Foundations Test 4
A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system? "CPOE systems are associated with a slightly higher error rate." "CPOE use does not include medication prescriptions." "CPOE systems can increase the speed of care delivery." "CPOE use is mandated by HIPAA under the Privacy Rule."
"CPOE systems can increase the speed of care delivery."
A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea? "Common causes of central sleep apnea are opioid overdose and congestive heart failure." "Central sleep apnea is caused by obesity and an inactive tongue." "Central sleep apnea is easily diagnosed using polysomnography." "Central sleep apnea is related to the recurrent episodes of upper airway collapse and obstruction."
"Common causes of central sleep apnea are opioid overdose and congestive heart failure."
A nurse is evaluating a client after measures to promote comfort have been implemented. Which of the following statements by the client indicates that the client has been comforted? "I wish the staff would listen closer to my needs." "I am concerned about what is going to happen during my tests tomorrow." "It seems to take the staff a while to answer the call light." "My health care team has helped me to feel safe during my stay."
"My health care team has helped me to feel safe during my stay."
A nurse is caring for a client who is scheduled for an emergency appendectomy and reports increasing anxiety. Which of the following statements should the nurse make to implement a complementary health strategy? "Try to take slow, deep breaths in and out." "Would you like a prescription for an anti-anxiety medication?" "Why are you feeling anxious?" "You'll have that appendix out in no time, then you'll feel better."
"Try to take slow, deep breaths in and out."
A nurse is assisting in recommending clients for chiropractic treatment. Which of the following clients should the nurse recommend? A client who has a sinus infection A client who has shoulder pain A client who has appendicitis A client who has heart failure
A client who has shoulder pain
A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the joint commissions do not use list? MSO4 IU PO qhs NKA
MSO4 IU qhs
A condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. Spiritual Healing Religion Hope Spiritual Health
Spiritual Health
A nurse is caring for a client who is receiving palliative care. Which of the following non-pharmacological nursing interventions should the nurse provide the client? Acupuncture Acupressure Chiropractic therapy Therapeutic touch
Therapeutic touch
A client recently diagnosed with cancer informs the nurse that they value faith and finds comfort in their faith. The nurse is aware that faith is best defined as: a belief in something for which there is no proof or material evidence. a positive outlook even in the bleakest moments. an organized belief system about a higher power. practices associated with all aspects of a person's life.
a belief in something for which there is no proof or material evidence.
A nurse is caring for a client who has narcolepsy (Nt1) with cataplexy. The nurse should identify that this condition is caused by a lack of which of the following hormones? Hypocretin Melatonin Estrogen Insulin
a. Hypocretin
What factor is necessary to express and experience spirituality? quiet time in isolation from others membership in an organized religion long-term suffering and pain connectedness with other people
connectedness with other people
A person who denies the existence of a god. Atheist Agnostic Spiritual Healer Religious Person
Atheist
A nurse provides care on the palliative unit of a hospital. Which intervention will support a client who has expressed strong spiritual beliefs? Carefully assessing verbal and nonverbal cues of spiritual needs by the client Allowing the client to deal with spiritual beliefs in the client's own way Quickly intervening when the nurse thinks the client has a spiritual need Attending to the client's spiritual needs when time permits
Carefully assessing verbal and nonverbal cues of spiritual needs by the client
A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further weight gain for the client? Increased ghrelin production Increased leptin production Decreased hypocretin levels Decreased melatonin levels
Increased leptin production
A nurse is assisting with an in-service for staff members about culturally competent care. Which of the following information should the nurse include about traditional Native American beliefs? There should be a balance between yin and yang. Cupping is used to promote wellness. Use biofeedback to reduce stress. Music can produce healing energy.
Music can produce healing energy.
A charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include? Reduces medical errors Improves listening skills among interdisciplinary team members Less convenient than paper-based charting Makes client medical history more easily available Increases accuracy of coding procedures
Reduces medical errors, makes clients medical history more easily available, increases accuracy of coding procedures
A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take? Mix the medication with the client's feeding infusion. Flush the feeding tube with 10 mL of water prior to administration of the medication. Administer the medication to the client in a liquid form. Place the client in a supine position prior to administering the medication.
Administer the medication to the client in a liquid form.
A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take? Administer the medication whenever the client reports specific manifestations, such as pain. Administer the medication at specific times until directed by health care provider. Administer the medication at regular intervals of 4 hr. Administer the medication within 30 min of the health care provider prescribing the medication.
Administer the medication within 30 min of the health care provider prescribing the medication.
