Fundamental of nursing 1 midterm

Martha Rogers

Science of Unitary Human Beings Model

Which type of crisis is an earthquake that has killed more than 7000 people? - situational - maturational - adventitious - developmental

An adventitious crisis RationaleAn adventitious crisis is also known as a disaster crisis. It occurs due to a major natural disaster or man-made disaster. A situational crisis occurs due to external sources such as a job change, a motor vehicle crash, or severe illness. A maturational crisis is also known as a developmental crisis. Developmental stages such as marriage, pregnancy, and the birth of a child require new coping styles. Failure to cope with the exposure to stressors during these stages leads to developmental crises.

Which stage of dying is being describe when a terminally ill patient tells the nurse, "I would do whatever you say. Please relieve me of this illness?" - anger - denial - depression - bargaining

Bargaining

Which statement about spiritual and religious institutions is true? · Both cause patients to avoid seeking patient care. · Their hospitals are created for the members of that religious group. · Both often provide an entry point for health care access in impoverished communities. · Both should remain separate from the health care arena.

Both often provide an entry point for health care access in impoverished communities

The risk for developing a deep vein thrombosis is highest in what part of body? Upper extremities Lower extremities Pulmonary artery Lungs

Lower extremities The risk of developing a deep vein thrombosis is highest in the lower extremities, due to pooling of blood in the veins particularly in patients with limited mobility.

Which intervention can be used to prevent heel pressure as well as keep the ankle and foot in proper alignment? PRAFO boots Foot boards Splints Heel protectors

RAFO boots Pressure-relief ankle-foot orthotic (PRAFO) boots can be used to prevent pressure on the heels. Evidence demonstrates that patients should spend 2 hour(s) or less in a chair without pressure relief.

Which is an example of data a public health nurse would collect during a windshield survey? · Life expectancy of target groups · Type of housing and transportation · Prevalence of STDs · Health literacy levels

Type of housing and transportation One commonly used community health assessment instrument is the windshield survey—done by walking or driving through a community—whether people are walking or are engaged in physical activity/availability of single or multiple-family private and public housing units/health/safety/social service agencies

Which cultural characteristic do pink ribbons represent? · Ethnicity · Enculturation · Cultural integration · Nonverbal symbols

noverbal symbols -breast cancer pts

The nurse has become aware of missing narcotics in the pt care area.Which ethical principle obligates the nurse to reprot the missing medicaitons? - advocacy - responsibility - confidentiality - accountability

responsibility

Which environmental substances are known to have a teratogenic effect on the developing fetus? Select all that apply. 1. Statins 2. Ethanol 3. Penicillin 4. Vitamin D 5. Acetaminophen (Tylenol)

1 2 Statins should be avoided during pregnancy—associated with hearing impairments in children of mothers who took statins during pregnancy/ethanol can lead to fetal alcohol syndrome

Promoting wellness approaches to family-centered care would include which ideas? Select all that apply. 1. Keep up to date on clinical research support for caregiver stress. 2. Discuss measures the family has used in times of stress. 3. Share family recipes related to healthy nutrition. 4. Provide a healthy diet plan to family members. 5. Refrain from discussions to reduce potential stress.

1 2 3 Remaining up to date on current clinically relevant evidence addressing stress reduction in caregiving helps stress reduction for all family members/ Supporting an open dialogue with family members related to positive past stress-related experiences helps to determine a family-centered approach to caregiving/ Encouraging open dialogue in a nurturing environment encourages a family-centered approach to health and wellness

What is an advantage of summarizing? select all that apply 1. Promotes recall of previous discussions 2. Participants focus on key issues 3. Reveals true personal experiences 4. Useful in the terminal phases of the patient relationship 5. Brings a sense of caring and human connection

1 2 4

Which factor is important during clinical care coordination? select all that apply 1. evaluation 2. use of resources 3. interruption control 4. time management 5. organizational skills

1 2 4 5

Which areas are at risk for the development of pressure ulcers in the immobile patient? Select all that apply. 1. Buttocks 2. Chest 3. Coccyx 4. Heels 5. Elbows

1 3 4 5

Which interventions should be implemented to prevent falls in the home? Select all that apply. 1. Keep a walker in the bedroom. 2. Install handrails where needed. 3. Repair uneven stairway surfaces. 4. Place nightlights in poorly lit areas. 5. Remove clutter from main walking areas.

2 3 4 5

Which organization addresses the quality of health care documentation? select all that apply 1. American Nurse Association (ANA) 2. The Joint Commission 3. Diagnosis-related groups (DRGs) 4. National Committee for Quality Assurance (NCQA) 5. Health Insurance Portability and Accountability Act of 1996 (HIPPA)

2 4

Which patient would be a candidate for hospice care? · 10-year-old child with cognitive disabilities · 25-year-old with terminal testicular cancer · 57-year-old paralyzed on the right side from a stroke · 79-year-old homeless person with heart disease

25-year-old with terminal testicular cancer

Which standards of practice requirements are identified by the ANA as similar for public health nurses and nurses in other practice areas? Select all that apply. Ethical behavior Participation in research Commitment to healthy behavior Advocacy Leadership Responsible resource utilization

Ethical behavior Participation in research Advocacy Leadership Responsible resource utilization

What is the primary product derived from nursing research? Health statistics Practice guidelines New theories Evidence

Evidence Evidence Nursing research produces evidence that must be critically evaluated to determine its value.

The nurse completed discharge teaching with an Asian male. The patient's wife arrived and was upset that she was not present for the teaching. Which consideration did the nurse fail to realize? Environmental Lifespan Language Family

Family

Which person is most important to the identity development of an adolescent? Friend Sibling Mentor Parent

Friend

Rosemarie Rizzo Parse

Human Becoming Theory

A patient has been diagnosed with heart failure. He asks the nurse for clarification on which part of the heart is ineffective. The nurse teaches the patient that heart failure is related to what? Impaired aorta Impaired ventricle Impaired atrium Impaired arteries

Impaired ventricle Heart failure is caused by any heart condition that impairs the ventricle's ability to fill and expel blood.

Which statement is true regarding responsibility? - it is the freedom of choice - it reflects a person's ownership - it is a legitimate power to give a command - it refers to an individual being answerable for his or her actions

It reflects a person's ownership

Registered nurses can delegate to which other level of health care provider? ADN LPN/LVN CNS DNP

LPN/LVN

Nurses are given autonomy for various nursing practices, so they should be dependent only in aspects of care beyond their scope of practice Which term is referred to as the pattern of beliefs that describe the domain of a discipline? - Paradigm - Phenomena - Content - Assumption

Paradigm Nurses are given autonomy for various nursing practices, so they should be dependent only in aspects of care beyond their scope of practice

Which aspect of positining a patient in the supported Fowler's position has a goal of decreasing flexion of vertebrae? - Place a small pillow underthe thigh - Place the head on a small pillow - Place a small pillow at the lower back - Place a pillow to support arms and hands

Place a small pillow at the lower back

Which level of prevention describes the nurse participating at a health fair in the local mall by administrating influencza vaccines to senior citizens? - Primary - Secondary - Tertiary - Quaternary

Primary

Which word does the P in the acronym PES stand for? - Period -problem -Prevention -Predication

Problems E-etiology or react factor S-symptoms

Which sense is affected by presbyopia? - Hearing - Sight - Smell - Taste

Sight

Which phrase accurately describes output? - Data entering the system - The end product - Data related to system functioning - The product and information obtained from the system

The end product

Hildegard Peplau

Theory of Interpersonal Relations

While positioning a patient with hemiplegia in the supported Fowler's position, the nurse elevates the head of the bed to 50 degrees. Which rationale explains this intervention? - To prevent shoulder subuxation - To prevent hyperextension of the neck - To improve the patient's ability to swallow - To improve the patient opporunity to relax

To improve the patient opportunity to relax

While helping a patietn move up in bed, the nurse turns the patient from side to side to place the drawsheet under the patient. Which rationale explains this nursing action? - To make lifting and positioning easier - To reduce the frictioin during the movement - To prevent striking of hte pt's head against the head of the bed - To provide strong handles to grip the drawsheet without slipping

To reduce the friction during the movement

Which type of loss is illustrated when a yound adult loses a limb from diabetes and is very upset about it? - actual - perceived - necessary - maturational

actual

What are signs of teenage drug or alcohol use? Select all that apply. 1. Stealing money 2. Skipping classes 3. Blood shot eyes 4. Coming home late 5. Using birth control

1 2 3 4

The student nurse is caring for a patient in the hospital setting. The student has been signed off on passing medications. In the process of giving Lasix to a patient, a medication error is made due to failure to verify the Six Rights of Medication Administration. Which responsibilities does the nurse educator share? Select all that apply. 1. Accountability for patient care provided 2. Professional development of the student 3. Advising and supervising the student 4. Ensuring the student has developed strong personal values 5. Ensuring the student understands professional standards

1 3

Arrange the steps of the scientific method in the correct sequence 1. identifying problem 2. formulating a question or hypothesis 3. collecting data 4. testing the question or hypothesis 5. evaluating results of the study

1 3 2 4 5

What are the key areas of social determinants of health as outlined by Healthy People 2020? Select all that apply. 1. Health and health care 2. Emotional stability and mood 3.Social and community context 4. Genetics and cultural traditions 5. Neighborhood and built environment

1 3 5

Which statements represent NORMAL cognitive functioning in older adulthood? Select all that apply. 1. Inability to learn new skills occurs. 2. Visual memory declines. 3. Ability to recall numbers is not impacted. 4. Recall of experiential procedures is unaffected. 5. Long-term memory for new information declines.

4 5

Nurses are responsible for the quality of care provided to patients. Which will help nurses practice safe nursing? Select all that apply - Acquiring knowledge - Minimizing documentation - Improving competencies - Acquiring technical skills - Exhibiting complete dependence

Acquiring knowledge Improving competencies Acquiring technical skills

Which illness manifests the loss of intellectual abilities, is treatable, but is not reversible or curable? · Delirium · Depression · Vascular dementia · Alzheimer's disease

Alzheimer's disease

Nurses become involved in evidence-based practice (EBP) when they do what? · Apply research findings to their practice · Access current clinical practice guidelines · Identify literature relevant to their practice · Recognize potential patient problems

Apply research findings to their practice When nurses actually apply research findings to their practice, they are engaging and becoming involved in evidenced-based practice.

Which statement describes accountability? - managing employees - being answerable for one's actions - having freedom to choose aspects of care - recommending appropriate teaching strategies

Being answerable for one's actions

Which statements best describes a fecal impaction? Slowdown of the gastrointestinal tract Buildup of hardened feces in the lower intestine Breakdown of muscle protein Decrease in bowel movement frequency

Buildup of hardened feces in the lower intestine A fecal impaction is best described as a buildup of hardened feces in the lower intestine.

How does QSEN ensure that nurses advance quality and safety in future health care settings? By opening new nursing schools By starting legislation to keep the project going By providing safety goals and hospital accreditation By preparing nurses with knowledge, skills, and a positive attitude

By preparing nurses with knowledge, skills, and a positive attitude The QSEN project is preparing nurses for the future through knowledge, skills, and attitude.

Being familiar with local health care service agencies is most essential for nurses in which practice arena? Long-term care Critical care Community-based Pediatrics

Community-based

which type of grief is exemplified when a father refuses to accept the death of child and no longer has a job, avoids communication with others, and remains aloof? - normal - complicated - anticipatory - disenfranchised

Complicated Rationale: In complicated grief, a person has a difficult time moving forward after loss. In normal grief, the person shows a common reaction characterized by complex emotional, cognitive, social, and spiritual responses to loss and death; however, in this case the father did not move on.

Which component of a nursing theory can be either abstract or concrete and is used to communicate meaning? - Concepts - Definitions - Assumptions - Phenomenon

Concept A concept, "a thought or idea of reality that is put into words or phrases to help describe or explain a specific phenomenon, "can be abstract or concrete and is used to communicate meaning. —definitions may be conceptual or operational. Assumptions are truths and are based on values and beliefs. Phenomenon is not described as abstract or concrete

When caring for a pt who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a - critical pathway - nurisng care plan - concept map - diagnostic label

Concept map

The nurse is working with a Jehovah's Witness patient who is refusing blood transfusion, despite low hemoglobin. The nurse does not agree with her decision but she respects her patient's religion. Which behavior is the nurse demonstrating? Cultural competence Cultural awareness Hidden bias Transcultural awareness

Cultural competence Cultural competence — loosely defined as the ability to understand, appreciate and interact with people from cultures or belief systems different from one's own

A pt with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess: A. posture B. activity tolerance C. Body mechanics D. range of joint motion

D

What should the nurse look for in the patient who is having problems with equilibrium? Inability to sleep Inability to eat Difficulties with balance Stiff joints

Difficulties with balance Problems with equilibrium affect the patient's ability to balance.

Direct care interventions Indirect care interventions

Direct Care Activities of daily living (ADLs) - direct care measures usually performed during a normal day Instrumental ADLs (IADLs) - activities that support daily life/are oriented toward interacting with the environment Physical care techniques - the safe and competent administration of nursing procedures - lifesaving measures counseling teaching controlling for adverse reactions preventive interventions Indirect care - nursing tx or procedures performed away from a pt but on behalf of a pt - communicating nursing interventions--written or oral - delegating, supervising, and evaluating the work of other staff members

What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? Early ambulation after surgery Administering calcium with vitamin D Coughing and deep breathing exercises Referring the patient to occupational therapy

Early ambulation after surgery Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity.

What is the belief that one's own culture is superior to those of other cultures? Ethnocentrism Ethnicity Discrimination Prejudice

Ethnocentrism

What consequences may result if an infant's needs are ignored by the parent? · Feelings of insecurity · Emotional resilience · An early development of independence · Inappropriate survival mechanism development

Feelings of insecurity If the infant's needs are not met, the child will develop feelings of insecurity at an early age, which can continue throughout life, along with a feeling of dissatisfaction

Which topic is a key issue in economic stability as a social determinant of health? Food security Health literacy Social cohesion Quality housing

Food security

Which patient action most likely indicates the patient is experiencing stress? · Heavy, labored breathing · Frequent adjustment of position · Eye-rolling while answering questions · Stomach growling during examination

Frequent adjustment of position

Communication is a component of which family attribute? - Hardiness or resiliency - Functioning - Structure - Development

Functioning Structure—based on the multiple relationships and makeup of the family Communication is a component of family functioning, whether it is setting goals/coping/or establishing discipline.

Which type of change in body systems is associated with the physiological process of aging? Acute Obvious Limited Gradual

Gradual Gradual changes in body systems result in a loss of homeostatic mechanisms during the aging process

Which is a characteristic of ethnicity? Select all that apply. Group customs Skin color Group beliefs Gender roles Common language

Group customs Skin color Group beliefs Common language

Puberty is considered delayed in males if which physical changes do not occur by age 14? Growth of testes Gynecomastia Penis enlargement Axillary hair growth

Growth of testes

Which intervention for controlling the spread of infections in the health care setting is considered the most effective? Placing all patients in contact isolation. Donning personal protective equipment. Hand washing before and after patient contact. Knowing the correct procedures for insertion of therapeutic drains.

