitor has permission to receive the information c. Leaving the mobile computer screen, which contains client information, open when a visitor asked questions d. Responding to the client's questions about the plan of care with a visitor present in the room e. Removing a printed report of a client from the hospital premises to write a case study for a staff meeting

a. Discussing the client's HIV status over lunch with a friend, a nurse on another team located on the same nursing unit b. Answering questions from a client's visitor before verifying the visitor has permission to receive the information c. Leaving the mobile computer screen, which contains client information, open when a visitor asked questions e. Removing a printed report of a client from the hospital premises to write a case study for a staff meeting

Which are appropriate actions for protecting clients' identities? Select all that apply. a. Document all personnel who have accessed a client's record. b. Have conversations about clients in private places where they cannot be overheard. c. Ensure that clients' names on charts are visible to the public. d. Orient computer screens toward the public view. e. Place light boxes for examining X-rays with the client's name in private areas.

a. Document all personnel who have accessed a client's record. b. Have conversations about clients in private places where they cannot be overheard. d. Place light boxes for examining X-rays with the client's name in private areas.

A nurse is caring for a client who is visually impaired. Which action is a recommended guideline for communication with this client? a. Explain the reason for touching the client before doing so. b. Ease into the room without announcing your presence until you can touch the client. c. Keep communication simple and concrete. d. Speak in a louder voice to make up for the client's inability to perceive visual cues.

a. Explain the reason for touching the client before doing so.

A nurse suspects that a client is a prostitute. The nurse documents this suspicion in the medical record and includes it in report to the oncoming shift. The nurse also mentions the suspicion to the nurse's sister saying, "I had a client named Susan in room 126 today who I think is a prostitute." Which violations has this nurse committed? Select all that apply. a. HIPAA b. Battery c. Assault d. Libel e. Slander

a. HIPAA d. Libel e. Slander

The nurse uses the acronym TEACH when planning care for clients on a busy hospital ward. Which interventions accurately represent aspects of this acronym? Select all that apply. a. H—The nurse honors the client as a partner in the education process. b. E—The nurse educates the client before treatment. c. T—The nurse turns to the doctor for support. d. H—The nurse helps the client cope when education fails. e. A—The nurse acts on every teaching moment. f. C—The nurse clarifies often.

a. H—The nurse honors the client as a partner in the education process. e. A—The nurse acts on every teaching moment. f. C—The nurse clarifies often.

Which action by the nurse would facilitate the nurse-client relationship during the orientation phase? a. Introducing oneself to the client by name b. Designing a specific education plan of care c. Providing assistance to meet activities of daily living d. Preparing for termination of the relationship

a. Introducing oneself to the client by name

The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply. a. Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. b. The client has a clean and dry abdominal dressing. c. No new labs have been ordered after surgery. d. The client's hobby is photography, which we had a conversation about. d. The client has two dogs at home; the client's spouse is taking care of the dogs. e. Pain level is currently a 3 following administration of intravenous morphine.

a. Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. b. The client has a clean and dry abdominal dressing. c. No new labs have been ordered after surgery. e. Pain level is currently a 3 following administration of intravenous morphine.

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

a. Observing a mother expressing the breast milk

A client with a body mass index (BMI) of 40.3 kg/m2 states, "I know I need to get rid of this fat. I just don't know how." Which is the best assessment for the nurse to make at this time? a. Past interventions for weight loss b. History of obesity in family members c. The client's understanding of BMI d. Dietary intake of the client that day

a. Past interventions for weight loss

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? a. Personal perception of health and aging b. Floor plan of the client's dwelling c. Formal religious beliefs d. Orthopedic surgical history

a. Personal perception of health and aging

During the admission assessment of a client with a suspected mandibular fracture, the client discloses to the nurse that the injury results from the client's spouse hitting the client. Which action should the nurse prioritize when responding to this disclosure? a. Reporting the abuse to the appropriate authorities b. Ensuring that the client's statement is confirmed by another nurse c. Performing an assessment to confirm the client's statement d. Informing the client of the client's right to keep this information private

a. Reporting the abuse to the appropriate authorities

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? a. Return demonstration b. Oral test c. Written test d. Simulation

a. Return demonstration

The nursing is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? a. Review the hospital's process for allowing clients to view their health care records. b. Access the health care record at the bedside and show the client how to navigate the electronic health record. c. Explain that only a paper copy of the health care record can be viewed by the client. d. Discuss how the hospital can be fined for allowing clients to view their health care records.

a. Review the hospital's process for allowing clients to view their health care records.