A nurse is caring for a client who has a sunburn. The nurse should identify that which of the following herbal supplements is used to treat sunburns? Green tea Aloe vera Lavender Milk thistle
Aloe vera
Based on religious practices, which client would be most likely to defer to her husband when making health care decisions? An Islamic woman A Jewish woman A Roman Catholic woman A Protestant woman
An Islamic woman
A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply) Ask the client what they know about the nitroglycerin patch. Find out whether the client is able to pay for the medication. Determine the client's ability to apply the patch. Check the client's reading comprehension level. Use medical terminology to instruct the client about the patch.
Ask the client what they know about the nitroglycerin patch. Determine the client's ability to apply the patch. Check the client's reading comprehension level.
The nurse cares for a client of the Islamic faith. Which lunch will the nurse recommend to the client? Salad with crumbled bacon and cheese with a cup of tea Barbecued pork sandwich with a milkshake Sliced ham and cheese sandwich and 2% milk Broiled chicken sandwich with skimmed milk
Broiled chicken sandwich with skimmed milk
A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? Charting by exception Subjective, objective, assessment, plan format Problem, intervention, evaluation model Data, action, response charting
Charting by exception
A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take? Leave the medication at the client's bedside. Prepare the medication to administer later. Document the medication was given prior to administration. Come back in a few minutes to administer the medication.
Come back in a few minutes to administer the medication.
A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action? Intramuscular Oral Buccal Intravenous
Oral
A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the Brian transmits the sensory data that is used to develop dreams? Hypothalamus Thalamus Cerebral cortex Pineal gland
Thalamus
Individuals who are Christian Scientists may not approve of: expensive treatments. circumcisions. contraception. immunizations.
immunizations.
A terminally ill client tells the nurse that he does not belong to an organized religion. It is safe for the nurse to assume: the client is an atheist. the client has no belief system. the client is an agnostic. the client may still be deeply spiritual.
the client may still be deeply spiritual.
The nurse is assessing a 27-year-old Navajo male who is being admitted for surgery. The client requests a visit from the spiritual healer. Which is the best response from the nurse? "Do you have a preference as to which spiritual leader you would like to visit?" "Would you like me to contact the hospital chaplain to come and visit with you?" "I will see who is available and ask him or her to come by and visit with you." "I will get a phone number for you so you can call a healer to ask for a visit."
"Do you have a preference as to which spiritual leader you would like to visit?"
A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make? "You can expect to experience a rash while taking this medication." "Natural supplements do not interact with antibiotics." "This medication is used to treat a viral infection." "Finish the entire course of the prescription."
"Finish the entire course of the prescription."
A nurse is assisting with teaching a client about homeopathy. Which of the following client statements indicates an understanding of the teaching? "Homeopathy uses traditional Chinese medicine to treat diseases." "Homeopathy uses imagery to promote wellness." "Homeopathy uses incantations to treat diseases." "Homeopathy believes a substance that can cause a disease can also cure it."
"Homeopathy believes a substance that can cause a disease can also cure it."
A client recently diagnosed with end-stage renal disease says to the nurse, "I feel so alone and trapped. I do not know why this is happening to me. My heart is aching." Which response by the nurse would be most therapeutic? "I will see if we can get something ordered for you for the pain." "I can only imagine how difficult this must be for you." "We have plenty of treatments that we can use to help you." "Do not worry. We can handle everything for you."
"I can only imagine how difficult this must be for you."
Which group of terms best defines spiritual distress? Spirituality, religion Alienation, despair Faith, prayer Forgiveness, purpose
Alienation, despair
Each of the major religions has several characteristics in common. What is one of those characteristics? Ministers are addressed as "Reverend." An ethical code defines right and wrong. Communion is delivered the same way. Men and women are viewed as equals.
An ethical code defines right and wrong.
A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating? Faith Hope Love Religion
Faith
A client who is on hospice care and has no immediate family has been given less than 1 week to live. The nurse caring for the client recognizes that providing presence is most important, especially when a client is dying. What would be the best way for this nurse to provide presence to this client? Check on this client every hour. Sit in the chair on the other side of the room for 10 minutes each hour. Hold the client's hand and sit by the bedside as often as possible. Tell the client that you are there when needed and to just ring the call bell.
Hold the client's hand and sit by the bedside as often as possible.