Hand washing before and after patient contact. Hand washing before and after patient contact is considered the single most effective measure to control the spread of infection in health care settings.

Rosenstock

Health Belief Model

Which sense is affected by prescycusis? - Hearing - Sight - Taste - Touch

Hearing Age-related hearing loss (or presbycusis) is the gradual loss of hearing in both ears.

The nurse is implementing concepts from which theory when facilitating a group discussion that involves problem-solving and interpersonal processes? Virginia Henderson Betty Newman Hildegard Peplau Dorothea Orem

Hildegard Peplau Hildegard Peplau's Theory of Interpersonal Relations focuses on the therapeutic process, group discussions, and problem-solving.

Virginia Henderson

Humane and holistic care for pts

An older adult patient lives at home with an adult child and several young grandchildren. The nurse is educating the patient about hazards in the home. What information should the nurse include in the patient's education plan? Marinate meat in an airtight container on the kitchen counter to avoid food poisoning. Keep all household cleaners in a secure cabinet, as they can be poisonous. Have the gas company come to the house every six months to check for carbon monoxide, which can be lethal. Store all medications within easy reach so as to avoid over stretching and falling.

Keep all household cleaners in a secure cabinet, as they can be poisonous. The education plan should include information about keeping all household cleaners stored in a secure cabinet away from children and pets, as these are poisonous substances.

Which process is involved in the nurse's socialization into the profession of nursing? Learning the theory necessary for the nursing role Recognizing nursing roles and what they entail Understanding the need for professional standards Being open and reflective about nursing values

Learning the theory necessary for the nursing role Socialization to professional nursing is a process that involves learning the theory and skills necessary for the nursing role.

Which statement below describes one of the ways that male physical development differs from females? · Males develop increased muscle mass. · Males develop increased adipose tissue. · Males experience height increase of 3.15 in (8 cm)/year. · Males experience an increase in body mass index.

Males develop increased muscle mass.

A nurse must obtain which educational degree prior to obtaining licensure as an advanced practice nurse? Doctor of nursing practice Master of science in nursing Advanced practice specialist Bachelor of science in nursing

Master of science in nursing

Which examination must a nursing student pass for licensure? MCAT APRN NCLEX ANCC

NCLEX

Which 3 risk factors have been cited as having a possible effect on prenatal development. - Nutrition, stress and mother's age - Prematurity, stress, and mother's age - Nutrition, mother's age, and fetal infections - Fetal infections, prematurity, and placenta Previa

Nutrition, stress and mother's age

Which condition is related to venous stasis? Heart failure Peripheral vascular disease Chronic obstructive pulmonary disease Angina

Peripheral vascular disease Peripheral vascular disease is a disturbance in the venous system caused by stasis of blood.

Erickson

Psychosocial Theory

A nurse is screening individuals for latent (hidden) diseases. Which type of prevention does this illustrate? Primary Secondary Tertiary Quaternary

Secondary

Betty Neuman

Systems Model

Which statement reflects the consequence of a mother suffering from postpartum depression in regard to an infant's psychosocial development? The child will not be affected by the mother's depression. The infant will develop empathy and respond to the mother's sadness. The infant will develop a preference for other caregivers and may avoid eye contact until two years of age. The infant will struggle to develop the basic sense of trust that the infant's needs will be met and instead develop a sense of suspicion or mistrust.

The infant will struggle to develop the basic sense of trust that the infant's needs will be met and instead develop a sense of suspicion or mistrust.

According to Dennis and Small, an awareness of the interaction of which three cultures is imperative to the nurse's cultural competence? The personal self, the patient, and the health care delivery system The patient, the patient's family, and the health care delivery system The personal self, the health care practitioner, and the patient The patient's culture of origin, his significant other's culture of origin, and the health care delivery system

The personal self, the patient, and the health care delivery system

You are writing a care plan for a newly admitted pt. Which one of these outcome statements is written correctly? - The pt will eat 80% of all meals - The nursing assistant will set the pt up for a bath every day - The pt will have improved airway clearance by June 5 - The pt will identify the need to increase dietary intake of fiber by June 5

The pt will identify the needs to increase dietary intake of fiber by June 5 Mr. Bagley's plan of care calls for oxygen therapy to improve his respiratory status A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a Standing order

Skin that appears darkened or reddened is indicative of what problem? Reactive hyperemia Deep vein thrombosis Tissue ischemia Tissue blanching

Tissue ischemia Skin that appears darkened or reddened is indicative of tissue ischemia.

Grief Mourining Bereavement types of grief

Types of grief - normal (uncomplicated) - anticipatory - disenfranchised (ambiguous) - complicated (chronic, exaggerated, delayed, masked)

After the birth of a baby, a divorced mother is finding it difficult to care for the baby and work at the same time. Which question would the nurse ask the patient during the crisis assessment? - do you know that you are in a situational crisis? - what does your husband do? - how is your work and responsibility as a mother affecting your life? - where is your husband now? why didn't you bring him along?

how is your work and responsibility as a mother affecting your life?

During which stage of the grieving process does the patient begin to express emotions openly? - Anger - Resolution - Bargaining - Acceptance

resolution

the nurse become aware of missing narcotics in the pt care area. Which ethical principle obligates the nurse to report the missing medication? - responsibility - advocacy - confidentiality - accountability

responsibility

The nurse teaches a patient with diabetes how to use a glucometer and then asks the patient to use the glucometer to measure his or her blood sugar. The nurse is using which teaching method? - Practice - Demostration - Independent projects - Return demonstration

return demonstration

In what situation should passive range-of-motion exercises be stopped? If resistance to movement is felt If the patient is unable to participate When joints move freely When atrophy occurs

when resistance to movement is experienced. Range-of-motion exercises are stopped if the patient begins to complain of pain, or if resistance to movement is experiencedIf resistance to movement is felt Range-of-motion exercises are stopped

The family of a patient who inadvertently ingested a poisonous substance states that if this happens again they will have the patient drink baking soda and water. What should the nurse say to the family? "That's a good idea as that works most of the time." "Call the Poison Control Center before giving any antidote." "Dial 911 if the patient is not feeling better within 20 minutes." "It is crucial to get the patient into fresh air as soon as possible."

"Call the Poison Control Center before giving any antidote." The Poison Control Center should always be contacted before administering any antidote.

The registered nurse is providing instructions to a nursing student about the interventions performed while moving the patient. Which instruction given by the registered nurse should be prioritized? - Determine the comfort level of the patient - Determine the effect of illness on exertion - Determine whether the pt understands what is expected - Determine whether it would be difficult to move the pt alone

"Determine the effects of illness on exertion." Before moving the patient, the nurse should first determine whether the patient's illness contradicts exertion. Then, the nurse should determine the patient's comfort level. The nurse should determine whether the patient comprehends what is expected after determining the number of people required to move the patient. In the end, the nurse should assess whether the patient is too heavy or immobile for the nurse to move alone.

A nurse is teaching a patient about medication safety. Which statement would indicate a need for further teaching? "I sometimes store my medications in alternate containers." "I never share my medications with anyone including my family." "I know my medications are not good past the expiration date on the bottle." "I use childproof caps all the time even though they can be hard to get off."

"I sometimes store my medications in alternate containers." This statement indicates teaching has not been effective as medications should be always stored in their original containers.

In which condition is the heart is unable to pump enough blood to meet the body's demand? Heart failure Peripheral vascular disease Chronic obstructive pulmonary disease Angina

Heart failure Heart failure is a complex condition in which the heart is unable to pump enough blood to meet the body's demand.

A critical thinking model for clinical decision making

Model components - competence -specific knwoledge base -Experience -The nursing process competency -Attitudes for critical thinking -Standards for critical thinking

Which critical thinking attitude motivates the nurse to communicate and know more about a patient? - Curiosity - Creativity - Perseverance - Self-confidence

curiosity

Which term most accurately describes the primary focus of public health nursing interventions? Disenfranchised groups Families Individuals at risk Populations

populations The primary focus of public health nursing interventions is populations.

Which cognitive change is characteristic of older adulthood? Visual memory remains robust. Short-term memory is unaffected. New skills can be learned at the same pace as before older adulthood. Long-term memory for new information is minimally reduced.

visual memory remains robust Visual memory, linked to the ability to read, remains robust

Which is an example of a goal with a measurable outcome for the nursing diagnosis Pain Related to Immobility? Patient will be free from falls during hospital stay. Patient will be pain-free during hospital stay. Patient will tolerate a regular diet after surgery. Patient will maintain a tolerable pain level of 2/10 during hospital stay.

Patient will maintain a tolerable pain level of 2/10 during hospital stay. This goal has a measureable quantity (2/10) and can be tracked in the patient record. It can be audited for the duration of the hospital stay.To plan, collaborate, and evaluate patient-centered care plans Nursing diagnoses related to movement and immobility help the nurse identify and determine measureable patient-centered goals, track the patient's progress, and adjust plans if needed.

In which position should the patient be placed to perform coughing, deep-breathing, and incentive spirometry? Right side-lying Left side-lying Supine Upright

Upright The best position is upright as it allows for increased lung expansion by relieving pressure on the diaphragm and chest wall. cough/deep-breathing/incentive spirometry shoudl be down in an fowler or semi-fowler position

The nurse is caring for a patient with cerebellar damage related to traumatic brain injury. What are expected side effects of this condition? Select all that apply. 1. Uncoordinated movement 2. Poor balance 3. Ability to walk 4. Inability to remain upright 5. Unsteady gait

1 2 4 5

Multifactorial birth defects result because of a combination of which two factors? Select all that apply. 1. Genetics 2. Economic 3. Environment 4. Physiological 5. Psychological

1 3

Which etiolgical factor may lead ot diffculty articulating words? select all that apply 1. Acne 2. FAcial trauma 3. Laryngeal cancer 4. Endotracheal intubation 5. Intravenous catheterization

2 3 4

When performing the initial interview for a patient admitted to the hospital, which characteristic of the patient should the nurse document as objective data? select all that apply 1. Severe throbbing headache 2. Body temperature of 104 F (40 C) 3. A raised, red swelling on the back 4. Nausea and feeling sick in the pit of the stomach 5. Drainage from wounds on the right hand and the right foot

2 3 5

Which is the mode for exchanging information among members of the health care team? select all that apply 1. pictures 2. a thesis 3. written reports 4. oral communicaiton 5. electronic cards

3 4

Which factor is associated with the development of chronic disease? Select all that apply. One, some, or all responses may be correct - Gender - Genetic - Environment - Lifestyle factors - Socioeconomic status

Genetic Environment Lifestyle factors

Which activity could help foster a sense of industry in the school-age child? · Discourage the child from competing on a team. · Give the child an allowance for completing chores. · Allow the child to watch a favorite television show. · Tell the child he must make an A on the test tomorrow.

Give the child an allowance for completing chores. Giving the child an allowance for completing chores could help foster a sense of industry in the school-age child by rewarding the child's accomplishment.

Which information indicates the nurse is using the World Health Organizations (WHO) definition of health? - Health is a strong force that helps people emphasize self-actualization. - Health is a process of living fully within one's culture and community. - Health is a method of self-care achieved by making choices leading to a healthy life. - Health is a state of complete holistic well-being and not just being illness free.

Health is a state of complete holistic well-being and not just being illness free. According to the WHO, health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

What is paralysis of one side of the body known as? Hemiparesis Paraplegia Hemiplegia Ischemia

Hemiplegia

The registered nurse is teaching a nursing student about positioning techniques. Which statement by the nursing student indicates effective learning? - I can use a thick pillow, b/c it decreases cervical flexion - I can use pillows of any size to position the patient - I can use folded sheets when additional pillows are unavailable - I can use thin pillow to protect the skin from pressure ulcers

I can use folded sheets when extra pillows are unavailable

A patient is in labor with her first baby, which is coming 2 weeks early. Her husband is in the military and might not get back in time, and neither family is able to be with her during labor. Which support person employed by the birthing area is the health care provider most likely to call in to be present during labor? - Nurse - Midwife - Assistant - Lay doula

Lay doula A lay doula is a support person who is present during labor to assist women who have no other source of support

Which of these conditions may result in right-sided hemiplegia? Right-sided brain injury Left-sided brain injury Lower spinal cord trauma Cervical spinal cord trauma

Left-sided brain injury Left-sided brain injury results in right-sided hemiparesis or hemiplegia.

Which provides specific performance-related patient safety outcomes? NCLEX Health Care provider on the unit for the day National Patient Safety Goals (NPSGs) Hospital policies about standards of care

National Patient Safety Goals (NPSGs) NPSGs define specific safety outcomes for each goal to provide direction for each provider.

How many nurses would be required to place a patient in the semi-prone position? - One - Two - Three - Four

one

Which factor can cause errors in data collection? select all that apply - missing data - inaccurate data - disorganization - lack of knowledge or skill - premature or early closure of clustering

- missing data - inaccurate data - disorganization - lack of knowledge or skill

Match the type of exercise with an example. 1. Isotonic 2. Isometric 3. Aerobic 4. Anaerobic a. Kegel exercises b. repeated stair-climbing c. heavy weigh-lifting d. walking

1-d 2-a 3-b 4-c

Arrange the levels of cognitive learning in increasing order of complexity 1. creating 2. applyiing 3. Analyzing 4. Evaluating 5. Remembering 6. Understanding

1.Remembering 2.Understanding 3.Applying 4.Analyzing 5.Evaluating 6.Creating

Which minimum font size (in points) should be used for the print for a visually impaired patient? whole number

14

A patient asks the nurse what dietary supplements to take to reduce the chance of developing brittle bones later on in life. What is the best response by the nurse? Select all that apply. 1. Vitamin C 2. Iron 3. Calcium 4. Vitamin E 5. Vitamin D

3 5

Which time frame would be the approximate duration required by a person to resolve a crisis? whole number _______ weeks

6

Which individual is at greatest risk for a work related fatality? Bus driver College professor Construction worker Agricultural worker

Agricultural worker An agricultural worker is at greatest risk for a work related injury. The fatality rate is 29 fatalities per 100,000 workers.

Which action by the nurse would be most appropriate when preparing the preschool child for a medical procedure? · Telling the child he or she will get a sticker if he or she does not cry at all · Explaining the entire sequence of the procedure to the child · Avoiding giving the medical procedure equipment silly names · Allow the child to practice the procedure on a stuffed bear

Allow the child to practice the procedure on a stuffed bear

which element of leadership involves the freedom of choice? - authority - autonomy - responsibility - accountability

Autonomy

Which characteristic exemplifies nursing as a profession? Autonomy in decision-making Licensure in multiple states Interdisciplinary expertise Expert nurse competencies

Autonomy in decision-making Autonomy in decision making and practice is a criterion (characteristic) of a profession. Nurses are able to make independent decisions within their scope of practice.