Which diagnosis would best describe a situation in which a parent has a knowledge deficit concerning child safety for a toddler who is currently being treated for burns and was previously treated for a fracture from a fall? a. Risk for Injury, related to mother's lack of knowledge about child safety b. Knowledge Deficit: child safety, related to inexperience with the active developmental stage of a toddler c. Potential for Enhanced Parenting, related to child safety knowledge deficit d. Non-compliance: child safety, related to mother's lack of experience and socioeconomic level

a. Risk for Injury, related to mother's lack of knowledge about child safety

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important? a. Speak directly to the client. b. Have the interpreter write out all of the information listed in the unit brochure. c. Ensure that family members are present. d. Give all of the discharge instructions at once.

a. Speak directly to the client.

The nurse is assessing the health literacy of a client and uses the Newest Vital Sign tool. The nurse completes the assessment tool with the following client answers to each question. 1. 1,000 calories 2. 1 cup 3. 24 grams 4. 1% 5. Yes After completing the tool, what assessments about the client's health literacy would the nurse make? Select all that apply. a. The client may not understand how to take the medication if prescribed a dose of 2 to 3 times each day. b. The client will be able to adhere to a diet that has restrictions, such as decreased fat. c. The client has difficulty making mathematical calculations. d. The completed assessment tool indicates that the client has adequate literacy. e. The client is unable to identify ingredients that could be harmful to oneself.

a. The client may not understand how to take the medication if prescribed a dose of 2 to 3 times each day. c. The client has difficulty making mathematical calculations. e. The client is unable to identify ingredients that could be harmful to oneself.

Which are areas of potential liability for the nurse? Select all that apply. a. The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour. b. The nurse fails to document refusal by the client to ambulate following surgery. c. The nurse documents that the client accurately prepared the correct amount of insulin after instruction was given. d. The nurse administers the client's preoperative medication after the informed consent is signed. e. The nurse notifies the physician of the client's adverse reaction to a medication.

a. The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour. b. The nurse fails to document refusal by the client to ambulate following surgery.

Which nursing actions would most likely help improve communication with clients and achieve a more effective helping relationship? Select all that apply. a. The nurse makes statements that are as simple as possible, gearing conversation to the client's level. b. The nurse feels free to use words that might have different interpretations when using the same language as the client. c. The nurse remains focused on the topic at hand and does not allow the client to diverge to another topic. d. The nurse never admits a lack of knowledge to the client to avoid undermining the client's confidence in the helping relationship. e. The nurse takes advantage of any available opportunities to communicate information to clients in routine caregiving situations f. The nurse controls the tone of voice so that it conveys exactly what is meant.

a. The nurse makes statements that are as simple as possible, gearing conversation to the client's level. e. The nurse takes advantage of any available opportunities to communicate information to clients in routine caregiving situations f. The nurse controls the tone of voice so that it conveys exactly what is meant.

A client in a mental health unit discusses personal thoughts and feelings with the nurse. The nurse can maintain the circle of confidentiality when reporting this information to which individuals? Select all that apply. a. The unit's mental health technicians b. The client's closest friend c. The client's family d. The client's physician e. The nurse from the oncoming shift

a. The unit's mental health technicians d. The client's physician e. The nurse from the oncoming shift

For which purposes would observing silence be appropriate? Select all that apply. a. To allow the client time to formulate an answer after asking the client a question b. To allow the nurse time to think of something to say when the nurse doesn't know the answer to a question c. To allow the client time to reflect on the client's thoughts d. To allow the client time to compose oneself when the client is upset e. To allow the client time to reflect on communication that has occurred

a. To allow the client time to formulate an answer after asking the client a question c. To allow the client time to reflect on the client's thoughts d. To allow the client time to compose oneself when the client is upset e. To allow the client time to reflect on communication that has occurred