While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion? Christianity Judaism Islam Hinduism
Islam - but was incorrectly stated as Judaism
The nurse is caring for a client who is preparing to undergo a left mastectomy. As the nurse performs the physical assessment, the client informs the nurse that she is unable to accept blood products as treatment due to her religion. The nurse interprets this as a belief of which religion? Buddhism Baha'i International Community Latter Day Saints Jehovah's Witnesses
Jehovah's Witnesses
When asked about his religious preference, the client becomes very upset with the nurse. Which response is appropriate for this situation? "There is nothing to be upset about. This is part of my assessment." "I can see that this upsets you. Let me come back later when you are feeling better." "You need to understand that I am just doing my job here." "I can see that this question upsets you. Do you have any questions about this?"
"I can see that this question upsets you. Do you have any questions about this?"
A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? "I can take a telephone prescription if a provider is making routine rounds in another area of the facility." "I can take a telephone prescription if a provider is directing a code for an unresponsive client." "If a client requires an over-the-counter medication for relief of nausea, it is okay to accept a telephone prescription." "If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription."
"I can take a telephone prescription if a provider is directing a code for an unresponsive client."
A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs? "I will be able to track my health information." "My personal information will be entered into a national database." "I will have one EHR that will encompass the health care I've received over my lifetime." "The goal of EHRs is to improve insurance coding."
"I will be able to track my health information."
A nurse is reinforcing teaching about traditional Chinese medicine (TCM) to a client. Which of the following statements by the client demonstrates an understanding of the teaching? "I will take my blood pressure medication every morning." "I will have my heart rate checked once a month." "I will practice Tai Chi every day." "I will weigh myself weekly."
"I will practice Tai Chi every day."
A nurse is assisting with teaching a client, who has a history of alcohol use disorder and is to be discharged following cataract surgery, about non-pharmacological therapies. Which of the following client statements indicates an understanding of the teaching? "I will take kava to reduce my eye pain." "I will find a Rolfing practitioner to help decrease my alcohol cravings." "I will practice meditating when I feel stressed." "I will take niacin to promote healing for my eyes."
"I will practice meditating when I feel stressed."
An employee health nurse is providing teaching about sleep promotion to a group of newly licensed nurses. Which of the following statements should the nurse include? "Taking a cool shower before bedtime can help with sleep." "If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music." "To promote nighttime sleep, limit daytime naps to 1 hour." "Exercising 1 hour before bedtime can help promote relaxation and sleep."
"If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music."
When conducting a spiritual assessment, the nurse must be sensitive to the client's personal beliefs. Which questions should the nurse ask? Select all that apply. "Is religion or God significant to you?" "Why do you still not believe in God?" "Do you feel your faith is helpful to you?" "Why can't you share your feelings with me? I am your nurse." "Is there anyone from your church you would like to talk to?"
"Is religion or God significant to you?" "Do you feel your faith is helpful to you?" "Is there anyone from your church you would like to talk to?"
A nurse manager is conducting an in-service about the physiological functions of sleep for a group of staff nurses. Which of the following statements by one of the nurses indicates an understanding of the teaching? "Sleep is a process that decreases the development of new neural pathways that assist with retention of knowledge and memorization." "The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake." "The circadian rhythm is an external process that controls the sleep-wake cycle." "Clients experience the highest quality sleep when they complete three out of the four stages of sleep."
"The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake."
A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation? "The client is now asleep, and they ate most of their breakfast a few hours ago." "The client vomited 240 mL of clear emesis but denies pain or nausea." "The client reports not feeling good, but they look fine." "The client has 8 to 10 sores on their body."
"The client vomited 240 mL of clear emesis but denies pain or nausea."
A nurse is teaching a client about food choices that promote immunity and healing. Which of the following foods is the best source of vitamin C? 1 cup grapes 1 cup strawberries 1 cup sliced apple 1 small banana
1 cup strawberries
A nurse is preparing to administer acetaminophen 320 mg oral solution to a school-age child. The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
10
A nurse is preparing to administer an intradermal injection to a client. At which of the following degree angles should the nurse insert the needle? 60° angle 90° angle 45° angle 10° angle
10° angle
A nurse is preparing to administer phenytoin suspension 300 mg PO, twice per day. The amount available is phenytoin suspension 125 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
12
A nurse is preparing to administer clindamycin 0.3 g IM to a client. Available is clindamycin 150 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2
A nurse is preparing to administer amikacin 7 mg/kg/day IM to a client who weighs 165 pounds. Available is amikacin 250 mg/mL solution for injection. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2.1
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity? A client who has a respiratory infection A client who has rheumatoid arthritis A client who has impaired kidney function A client who has hyperthyroidism
A client who has impaired kidney function
A nurse is assisting a massage therapist to identify the best client for massage therapy. Which of the following clients should the nurse recommend? A client who is receiving anticoagulants following a mitral valve replacement An older adult client who has osteoporosis A client who has postpartum depression A client who has a thrombophlebitis
A client who has postpartum depression
A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include? Providers designate to other staff which abbreviations cannot be used. A nurse who delegates a task to an AP will review the charting for that task. Providers read and cosign nursing documentation for accuracy. Licensed personnel should document out-of-range vital signs for AP.