Self-awareness is the conscious knowledge of one's own____________. Select all that apply. Character Feelings Motives Needs Desires

Character feelings Motives Desires

A nurse lists cultural biases and prejudices with which he or she was raised. Of what component of cultural competency is this most a part? - Valuing diversity - Institutionalizing cultural knowledge - Managing the dynamics of difference - Conducting a cultural self-assessment

Conducting a cultural self-assessment

Which strategy for creating work environments enables nurses to demonstrate caring behaviors? - Increasing the working hours of the staff - Decreasing salary benefits of the staff - Creating a setting that allows flexibility and autonomy for staff - Encouraging increased input concerning nursing functions form physicians - Encouraging increased input concerning nursing functions form physicians

Creating a setting that allows flexibility and autonomy for staff

Which theory states life span can be lengthened if a change is made to minimize damage? Immunological Theory Cross Linking Theory Neuroendocrine Theory Programmed Senescence Theory

Cross Linking Theory Cross linking Theory--protein fibers form bonds and decrease elasticity Wear and Tear Theory--body wears out from use and abuse

Which theory of aging states protein fibers form bonds instead of remaining separate, causing tissue to become less elastic? Cross Linking Theory Wear and Tear Theory Immunological Theory Neuroendocrine Theory

Cross Linking Theory The Cross Linking Theory states protein fibers form bonds instead of remaining separate, causing tissue to become less elastic.

After evaluating a pt's external variables, the nurse concludes that health beliefs and practices can be influenced by A. Emotional factors B. Intellectual background C. Developmental stage D. Socioeconomic factors

D

Which purpose does a theory fulfill? - Formulates legislation - Explains a phenomenon - Measures nursing function - Reflects the domain of nursing practice

Explains a phenomenon Theories are designed to explain a phenomenon such as self-care or caring. A theory is a way of seeing through a set of concepts and propositions that describe or link the concepts to the phenomenon

According to Gould's theory on adult development, on which transitional stage do 22- to 28-year-old people focus? Leaving the parents' world Getting into the adult world Reconciliation and mellowing Questioning and reexamination

Getting into the adult world

Which model is demonstrated when nurses collect information about the six cultural domains? Primary Nursing Care Model Giger and Davidhizar's Transcultural Assessment Model The Sunrise Model Galanti's C's of Culture

Giger and Davidhizar's Transcultural Assessment Model communication space social orientation time environmental control biologic variation

Which health model addresses the application of guided imagery and music therapy? · Health Belief Model · Holistic Health Model · Health Promotion Model · Hierarchy of Needs Model

Holistic Health Model Nurses participate in holistic care through the use of natural healing remedies and complementary interventions when using the Holistic Health Model. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

Which behavior of a home care nurse is consistent with the standard of professional practice related to resource utilization? Attends a seminar on medication administration Incorporates research findings in current practice Discusses the plan with the patient only Informs a patient's family about the cost of an adult day care program

Informs a patient's family about the cost an adult day care program The standard of professional performance for home care nursing related to resource utilization requires that home health nurses assist the patient and family in becoming informed consumers about the risks and benefits in planning and delivering patient care

Which Nursing Outcome Classification (NOC) should the nurse include in the plan of care for patient with the nursing diagnosis Risk for Injury? Knowledge: Ambulation Knowledge: Fall Prevention Knowledge: Activity Tolerance Knowledge: Body Mechanics Performance

Knowledge: Fall Prevention Knowledge: Fall Prevention is an appropriate NOC for the nurse to include in this patient's plan of care.

Who can update a patient's plan of care, but cannot initiate that plan of care? LPN/LVN RN UAP/CNA CNS

LPN/LVN An LPN/LVN has 12-18 months of education and work under the supervision of an RN. They can update a patient's plan of care, but it is not within the LPN/LVN scope of practice to initiate that plan of care.

A charge nurse in the intensive care unit (ICU) is trying to motivate other staff members to obtain certification. Which nursing role does this action represent? - Manager - Collaborator - Educator - leader

Leader The charge nurse is trying to lead, encouraging others to obtain certifications. Leaders motivate others toward common goals.

Novice Competent Proficient Expert

Novice—nursing student or nurse w/no previous experience/competent—nurse who has been in the same clinical position for 2-3 years/proficient—nurse w/more than 2-3 years of experience in same clinical position/expert—nurse w/diverse experience and intuitive grasp of a clinical practice

In most ethical dilemmas in health care, the solution ot the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? - nurses understand the prinicple of autonomy in guiding respect for pts' self-worth - nurses have a scope of practice that encourages their presence during ethical - nurses develop a relationship to the pt that is unique among all professional health care providers - the nurse's code of ethics recommends that the nurse be present at any ethical discussion about pt care

Nurses develop a relationship to the patient that is unique among all professional healthcare providers.

Which action falls under the role of a lay doula? - Deliver the infant - Administer pain medications to the pt in labor - Monitor vital signs when the pt is in labor - Provide emotional support and physical assistance to pt in labor

Provide emotional support and physical assistance to pt in labor A doula is a professional labor assistant who provides physical and emotional support to you and your partner during pregnancy, childbirth and the postpartum period.

A nurse is providing tertiary prevention for a patient with a stroke that resulted in left-sided weakness. Which focus is priority? Early diagnosis Prompt detection Health promotion Rehabilitation efforts

Rehabilitation efforts Nursing care focused on rehabilitation efforts occurs in the tertiary level of prevention.

Which activity shifts roles for older adults, causing feelings of loneliness and isolation? · Reminiscence of the past · Participation in social events · Retirement from a fulfilling and productive career · Inability to share wisdom gained from life experience

Retirement from a fulfilling and productive career Following retirement from a fulfilling/productive career, older adults might face spending time alone for the first time, resulting in feelings of loneliness and isolation

What nursing diagnosis would be directly related to the goal, "Patient will experience no falls during hospital stay"? Impaired Physical Mobility Imbalanced Nutrition Risk for Falls Activity Intolerance

Risk for Falls The staff monitors a patient who is at a high risk for falls closely, and a common goal for this type of patient would be to not experience a fall during the hospital stay.

What is the definition of genetic vulnerability? Study of inherited disorders Principles and mechanics of heredity Risk of disease expression based on genotype Determinant of health involuntarily passed from sibling to sibling

Risk of disease expression based on genotype

Which dimension(s) of wellness will the nurse include in a patient teaching session? Select all that apply. Goal Social Spiritual Occupational Environmental

Social Spiritual Occupational Environmental

The nurse is providing care to a patient who had a stroke several weeks ago. The patient is being discharged to home in a few days. Which collaborative member of the health care team should the nurse include to enhance safety related to swallowing? Speech therapist Hospital pharmacist Occupational therapist Unlicensed assistive personnel

Speech therapist A speech therapist is often the member of the collaborative health care team who assists patients who have experienced a stroke with safety related to swallowing.

A patient has a paralyzed right upper extremity and will be undergoing physical rehabilitation. What device would be appropriate to keep the wrist in a functional position? Trochanter roll Hand roll Splint Arm board

Splint A custom-made splint would be the most appropriate device to maintain long-term proper alignment of the hand and wrist.

According to Freud's theory of development, at which stage does a child start identifying with the parent of the same sex? - Stage 1 - Stage 2 - Stage 3 - Stage 5

Stage 3 Stage 1—oral region - Stage 2—anal region - Stage 3 - Stage 5—sexual pleasure is directed toward outside the family circle Each person goes through five different stages of psychosexual development, and each stage is characterized by pleasure with different body parts. In 3rd stage (phallic stage), the focus of sexual pleasure is in the genital organs. In this stage, the child fantasizes about the parent of the opposite sex oral sucking anal fences phallic penis or ciltoris latent little or no sexual motivation genital the penis or vigina sexual intercourse

Which requirement is mandatory to obtain the RN credential in the United States? Continuing education State licensure Registered nurse degree Registered nurse certification

State Licensure

Which action by the nurse best describes knowing according to Swanson's theory? - Sustaining faith in one's capacity to get through a situation - Striving to understand an event's meaning for another person - Being emotionally there for another person - Providing for others as they would do for themselves

Striving to understand an event's meaning for another person

Which statement describes a Cochrane Review? 1. Organized-by-medical-specialty review of research studies designed to translate findings into practice 2. Presentation of medical research findings before a review panel of expert scientists 3. Compilation of reviews of medical research used to develop practice guidelines 4. Systematic review or meta-analysis that interprets the results of medical research

Systematic review or meta-analysis that interprets the results of medical research A Cochrane Review takes a question such as, "Are antibiotics effective in treating middle ear infections?" and examines all the relevant research that meets set criteria to determine the answer, based on available evidence.

Which term describes the establishment of a support group for patients following hospitalization for heart failure? Early intervention Primary prevention Secondary prevention Tertiary prevention

Tertiary prevention Tertiary prevention involves interventions for those already experiencing symptoms of disease or disability. It focuses on maintenance or restoration of health, and rehabilitation. Tertiary interventions include patient support groups.

A student nurse is participating in fire safety drills at the hospital. Which action made by the nurse indicates a need for further teaching? The nurse closes the patient and fire doors immediately. The nurse disconnects patients on mechanical ventilation. The nurse transports ambulatory patients to a safe area via bed or stretcher. The nurse attempts to extinguish the fire after patients are removed from the area.

The nurse transports ambulatory patients to a safe area via bed or stretcher. Ambulatory patients are directed to safe areas, but only patients who are immobile are transported by bed, stretcher, or wheelchair to safe areas.

A patinet with poorly controlled hypertension and diabetes expresses that it is difficult to choose a diet low in sugar as well as low in salt and carbohydrates. The patient reports working extra hours and not having the time to cook. Which information would the nurse report first to the dietitian using SBAR (Situation-Background-Assessment-Recommendation) technique? - The pt has chronic diabetes with hypertension - The pt needs a diet revison - The pt wants a dietary consult - The pt should be persuaded to eat low-salt, low-sugar meal

The patient has chronic diabetes with HTN

Which statement is true regarding the goal of core measures? - They help recognize prejudices and assumptions about other people - They help reduce mortality, complications, and inpatient readmissions - They help provide care that fits with pt's own values/beliefs/traditions - They help assess social/cultural/biophysical factors that influence pt treatment and care

They help reduce mortality, complications, and inpatient readmissions

Which tool would the nurse use to identify the needs of a patient at home suffering from a terminal illness? Palliative Performance Scale Karnosfsky Performance Scale Functional Assessment Staging tool (FAST) Toolkit of Instruments to Measure End of Life Care (TIME)

Toolkit of Instruments to Measure End of Life Care (TIME) rigor mortis--stiffening of the joints of the body algor mortis--body T 97.6

The term diagnosis of breast cancer and roles of the family are examples of which elements in the research question, "What is the effect of the diagnosis of breast cancer on the roles of the family?" - Surveys - The sample - Variables - Data collection

Variables Variables are concepts, characteristics, or traits that vary within or among subjects

According to R.W Paul, which intellectual standard would the nurse have for critical thinking? select all that apply - clear - intuitive - plausible - general - complete

clear plausible complete

Standard Nursing Interventions

clinical practice guidelines and protocols - a systematically developed set of statement about appropriate health care for specific health care problems or clinicla situations Care bundle group of interventions related to a disease process or condition Standing orders -preparinted document containing medical orders - directs pt care in a specific clinical setting nursing interventions classificaiton interventions standards of practice - nurses use the ANA standards of professional nursing practice as evidence of the standard of care provided ot pts Quality and safety education for nurses (QSEN) - standard competencies in knowledge, skills, and attitudes for the preparation of future nurses

Match the fall risk assessment method with the appropriate description. 1. Seven-item assessment tool used in hospitals 2. Six-item assessment tool used in acute care and long-term care settings 3. Eight-item assessment tool used in acute care settings a. Johns Hopkins Fall Assessment Tool b. Morse Fall Scale c. The Hendrick II Fall Risk Model

1-a 2-b 3-c

Match the situation with the type of cognitive development 1. Early adolescent abstract thinking 2. Late adolescent abstract thinking 3. Adolescent logical reasoning a. understanding bad grades will harm chances of getting into college b. comprehending the importance of community recycling c. analyzing career paths and taking pre-emptive action

1-a 2-c 3-b

Match the Tanner stage of male sexual development with the appropriate physical description 1. Enlarge, pink scrotum with long straight public hair 2. Slightly curly, brown pubic hair with a penis slightly larger than a child's 3. Dark scrotum and enlarged glans penis 4. Pubic hair on inner thighs a. tanner stage 2 b. tanner stage 4 c. tanner stage 3 d. tanner stage 5

1-a 2-c 3-b 5-d

Which task explains a component of acute family caregiving? 1. Discussion of toileting measures postdischarge 2. Changing caregiving schedules postdischarge 3. Allowing family members to partner in care 4. Resources available postacute illness a. Flexibility b. Openness c. Communication d. Self-efficacy

1-b 2-a 3-d 4-c

Match the item with the correct description of programmed aging theory 1. Immunological theory 2. Neuroendocrine theory 3. Programmed senescence theory a. turning on/off of specific genes results in aging b. decrease in immune response causes chronic disease c. hypothalamus becomes less functional

1-b 2-c 3-a

Which statements are ones nursing students should learn about the relationship between beliefs and values? Select all that apply. 1. The patient's beliefs and values should not interfere with competent medical treatment. 2. It is important for nurses to have strong professional values to guide their practice that are consistent with society's expectations of a trusted professional. 3. It is essential for nursing students to develop and continue adhering to critical professional nursing values throughout their careers. 4. Understanding the importance and the relatedness of beliefs and values is a vital first step. 5. A patient entering a medical facility gives up the right to comment on his or her own treatment.

2 3 4

Which technique would the nurse use to actively listen to a patient? select all that apply 1. Stand away with hands folded 2. Lean forward toward the patient 3. Sit erect facing the patient with uncrossed arms 4. Make eye contact 5. Pace up and down the room 6. Close eyes and listen

2 3 4

Which problem is a collaborative problem? select all that apply 1. Cold 2. Nausea 3. Paralysis 4. Hemorrhage 5. Wound infection

3 4 5 an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status. Collaborative problems could include: hemorrhage, infection, and paralysis using medical, nursing, and allied health interventions.