A client is requesting to view all medical record information regarding the care received while hospitalized. What rights does the client have regarding accessing the medical record according to HIPAA regulations? Select all that apply. a. To copy the health record b. To restrict certain disclosures of the health record c. To make additions to the health record d. To cross out sections of the health record e. To see the health record

a. To copy the health record b. To restrict certain disclosures of the health record e. To see the health record

A nurse is teaching a 5-year-old boy who was recently diagnosed with type 1 diabetes. The client's mother, who is the primary caregiver, informs the nurse of having a fear of needles. What actions are appropriate for the nurse to take to ensure a successful education session? Select all that apply. a. Using a doll to demonstrate giving an insulin injection b. Asking the client's mother to leave the room to avoid distractions c. Ensuring 20 minutes of uninterrupted teaching time d. Providing the client's mother with an informational pamphlet about insulin injection

a. Using a doll to demonstrate giving an insulin injection c. Ensuring 20 minutes of uninterrupted teaching time d. Providing the client's mother with an informational pamphlet about insulin injection

Which actions should the nurse take to ensure that client information remains confidential? Select all that apply. a. Verify the number in the fax machine as correct prior to transmission. b. Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. c. Access client information on the portable computer in the hallway where visitors are present. d. Exit the client's room when called on the hospital-issued cell phone about another client on the team. e. Print client information to a printer shared with another unit.

a. Verify the number in the fax machine as correct prior to transmission. b. Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. d. Exit the client's room when called on the hospital-issued cell phone about another client on the team.

A nurse touches the client's hand while discussing the client's diagnosis. This action is: a. a communication channel. b. a dynamic process. c. a translation. d. an auditory channel.

a. a communication channel.

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by: a. asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate. b. asking the client to provide a stool specimen for guaiac testing. c. insisting that the client not eat or drink anything until further instructed. d. determining whether the client has any food or drug allergies.

a. asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

A nurse gives a speech on nutrition to a group of pregnant women. Within the model of the communication process, what is the speech itself known as? a. Message b. channel of communication c. sender d. communication process

a. message

A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply. a. "That's a lot of information to take in. Would you like to talk about it?" b. "Don't worry. You will be just fine in another day or two." c. "Cheer up. Tomorrow is another day." d. "Your doctor knows best." e.. "Everything will be all right."

b. "Don't worry. You will be just fine in another day or two." c. "Cheer up. Tomorrow is another day." d. "Your doctor knows best." e. "Everything will be all right."

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic? a. "Why don't you try laser surgery?" b. "Have you ever thought of laser surgery?" c."You should try laser surgery." d. "My grandfather also benefited from laser surgery."

b. "Have you ever thought of laser surgery?"

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn? a. "May I have something to eat?" b. "I am having difficulty breathing." c. "The pain in my chest has gone." d. "Finally, I am getting medical attention."

b. "I am having difficulty breathing."

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? a. "I can lower my blood pressure by losing weight." b. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week." c. "I can monitor my caloric intake by measuring portions." d. "Osteoarthritis in my knees may be because of my weight."

b. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response? a. "You should follow your physician's recommendation and have the surgery." b. "Share with me the advantages and disadvantages of your options as you see them." c. "It is a minimally invasive surgery with rapid recovery time, so you will do fine." d. "When you see the physician this morning, request more information about the surgery."

b. "Share with me the advantages and disadvantages of your options as you see them."

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. "We have it on file here, so any hospital can call and get a copy." b. "Take it with you. It is recognized universally in the United States." c. "A living will can only be used in the state in which it was created." d. "As long as your family knows your medical wishes, you will not need it."

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

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement? a. "Board of nursing rules keep unlicensed people from practicing nursing." b. "The rules made by the board of nursing don't reflect my practice." c. "The board of nursing exists to protect the safety of the public." d. "The board of nursing is established by state legislation."

b. "The rules made by the board of nursing don't reflect my practice."