A nurse who delegates a task to an AP will review the charting for that task.
A nurse is assisting with teaching a class about U.S. Food and Drug Administration (FDA) regulation of nutritional supplements. Which of the following information should the nurse include in the teaching? A nutritional supplement can be applied topically. If a nutritional supplement contains natural products, it is considered safe. The FDA approves nutritional supplements for safety before they are placed on the market. A nutritional supplement contains at least one nutritional component.
A nutritional supplement contains at least one nutritional component.
Intervention was Effective? A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2° C (100.8° F) An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min
A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg
A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? A problem-oriented medical record is created using the PIE model for documentation entries. A problem-oriented medical record contains separate sections for laboratory and diagnostic information. A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. A problem-oriented medical record is rarely used in acute care settings.
A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.
A nurse is preparing to administer medications to a client. The nurse should identify that which of the following factors contributes to medication errors? (Select all that apply.) The use of automated dispensing systems Administering a generic medication Administering medication outside of prescribed time intervals Failing to administer a medication Incorrect dose of the prescribed medication administered to the client
Administering medication outside of prescribed time intervals Failing to administer a medication Incorrect dose of the prescribed medication administered to the client
A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.) Age of the client First pass effect Lipid solubility of a medication Route of administration Metabolism of the medication
Age of the client. Lipid solubility of a medication. Route of administration
A person who believes that nothing can be known about the existence of a god. Atheist Agnostic Spiritual Healer Religious Person
Agnostic
A nurse is caring for a client who is upset after being told about a diagnosis of cancer. The client asks the nurse to stay a minute to pray. Which is the nurse's most respectful and appropriate behavior? Tell the client that there are medications to be given to other clients. Agree to pray with the client and stand in silence by the bed. Inform the client that someone else of the same religion would be better to pray with. Tell the client that praying will not help the cancer go away.
Agree to pray with the client and stand in silence by the bed.
The nurse is reviewing the medical record of a client scheduled for a left hip replacement the following morning. The client lists Jehovah's Witness as the religious belief. Which action should the nurse take? Notify the surgeon of the client's religious preference. Call the surgical department and cancel the procedure. Assess the client's belief regarding blood transfusions. Highlight "Jehovah's Witness" on the client's medical record.
Assess the client's belief regarding blood transfusions.
While admitting a client who is having elective surgery tomorrow, the nurse asks if the client has a preferred religion or faith. The client indicates that they do not believe in a higher power and therefore have no preferred religion. The nurse uses which term to document the client's feelings about religion? Atheist Jehovah's Witness Agnostic Spiritualist
Atheist
A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? By mouth Intramuscularly Per rectum Intravenously
By mouth
A nurse is caring for an older adult client who is having difficulty sleeping and has a new prescription for a medication to help them sleep. Which of the following medications should the nurse identify as a first-line sleep aid for older adults? Alprazolam Eszopiclone Controlled-release melatonin Diphenhydramine
Controlled-release melatonin
A nurse is caring for a client who reports that they use their phone at night while they are in bed. The nurse should identify that excessive smartphone use can increase the client's risk for which of the following? Depression Binge eating disorder Restless leg syndrome (RLS) Diminished circadian rhythm
Depression
A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions? Diabetes mellitus Central sleep apnea Hypersomnia Restless leg syndrome (RLS)
Diabetes mellitus
A nurse is caring for a client who asks about naturopathy. The nurse should include that which of the following is a component of naturopathy? (Select all that apply. Dietary supplements Exercise Establishing harmony between fire, water, air, earth, and sky Traditional Chinese medicine Homeopathy
Dietary supplements Exercise Traditional Chinese medicine Homeopathy
A nurse is caring for a client who is having difficulty falling asleep. Which of the following interventions should the nurse implement to promote sleep for the client? Offer the client a caffeinated beverage 3 hr before their bedtime. Turn on the client's television before they go to bed. Warm the temperature of the client's room before they go to bed. Dim the lights in the client's room at bedtime.
Dim the lights in the client's room at bedtime.