A preschooler who was 37 inches/94 cm tall on his or her third birthday would be expected to measure ____ inches/cm on his or her fifth birthday. 41 inches/104 cm 43 inches/109 cm 45 inches/114 cm 47 inches/119 cm

43 inches/109 cm Height increases approximately 3 inches/7.62 cm per year during the preschool years. Therefore, the child would be expected to grow by 6 inches (3 x 2), or 15.24 cm (7.62 x 2), to a height of 43 inches, or 109 cm. preschool 5 lb per year Middle childhood weigh gain 5.5 per year, and 2 inches per year

How many interrelated components are present in Campinha-Bacote's model of cultural competency—whole number

5 Cultural awareness/cultural skills/cultural encounters/cultural knowledge/cultural desire are the five interrelated components

Evaluation

5th step nursing process - determines whether a pt's condition or well-being improved after nursing interventions were delievered - the outcomes of nursing practice are the measurable conditions of pt, family, or community status; behavior or perception standards for evaluation evaluation measures - evaluative measures are assessment skills/techniuqes - evaluating behavior - self-management - nursing outcomes classification (NOC) evaluate whether the results of care match the expected outcomes and goals set for a pt

Nurses may be in a position of providing emotional support during difficult decisions related to genetic testing. Which is an ethical dilemma associated with genetic testing? · Abortion of an abnormally developing fetus · Surgical treatment for cancer diagnosis · Having children with a known genetic disorder · Elective abortion for maternal complications

Abortion of an abnormally developing fetus

The nurse has to examine a patient and administer and intravenous medication that is not a lifesaving drug. The patient is a devout Muslim. When the nurse goes to administer the medication, the nurse finds that patient is getting ready for namaz (prayers). The nurse understands that the patient prays at certain times, as specified in his culture. What should the nurse do in this scenario? Mamaz (prayers) - Administer the drug while the patient prays - Ask the patient to pray after the medication is administered - Allow th patient to pray and come back later to administer the medication - Tell the pt that the nurse has other pts to look after and cannot come later

Allow th patient to pray and come back later to administer the medication

The nurse is caring for a patient who has been in bed for several days after surgery. The nurse has orders to get the patient out of bed to a chair. What action should the nurse take first? Stand the patient up with assistance. Stand the patient up without assistance. Allow the patient to dangle. Transfer the patient with a slide board.

Allow the patient to dangle. The first action the nurse should take to get the patient out of bed is allow the patient to dangle.

What anticipatory guidance can the nurse give parents of a toddler to support the toddler's need for increasing autonomy? · Take the food away if the toddler spills it. · Continue feeding the toddler during mealtime. · Give the toddler finger foods to decrease messes. · Allow the toddler to practice feeding with a spoon.

Allow the toddler to practice feeding with a spoon.

What is a public health nurse doing during a Windshield Survey? · Promoting compliance with safety standards · Ensuring street safety · Evaluating population demographics · Assessing the community

Assessing the community A windshield survey is a type of community assessment in which a person walks or drives through a community and observes its characteristics, such as geography, type of housing, presence of educational, religious, recreational facilities, health and other service facilities, types of transportation, and types of businesses, including pharmacies and grocery stores.

While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that A. teenagers need to practice safe sex B. a 3-year-old can safey sit in the front seat of the car C. children need to wear safety equipment when bike riding D. children need to learn to swim even if they do not have a pool

B

Which sentence best describes a healthy parent-infant attachment during the first month? Bonding is critical for normal development and survival. Bonding is critical but too much love can create a needy child. Bonding is important but meeting every emotional need will spoil the child. Bonding is necessary but the infant has built-in mechanisms to help if the child's needs are not met.

Bonding is critical for normal development and survival.

The nurse is walking down the hall and witnesses a small child dumping his juice on the floor. The parent acknowledges the incident but does nothing to stop it. What is the appropriate nursing action to promote safety? Clean up the juice immediately. Call housekeeping to mop up the juice. Call security to deal with child's parent. Ask the parent to clean up the child's mess.

Clean up the juice immediately. The nurse has a responsibility to promote safety, and therefore, should clean up the juice immediately. This action can help prevent an occurrence of injury from fall.

Which term is used to refer to the recipient of community-based care? Population Patient Target Client

Client Client is defined as one that is under the protection of another or a person who engages the professional advice or services of another (Merriam-Webster). This is the term used to refer to the recipient of community-based care because it indicates active participation and collaboration in care.

Nurses function in which role when they ensure two or more people work together to accomplish a common goal? · Change agent · Manager · Collaborator · Advocate

Collaborator When nurses function as collaborators they work with two or more people toward accomplishing a common goal. In nursing, collaboration occurs with other nurses, physical therapists, respiratory therapists or other medical professionals to meet the patient's needs.

Which activity for play therapy would be most appropriate for the nurse to suggest for the hospitalized preschool child? · Reading riddles and jokes · Playing complex a card game · Holding onto a push-pull toy · Coloring with colored pencils

Coloring with colored pencils

Which statement best characterizes the early adolescent mindset regarding body image and self-perception? Unaware of physical changes Comfortable in his or her body Concerned only with him/herself Not concerned about body changes

Concerned only with him/herself Adolescents are developmentally egocentric, believing everyone is obsessed with them.

Inactivity, decreased appetite, and decreased fluid intake can lead to what problem with elimination? Diarrhea Urinary frequency Urinary retention Constipation

Constipation Inactivity, decreased appetite, and decreased fluid intake leads to constipation.

When the nurse has a prejudice against a particular culture, which type of behavior is likely to result? - Discrimination - Culturally congruent care - Effective intercultural communication - Sufficient knowledge of diverse group

Discrimination Prejudices associate negative characteristics with people who are different from the valued group. When a person acts on these prejudices, discrimination occurs/they are not compatible with culturally congruent care/effective intercultural communication or sufficient knowledge of diverse groups

The nurse overhears another health care worker state, "I am not giving that homeless woman in bed 12 a bath because homeless people have lice." Which is the nurse exhibiting? · Generalization · Stereotype · Discrimination · Ethnicity

Discrimination—a potentially harmful practice

A nurse is assessing a 14-year-old female patient who admits to being sexually active. Which action made by the nurse promotes safe sex intervention for the teen? Discussing the need for and use of birth control. Asking the teen about her relationship with her partner. Talking about the link between sexual activity and school performance. Encouraging the teen to talk to her parents or caregivers about her sexual activity.

Discussing the need for and use of birth control. The nurse can promote safe sex by discussing the need for, and use of, birth control with sexually active teens.

To assess the patient's risk of exposure to biohazards in the home, what question should the nurse ask? Do you have air conditioning? What recreational activities do you engage in? Is there adequate outside lighting? Do you or does anyone in the home use hypodermic needles?

Do you or does anyone in the home use hypodermic needles? Asking about hypodermic needles helps the nurse identify the patient's risk for exposure to biohazards, as used needles may be contaminated with blood and infectious microorganisms.

The nurse is teaching a recently diagnosed diabetic patient to administer insulin injections. Whose theory was the nurse demonstrating? · Betty Newman · Sister Callista Roy · Dorothea Orem · Florence Nightingale

Dorothea Orem Dorothea Orem's Self-Care Deficit Theory focuses on guiding, teaching, and supporting to promote patient's abilities.

A nurse who holds a PhD can engage in which role? Select all that apply. Educator Clinician Manager Researcher Scholar

Educator Researcher Scholar

When caring for a patient, the nurse identifies factors that affect the outcomes of the treatment. To which phase of the nursing process does this nursing activity belong? - Planning - Evaluation - Assessment - Implementation

Evaluation

Magnet REcognition Program

Five model components - transfromational leadership - Structural empowerment - Exemplary professional practice - New knowledge, innovation, and improvements - Empirical quality results

Which is the major characteristic of community-based nursing that differentiates it from public health nursing? Focus on vulnerable patients Focus on the individual Focus on chronic illness Focus on tertiary prevention

Focus on the individual Both community-based and public health nursing care for vulnerable patients, which include the homeless, veterans, and members of minority groups.

"All Asians eat fish and rice" is an example of which concept that affects cultural competency? Generalization Stereotyping Racism Discrimination

Generalization A generalization is a broad statement about the behaviors, beliefs and common customs of a culture

Which characteristic defines research and differentiates it from evidence-based practice (EBP)? Concerns individuals, not groups Focuses on theories of care Guides clinical decision-making Generates evidence

Generates evidence Research involves systematic inquiry using disciplined methods to produce evidence that validates and refines existing knowledge or develops new knowledge.

Multifactorial Nature of Chronic Disease

Genetic factor: influence of genetics, family history genetic screening Environmental factors: ongoing exposure to toxic elements Lifestyle and risk factor: tobacco use, effects of alcohol, nutrition psychosocial needs of pts with chronic illness - depression, social isolatin, loneliness

Which type of testing is recommended for women who are sexually active? · Trisomy 21 testing · Breast cancer testing · Hyperlipidemia testing · Genital human papillomavirus testing

Genital human papillomavirus testing

Which statement describes an example of how the environment affects aging? · Good nutrition can slow the aging process. · Cellular maintenance and repair affect aging. · Gene mutations occurring after birth can affect aging. · People whose ancestors have lived longer lives tend to also live longer lives.

Good nutrition can slow the aging process.

At the end of a shift, the nurse deocuments a patient's conditon, anticipated condition, medications, and nursing interventions fulfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. The describes which type of report? - Discharge summary - Incident report - Hand-off report - Telephone report

Hand-off report Hand-off reports are prepared when client care is transferred from one caregiver to another in the health care setting at any time. The report prepared during a shift change is also a hand-off report. A discharge summary is the summary of the client's hospital stay, condition at discharge, diagnosis, prognosis, and treatment plan and goals. An incident report records any incident happening that is inconsistent with the routine care of a client or with the routine operation of a health care unit, such as a fall or injury from medical equipment. A telephone report is made when the nurse reports any significant changes in the client's health condition to the health care provider or other medical personnel.

To assess the patient's risk of health issues related to home safety, what question should the nurse ask? Do you have any safety concerns? Have you ever had a seizure? Are you stressed out or tired? Do you require assistance bathing?

Have you ever had a seizure? Asking if the patient has ever had a seizure helps the nurse identify a health issue that can pose a risk to the patient's safety, as patients may fall or injure themselves during seizures.

The registered nurse is teaching a nursing student about the positioning of a postsurgical patient. Which statement by the nursing student indicates a need for further learning? - I will position the pt in the Sims' position to prevent footdrop - I will position the pt int he supine position to reduce musculoskeletal injury - I will position the pt in the prone position to prevent prssure ulcers - I will position the pt in the supported Fowler's position to prevent deep vein thrombosis

I will position the patient in the prone position to prevent pressure ulcers prone is good for pt with respiratory distress

A nurse is caring for a patient with neurologic impairment. The health care provider has documented that the patient has lower extremity flaccidity. What does this mean? Bone fragility Muscle spasms Lack of muscle tone Joint inflammation

Lack of muscle tone Flaccidity is a lack of muscle tone.

In compliance with Leininger's theory, which action would the nurse take when told by some villagers that they are willing to take vaccines only in the presence of the pastor of their church, who has gone to another village and will return in a day? - Explain to the villagers that the vaccinations can be given safely even in the absence of the pastor - Give the vaccine to the people on the scheduled day - Listen to the villagers and give them the vaccines the next day in the presence of the pastor Contact the pastor and ask him come back because the people from the village need his presence during the vaccinations

Listen to the villagers and give them the vaccines the next day in the presence of the pastor

The nurse is caring for a comatose patient with two intravenous (IV) access catheters and a urinary drainage catheter. What would be the patient's fall risk category using the Johns Hopkins Fall Assessment Tool? Low Moderate High Tool not appropriate

Low A patient who is comatose would be considered completely immobilized and would be considered a low fall risk based on the Category 1 criteria of the Johns Hopkins Fall Assessment Tool.

The Institute of Medicine published To Err is Human more than a decade ago and we still use this document to guide our safety practices within the hospital setting. What performance standards has The Joint Commission developed from this? NCLEX Assessments National Patient Safety Goals Employer's Annual Performance Review Advanced Cardiac Life Support (ACLS)

National Patient Safety Goals NPSGs provide safety standards and defined outcomes to guide professional toward a safer environment for patients.

The registered nurse prepares a mutually agreeable, culturally oriented patient-centered plan. Which step of the LEARN communication technique is the nurse using? - Perception - Negotiation - Recommend - Acknowledge

Negotiation Negotiation is the fifth step of the communication technique, which involves preparing a culturally oriented and patient-centered plan by mutual agreement with the pt. perception involves explaining the nurse's perception of the problem to the pt. Recommend is involving the pt and his or her family is making decisions. Acknowledge is the recognition of the similarities and difference btw the pt's perception and nurse's perceptions

According to Holland-Hall and Burnstein, which developmental change in the brain allows for the adolescent's ability to think critically and solve problems? · Demyelization · Increased brain size · Neuron maturation · Decreased cortex growth

Neuron maturation

When an ethical dilemma occurs on the unit, can nurse resolve the dilemma by taking a vote? - Yes; ethics is essentially a democratic process, with all participants sharing an equal voice - No; an ethical dilemma involves the resolution of conflicting values and principles rather than simply the identification of what people want to do - Yes; ethical dilemmas otherwise take up time and energy that is better spent at the bedside performing direct pt care - No; most ethical dilemma are resolved by deferring to the medical director of the ethics department

No; an ethical dilemma involves the resolution of conflicting values and principals rather than simply the identification of what people want to do.

A nurse provides compassionate care for a patient who is undergoing painful medical interventions. These interventions are designed to cure a disease but cause a great deal of pain in the process. Which ethical concept is challenged most? Confidentiality Fidelity Nonmaleficence Justice

Nonmaleficence Nonmaleficence requires nurses to provide compassionate care for all patients, especially those who are undergoing painful medical interventions developed to cure debilitating diseases.

n immobile patient had been admitted to the unit following a fall out of bed. The patient is coughing up thick secretions. What action should the nurse take next? Encourage the patient to take deep breaths. Assess the patient for signs of a deep vein thrombosis. Notify the health care provider that the patient may have pneumonia. Place the patient flat in bed.

Notify the health care provider that the patient may have pneumonia . The nurse should notify the health provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.

Which finding is a nursing-sensitive outcome that can be measured? - Incidence of asthma among children of parents who smoke - Frequency of episodes of low blood sugar in children at a local school - Number of patients who fall and experience subsequent injury on the evening shift—only one related nurse-pts - Percentage of sexual active adolescent girls who attend the nurses' teaching sessions for birth

Number of patients who fall and experience subsequent injury on the evening shift—only one related nurse-pts

Consultation occurs most often during which phase of hte nursing process? - Assessment - Diagnosis - Planning - Evaluation

Planning implementation begins after you develop a pt's plan of care - direct care interventions Treatments nurses provide through interactions with pts or a group of pts - indirect care interventions 1. tx performed away from a pt but on behalf of the pt or group of pts 2. documentation/intreprofessional collaboraton

Tissue ischemia related to immobility can lead to the development of what problem? Contractures Muscle atrophy Atelectasis Pressure ulcers

Pressure ulcers Tissue ischemia related to immobility can lead to the development of pressure ulcers.

While positioning a patient with hemiplegia in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. Whcih rationale explains this nursing action? - Promote circulation - Support lumbar vertebrae - Prevent shoulder dislocation - Prevent flexion contractures

Prevent flexion contractures

Which level of prevention describes a nurse administering a vaccine to an infant? - primary - secondary - tertiary - rehabilitation

Primary primary prevention aims at health promotion

Which position may lead to plantar flexion of the feet? - Prone position - Supine position - Side-lying position - Supported Fowler's position

Prone position Placing the patient in the prone position may lead to plantar flexion of the feet. The supine position may increase cervical flexion if a thick pillow is placed below the head. The side-lying position may lead to excessive lateral flexion of the spine. The supported Fowler's position may lead to increased cervical flexion.

