Foundations PrepU

Caring for Hawaiian patient, what is a good culturally appropriate question

"Do you use any medicinal plants or minerals"

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The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% of circumference of arm used

A family has moved from Spain to a primarily Spanish-speaking neighborhood near a large metropolitan area in the United States. The nurse caring for this family recognizes that which of the following family members will likely require the greatest amount of time to learn the English language?

45 year old mother who doesn't work outside home

The nurse is performing a telephone follow-up with parents that she taught to monitor their newborn's BP and pulse at home. What results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern

80/50mmHg 145 bpm Newborns have higher BP than adults

BP should be taken on ______ extremities for newborn

All four extremities

Malaysian client complains of cramping, where should nurse be seated

At more than an arms distance

An obese patient has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the patient's peripheral pulses. How should the nurse proceed with this assessment?

Auscultate the apical pulse

nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

Auscultatory gap An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique. (less)

Example of stereotyping in hospital done by nurse

Avoiding elderly clients because their care is time consuming

A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?

BP last

Nurse is assessing a newborn at the healthcare facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?

Babies temp regulation is immature

Good definition of culture

Belief system that guides behavior

Accurate parameter to base dosage calculations?

Body surface area

Which peripheral pulse site is generally used in emergency situations?

Carotid

The nurse is assessing a client for pain and suspects that the client's culture may be affecting her pain response. What nonverbal assessment would the nurse expect?

Client grasps area in pain

A nurse touches the patient's hand while discussing his diagnosis. This action is a(an) a) Auditory channel b) Dynamic process c) Translation d) Communication channel

Com Channel

client is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse? Left ventricle pumps more forcefully; pulse is stronger Stimulates the vagus nerve to increase the rate Right ventricle is less efficient; pulse is thready

Correct answer: Stimulates the vagus nerve to decrease the rate' When the vagus nerve is stimulated, the heart rate DECREASES, not increases. Straining to have a bowel movement when constipated is one way to stimulate vagus nerve causing bradycardia

When discussing culture, the nurse educator correctly identifies which terminology to describe a health care practitioner who is respectful of the health care traditions of other cultures?

Culturally SENSITIVE

The nurse has just attended a seminar on concepts of cultural diversity. Which statement made by the nurse would require further education?

Culture can not be influenced, and you are born with your culture YEA RIGHT

Hispanic woman wants care at local clinic, what is an example of cultural assimilation

Daughter learned English as her second language

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? a) Determine whether the prescribed treatment was effective. b) Check the client's skin turgor. c) Administer an additional liter of intravenous fluids. d) Formulate a plan of care based on risk for dehydration.

Determine whether effective

Paramedics arrive in the emergency department with a victim of a motor vehicle collision. The paramedic reports the driver was restrained, the car was traveling about 30 miles per hour, and the air bags were not deployed. The paramedic continues to report 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) "Were there any fatalities in the other vehicle?" b) "All of the victims got themselves out of the car?" c) "Did a police officer take a report at the accident scene?" d) "Was there any cracking of the windshield?"

Did all victims get out of car

Client smoked most life and has labored breathing

Dyspnea

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy

Which qualities in a nurse help the nurse to become effective in providing for a client's needs while remaining compassionately detached? a) Commiseration b) Empathy c) Kindness d) Sympathy

Empathy

patient informs the nurse that she still uses a mercury thermometer to take the temperature of her children when they are sick. Which of the following is a recommended teaching guideline for patients using these types of thermo

Encourage them to use alternative ones Mercury ones are NOT used in healthcare setting anymore

Nurse notes client identifies as Hispanic American What factor are the referring to?

Ethnicity

"I only want an American Doctor" What is patient expressing

Ethnocentrism

Example of unnatural illness

Evil forces made me have schizo

Client has impaired swallowing, what kind of med CANT be crushed?

Extended release (XR) Venlafaxine

A 36-year-old patient 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 patient to expand on this and express her concerns in more specific terms? a) "Feel like a woman . . ." b) "When did you begin to wonder about this?" c) Remaining silent d) "Do you want more children?"