A nurse is explaining the practice of Ayurveda to a newly licensed nurse. The nurse should include that Ayurveda is based on establishing a balance between the body, mind, and spirit with which of the following elements? (Select all that apply.) Earth Sky Darkness Light Water
Earth Sky Water
A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include? Use closed-ended questions. Provide written material at a 9th-grade reading level. Use passive listening skills. Encourage the client to ask questions.
Encourage the client to ask questions.
A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? American Nurse Association (ANA) standards prevent client records from being used for legal proceedings. HIPAA regulations vary from one state to another. Privacy regulations apply to electronic data transfer rather than verbal communication. Facilities can establish their own rules for documentation methods.
Facilities can establish their own rules for documentation methods.
A nurse is completing a preoperative health history for a client who reports taking several herbal supplements. Which of the following herbal supplements is the priority for the nurse to report? Ginkgo biloba Echinacea Valerian Aloe vera
Ginkgo biloba
A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first? Document the insulin administration. Assist with teaching the client about the insulin. Have a second nurse confirm the insulin dose. Monitor the client for adverse effects of the insulin.
Have a second nurse confirm the insulin dose.
A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications? Verify the client's identity using their diagnosis. Use one identifier to confirm the client's identity. Use the client's room number to identify the client. Have the client confirm their name and date of birth.
Have the client confirm their name and date of birth.
A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take? Repeat the least important information to the client. Have the client perform a return demonstration of the procedure. Provide the client with educational materials written at an 8th-grade reading level. Dim the lights in the client's room before beginning the teaching.
Have the client perform a return demonstration of the procedure.
A nurse is assisting with teaching a class about using holistic nursing interventions to care for clients. Which of the following information should the nurse include? Holistic nurses use herbal supplements because they do not cause adverse effects. The goal of holistic nursing is to cure a client's illness. Holistic nurses empower clients to actively participate in their own care. A holistic nurse discourages the use of prescribed medications for clients.
Holistic nurses empower clients to actively participate in their own care.
A nurse is contributing to a presentation about hypersomnia. Which of the following information should the nurse recommend including in the presentation? Hypersomnia does not improve with increased sleep. Hypersomnia is associated with a disturbed circadian rhythm. Clients who experience hypersomnia have a longer attention span. Clients who experience hypersomnia lack the hormone hypocretin.
Hypersomnia does not improve with increased sleep.
A nurse has developed a plan of care to meet the needs of a client with the nursing concern of spiritual distress. What is an expected outcome? Attend religious services on a weekly basis. Share feelings about religion with other health care providers. Identify factors in life that challenge spiritual beliefs. Commit to reading passages from the religious text daily.
Identify factors in life that challenge spiritual beliefs.
A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? Immunization data Record of client health care payments Complete medical information for household members Facility policies
Immunization data
A client who is admitted to the ER with severe right-sided abdominal pain is diagnosed with appendicitis. The surgeon is called and proceeds to explain the procedure to the client and asks her to sign the consent. The client refuses and informs the doctor that her husband needs to be called to do this. Which of the following religions does this client likely practice? Hinduism Catholicism Islam Judaism
Islam
A nursing student is studying spirituality and completing a report on The Church of Jesus Christ of Latter-day Saints. Which fact about this faith should the student include in the report? Latter-day Saints are not allowed to practice birth control. Latter-day Saints are not allowed to use tobacco or alcohol. Latter-day Saints are not allowed to have blood transfusions. Latter-day Saints are not allowed to have a health care provider of a different sex.
Latter-day Saints are not allowed to use tobacco or alcohol???
A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.) Mark the area around the automated medication dispensing system. Encourage the use of cell phones while dispensing medications. Override the automated medication dispensing system during emergencies. Provide the nurse administering medications with a vest. Double check dosages of high-alert medications.
Mark the area around the automated medication dispensing system. Provide the nurse administering medications with a vest. Double check dosages of high-alert medications.