After assessing a patient with immobility, the nurse observes that the patient has acute respiratory distress syndrome. Which positioning of the patient would be appropriate to improve oxygenation? - Prone position - Supine position - 30-degree lateral position - Semi-Fowler's position

Prone position Positioning the patient in the prone position would be beneficial in certain patients with pulmonary conditions such as acute respiratory distress syndrome, because it helps improve oxygenation. The supine position would be beneficial for a postoperative patient to prevent footdrop. Patients with pressure ulcers would benefit from being placed in a 30-degree lateral position. Patients with a head injury would benefit from the semi-Fowler's position.

Which intervention should be included in a poisoning prevention plan? Properly dispose of expired medications. Pour chemicals into smaller containers for storage. Use non-childproof caps to allow access for geriatric patients. Take unused medication before newly prescribed medication.

Properly dispose of expired medications. All expired medications should be properly disposed in accordance with city, state, and federal regulations. If poison gets on the skin, remove clothing that was in contact with the poison, and rinse the patient's skin with water for at least 15 minutes.

Which action would the nurse take for a patient newly diagnosed with a serious, life-changing illness whose conversations are abrupt, superficial, and unrelated to the illness? - strongly suggest the pt talk about feelings - focus on the family to obtain info needed - avoid discussing illness-related topics with quiet pts - remain alert for signals that the pt wants to talk

Remain alert for signals that the patient wants to talk

A nurse is screening individuals for latent (hidden) diseases. Which type of prevention does this illustrate? Primary Secondary Tertiary Quaternary

Secondary Teaching about safe sex practice—primary/screening for HIV—secondary/administering medication to stop a disease process--tertiary

Why is it essential for a nurse to be self-aware of his or her own beliefs and values? Self-awareness makes nurses more clinically competent. Patient anxieties are lessened when a nurse is self-aware. A self-aware nurse is better able to recognize vulnerabilities within the patient. Self-awareness helps a nurse respect a patient's privacy, dignity, and religious or cultural beliefs.

Self-awareness helps a nurse respect a patient's privacy, dignity, and religious or cultural beliefs.

Which statement can the nurse use to educate the parent on leaving a child who shows emotional distress when having to leave the parent? Separations should be accomplished swiftly without dwelling on the separation. The mother should reciprocate and show the child that she too is emotionally a bit upset. Separations should not be done too fast as this can create emotional turmoil in the child. Separations should be accomplished swiftly, and with repeated emphasis on reassuring the child that the mother will return shortly.

Separations should be accomplished swiftly without dwelling on the separation.

A patient is considering a new health care provider. What is the difference between a FNP and a CNS? Have a master of science degree. Hold a license as a registered nurse. Acquire research-based knowledge. Serve as primary care providers.

Serve as primary care providers. Family Nurse Practitioner/clinical nurse specialist NPs may serve as a patient's primary care provider. This differs from the CSN who works manages a wide range of physical and mental health problems. This characteristic differentiates these professionals.

Which activity shows the school-age child has normal gross motor skill development? Tying shoelaces Drawing a picture Walking backwards Skipping on sidewalk

Skipping on sidewalk Skipping is an activity that shows normal gross motor skill development of the school-age child.

The nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the insurance of the nurse's employing institution does not cover the nurse. Which would probably cover the nurse in this situation? - the nurse's automobile insurance - the nurse's homeowners insurance - The Good Samaritan laws, which grant immunity from suit if there is no gross negligence - the Patient Care Partnership, which may grant immunity from suit if the injured party consents

The Good Samaritan law, which grants immunity from suit if there is no gross negligence The Good Samaritan law holds the health care provider immune from liability as long as he or she functions within the scope of his or her expertise.

Which topic is best suited for quantitative research? - The perception of a patient with chronic back pain on quality of life - The parent's perception of nursing care on a pediatric unit - The caregiver's perception of stress while caring for patients with dementia - The different types of dressing to measure the extent of surgical wound healing

The different types of dressing to measure the extent of surgical wound healing

A patient in the telemetry unit is preparing for discharge after suffering an acute myocardial infarction. What does the nurse tell the patient about his expected level of activity after discharge? The patient should expect to resume all previous activity. The patient should begin an aggressive physical fitness plan. The patient should be on complete bed rest for two weeks. The patient should expect that previous levels of activity will take time to rebuild.

The patient should expect that previous levels of activity will take time to rebuild. After an acute myocardial event, the patient cannot expect to resume all previous levels of activity because movement and exercise may be compromised.

What is the main goal of focused questioning of the patient? To develop a rapport with the patient To detect alterations due to immobility To obtain information for the practitioner To determine the patient's normal activity level

To detect alterations due to immobility The goal of focused questioning is to detect alterations due to immobility. Answers to these questions provide data about body systems that are affected by a person's activity and agility.

Why is it important for the nurse to have nursing diagnoses when assessing patients for movement and immobility issues? To plan, collaborate, and evaluate patient-centered care plans To evaluate if their daily medications are effective To educate families about the patients' care plans To plan for patients' discharges

To plan, collaborate, and evaluate patient-centered care plans Nursing diagnoses related to movement and immobility help the nurse identify and determine measureable patient-centered goals, track the patient's progress, and adjust plans if needed.

Which statement relates more to Latin culture rather than Asian culture? Traditional diagnoses and treatments are categorized as "hot" or "cold." There is an emphasis on accommodation rather than confrontation. There is a strong respect for the hierarchical family structure. A strong sense of personal honor and perceived loss can be devastating.

Traditional diagnoses and treatments are categorized as "hot" or "cold." In traditional Latin culture, diagnoses and treatments as considered to be hot or cold

What facet of nursing is being considered when nurses focus on human caring-associated differences and similarities among the beliefs, values, and patterned ways of cultures? Cultural sensitivity Cultural awareness Cultural competence Transcultural care

Transcultural care Transcultural nursing is when the nurse focuses on human caring associated differences and similarities among the beliefs, values, and patterned ways of cultures to provide culturally congruent (similar), meaningful and beneficial health care

Which information is priority when determining which preventive genetic screenings the nurse will perform? Whether the patient is male or female Whether the patient is right or left-handed Whether the patient is married or divorced Whether the patient is internally or externally motivated

Whether the patient is male or female

A mother questions the nurse about motor skills she should expect to see in her 9-year-old child. Which response by the nurse is appropriate? There are no new motor skills you should expect. It is normal for your child to need help zipping a jacket. Your child has fine motor control similar to an adult. School-age children have trouble with hand-eye coordination.

Your child has fine motor control similar to an adult.

Which community assessment questions would the public health nurse answer through online research? Select all that apply. a. What is the incidence of teen pregnancy in the community? b. How many cases of tuberculosis occurred in the state in the last five years? c. What is the number of traffic accident-related deaths in the state last year? d. What is the average income level of the local population? e. How often are the community playgrounds being used?

a/b/c/d

Which descriptive phrases apply to public health nursing practice? Select all that apply. a. Focuses on threats to health as well as disease b. Develops plans of care for groups of people c. Examines the community as a whole d. Employs collaborative and interdisciplinary strategies e. Advocates for individual patients from special interest groups

a/b/c/d

Which examples are public health nursing interventions? Select all that apply. a. Developing a water safety guide for distribution at local water recreational areas b. Organizing a "Dispose of Unused Medications Safely Day" c. Distributing informational materials on proper preparation and storage of foods at a local health fair d. Arranging for home delivery of a patient's medications e. Speaking at the senior citizens' center about the benefits of the pneumonia vaccine

a/b/c/e

if a nurse decides to withhold a medication b/c it might further lower the pt's BP, the nurse will be practicing the principle of - responsibility - accountability - competency - moral behavior

accountability Accountability is the obligation to explain, justify, and take responsibility for one's actions accountabilit refers to the ability to answer for one's actions--key "ACTION" responsibility refers to one's willingness to respect and adhere to one's professional obligationw

A nurse who is speaking to nursing students explains the importance of respecting patients' own personal values. She tells the students that personal values include the life principles that are most important to people and shape the way they think. Besides shaping people's thoughts, what else do values shape? · Family relations · Actions · Genetic predisposition · Intelligence

actions Personal values include the life principles that are most important to people and shape their thoughts, feelings, and, ultimately, actions.

Which pt scenario of a surgical pt in pain is MOST indicative of critical thinking? - asking the pt what pain-relief methods, pharmacological and nonpharmacological, have worked in the past - administering pain-relief medicaiton according to what was given last shift - offering pain-relief medication based on the health care provider's orders - explaining to the pt that self-reporting of severe pain is not consistent with the minor procedure that was performed

asking the pt what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to: - assign only bed-making and feeding skills - assess the knowledge of the certified nursing assistant - remind the staff member that she is working under the license of the RN - allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform

assess the knowledge of the certified nursing assistant Basic terms in health ethics - morals/value/bioethics/autonomy/beneficence/nonmaleficence/justic/fidelity professional nusring code of ethics -code of nursing ethics principles--includes advocacy, responsibility, accountability, and confidentiality

Lee refers to the Code of Ethics for Nursing for more guidance. Which of the following statements are true about the American Nurses Association (ANA) Code of Ethics? (Select all that apply.) A. All health care disciplines have the same code of ethics. B. The ANA Code of Ethics promotes principles of responsibility, accountability, and advocacy. C. The ANA Code of Ethics requires all nurses to have the same values. D. The ANA Code of Ethics states that the nurse is the center of the health care team.

b a code of ethics is written guidelines issued by an organizaiton, such as the ANA

There are seven key steps in the resolution of an ethical dilemma. Which step involves distinguishing among facts, opinions, and values? - clarifying values - negotiating a plan - verbalizing the problem - evaluating the plan over time

clarifying values Clarifying values involves distinguishing among facts, opinions, and values. The process of clarifying values is an important part of resolving ethical dilemmas. Negotiating a plan requires confidence in one's own point of view and also deep respect for the opinions of others. Verbalizing the problem helps to ensure effectiveness in the final plan and facilitates discussion. Evaluation of the plan over a period of time is helpful for positive outcomes.

Which statement is true of ethnicity? · "Art, rituals, and patterns of life make up a person's ethnicity." · "Ethnicity and race are not associated with quality of patient care or patient outcomes." · "Transcultural nursing as a specialty seeks to address the role disparities among health care workers." · "Ethnicity is based on cultural similarities and differences within a society or nation."

"Ethnicity is based on cultural similarities and differences within a society or nation."

Which statement would block communication? - You look kind of tired today - Why do you always put so much salt on your food - It sounds like this has been a hard time for you - If you use your oxygen when you walk, you may be able to walk farther

"Why do you always put so much salt on your food?"

Six standards of practice

- Assessment - Diagnosis - Outcomes identification - Planning - Implementation - Evaluation DO PA IM England

which type of interpretation error may occur with a nursing diagnosis? select all that apply - inaccurate interpretation of cues - use of an insufficient number of cue - failure to consider conflicting cues -failure to validate the nursing diagnosis with the pt - insufficient cluster of cues

- inaccurate interpretation of cues - use of an insufficient number of cues - failure to consider conflicting cues

What is a common trouble area for a patient in the supine position? select all that apply 1. extended elbows 2. Unsupported feet 3. Externally rotated hips 4. Decreased circulaton to the feet 5. Increased shearing force on teh back of the knees

1 2 3

Which effect does reality orientation have on the older adult? Select all that apply 1. Minimizing confusion 2. Promoting socialization 3. Restoring a sense of reality 4. Improving the level of awareness 5. Providing assistance for functioning

1 2 3 4

which stage encompasses general adaptation syndrome (GAS)? select all that apply 1. alarm reaction 2. Resistance 3. Appraisal 4. Crisis 5. Exhaustion

1 2 5

Which attitude is essential for critical thinking? select all that apply 1. confidence 2. Risk avoidance 3. Fairness 4. Discipline 5. Curiosity

1 3 4 5

Which cellular factors are significant to the aging process? Select all that apply. 1. Increased cell damage 2. Improved capacity to divide 3. Altered protein homeostasis 4. Decrease in number of cells 5. Diminished capacity to repair damaged DNA

1 3 4 5

Which are examples of unintentional injuries? Select all that apply. 1. Falls 2. Suicide 3. Drowning 4. Homicide 5. Fire-associated injuries

1 3 5

Which age-related finding related to reproductive health can be seen in an older adult female patient? Select all that apply 1. Dry vagina 2. Firm breasts 3. Large breasts 4. Presence of pubic hair 5. Reduced size of the vagina

1 5

In which settings is community-based nursing care practiced? Select all that apply. 1. Correctional facilities 2. Hospital outpatient clinics 3. Long-term care facilities 4. Emergency departments 5. Private schools 6. Workplaces

1 5 6

Match the component to the function. 1. Tendons 2. Ligaments 3. Cartilage 4. Joints a. assist movement b. cushion joints c. connect bone to cartilage d. connect bone to muscle.

1-d 2-c 3-b 4-a

Order approaches of an ecological model to reduce barriers to health care Identify family support system understand national healht policies understand interpersonal relationship with family members locate community healht resources

1. Understand interpersonal relationship with family members 2. Identify family support systems 3. Locate community health resources 4. Understand national health policies

Processing an Ethical Dilemma

1. ask if this is an ethical problem 2. Gather all relevant information 3. Identify the ethical elements in the problem and examine your values 4. Name the problem 5. Consider possible courses of action 6. Create an action plan and carry it out 7 Evaluate the action plan 8. Ethics committees

Processing an Ethical Dilemma

1. ask if this is an ethical problem 2. gather all relevant info 3. identify the ethical elements in the problem and examine your values 4. name the problem 5. consider possible courses of action 6. create an action plan and carry it out 7. evaluate the action plan

What is the average weight of health 3-year-old? - 12.3 kg - 14.5 kg - 16.8 kg - 18.6 kg

14.5 kg the average wt. of a child at 3 years of age is 14.5 kg. a healthy child gains approximately 2.3 kg per year. Therefore, a child weighing 12.3 kg is underweight. The child should be around 16.8 kg at 4 years of age. The child should weight around 18.6 about 5 years of age.

Which findings are associated with higher education levels? Select all that apply. 1.Higher stress levels 2. Lower self-confidence 3. Longer life expectancy 4. Lower childhood obesity levels 5. Higher rates of chronic diseases 6. More percentage of nonsmokers

3 4 6

A preschooler who weighed 33 lbs (15 kg) on his or her fourth birthday would be expected to weigh ____ lbs/kg on his or her fifth birthday. 34 pounds/15.42 kg 38 pounds/17.23 kg 40 pounds/18.14 kg 42 pounds/19.05 kg

38 pounds/17.23 kg Preschool children gain approximately 5 pounds/2.23 kg per year. Therefore, the child would be expected to gain 5 pounds/2.27, for a total weight of 38 pounds or 17.26 kg. 3 inches per year Middle childhood weigh gain 5.5 per year, and 2 inches per year

A weight gain of 1.49 lb (0.68 kg) per month is expected from birth until which month? 6 months 8 months 10 months 12 months

6 months

Approximately how many centimeters does a toddler grow each year? - 1.7 - 3.5 - 6.2 - 7.5

7.5 toddler—rapid physical growth---~7.5 cm in height each year—wt. gains 4-6 lb each year

You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with A. atelectasis B hypertension C. othrostatic hypotension D. coagulation of blood

A

Which action reflects the anticipated cognitive changes associated with older adulthood? · A 65-year-old person is able to remember a grandchild's new phone number. · A 70-year-old person who has a driver's license forgets how to drive the family vehicle. · A 75-year-old person enrolls in a class to earn a digital photography certificate. · An 80-year-old person struggles to remember how to read when trying to read a newsletter.