Feel like a woman...

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

Fifth intercostal space left mid clavicle line

Person comes in with language nurse doesn't know, what is most appropriate solution

Get that prof. Interpreter

Nursing students are socialized into the

Healthcare culture

Who is best to help perform translation?

Hospital translator Not family Not language speaking employee

What can spread by touching inanimate object

Influenza

Number one assessment when working with Hispanic migrant workers

Language assessment

What is a way to display linguistic competence?

Learn pertinent words and phrases in clients language

The nurse is assessing the apical pulse of a patient using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds *Watch video to list steps here

A nurse gives a speech on nutrition to a group of pregnant women. What is the speech itself known as? a) message b) source c) stimulus d) channel

Message

Example of assumption nurse might are based on common cultural practices

Muslim-Arab woman refuses to make eye contact with male nurse -She is being modest

When assessing an infant's axillary temperature, it will be

One degree lower than oral

Assessment of the pulse amplitude is accomplished by which of the following?

Palate flow of blood thru artery

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apicalradial pulse indicates that the two values differ significantly, a finding that suggests which of the following health problems?

Peripheral vascular disease A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease. It does NOT signal a lack of circulation to the heart muscle (coronary artery disease), a pulmonary embolism, or COPD

Which of the following terms indicates a potentially serious patient condition?

Pyrexia

What abbreviation is greatest frequency? Bid Tid Qid

Qid

What pulse should the nurse recommend the client use for home monitoring?

Radial

Which of the following accurately reflects a recommended guideline when assessing blood pressure?

Raise the patient's arm over the head to help relieve congestion of blood in the limb and make the sounds louder and more distinct. Helps relieve congestion of blood in the limb and increases pressure differences to make the sounds louder and more distinct. On initial assessments, use the arm with the higher reading for subsequent pressures. Electronic monitoring devices are contraindicated for patients with heart problems or tremors.

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment, however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering healthcare provider. In the final step of the report the nurse should: a) Provide detailed findings of the head to toe assessment. b) Discuss the client's situation and request a chest X-ray to assess lung function. c) Detail the client's past medical history and active medication orders. d) Recommend 40 milligrams of furosemide (Lasix) be administered because the client had improvement with past administration.

Recommend 40 milligrams of furosemide (Lasix) be administered because the client had improvement with past administration.

Which of the following sites results in measuring a client's core body temperature?

Rectal

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 of the following activities would the nurse be carrying out? a) Establishing trust and rapport b) Attending physical healthcare needs c) Developing solutions that are enacted d) Reviewing health changes

Reviewing health changes

What is SBAR

Situation Background Assessment Recommendation

A nurse is attempting to communicate with a patient who speaks a different language and does not understand what is being communicated. Which nursing action would best facilitate the communication process? a) Avoiding using a dictionary to help maintain focus on patient b) Speaking slowly and distinctly, but not loudly c) Repeating the message in the same manner many times until understood d) Using medical terms and abbreviations more frequently

Speaking slowly and distinctly, but not loudly

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

Stare at floor and says im fine

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

TOO NARROW = BP WRONGLY HIGH This occurs when an average-sized cuff is used on an obese person. This mismatched cuff will not, however, make it particularly difficult to inflate the cuff and brachial occlusion is not a significant risk

The nurse is assessing an adult who has a pulse rate of 180 beats/minute. Which condition would the nurse document?

Tachycardia (normal = 60-100 beats/min)

A client with newly diagnosed hypertension on BP medication has been taking her own BP at home for two weeks. When she calls and reports her BP readings to the nurse, the nurse notes an elevated BP in the morning. The client states that she wakes up, has her daily cup of coffee and takes her BP before eating as she was instructed. What should the nurse recommend to this client?

Take meds BEFORE coffee

An 80-year-old client has a body temperature of 97°F. Which condition best accounts for this client's temperature reading?

Temp drops with age

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) ?You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically.? b) ?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.? c) ?The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120.? d) ?I will be by your side throughout the procedure; the procedure will be painless if you don't move.?