Which is important to remember when teaching adult learners? a. That all students, regardless of age, learn the same b. A focus on the immediate application of new material c. A need for support to reduce anxiety about new learning d. That older students may feel inferior in terms of new learning

b. A focus on the immediate application of new material

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? a. A proxy directive b. A living will c. A will d. Proof of health care power of attorney

b. A living will

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? a. A sentinel event b. A variance c. A never event d. An audit

b. A variance

The nurse is assisting a 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? a. Pedagogy b. Andragogy c. Psychomotor d. Affective

b. Andragogy

When preparing client teaching materials, how does the nurse best assess a client's preferred learning style? a. Provide teaching that works for the broadest base of clients. b. Ask the client, "Do you learn best by observing, valuing, or doing?" c. Observe the client's behaviors. d. Determine client learning needs based on age and ability to hear effectively.

b. Ask the client, "Do you learn best by observing, valuing, or doing?"

The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client? a. Taught lesson at an adult developmental level (age 35) using short sentences and assessed motor skills b. Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification c. Assessed the client's understanding of health and answered questions on an age-appropriate level while the television was on in the room d. Taught lesson at a school-age developmental level in an authoritarian style while the client was at meal time

b. Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification

A nurse educating a new mother on how to bathe an infant uses the acronym TEACH to maximize the effectiveness of the education plan. Which actions are guidelines based on this acronym? Select all that apply. a. Always refer a client to counseling. b. Clarify often. c. Edit client information. d. Tune out the individual client. e. Act on every teaching moment.

b. Clarify often. c. Edit client information. e. Act on every teaching moment.

The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching? a. After all of the diagnostic testing has been completed b. During the admission process c. Immediately prior to discharge d. After having venipuncture for laboratory work

b. During the admission process

A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability? a. Telling the client that the medication will be given the following morning b. Filling out an occurrence report and notifying the healthcare provider c. Documenting in the chart a narrative note about the occurrence d. Administering the medication with the other evening medications

b. Filling out an occurence report and notifying the healthcare provider

During the health education session at the health care facility, the nurse notes that a client is able to recognize, describe to others, and explain the information learned. What is the final learning stage of the client in this case? a. Involvement in the education in an active way b. Independent use of new learning c. Repetition of information for memorization d. Recall of the information being taught

b. Independent use of new learning

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? a. Defamation of character b. Invasion of privacy c. Negligence of duty d. Unintentional tort

b. Invasion of privacy

Which actions should the nurse take before making an entry in a client's record? Select all that apply. a. Choosing the charting format that the nurse prefers b. Locating clients' files within an electronic health record system c. Reviewing the agency's list of approved abbreviations d. Checking that clients' names are not identified within the chart forms e. Identifying the form appropriate to be used for documenting

b. Locating clients' files within an electronic health record system c. Reviewing the agency's list of approved abbreviations e. Identifying the form appropriate to be used for documenting

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? a. Documenting clients' health histories and discharge planning b. Omitting clients' responses to nursing interventions c. Identifying nursing diagnoses or clients' needs d. Recording nursing interventions

b. Omitting clients' responses to nursing interventions

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established? a. Working phase b. Orientation phase c. Evaluation phase d. Termination phase

b. Orientation phase

The nurse is preparing to teach a client about postsurgical care after a laparoscopic cholecystectomy. Which factor should the nurse most consider when determining whether the client is ready and able to learn? a. Culture b. Physical condition c. Emotional health d. Social and economic stability

b. Physical condition

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress? a. Health promotion b. Positive feedback c. Reinforcement d. Motivation

b. Positive feedback

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall? a. Cognitive b. Psychomotor c. Interpersonal d. Affective

b. Psychomotor

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? a. The client is a passive learner. b. The client belongs to a different culture. c. The client has a short attention span. d. The client is not interested.

b. The client belongs to a different culture

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation? a. The client looks at the nurse and states, "I am still not feeling my best." b. The client stares at the floor and states, "I feel fine." c. The client smiles at the nurse and states, "I cannot wait to go home." d. The client is sitting in a chair and states, "I feel a lot better than I did yesterday.

b. The client stares at the floor and states, "I feel fine."