A nurse is planning complementary therapy for a client who has breast cancer. Which of the following treatments is a complementary therapy that the nurse can implement? Massage therapy Chemotherapy Teletherapy Brachytherapy
Massage therapy
A nurse is assessing a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions? Hypersomnia Narcolepsy (NT2) Narcolepsy (NT1) Insomnia
Narcolepsy (NT1)
Mr. Field is a 45-year-old man who has suffered a myocardial infarction. Mr. Field provided for his family by working in the construction industry, which he will no longer be able to do. He tells his nurse that he fears he will be of no use to anyone now. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people? Need for meaning and purpose Need for love and relatedness Need basic necessities of life Need for forgiveness
Need for meaning and purpose
Three Spiritual Needs Need for meaning and purpose Need for love and relatedness Need for forgiveness Need for cande
Need for meaning and purpose Need for love and relatedness Need for forgiveness
A nurse is contributing to a presentation about non pharmacological interventions used to promote sleep. Which of the following information should the nurse recommend including in the presentation? Nonpharmacological interventions should only be practiced in the client's home setting. Massage is a nonpharmacological intervention that should be used to promote sleep for clients who are taking anticoagulants. Nonpharmacological interventions used to help promote sleep include acupuncture and thermotherapy. Before implementing nonpharmacological interventions, clients should be evaluated by a sleep specialist for sleep apnea and chronic lung
Nonpharmacological interventions used to help promote sleep include acupuncture and thermotherapy.
A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which of the following findings should the nurse identify as a risk factor for obstructive sleep apnea? Hypersomnia Obesity Active glossal muscle History of tonsillectomy
Obesity
Nurses provide care to meet needs in all the human dimensions. What is one intervention nurses can implement to meet spiritual needs? Refer all questions to a spiritual advisor. Remind clients that nurses are not ministers. Avoid any discussion of religion or spirituality. Offer a compassionate presence.
Offer a compassionate presence.
A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify that which of the following is a characteristic of older adult sleep patterns that might explain the client's frequent awakenings? Older adults tend to spend more time in stage 4 sleep. Older adults tend to spend more time in stage 3 sleep. Older adults tend to spend less time in stage 1 sleep. Older adults tend to spend more time in stage 2 sleep.
Older adults tend to spend more time in stage 2 sleep.
A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.) Place the medication reconciliation form with the client's transfer documents. Reinforce teaching about the medications to the client upon discharge. Add medications the client is no longer taking in the medication reconciliation. Include over-the-counter medications in the medication reconciliation. Compare the client's home medications with prescribed discharge medications
Place the medication reconciliation form with the client's transfer documents. Reinforce teaching about the medications to the client upon discharge. Include over-the-counter medications in the medication reconciliation. Compare the client's home medications with prescribed discharge medications.
A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain medications, which of the following interventions should the nurse implement to promote comfort? Present information honestly. Have another nurse present difficult information. Do not include the client's concerns in the plan of care if they interfere with treatment. Perform cognitive behavioral therapy with the client.
Present information honestly.
A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? The client states, "I've had abdominal pain for the past 3 days." The client reports consuming about 1,500 mL of water per day. Rebound tenderness noted in RLQ of the abdomen. Recommend client referral to a registered dietitian.
Rebound tenderness noted in RLQ of the abdomen.
A nurse caring for a client of the Jewish faith knows the importance of asking about any food preferences when discussing diet. This is important for which reason? Religious practices and beliefs make caring for clients interesting. Religious practices and beliefs can directly influence a client's self-care practices. Religious practices and beliefs are not that important in relation to the client's illness. Religious practices and beliefs are difficult to understand.
Religious practices and beliefs can directly influence a client's self-care practices.
A nurse is caring for a client who follows a vegan diet and reports lethargy. Which of the following interventions should the nurse implement? Offer a massage with lavender oil. Request a prescription for vitamin B12 supplements. Give the client a cup of chamomile tea. Provide peppermint oil for the client to inhale.
Request a prescription for vitamin B12 supplements.
The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion? Roman Catholic Christian Scientist Jehovah's Witnesses Jewish
Roman Catholic
A nurse is caring for a client who has a history if migranes. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines? (Select all that apply) Sleep-wake homeostasis Sensory overload Sleep deprivation Increased melatonin Decreased hypocretin levels
Sensory overload Sleep deprivation
A client states, "My life has meaning and purpose, I feel loved, and have experienced forgiveness in my life." What is the term that describes this state of spirituality? Spiritual belief Spiritual alienation Spiritual health Spiritual bliss
Spiritual health
A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? Synthroid 100 mg PO every morning ac Enoxaparin 75 mg SQ bid Digoxin 0.25 mg PO qd Metformin 500.0 mg PO with evening meal
Synthroid 100 mg PO every morning ac
A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs. The Institute of Medicine Department of Veteran Affairs American Hospital Association The Joint Commission
The Institute of Medicine
A nurse is caring for a client after a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? The admitting provider The charge nurse on the unit The client's sibling The client The client's spiritual advisor
The admitting provider The charge nurse on the unit The client
A nurse is caring for a client who needs to be awakened for the administration of an oral medication. Which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened? The client was easily awakened. The client states that they were having a pleasant dream. The client experiences mental cloudiness for 30 to 60 min. Prior to being awakened, the client's breathing was irregular and their heart rate was elevated.