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

In order to provide effective nursing care, the nurse should engage in what type of communication with the patient and significant others?

Therap communication

A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with her in a one-bedroom apartment. Which of the following is a primary nursing concern?

They don't have running water

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

This must be difficult for you to hear how do you feel

A good interpreter should _____

Understand healthcare system

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

Use their stuffed animal in educational part

A client with a cardiac dysrhythmia was recently prescribed metoprolol (Lopressor) and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask: a) "Do you check your blood pressure and pulse before you take your medication?" b) "Have you tried exercising at all in the last week or two?" c) "Tell me about the foods you are eating." d) "Were you tired and depressed before starting the new medication?"

Were you tired and depressed before starting the new medication?"

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

What day of the week is it?"

The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions? a) "How many tablets do you take at one time?" b) "How often do you take this medication?" c) "When was the last time you had your prescription refilled?" d) "Why did the health care provider prescribe this medication for you?"

Why did they prescribe this for you

Asian American taking saffron for blood sugar but not taking his medicine, what is appropriate response

Why don't you take the medicines too, and benefit from both?

Care provided to a patient following surgery and until discharge represents which phase of the helping relationship? a) Working phase b) Termination phase c) Evaluation phase d) Orientation phase

Working

Are soaps/detergents good to remove transient microbes?

Yes

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) nurturing. b) passive. c) assertive. d) aggressive.

aggressive

A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with the diagnosis include: a) slow heart rate and prolonged capillary refill. b) easy wrinkling of the skin and sunken eyes. c) cold intolerance and brittle nails. d) pallor and diaphoresis.

easy wrinkling of the skin and sunken eyes.

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) have group members confront the dominant member to promote the needed team work. b) plan a meeting where the dominant person cannot attend. c) have group members issue a written warning to the dominant member. d) pick a team leader who is not the dominant member.

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

102 heatwave, what should nurse expect

hyperthermia, increased body temp

A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an) a) congruent relationship. b) incongruent relationship. c) functional focus. d) therapeutic relationship.

incongruent

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by a) swaddling the child and gently stroking its head. b) softly humming a song near the neonate. c) staring into the neonate's eyes and smiling. d) offering the neonate infant formula.

swaddling the child and gently stroking its head.

A holistic nurse is caring for a patient experiencing anxiety. The nurse assesses the patient's energy field than uses her hands to promote comfort and a feeling of well being. This practice is termed:

therep touch

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

tone of voice

Nurses focus on the whole client. Statements that acknowledge the client as a human being are (select all that apply): a) "Honey, can you tell me why you are crying?" b) "I have your medications ready for you Ms. Jackson." c) "Hey buddy, how was your night last night?" d) "Hi Tom, please take your clothes off and put this gown on with the opening in the back." e) "Mr. Smith, I will be taking you to x-ray now." f) "I am going to cleanse your back, turn over for me sweetie."

• "Mr. Smith, I will be taking you to x-ray now." • "I have your medications ready for you Ms. Jackson." DONT SAY HONEY, SWEETIE

A client has just been given a diagnosis of cirrhosis of the liver. Which of the following 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) ?Your doctor knows best.? c) ?Don?t worry. You will be just fine in another day or two.? d) ?Everything will be all right.? e) ?Cheer up. Tomorrow is another day.?

• ?Don?t worry. You will be just fine in another day or two.? • ?Cheer up. Tomorrow is another day.? • ?Everything will be all right.? • ?Your doctor knows best.?

A nurse is communicating the plan of care to a patient who is cognitively impaired. Which nursing actions facilitate this process? (Select all that apply.) a) The nurse is patient and gives the patient time to respond. b) The nurse communicates in a busy environment to hold the patient's attention. c) The nurse gives lengthy explanations of the care that will be given. d) The nurse keeps communication simple and concrete. e) If there is no response, the nurse does not repeat what is said and takes a break. f) The nurse maintains eye contact with the patient.

• The nurse maintains eye contact with the patient. • The nurse is patient and gives the patient time to respond. • The nurse keeps communication simple and concrete.