Nurses on a hospital burn unit meet as a group to discuss procedures. Which statements accurately describe effective functioning in a group? Select all that apply. a. The group leader alone uses individual talents and interpersonal strengths to assist the group to accomplish goals. b. The leader or other group members confront any member who dominates or thwarts the group process. c. Group members support, praise, and critique one another. d. The group's effectiveness depends on only the group leader's sensitivity to the needs of the group and its individual members. e. Group members elicit mutually respectful relationships. f. Group members use power to fix immediate problems without considering the needs of the powerless.

b. The leader or other group members confront any member who dominates or thwarts the group process. c. Group members support, praise, and critique one another. e. Group members elicit mutually respectful relationships.

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? a. The nurse informs the family about the living will. b. The nurse ensures that the client's family signs the consent form. c. The nurse ensures that the client signs the consent form. d. The nurse informs the family about advance directives.

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

A nurse has been providing care to a client in the home for years. The nurse is asked to witness the client's signature on a will. What factors should cause the nurse to question whether to act as a witness on this document? Select all that apply. a. The client is alert and free of drugs that could distort thinking. b. The nurse is included as a beneficiary in the will. c. A relative is telling the client, "You must sign this document now." d. The client knows what the client is doing. e. The nurse did not watch the client sign the will.

b. The nurse is included as a beneficiary in the will. c. A relative is telling the client, "You must sign this document now." e. The nurse did not watch the client sign the will.

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? a. The nurse should remind the physician later to write the work order. b. The nurse should ask the physician to come back and write the order. c. The nurse should inform the client of the change in medication. d. The nurse should write the order and implement it.

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

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? a. The nurse should warn the client that the client cannot come to the hospital again. b. The nurse should call and inform the nursing supervisor of the situation. c. The nurse should let the client go because the nurse cannot do anything. d. The nurse should have the client restrained and call the physician.

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

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario? a. The introduction phase b. The working phase c. The orientation phase d. The termination phase

b. The working phase

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? a. Peer group acceptance is a critical issue for this age group. b. Their readiness to learn is often related to a developmental task or social role. c. Previous experiences have little impact on learning. d. The material presented should focus on future application.

b. Their readiness to learn is often related to a developmental task or social role.

A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to: a. return to the nurse's home unit and ask to meet with the charge nurse. b. ask to speak to the physician in private and address the disrespectful remark. c. write a written account of what transpired and contact an attorney. d. call the nursing supervisor to address the situation at hand.

b. ask to speak to the physician in private and address the disrespectful remark.

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is: a. noting the client's response to interventions. b. conveying information. c. reducing legal liability risks. d. assisting in organization of care.

b. conveying information.

A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse: a. creating specific learning sessions for new information. b. creating an atmosphere for discussion of feelings. c. creating an opportunity for rational thought and learning. d. creating an educational opportunity for the future.

b. creating an atmosphere for discussion of feelings.

Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged? a. Unintentional negligence b. Invasion of privacy c. Defamation of character d. intentional negligence

b. invasion of privacy

When the nurse informs a client's employer of the client's autoimmune deficiency disease, the nurse is committing the tort of: a. battery b. invasion of privacy c. breach of contract d. assault

b. invasion of privacy

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should: a. ignore the statement and empty the urinary catheter. b. sit at the bedside and allow the client to explain the statement. c. smile at the client and apologize. d. inform the client that the unit was very busy that day.

b. sit at the bedside and allow the client to explain the statement

A home health nurse is visiting a 40-year-old client who has had abdominal surgery. The client is unable to change a dressing because of obesity. The nurse is to instruct the client's spouse on the sterile dressing technique. During the visit, the nurse notes that the spouse has limited abilities due to mental disabilities. One assessment to determine the spouse's literacy would be: a. to assess her educational records. b. to assess her reading with WRAT. c. to assess her manner of speech. d. to assess her motivation to provide care.

b. to assess her reading with WRAT.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? a. "All aspects of clinical practice are confidential and should not be discussed." b. "You may continue to post about a client, as long as you do not use the client's name." c. "Any information that can identify a person is considered a breach of client privacy." d. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

c. "Any information that can identify a person is considered a breach of client privacy."