The client experiences mental cloudiness for 30 to 60 min.
A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client? The dosage is calculated by height. The preschooler is unable to take capsules. Preschoolers receive the same amount of medication as adults. The deltoid muscle can be used to administer intramuscular injections.
The deltoid muscle can be used to administer intramuscular injections.
A client is in the late stages of lung cancer with bone metastases. Since receiving the terminal diagnosis, the client has often made mentioned an estranged child and being a "miserable parent." Which conversation will the nurse have with the client to attend to unfinished business? The need for forgiveness The need to find purpose The need for meaning The need for love
The need for forgiveness
A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation? The system alerts providers of possible actions that could cause client harm. An electronic system prevents breaches of confidentiality of client data. Providers can document client information in the electronic record during system downtime. System encryption eliminates the need for security firewalls.
The system alerts providers of possible actions that could cause client harm.
A client scheduled for complex heart surgery has been reading their religious text for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client? These behaviors are expected before major surgery. These behaviors are signs of spiritual distress. Family members live far away and the client is lonely. The client is naturally emotional and reactive.
These behaviors are signs of spiritual distress.
A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include? To convert g to mg, move the decimal point 3 places to the right. Liters is a unit of measurement for distance. The metric system uses fractions rather than decimals. Grains is used as a measurement of weight in the metric system.
To convert g to mg, move the decimal point 3 places to the right.
Faith is a confident belief in something for which there is no proof or material evidence True False
True
A nurse is assisting with teaching a newly licensed nurse about holistic nursing. Which of the following information should the nurse include? (Select all that apply.) Use deep breathing to promote relaxation in clients. Encourage clients to use guided imagery to decrease pain. Apply essential oils to treat anxiety in clients. Treat one medical issue for clients at a time. Discourage family involvement in client care.
Use deep breathing to promote relaxation in clients. Encourage clients to use guided imagery to decrease pain. Apply essential oils to treat anxiety in clients.
A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include? Place a new transdermal patch over the same site as an old patch. Apply no more than two transdermal patches at a time. Expect the transdermal medication to absorb rapidly. Wear clean gloves to apply the transdermal medication
Wear clean gloves to apply the transdermal medication
A nurse is caring for a client who has a new prescription for a nonbenzodiazepine hypnotic to promote sleep. For which of the following adverse effects should the nurse monitor the client? a. Retrograde amnesia b. Urinary discomfort c. Dry mouth d. Hallucinations
d. Hallucinations
The client states "I have lifted my cancer to God and am accepting of God's plan for me." This is an example of an adaptive expression of spiritual needs labeled: trust. forgiveness love and relatedness, faith.
faith.
Which set of terms best reflects nursing's view of clients as holistic beings? physical, psychosocial, religious mind, body, spirit id, ego, superego spiritual, egocentric, naive
mind, body, spirit
When preparing for a spiritual counselor to visit a hospitalized client, the nurse should: take measures to ensure privacy during the counselor's visit. ask the spiritual counselor to summarize the visit in the client's medical record. ask to be present during the visit in order to explain any medical information or answer questions about the client's care. ensure that the counselor is approved by the hospital administration.
take measures to ensure privacy during the counselor's visit.
Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety? "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable." "I always tried to do the right thing, so I don't understand why I have to suffer so much now." "I guess I should have taken a lot more time to go to church when I was younger."
"Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life."
A nurse is reviewing the concept of comfort with an assistive personal (AP). Which of the following statements by the AP indicates an understanding of comfort? "Providing comfort for a client is achieved by the relief of physical pain through the administration of medication." "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." "Providing comfort for a client is achieved by taking control of the client's care and creating routines for the client to become familiar with." "Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing."
"Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy."
A nurse is assisting with providing an in-service for staff members about complementary and integrative health. Which of the following statements by a staff member indicates an understanding of the teaching? "Scented oils might decrease discomfort." "Natural substances do not have adverse effects." "Acupressure and acupuncture are the same thing." "Meditation involves the use of an electronic device to regulate body function."
"Scented oils might decrease discomfort."
A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse plan to include to promote emotional comfort for the client? Encourage the client to verbalize their needs and concerns. Limit time spent with client. Ask the client to splint the incision when coughing. Administer pain medications as prescribed.
Encourage the client to verbalize their needs and concerns.