A 75-year-old person enrolls in a class to earn a digital photography certificate.

What is a benefit for new nurses who join professional organizations as part of the socialization process? · Reduced conference fees · Being around like-minded nurses · Access to current resources · Practice research mentorship

Access to current resources Professional organizations contribute to the new nurse's role socialization because they allow the nurse to access current theoretical and skill resources necessary for the role of the nurse.

Michael grew up in a family where all the women were homemakers and nursed their sick children back to health using natural remedies, while all the men went to work all day long. Which of the following was most likely one of Michael's first-order beliefs? Men should not have children. Women should be allowed to work. Children are homeschooled by their mothers. All medicines are made of natural ingredients.

All medicines are made of natural ingredients.

Which term describes the most common form of dementia, affecting 38% of people over age 85? Delirium Depression Vascular dementia Alzheimer's disease

Alzheimer's disease

The nurse is teaching a student nurse the relationship between body system integrity and safety. Which statement by the student nurse shows further teaching is needed? "A neurologic impairment can cause alterations in vision." "A comprised cardiopulmonary system can cause activity intolerance." "An altered renal/hepatic system can cause short-term memory loss." "An alteration in the musculoskeletal system can cause an unsteady gait."

An altered renal/hepatic system can cause short-term memory loss." This statement shows a need for further education. An altered renal/hepatic system can cause toxicity. An altered neurologic system caused short-term memory loss.

Which stage of cognitive learning involves the breakdown of information into organized parts? - Applying - Analyzing - Evaluating - Understanding

Analyzing

Which action would the nurse take for a dying patient with chronic dull pain who does not have a support person to provide home care? - hospitalize the pt in the intensive care unit - arrange for inpatient hospice care - provide acute care to the pt - seclude the pt in a separate room

Arrange for inpatient hospice care

A pt comes into th eER complaining of ches pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the pt is depressed b/c of the loss a job. This type of crisis can be classified as A. maturational B. situational C. sociocultural D. postraumatic

B

You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that accroding to the general adaptation syndrome, the athlete will be exhibiting A. an increased appetite B. an increase heart rate C. a decrease in perspiration D. a decrease in respiratory rate

B

A 40-year-old patient is admitted with severe pain in the lower abdomen. A newly hired nurse is assigned to care for this patient. Which level of critical thinking according to Ktaoka-Yahiro and Saylor's model would the nurse use? - Basic - complex - Advanced - Intermediate - Commitment

Basic Complex Commitment

Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor modification? A. Per-contemplation B. Contemplation C. Preparation D. Action E. Maintenance

C

Within which roles do nurses serve? Select all that apply. Care provider Educator Therapist Researcher Analyst

Care provider Educator Researcher

Jean Waston

Clinical caring processes include sensitivity/mindfulness

The critical milestone in language development

Cooing with a reciprocal smile—1-3 months Babbling is common—3-4 months Repeating sounds to self—4-6 months Increase interest in sounds—6-8 months

A nurse is teaching parents about child safety in their home. Which action should the nurse take to demonstrate proper safety interventions? Turn all car seats rear-facing in the car. Cover electrical outlets inside the house. Keep firearms and bullets locked up together in a secure spot. Store household chemicals in containers that are clearly labeled.

Cover electrical outlets inside the house. To prevent electrical shock, cover all outlets with covers.

Paul Elder

Critical-Thinking Theory

Your pt has met the goals set for improvement of ambulatory status. You would now: - modify the care plan - discountinue the care plan - create a new nursing diagnosis that states goals have been met - reassess the pt's response to care and evaluate the implementation step of the nursing process

D/C the care plan

Which assessment would the nurse make a priority before moving a patient? - Determine the pt's comfort level - Determine whether the pt understands what is expected - Determine whether the pt's illness contradicts exertion - Determine whether the pt is too heavey/immobile to move alone

Determine whether the patient's illness contradicts exertion

Which nursing theory is the nurse exhibiting when teaching the diabetic patient, the correct procedure for blood glucose monitoring? Imogene King Dorothea Orem Jean Watson Florence Nightingale

Dorothea Orem self-care deficit theory

Dorothea Dix Florence Nightingale

During the American Civil War were Dorothea Dix, who headed the U.S. Sanitary Commission (a forerunner of the Army Nurse Corps) 1854—Florence Nightingale cared for the injured in the Crimean War/2002 U.K. Nursing and Midwifery council was initiated/1949-U.S. Air Force Nurse Corps was formed/1901-Army Nurse Corps was founded

Which attribute describes a genetic factor affecting aging? · Exercise · Good nutrition · Infectious disease · Epigenetic changes

Epigenetic changes Epigenetic factors alter gene activity and switch genes on and off

What should a patient be instructed to do first if the carbon monoxide detector alarm sounds? Call 911. Evacuate the premises. Notify the gas company. Check the carbon monoxide detector.

Evacuate the premises. When the carbon monoxide detector sounds the patient should be instructed to evacuate the premises immediately and then call 911.

Which term correlates with the ability of a family to cope with expected and unexpected stressors? - Family diversity - Family durability - Family resiliency - Family dynamics

Family resiliency Family diversity—relates to the unique makeup of a family unit - Family durability—system of support w/in the family structure - Family dynamics—interactions btw members of the family and is affected by multiple factors

Which theorist stated that the imbalance between the patient and environment decreased the patient's capacity for health? Hildegard Peplau Sister Callista Roy Betty Newman Florence Nightingale

Florence Nightingale

Which nursing model can be used when collecting patient data related to the six cultural domains? - Galanti's 4 Cs of culture - Leininger's transcultural theory and assessment model - Giger and Davidhizar's transcultural assessment model - Dorthea Orem's cultural deficit assessment model

Giger and Davidhizar's transcultural assessment model The Giger and Davidhizar's transcultural assessment model calls for collecting data related to six cultural domains (communication, space, social orientation, time, environmental control, and biological variation)

Which intervention is included in strategies to prevent teenage vehicle crashes? Encouraging the teen to drive anytime. Restricting the car to three passengers. Requesting a restricted license for the teen. Having the teen participate in a safe driving course.

Having the teen participate in a safe driving course. Strategies to prevent teenage vehicle crashes include having the teen participate in a safe driving course.

The nurse is assessing an African American patient who states that her illness was caused by conflict with her brother. By discussing this belief with the patient, the nurse is assessing which domain? Spirituality Gender roles Mental health Health beliefs

Health beliefs Broadly, beliefs and practices related to disease causation treatment of illness, and folk practices are in the realm of health beliefs

Which key issue in education is a leading health indicator of Healthy People 2020? Master's graduation Doctorate graduation Bachelor's graduation High school graduation

High School Graduation

The nurse would assign which nursing diagnosis to a patient with an unsteady gait? Impaired Bed Mobility Impaired Ambulation Impaired Wheelchair Mobility Sedentary Lifestyle

Impaired Ambulation Patients with Impaired Ambulation would have an unsteady gait.

The nurse is just coming on shift and is getting the report on a bed-ridden patient. Upon entering the room, the nurse sees the patient in bed and family visiting. What type of movement and immobility nursing diagnosis could the nurse identify for this patient? Pain Constipation Impaired Bed Mobility Social Isolation

Impaired Bed Mobility Impaired Bed Mobility can be identified because the patient is unable to get out of the bed.

Which is a patient-related fall risk hazard? Wound drain Floor surfaces Intravenous access Incontinence

Incontinence Incontinence is a patient-related fall risk hazard.

A nurse is encouraging an immobile patient to turn in bed as a form of isotonic exercise. The patient asks how isotonic exercises work. What is the nurse's best response? Isotonic exercises build power and body mass. Isotonic exercises involve active movement with constant muscle contraction. Isotonic exercises require tension and relaxation of muscles without joint movement. Isotonic exercises require oxygen metabolism to produce energy.

Isotonic exercises involve active movement with constant muscle contraction. Isotonic exercises involve moving joints and muscles rhythmically and repetitively through their ranges of motion using low resistance. e.g., walking, hiking, swimming, skiing

The nurse is caring for a patient in the emergency department. The health care provider has ordered antibiotics for a positive fluid specimen of the synovial joint. Which joint is infected? Rib Skull Knee Vertebrae

Knee The knee is considered a synovial or movable joint.

Which national organization categorizes injuries as intentional or unintentional? The Joint Commission (TJC) Center for Disease Control (CDC) American Nursing Association (ANA) National Center for Health Statistics (NCHS)

National Center for Health Statistics (NCHS) The National Center for Health Statistics categorizes as intentional or unintentional, because they track statistics of health.

Which type of problem is a high priority? - One related to non-urgent needs of the patients - One related to life-threatening needs of the patients - One focused on the patient's long-term health care needs - One focused only on the physiological diagnosis-

One related to life-threatening needs of the patients

Which action will the patient take to implement an active strategy for health promotion? Using safe-sex practices Drinking milk fortified with vitamin D Participating in a stress-reduction class Wearing a helmet when riding a motorcycle

Participating in a stress-reduction class

When instructing a patient on incentive spirometry, what is the last step of the procedure? Perform 2 controlled coughs. Exhale through pursed lips. Exhale through the mouthpiece. Take 2 deep breaths.

Perform 2 controlled coughs. After using the incentive spirometer the patient should be instructed to perform 2 controlled coughs.

The emergency department nurse is caring for a patient who recently had a stroke, has been stumbling often and has a large cut on his head. Who would be appropriate to consult with in order to get assistance for this patient? Pharmacist Acute stroke team Social worker Physical therapy team

Physical therapy team Recognizing that the patient is having mobility issues, a physical therapist's evaluation could be very important so that the patient could get a walker or cane to help stabilize gait and prevent falls.

A mother of a 3-month-old infant is requesting information on the motor milestones she can expect to see in her child. The nurse can tell the pt to expect to see which activities at 3 months? select all that apply - Puts foot in mouth—5 months - Places hand in mouth - Turns from back to abdomen - Turns from abdomen to back - Can life head off bed in prone position

Places hand in mouth Can life head off bed in prone position

While logrolling a patient, the nurse crosses the patient's arms on the chest. Which rationale explains the nurse's action? - Prevent injury to arms - Maintain alignment of the body - Prevent tension on spinal column - Prepare patient for turning onto one side

Prevent injury to arms

During the role of socialization process, which ability does the student acquire to transform into a nurse? - Prioritize concerns - Speed and flexibility - Analytical decision making - Use of previous experience

Prioritize concerns During the role socialization process, transformation to being a nurse requires students to become response-based nurses with the ability to recognize complex situations and prioritize concerns.

What is wellness? -State of being -Living life based on goals and objectives -Interconnection of two major dimensions -Process of self-care achieved by making choices leading to a healthy life

Process of self-care achieved by making choices leading to a healthy life

What does the nurse teach the student nurse about quality health care to prevent health disparities? - Quality health care should be variable - Quality health care should be effective - Quality health care should be slow and thorough - Quality health care should be health care organization-centered

Quality health care should be effective

Many hospitals use the acronym RACE to describe emergency fire response. What does RACE stand for? Rescue, Advise, Comfort, Expedite Rescue, Alarm, Contain, Extinguish Restrain, Action, Continue, Emergency Resuscitate, Action, Control, Emergency

Rescue, Alarm, Contain, Extinguish Rescue, Alarm, Contain, Extinguish is what RACE stands for.

The Cochrane Library is a collection of what type of materials? Current and historical health care texts and periodicals Patient education materials for use in health care Simulation software for health care education Research databases for health care

Research databases for health care

Which is the most important reason for encouraging the patient to participate in his usual health care-related rituals? Participating in rituals often enhances physical comfort Western medicine blends well with most ritualistic beliefs Allowing rituals increases patient trust and cooperation Rituals can provide the support needed during times of illness

Rituals can provide the support needed during times of illness ritual-customs

What is most essential for the public health nurse when planning interventions for a community with multiple nursing diagnoses? · Review community demographics · Consult with colleagues · Reassess the problems · Set priorities

Set priorities When a community has multiple nursing diagnoses, the public health nurse must establish priorities because all problems cannot be treated simultaneously. Financial, time, staff and other restraints prevent this.

Using the Health Belief Model, which perceptions will the nurse assess to determine a patient's motivation to change? Select all that apply. Signals Severity Barriers Adjustments Susceptibility

Severity Barriers Susceptibility

Which step would a group of nurse take next after implementing an evidence-based practice (EBP) change and evaluating the effectiveness of the change? - Search the literature - Share the findings with others - Conduct a statistical analysis - Create a well-define PICOT question

Share the findings with others

The communication tool SBAR is an acronym for which words? - Symptoms-Background-Alignment-Referral - Site-Benefits-Agreement-Resolutino - Situation-Background-Assessment-Recommendation - Stiutation-BAckground-Assignment-Reconciliation

Situation-Background-Assessment-Recommendation

When assessing the patient, the nurse asks, "What is your role in the family unit?" Which cultural domain is the nurse assessing? Communication Space Social orientation Environmental control

Social orientation

A patient reports severe abdominal pain in the right iliac region. The nurse is completing the nursing history. Which information would the nurse elicit to help arrive at the probable cause of abdominal pain? - A detailed history of the cardiovascular system - A detailed history of the respiratory system - Some questions about the digestive system - Some questions about the integumentary system

Some questions about the digestive system When gathering the history, the nurse should focus on the current complaints and the body system currently involved. In this case, the nurse should focus on the digestive system, because it is most related to the abdominal and iliac regions. Although it is also important for the nurse to elicit information about other systems, such as the respiratory and cardiovascular systems, the nurse does not need to take a detailed history. If unexpected symptoms or signs are noticed, the nurse can take a detailed history.

Which action will the nurse take to help a patient implement a risk reduction plan? · Offer a high fat nutritious diet · Collaborate solely with physical therapy · Suggest using Healthy People 2020 resources · Encourage assistive personnel to teach healthy strategies

Suggest using Healthy People 2020 resources Healthy People 2020 provides educational materials for individuals, families, and communities, enabling them to lead healthier lifestyles and to make permanent changes in wellness habits.

The nurse finds that a patient has not understood the health education provided on personal hygiene. How does the nurse ensure that the patient understands the teachings? - The nurse provides reading material on personal hygiene - The nurse clarifies the information and requests a tech-back - The nurse provides a video demonstration of personal hygiene - The nurse requests that a family member help the pt understand

The nurse clarifies the information and requests a tech-back

Which statements apply to nursing diagnoses used in home care? · They are similar to those used in acute care. · They are focused on a vulnerable population. · They are actual as opposed to risk diagnoses. They pertain to the family, not the individual.