A nurse confides in a nurse friend, "I never report minor incidents. The charge nurse always wants a variance report filled out and they take so much time." Which responses by the friend are indicated? Select all that apply. a. "I don't blame you, I think the charge nurse is just trying to get us in trouble." b. "As long as no one is hurt, I don't see a problem with not reporting minor incidences." c. "Having documentation might keep you out of trouble someday." d. "Reporting helps us fix problems that result in danger to clients." e. "I usually document the problem in the chart, but don't fill out a report."

c. "Having documentation might keep you out of trouble someday." d. " Reporting helps us fix problems that result in danger to clients."

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally? a. "Do you have any identification proving that you are related to the client?" b. "I will call the client and ask for permission to share this information with you." c. "I cannot give you that information due to client confidentiality." d. "I'm busy right now but can talk later."

c. "I cannot give you that information due to client confidentiality."

A new mother asks the nurse in a pediatric office for information about safety, diet, and immunizations for the baby. What is the best response by the nurse to address the mother's readiness for enhanced coping? a. "You don't need to worry about all of these things at once." b. "Are you having a difficult time coping with the new baby?" c. "I have several pamphlets and online parenting videos that are helpful." d. "Would you like to talk with a counselor about your depression?"

c. "I have several pamphlets and online parenting videos that are helpful."

A nurse pays a house visit to a client who is on parenteral nutrition. The client reports missing enjoying food with the client's family. What is the most appropriate response by the nurse? a. "In a few weeks you may be allowed to eat a little; you may enjoy it then." b. "You can sit with your family at meal times, even though you don't eat." c. "Tell me more about how it feels to eat with your family." d. "I know that you must be missing your favorite foods."

c. "Tell me more about how it feels to eat with your family."

In which situation would the SBAR technique of communication be most appropriate? a. A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke. b. A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure. c. A nurse is calling a physician to report a client's new onset of chest pain. d. A nurse is facilitating a family meeting to coordinate a client's discharge planning.

c. A nurse is calling a physician to report a client's new onset of chest pain.

The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first ask the client in this interaction? a. A directing question b. A reflective question c. A yes or no question d. A focused question

c. A yes or no question

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing? a. Defamation b. Negligence c. Assault d. Battery

c. Assault

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing? a. Licensure b. Validation c. Certification d. Accreditation

c. Certification

Which note includes all elements of a SOAP note? a. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. b. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. c. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.

c. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain? a. Explaining what to do if hypoglycemia occurs b. Reviewing with the client appropriate foods to eat c. Demonstrating the technique for insulin self-injection d. Describing the signs and symptoms of low blood sugar

c. Demonstrating the technique for insulin self-injection

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique? a. Clarification b. Reflection c. Encouraging elaboration d. Restating

c. Encouraging elaboration

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase? a. Provide assistance to achieve goals b. Make formal introductions c. Examine goals of the relationship to determine whether they were achieved d. Create a contract regarding the relationship

c. Examine goals of the relationship to determine whether they were achieved

A nurse caring for an unconscious client knows that communication is important even if the client does not respond. Which nonverbal action by the nurse would communicate caring? a. Waving to the client when entering the room b. Making constant eye contact with the client c. Holding the client's hand while talking d. Sighing frequently while providing care

c. Holding the client's hand while talking

Which strategy might a nurse use to increase compliance with education? a. Provide verbal instruction at all times. b. Maintain a clear role as the authority. c. Include the client and family as partners. d. Use short, simple sentences for all ages.

c. Include the client and family as partners.

A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a 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 this client in related to her weight loss? a. Contemplation b. Maintenance c. Preparation d. Precontemplation

c. Preparation

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

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

The nurse has completed teaching. Which client behaviors demonstrate understanding within the cognitive domain? Select all that apply. a. States, "I feel comfortable using my walker" b. Provides return demonstration of use of an inhaler c. Provides a description of what appropriate wound healing should look like d. Verbalizes key points of a brochure about diabetes that was read e. Expresses a belief system in a higher power

c. Provides a description of what appropriate wound healing should look like d. Verbalizes key points of a brochure about diabetes that was read

A client 36 years of age is able to understand the health education when given the opportunity to put the education into practice. The nurse helps the client to self-administer the medication dosage before the client is discharged from the health care facility. Which domain correctly identifies the client's learning style? a. Interpersonal b. Cognitive c. Psychomotor d. Affective

c. Psychomotor

The nurse is leading a discussion with a group of adolescents about what to do "if a friend shows you a gun at school in a backpack." The nurse is encouraging the adolescents to explore consequences of their actions for decisions made. What value transmission is the nurse demonstrating? a. Rewarding and punishing b. Modeling behavior c. Responsible choice d. Laissez-faire approach

c. Responsible choice

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

c. The client describes signs and symptoms of hypoglycemia.