A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? PRN NPO AC Ad lib
PRN
A nurse is caring for a client who asks about using aromatherapy for nausea. Which of the following scents should the nurse recommend? (Select all that apply.) Ginseng Evening primrose Peppermint Ginger Orange
Peppermint Ginger Orange
A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? "Accessing the medical record of clients on units other than where you are assigned is allowed." "There are large financial penalties for charting vital signs you obtain for another nurse's client." "Personnel can be terminated for breaching a client's confidentiality." "Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."
Personnel can be terminated for breaching a client's confidentiality
A bedridden hospitalized client expresses a belief that missing weekly church service is a failure to live by the church's rules. The notes not missing a service in the past 50 years. Which is an appropriate nursing diagnosis for this client? Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt Spiritual Need as evidenced by verbalizations and distress at missing Methodist church services Dysfunctional Grieving related to inability to attend church services as a result of his medical condition Potential for Enhanced Spiritual Well-Being related to distress at missing Methodist church services
Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt
An older adult client of the Catholic faith has been admitted to the unit for bleeding due to diverticulitis. She tells the nurse that she is concerned because the next day is Ash Wednesday and if she is in the hospital, she will not be able to receive ashes. What would be the nurse's best action in this case? Tell the client that it will be OK to miss ashes since she is in the hospital. Tell the client you will contact her priest to see if he can bring the ashes. Tell the client that it is not a big deal, as she can get ashes next year. Tell the client that you understand how she must feel but there is nothing you can do about it.
Tell the client you will contact her priest to see if he can bring the ashes.
A nurse is caring for a client who takes an over-the-counter (OTC) sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effect of OTC sleep aid medications? Hyperactivity Diarrhea Excessive salivation Urinary retention
Urinary retention
The nursing instructor has been discussing spirituality with a group of nursing students. Which statement by a student would indicate a need for further education? "Spiritual beliefs and practices do not give strength when a person is in crisis." "Spiritual beliefs and practices give healing strength and support." "A person's daily living habits can be guided by their spiritual beliefs." "Spiritual beliefs can help give a person meaning in their life."
"Spiritual beliefs and practices do not give strength when a person is in crisis."
While reviewing the chart of a client before beginning care, the nurse notices that the spiritual assessment form is blank. Which question will the nurse use to begin the assessment process? "Tell me about spiritual beliefs that are important to you." "What religion do you belong to?" "Do you want me to call a priest or minister?" "Are you a spiritual person?
"Tell me about spiritual beliefs that are important to you."
Anything that pertains to a person's relationship with a nonmaterial life force or higher power. Spirituality Religion Hope Faith
Spirituality
A nurse is discussing the stages of the sleep cycle with a client. The nurse should include that the immune system is strengthened and tissues and bones are repaired during which of the following stages of the sleep cycle? Stage 1 Stage 2 Stage 3 Stage 4
Stage 3
A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first? Notify the client's provider. Stop the infusion of the vancomycin. Administer diphenhydramine to the client. Document the incident in the client's chart.
Stop the infusion of the vancomycin.
A nurse is developing a plan of care to meet a client's spiritual needs. When identifying appropriate interventions, which concept would the nurse need to integrate as the foundation for all the intervention Prayer Supportive presence Strength Religion
Supportive presence
Upon assessment, the client reports not belonging to an organized religion. Which assessment question would the nurse ask to assess the client's spirituality? "Tell me about spiritual or religious beliefs that are important to you." "Why do you not belong to an organized religion?" "Do you think of yourself as a religious person?" "Can I set up an appointment for you with our hospital chaplain?"
Tell me about spiritual or religious beliefs that are important to you."
A nurse is documenting information in a clients chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry? The "I" in PIE The "S" in SOAP The "R" in DAR The "E" in PIE
The "S" in SOAP
The nurse is caring for a client who asks that the special undergarments not be removed for an upcoming procedure. The nurse is aware that these undergarments are related to the client's religion. This religion is: The Church of Jesus Christ of Latter-day Saints. Christian Scientist. Adventist. Islam.
The Church of Jesus Christ of Latter-day Saints.
The nurse is creating a plan of care for a client experiencing spiritual distress. What is the priority outcome for this care plan? The client expresses meaning and purpose in life. The client expresses satisfaction with spouse's life circumstances. The client has a sense of optimism and hope from the past. The client states belief in a higher being.
The client expresses meaning and purpose in life.
The nurse working on a hospice unit is giving an in-service on the importance of faith and religion in client care. What does the nurse tell the group is a benefit of religious fellowship? It distracts the client. It offers support for the client. It puts a good label on the client. It allows for further isolation.
It offers support for the client.