They are similar to those used in acute care Home care nurses are caring for individual patients with the same types of problems as patients in acute care settings; therefore, the nursing diagnoses are similar.

Which word does the letter "T" represent in the SMART acronym as it related to setting goals for the patient? - Timed - Treatment - Therapeutic - Thermoregulation

Timed SMART acronym, Specific, Measurable, Achievable, Realistic, and Timely.

What is the goal of secondary prevention? To protect from accidents To restore functional abilities To manage a diagnosed disease To provide early detection of health problems

To provide early detection of health problems

The nurse recognizes that the patient seems disinterested when discussing needed dietary changes. Based on Lewin's Change Theory, which stage does the patient's disinterest represent? Moving Unfreezing Refreezing Contemplating

Unfreezing 3 stages: unfreeeze, change (transition) and freeze (refreeze)

The nurse is carrying out an assessment of a patient with pain in the abdomen. Which question by the nurse is open-ended? - Is the pain here? - Is the pain very severe or mild? - What do you think of your problem? - How many days have you had this pain?

What do you think of your problem?

Committee work advocating for which groups would be an appropriate public health nursing intervention? Select all that apply. a. Homeless b. Domestic violence victims c. Cardiac care unit patients d. Hearing impaired adults e. Sexually abused children f. Migrant workers

a/b/d/e/f

Middle-range theories have which characteristics? Select all that apply. a. Define a broad perspective for nursing practice b. Focus on a specific condition or population c. Cannot be tested directly through application to practice d. Narrow focus with a limited number of variables e. Can be tested through direct application

b d e Robert K. Merton, is an approach to sociological theorizing aimed at integrating theory and empirical research-it provides a middle reality view/more specifically generalized practice areas for the nurses

Nurse-Initiated interventions are - determined by state Nurse Practice Acts - supervised by the entire health care team - made in concert with the plan of care initiated by the physician - developed after interventions for the recent medical diagnoses are evaluated

determined by state Nurse Practice Acts

responsibilities of the nurse educator

instilling values and professional standards of nursing advising and supervising students sharing accountability for pt care collaborating with students to identify learning needs role of an ethics committe w/in a healthcare institutin - respond to ethical challenges related to pt cre - px unnecessary legal intervention in pt care matters - ensure equitable and legal pt care e.g., providers/attorneys/ethicists personal ethics are influenced by values/practices/societal norms

The nurse explains to a patient that self-talk can improve self-awareness and help build a positive self-concept. To which level of communicaiton does this refer? - Intrapersonal - Interpersonal - Transpersonal - Small-group

intrapersonal

Palliative care hospice care

palliative care - focuses on the prevention, relief, and reduciton of symptoms - goal is to help achieve the best possible quality of life hospice care - focuses on the care of terminally ill pts - goal is manage pain, provide comfort, ensure aquality of life - prioritize care accroding to pt wishes

Which cognitive advancements are expected between 19 and 24 months? · Domestic mimicry · Ability to relate to time of day · Abstract thinking to solve problems · Imitating an action only while another person is performing it

· Domestic mimicry Domestic mimicry (imitating a parent of the same sex) and deferred imitation (imitating an action hour after the toddler watched the original action) are expected cognitive advancements of the toddl

Which question should the nurse ask a patient to elicit the patient's ethnicity (background)? · "What racial, national, or cultural group do you identify with?" · "What part of the world or geographic region are you from?" · "What is your native language or dialect?" · "What customs or rituals do you observe regarding illness?"

"What racial, national, or cultural group do you identify with?"

A 14-year-old female patient tells the nurse she is concerned about being taller than her peers and is worried she will continue to grow in height. Which question by the nurse is most useful for giving guidance regarding expected changes in height related to puberty? "How tall is your mother?" "What was your height at age 11?" "Have you noticed any pubic hair?" "When did you start menstruation?"

"When did you start menstruation?" Typically, girls cease height growth 2 to 2 ½ years after menarche. Asking when menstruation began can help the nurse give appropriate guidance related to height growth for the adolescent.

While talking about nutrition with a patient who has been on bed rest for several days, the patient states, "I am just not hungry. I don't understand it. I am always hungry." What is the nurse's best response to this statement? "Don't worry about it, every patient gets that way in the hospital." "You have been immobile for several days, which can decrease your basal metabolic rate and appetite." "Your loss of appetite is unusual; I will let your practitioner know." "Your lack of appetite is your body's way of telling you that bed rest interferes with your body's ability to digest food and not to eat too much."

"You have been immobile for several days, which can decrease your basal metabolic rate and appetite." Decreased activity decreases the body's basal metabolic rate (BMR) and appetite.

Nursing Interventions Classification (NIC)

- The lowa Intervention project developed a set of nurisng interventions that provides a level of standardization to enhance communication of nursing care across health care settings/to compare outcomes -NIC model indludes 3 levels--domains, classes, and interventions NIC interventions are linked with NANDA internaitonal nurisng diagnoses

Building a nursing team

- a strong nursing team works together to achieve the best outcomes for pts - effective team development requires team building and traning, trust, communication, and a workplace that facilitates collaboration - empoweredteams begin with the nurse executive Transformational leadership TEEAMS Time, Empowerment, Enthusiasm, Appreciation, Management, Support--approach

five-step nursing process

- assess gather info about the pt's condition 1. collection of info from primary source: a pt and seoncdary sources 2. interpretation/validation data (knowledge/experience/standards/attitudes) - diagnose identify the pt's problems/is made when a nurse identifies a health-related problem - plan set goals of care and desired outcomes and identify appropriate nurisng actions - implement perform the nurisng actions identiitfed in planning - evaluate determine if goals and expected outcomes are achieved

Components of the nurisng health history

- biographical info - family/psychosocial/past health hx - chief concern or reason for seeking care -review of systems -observation of pt behavior -diagnostic and laboratory data -pt expectations - present illness or health concerns documentation - record: health hx/physical examination/identify health problems, to plan an dimplement care, to evaluate pt's response to interventions -record all obervations - record any subjective info by using QUOTATION marks

Developing critical thinking skills

- reflective journaling define/express clinical experiences in your own words - metting with colleagues discuss and examine work experiences and validate decisions - concept mapping visual representation of pt problems and interventios that shows their relationship to one another organize assessment data/placing all the cues together into the clusters--lead to the next

Nursing diagnoses for pts with safety risk:

- risk for fall - impaired home maintenance - risk for injury - impaired cognition--confusion - lack of knowledge - risk for poisoing - risk for trauma

Which statement identifies different types of nursing diagnoses, according to North American Nursing Diagnosis Association International (NANDA-I)? select all that apply - Risk diagnoses - Acute diagnoses - Problem-focused diagnoses - Chronic diagnoses - Health promotion diagnoses

-Risk diagnoses - Problem-focused diagnoses - Health promotion diagnoses

Critical thinking

-ability to think systematic/logical manner -continuous process--opn-mindedness, continual inquiry, perseverance look at pt situatin and determine which identitifed assumptions are true/relevant - recognizing that an issue exists, analyzing info, evaluating info, drawing conclusions - Evidence-based knowledge in critical thinking

the pt-centered interview

-movtivational interviewing -interview preparation phases of the interview - orientation and setting an agenda - working phase--collecting data: interveiw techiques/observation/open-end questions/direct closed-ended quesitons/leading questions/back channeling/probing/interpret -termination phase cultural considerations - cultural competence: self-awareness/reflective practice/knowledge of a pt's core cultural background - cultural humility: recognize your own knowledge limitation/cultural persective

A rapid pace of growth is common in which age group? Select all that apply. 1. From birth to 2 years 2. From 10 years to puberty 3. From 2 years to 10 years 4. From 16 to approx. 24 years 5. From puberty to 15 years

1 5 The child grows rapidly, tripling birth weight at 1 year and quadrupling birth weight by age 2/puberty-15 years—hormonal influences during this time prepare the body for adulthood—a deposition of fats stores, secondary sexual characteristics, and for girls, menarche

Match the item with the correct description of damage theory of aging 1. Cross linking Theory 2. Wear and Tear Theory a. body wears out from use and abuse b. protein fibers form bonds and decrease elasticity

1-b 2-a

Match the item with the correct stage of transformation according to Gould's theory 1. 28-34 year of age 2. 34-43 years of age 3. 43-50 years of age 4. 50-60 years of age a. stability and acceptance b. questioning and re-examination c. midlife decade d. reconciliation (settlement) and mellowing (mature)

1-b 2-c 3-d 4-a

Match the nursing diagnosis with the patient assessment. 1. Altered mobility secondary to stroke 2. Decreased peristalsis related to immobility 3. Strict bed rest restriction 4. Evidence of shortness of breath and increased heart rate with activity a. activity intolerance b. Risk for falls c. constipation d. impaired skin integrity

1-b 2-c 3-d 4-a

Match the types of environmental pollution with the potential hazards 1. Air pollution 2. Land pollution 3. Noise pollution 4. Water pollution a. elevated blood pressure b. birth defects and cancer c. chronic lung disease d. infection and disease

1-c 2-b 3-a 4-d

Math the item with the physical change related to agining in older adulthood 1. functional impairment 2. acute illness and injury 3. weakened immune system a. higher risk of dementia or osteoporosis b. chromic care issues c. susceptibility to infection

1. - a 2. - b 3. - c

Match the item with the description of commonly occurring diseases in older adults 1. delirium 2. depression 3. Alzheimer's disease a. transient, generally reversible disease b. underdiagnosed disease in older adults c. most common form of dementia that has no cure

1. -- a 2. --b 3. --c

Match Freud's stage of psychosexual development to the corresponding activity 1. gild is found playing with contents of diaper 2. child has an increased interest in genitals 3. child's superego represses thoughts of sexuality 4. child experiences personl and family turmoil a. latency stage b. phallic stage c. anal stage d. puberty stage

1. -- c 2.--b 3.--a 4.--d

Performance improvement programs - it is to use the Joint Commission's annual pt safety goals, which provide an excellent focus for PI initiatives—sometimes a problem is presented to a committee in the form of 3:

1. Sentinel event an unexpected occurrence involving death or serious physical or psychological injury of a pt—after this event, th unit conducts a root cause analysis (RCA)à goal of the RCA is to review all info/identify how the event occurred through identification of active errors 2. active errors e.g., the acts that personnel perform and why it occurred through identification, analysis of latent error 3. Latent errors e.g, the organization or steps of the process PI improves local work processes to improve pt outcomes and health system efficiency Definition of Health WHO A state of complete physicla, menatl, and social well-being, not merely the absence of disease or informity--free from disease

Research process

1. identifies the problem 2. area of interest to study 3. planning and conducting a research study are systematic and orderly 4. control external factors that are not being studied but can influence a relationship btw the phenomena they are studying 5. researchers gather empirical data through the use of observations, assessment, use the data to discover neew knowledge Quntitative--precisely measure and quantifies a study's variable - experimental reserch, non-experimental research, survey, evaluation research Qualitative--aim to inderstand pts' experiences with health problems

1. Good Samaritan Laws 2. Public health laws 3. The uniform determination of death act

1. limit liability and offer legal immunity if a nurse helps at the scene of an accident 2. laws affect individuals, populaitons, and communities hat are intended to imporve the health of people 3. determines actual death - the cardipulmonay standard requires irreversiblie cessation of circulatory and respiraoty functions

1. Neuman system model 2. Roy's adaptation model 3. Pender's health promotion model

1. uses ystems approach, based on teh concepts of stress and reaction to stress 2. a person has the ability to modify external stimuli to allow adaptation to occur 3. focuses on promoting health and managing stress

Match the scenario with the corresponding stages or levels of morality as stated by Kohlberg 1. Premorality or Preconventional morality, stage 0 2. Morality of conventional role conformity 3. Morality of self-accepted moral principles 4. Premorality or Preconventional morality, stage 2 a. morality is based on avoiding disapproval or disturbing the conscience b. decisions are made on the basis of what pleases the child c. child conforms to rules out of self-interest d. right is determined by what is best for the majority

1.-b 2.-a 3.-d 4.-c

According to the CDC, which percentage of high school students indicated that they had seriously contemplated suicide? - 15% - 16%--2017 - 17% - 18%

16%

Which head circumference measurement would be expected for a two-year-old whose head circumference was 18 inches at the 12-month checkup? · 18 inches · 17 inches · 19.5 inches · 21.5 inches

19.5 inches

The registered nurse is teaching a nurisng student about restorative and ocntinuing care for a patient who underwent hip replacement. Which statement by the nursing student indicates effective learning? select all that apply 1. I will provide a cane to facilitate walking 2. I will assist the patient while bathing 3. I will ensure that the patient can eat by him- or herself 4. I will ensure that the patient can take medication by him- or herself 5. I will ensure that the caregiver is assistin the patient during meal preparation

3 4

Which developmental changes are expected in females beginning with menarche? Select all that apply. 1. Regular periods 2. Budding of breasts 3. Ovulation 4. Increase in progesterone 5. Increase in estrogen

3 5 asking beginning with menarche it relates to ovulation and high level of estrogen

Place in the correct the steps for positioning a patient in Sims' (semi-prone) position 1. Place pillow under flexed upper leg 2. Place pillow under flexed upper arm 3. Position the patient in the supine position 4. Place a small pillow under patient's head 5. Move to another side of the bed and turn patinet on side 6. Support feet in dorsiflexion with foot support devices

3 5 4 2 1 6

A child who feels guilty about stealing a toy is demonstrating which of Kohlberg's stages of moral development? Select all that apply. 1. Preconventional morality (stage 1) 2. Preconventional morality (stage 2) 3. Morality of conventional role conformity (stage 3) 4. Morality of conventional role conformity (stage 4) 5. Morality of self-accepted moral principles (stage 5)

3-start to have feelings of guilt-socially sensitive 4. start have a concern for social order/begin to show respect for authority—feel guilty about stealing a toy 5-there is a concern for what is good for all—the individual will develop a conscience at this stage

What is the correct order of steps involved in the LEARN communication technique for cultural assessment and planning? 1. involving the pt and his or her family while providing recommendation 2. explaining the nurse's perception of the problem to the patient 3. Obtaing a mutually agreeable, culturally oriented, patient-centered plan 4. Listening to the pt's explanation of the present problem 5. Recognizing the similiarities and differences between the pt's and nurse's perceptions

4 2 5 1 3

An intubated patient is repeatedly trying to pull out his endotracheal tube. The nurse applies soft wrist restraints in order to protect the patient's airway. When she goes back to reassess the patient's wrist, she finds redness developing under the restraint. The nurse suspects that the patient is developing what type of problem? Select all that apply. 1. Aspiration 2. Muscle atrophy 3. Impaired hydration 4. Compromised circulation 5. Impaired skin and tissue integrity

4 5 Compromised circulation could occur following a short period of physical restraint.