At completion of a teaching session with a client, the nurse documents the details of this education encounter in the client's health record. What should another nurse be able to determine from reading this documentation? a. The client's highest level of formal education achieved b. The client's prognosis for recovery c. The client's response to the health education that was provided d. The client's long-term application of the health education

c. The client's response to the health education that was provided

When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication? a. The client's religious practices b. The client's ethnicity c. The client's tone of voice d. The client's accent

c. The client's tone of voice

The nurse enters a client's room after receiving a morning report. The nurse rapidly assesses the client's airway, breathing, and circulation and greets the client by saying "Good morning." The client makes no reciprocal response to the nurse. How should the nurse best respond to the client's silence? a. The nurse should document the client's withdrawal and diminished mood in the nurse's notes. b. The nurse should ask the client whether the client feels afraid or angry. c. The nurse should ask appropriate questions to understand the reasons for the client's silence. d. The nurse should apologize for bothering the client, perform necessary assessments efficiently, and leave the room.

c. The nurse should ask appropriate questions to understand the reasons for the client's silence.

A nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply. a. The nurse raises environmental noises to help stimulate the client. b. The nurse does not use touch to communicate with the client. c. The nurse speaks with the client before touching the client. d. The nurse is careful what is said in the client's presence because hearing is the last sense to go. e. The nurse assumes the client can hear and discusses things that would ordinarily be discussed. f. The nurse speaks to the client in a louder-than-normal voice.

c. The nurse speaks with the client before touching the client. d. The nurse is careful what is said in the client's presence because hearing is the last sense to go. e. The nurse assumes the client can hear and discusses things that would ordinarily be discussed.

What is the primary purpose of FOCUS charting? a. To make it easier to identify nursing diagnoses for each client b. To help nurses idenify client responses to medical problems c. To concentrate on the client and client concerns in documentation d. To make it easier to identify successes in meeting expected outcomes in the chart

c. To concentrate on the client and client concerns in documentation

A client is admitted to the health center with chronic diarrhea. When should the nurse begin imparting health teaching about the benefits of proper diet to the client so that the risk of diarrhea is minimized? a. When discharging the client b. When providing treatment c. When admitting the client d. When performing follow-up care

c. When admitting the client

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. A single witness is sufficient for a will. b. A beneficiary to a will is allowed to act as a witness. c. Witnesses to a signature do not need to read the will. d. Witnesses do not need to observe the signing of the will and can sign it at a later time.

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

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: a. pick a team leader who is not the dominant member. b. plan a meeting where the dominant person cannot attend. c. have group members confront the dominant member to promote the needed team work. d. have group members issue a written warning to the dominant member.

c. have group members confront the dominant member to promote the needed team work.

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client? a. "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." b. "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?" c. "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?" d. "The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"

d. "The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client? a. "I will be by your side throughout the procedure; the procedure will be painless if you don't move." b. "You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically." c. "The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120." d. "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

d. "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation? a. "Is today the first day of the month?" b. "Are you in a hospital?" c. "Is your name Evelyn?" d. "What day of the week is it?"

d. "What day of the week is it?"

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 mother understands what to do?" What is the appropriate nursing response? a. "After I demonstrate it once, your mother will be able to do it." b. "We can never be completely sure that your mother understands instructions." c. "I will have you bring your mother back next week to see how things are going." d. "When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

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

Which is an open-ended question? a. "When was the last time you had your prescription refilled?" b. "Do you take this medication daily?" c. "How many tablets do you take at one time?" d. "Why did the health care provider prescribe this medication for you?"

d. "Why did the health care provider prescribe this medication for you?"

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: a. "Are you allergic to any medications?" b. "Can you tell me the medications you take on a daily basis?" c. "Do you have an advanced directive or a living will?" d. "Why did your physician send you here to be admitted?"

d. "Why did your physician send you here to be admitted?"

Which is the proper way to document midnight in a client's record? a. 1200 b. 1201 c. 2401 d. 0000

d. 0000

A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating? a. Emotional b. Affective c. Psychomotor d. Cognitive

d. Cognitive

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall? a. Affective b. Interpersonal c. Psychomotor d. Cognitive

d. Cognitive

What is the most critical element to document regarding client education? a. A summary of the education plan b. The implementation of the education plan c. The client's need for learning d. Evidence that learning has occurred

d. Evidence that learning has occurred

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request? a. Encourage the spouse to avoid online resources due to the unregulated nature of the Internet. b. Provide the spouse with print-based materials that are clearly referenced and reflect the spouse's learning style. c. Direct the spouse to online databases such as the Cumulative Index to Nursing and Allied Health Literature. d. Identify and recommend some credible websites appropriate to the spouse's learning needs.

d. Identify and recommend some credible websites appropriate to the spouse's learning needs.

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy? a. Conveying genuine care to the client b. Caring for the client without negative judgment c. Experiencing feelings similar to those of the client d. Identifying with the client's feelings

d. Identifying with the client's feelings

A client age 42 years recovering from a myocardial infarction (MI) is having difficulty following the care plan to stop smoking and exercise. What is the nurse's best response to this client? a. State that the client is not trying hard enough. b. Warn that the client will have another MI and that it will be the client's own fault. c. Explain that the client's cigarettes will be taken away if the client smokes again. d. Ignore the behavior and recommend a behavior modification program.

d. Ignore the behavior and recommend a behavior modification program.

When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized? a. Administer tests to evaluate learning. b. Be sure that clients are formally engaged. c. Have the clients read material after client education. d. Include educational strategies that encourage clients to be active participants.

d. Include educational strategies that encourage clients to be active participants.

The family of a client in a burn unit ask the nurse for information. The nurse sits with the family and discusses their concerns. What type of communication is this? a. Organizational b. Focused c. Intrapersonal d. Interpersonal

d. Interpersonal

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? a. Demonstration b. Role play c. Test taking d. Lecture/discussion

d. Lecture/discussion

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal 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 feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client? a. Situational b. Developmental c. Long-term d. Motivational

d. Motivational

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship? a. Termination phase b. Intimate phase c. Working phase d. Orientation phase

d. Orientation phase

A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Transtheoretical Model of Change, which stage of change is the client in related to diet? a. Maintenance b. Contemplation c. Preparation d. Precontemplation

d. Precontemplation

A nurse assisting a new mother in the act of breastfeeding represents which form of learning? a. Affective b. Simplistic c. Cognitive d. Psychomotor

d. Psychomotor

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? a. The plaintiff's lawyer b. The local press c. A colleague d. The agency's risk manager

d. The agency's risk manager

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? a. The nurse is the expert in the teaching-learning environment. b. Assimilation and application of psychomotor concepts is essential. c. The nurse must be able to handle criticism during the process. d. The client and the nurse are equal participants.

d. The client and the nurse are equal participants.

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? a. To provide information to local, state, and federal agencies b. To determine the nurse's fault in the incident c. To evaluate the immediate care provided by the nurse to the client d. To evaluate the quality of care provided and assess the potential risks for injury to the client

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

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using: a. demonstration. b. audio-visual material. c. written material. d. medical terminology.

d. medical terminology.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should: a. inform the client that several nurses will be needed to care for this wound. b. tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. c. ask the charge nurse to change the assignment. d. tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

d. tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

The nurse is caring for a client who speaks Chinese, which the nurse does not speak. An appropriate approach to communicating with this client would be: a. speaking directly and loudly to the client. b. avoiding the use of gestures or play-acting. c. writing messages for the client and offering a dictionary for translation. d. using a caring voice and repeating messages frequently.

d. using a caring voice and repeating messages frequently.