What is the normal duration of the postpartum period? Using whole number

6 weeks postpartum is the post-delivery period when the woman who has given birth to a child returns to her prep-regnant physical status. The duration of postpartum is approximately 6 weeks

At which age should a child be able to perform fine-motor skills such as transferring objects form hand to hand? - 2-4 months - 4-6 months - 6-8 months - 8-10 months

6-8 months 2-4 months—infant can hold a rattle for short periods/look at/play w/fingers/bring objects form hand to mouth - 4-6 months—grasp objects at will/can drop them to pick up another objects - 6-8 months—banging objects together/pulling strings to obtain an object - 8-10 months—able to pick up small object/shows hand preference

When a nurse enters a patient's room and says "Good morning" before starting care, the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to A. Establish a relationship B. Gather assessment data C. Treat discomforts quickly D. Assess the pt's emotional needs

A

Which scenario would indicate that a child is at the latency stage of psychosexual development? A 2-year-old child who constantly places objects in his or her mouth A 13-year-old boy who finds excuses to talk to his female friend in class A 9-year-old girl who refuses to sit next to a boy on the bus because she is afraid of "boy germs" A 15-year-old child who fights with his or her mother about wanting to stay out late on weekends

A 9-year-old girl who refuses to sit next to a boy on the bus because she is afraid of "boy germs" Younger school-age children often refuse to play with children of the opposite sex, whereas prepubescent children begin to desire the companionship of opposite-sex friends.

Which statement best describes the evidence supporting the use of antiembolism stockings and sequential compression devices (SCDs)? Thigh-length stockings are a better prevention measure for deep vein thromboses than knee-length stockings. A major reason SCDs do not prevent deep vein thromboses is that the devices often fail to function properly. Thigh-length antiembolism stockings are more comfortable and cost less than knee-length stockings.

A major reason SCDs fail to prevent deep vein thromboses is improper use by the staff. Evidence show that improper staff use of SCDs is a major reason they fail to prevent deep vein thromboses. A major reason SCDs fail to prevent deep vein thromboses is improper use by the staff.

Dorothea Orem

A self-care deficit exists when pts cannot meet their own needs

Which is the best document for the nurse to consult to ensure delivery of quality patient care? Nurse practice act ANA Code of Ethics Agency procedure manual ANA Standards of Nursing Practice

ANA Standards of Nursing Practice The ANA's Standards of Nursing Practice provides guidelines for ensuring quality of care to patients. This is the document nurses should consult.

Which nursing action describes the nurse's role of advocate? · Assessing and documenting the amount of urine in a patient's catheter bag · Reviewing and revising the treatment plan with a patient following hip surgery · Accepting a patient's advanced directive for limited life-sustaining treatment · Transferring the responsibility for taking vital signs to the nurse's aide

Accepting a patient's advanced directive for limited life-sustaining treatment This is an example of the nurse's role as patient advocate. The nurse demonstrates acceptance for the patient by respecting the patient's decision for limited life-sustaining treatment even though the nurse might disagree with it; the nurse also ensures the patient's wishes are followed by providing her wishes to other members of the health care team.--w/out reverse medical condition

Information about which aspect of a community could best be obtained by walking or driving through a neighborhood? · Likelihood of violence · Bus routes servicing the hospital · Emergency medical response speed · Accessibility of grocery stores to senior housing

Accessibility of grocery stores to senior housing Accessibility of grocery stores to senior housing is best accessed by going to senior housing facilities and then walking or driving the neighborhood to check for grocery stores.

A nurse is caring for a patient and makes a medication error. After notifying the physician, she informs the patient of her mistake and need for additional monitoring and observation. She offers the patient an apology. This action demonstrates which ethical concept? · Autonomy · Accountability · Responsibility · Beneficence

Accountability

The nurse is caring for a patient diagnosed with diabetes who does not believe in taking medication for the condition. The patient refuses to take insulin even though the medication will help decrease the symptoms of diabetes in the patient. In order to promote wellness in this patient, what is the best action for the nurse to take? · Actively involve the patient. · Ask the supervisor for advice. · Do what the nurse thinks is best for the patient. · Confer with the physician to make the care plan together.

Actively involve the patient Actively involving the patient in establishing goals and outcomes may promote healthy outcomes as the patient may hold a worldview that is different from the scientific paradigm in which the advised treatment is based.

When the nurse recognizes a problem and collects data to sufficiently support the need for policy updates, what role is the nurse demonstrating? Select all that apply. Advocate Manager Researcher Delegator Change agent

Advocate Researcher Change agent When nurses research problems and collect data to support the need for change, they are demonstrating the role of change agent/When nurses collect data to support the need for policy changes they are advocating for current and future patients. This demonstrates the nursing role of advocate/When nurses identity a problem

a crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia. During this hospitalization, the mother lost her entitlement check. after whcih time frame would the nurse expect the mother to regain stability? - 2 weeks, when the child's pneumonia begins to improve - 6 weeks, when she adjusts to the child's respiratory status and reestablishes the entitlement checks - 1 month, when the child goes home and the mother gets help from a food pantry - 6 months, when the child is back in school

After 6 weeks when the child's respiratory illness has resolved and entitlement checks are re-established RationaleGenerally, a person resolves the crisis and reaches psychological equilibrium in about 6 week

Which piece of patient information is a biologic and genetic determinant of health? Age Occupation Education level Living conditions

Age

Which factors will the nurse include in an assessment of biologic and genetic determinants of health? Select all that apply. Age Gender Education Employment Discrimination

Age Gender

Which action by the nurse when caring for the preschool child is appropriate, given preschoolers' level of independence? Allowing the child to brush teeth alone Hand-feeding the child during mealtimes and snacks Explaining the entire procedure for ear tube surgery Allowing the child to put on the exam gown by him- or herself

Allowing the child to put on the exam gown by him- or herself The nurse should allow the child to undress him-/herself to put on the exam gown. Preschool children want to assert independence and undressing without assistance is appropriate given preschooler's level of independence.

What psychosocial condition is associated with the inability to interact with the environment? Mood alterations Alteration in self-concept Sleep pattern disturbances Dyssomnia

Alteration in self-concept Alteration is self-conceptis associated with the inability to interact with the environment.

which loss occurs when the lost person is physically present but not psychologically available? - actual - maturational - necessary - ambiguous

Ambiguous loss

Which action would the nurse take when unable to perform a complex intervention successfully? - Continue until the intervention is successfully - Ask for assistance form an experienced nurse - Tell the patient about the inability to perform it - Compromise on the intervention to make it easier to perform

Ask for assistance from an experienced nurse

The nurse is caring for a postoperative patient who is confused and keeps attempting to get out of bed. What action should the nurse take first to protect the patient? Place a vest restraint on the patient. Apply bilateral wrist restraints on the patient. Notify the practitioner and obtain an order for restraints. Assess the patient for pain, hunger, or the need to use the toilet.

Assess the patient for pain, hunger, or the need to use the toilet. Assessing the patient for pain, hunger, or the need to use the toilet is an appropriate measure and should be performed prior to notifying the practitioner or applying any type of restraint.

Which method is demonstrated when an individual blends into another cultural group? Immigration Generalization Acculturation Assimilation

Assimilation It is the process by which an individual blends into a different cultural group. It facilitates changes w/in the culture over time in language/technology/food/clothing assimlilation--adjustment

The nurse states that being self-directed and independent are essential for accomplishing goals. Which element of communication is the nrse describing? - Empathy - Autonomy - Courtesy - Assertiveness

Autonomy

Which statement describes sexuality in older adults? · Sexuality in the older adult is focused on procreation. · As people age, the need to express sexual feelings decreases. · Sexuality has fewer moral considerations once a person reaches the older adult phase of life. · Behavioral modifications allow older adults to experience sexual pleasure in the presence of illness

Behavioral modifications allow older adults to experience sexual pleasure in the presence of illness Disease or illness impacting mobility and level of physical activity can affect the ability to participate in sexual activity, but behavioral modifications can allow older adults to experience sexual pleasure anyway

What is the perception of what is right, true, and real? Values Self-awareness Beliefs Culture

Beliefs

A patient with left-sided weakness asks the nurse, "Why are you walking on my left side? I cna hold on to you better with my right hand." Which therapeutic response would be best? - Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you - Would you like me to walk on your right side so you feel more secure? - Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you whol will hold you on the right side - By walling on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist, I would protect your shold if you should start to fall or faint

By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.

A nurse floats to a busy surgical unit and administers a wrong medicaiton to a pt. This error can be classified as A. a poisoning accident B. an euqipment-related accident C. a procedure-related accident D. an accident related to time management

C

Which cardiopulmonary condition is caused by chronic airway inflammation? COPD HF PVD DM

COPD COPD is a progressive lung disease associated with chronic inflammation of the airways.

Which mineral is stored in bone and assists with maintenance of phosphorous? Potassium Sodium Chloride Calcium

Calcium Calcium is stored in the bone and assists with maintenance of phosphorous.

A nurse is providing pt education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? - Ca should be taken with vitamin D to increase calcium absorption - African American women are more prone to developing osteoporosis than are Asian American women - Increased phosphorus metabolism may lead to bone fragility - Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis

Calcium should be taken with vitamin D to increase calcium absorption. Vitamin D is required for calcium metabolism.

The patient's difficulties with posture are magnified by problems in what part of the brain? Cerebellum Pituitary gland Meninges Occipital lobe

Cerebellum Problems with posture are magnified in patients with cerebellar problems, as this part of the brain is responsible for maintaining equilibrium.

What injury is associated with breathing difficulties? Right-sided brain injury Left-sided brain injury Lower spinal cord trauma Cervical spinal cord trauma

Cervical spinal cord trauma Quadriplegia and breathing difficulties are associated with cervical cord trauma. Quadriplegia and breathing difficulties are associated with cervical cord trauma.

Lewin

Change Theory

Who is at greatest risk of drowning? Children between 1 and 4 years of age Children between 5 and 10 years of age Adults who do not use approved life jackets Teenagers who are under the influence of alcohol

Children between 1 and 4 years of age Children between 1 and 4 years of age are at the greatest risk of drowning due to lack of supervision in bathtubs and swimming pools.

Which factor is a strong biologic determinant of susceptibility to disease or disabling conditions? · Incarceration · Food security · Chronologic age · Environmental conditions

Chronologic age

Which system in the electronic health record (EHR) provides warnings to alert a health care provider of patient allergies when prescribing medications? - Administrative information system - Computerized provider order entry (COPE) - Clinical decision support system (CDSS) - Clinical information system (CIS)

Clinical decision support system (CDSS)

Which is the best document for the nurse to consult when making decisions about nursing practice or conduct? Nurse practice act Code of ethics Standards of practice Facility protocol manual

Code of ethics The code of ethics guides nurses in their decisions for practice and conduct. This document is the one nurses select because it provides standards about right and wrong behaviors.

The nurse works with the physical therapist and the family to allow a child who is confined to a wheelchair to eat lunch outside. What nursing role does this action represent? Collaborator Educator Leader Change agent

Collaborator The nursing role of collaborator is represented in this situation by the nurse working with the family and physical therapist as a team toward the common goal of allowing the child to have lunch outside. --change agent—the nursing role of change agent refer to encouraging change and providing strategies for effecting change—this does not address change

A nurse is teaching a class of new nursing students about the scientific method. The class determines that _______ __________ in the early 1900s changed the approach of nursing from superstition to evidence-based practice. · Treating patients · Assisting providers · Conducting research · Developing protocols

Conducting research

Increasing the fiber in a patient's diet helps prevent what problem? Deep vein thrombosis Loss of muscle mass Constipation Urinary stasis

Constipation Increasing the fiber in a patient's diet helps prevent constipation.

According to the American Nurses Association (ANA, 2013), public health nurses use the nursing process to perform which specific role functions? Select all that apply. Coordinate services Staff publicly funded clinics Consult with government officials Promote healthy lifestyles Provide health education Participate in regulatory activities

Coordinate services Consult with government officials Promote healthy lifestyles Provide health education Participate in regulatory activities

Which complication associated with immobility affects the neurologic system? Decreased physical exercise Compromised cardiac function Damage to the cerebrum of the brain Chronic obstructive pulmonary disease

Damage to the cerebrum of the brain Damage to the cerebrum of the brain directly affects the ability to ambulate and control movement, and affects the neurologic system.

Which explanation describes input as it relates to the nursing process as a system? - data entering the system - The end product - Data related to system functioning - The product and information obtained from the system

Data entering the system Input is data entering the system—input for the nursing process is the data or info that comes from a pt assessment (e.g., how th pt interacts with the environment and the pt's physiological fx)—the end product is output—Data related to system functioning is feedback/content—product and information obtained from the system

Which phrase accurately describes feedback as it relates to the nursing process as a system? - Data entering - The end product - Data related to system functioning - The product and information obtained from the system

Data related to system functioning

Decision Making

Decentralized management - decision making occurs at the level of the staff/shared governance Emcompassess - responsibiliity: duties and activities an individual is employed to perform - autonomy: independent decisions about pt care - authority: legitimate power to give commands and make final decisions specific to a given position - accountability: answerable for actions

The nurse initiates a variety of interventions to decrease a patient's stress level before undergoing a series of surgical procedures. The nurse knows this is important because stress places the patient at risk for which complication? Delayed wound healing Immobility Pulmonary embolism Pressure ulcers

Delayed wound healing The evidence indicates that stress places the patient at risk for infection and delayed wound healing.

The nurse asks unlicensed assistive personnel (UAP) to take a patient's vital signs prior to surgery. Which nursing role does this action represent? Educator Delegator Leader Change agent

Delegator The nurse asking the UAP to take the patient's vital signs represents the nursing role of delegation. As a delegator, the nurse would need to know the delegatee's scope of practice and the Five Right of Delegation.

The pt's response indicates that the pt is in the per-contemplation stage and does not intend to change his behavior in the next 6 months Which chronic disease is associated with the costliest health care? - Cancer - Diabetes - Dementia - Heart disease and stroke

Dementia

The nurse assures a patient that the nurse is always available to talk. Which stage of grieving would trigger this action of nurse? - Anger - Resolution - Bargaining - Denial or disbelief

Denial or disbelief In the denial or disbelief stage of grieving, the patient is not prepared to deal with a problem. Therefore, the nurse should provide support and empathy and ensure the patient that he or she is always available for discussion. In the anger stage of grieving, the nurse should not argue with the patient and should calmly listen to patient's concerns. In the resolution stage of grieving, the nurse should encourage the patient to express his or her feelings. In bargaining stage of grieving, the nurse should convey only reality to the patient.

Deontology ultitarianism

Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions (Aiken, 2015). providing nursing care that meets the needs of the pt while maintaining the right to privacy, confidentiality, autonomy, and dignity is deontology eithcia theory The utilitarian concept of greatest happiness maintains that the right action is one that brings the greatest happiness to the most people. "The end justifies the means" is a phrase that expresses the essence of pure utilitarianism. purpose of a code of ethics? promote behaviro that is of a higher standard than required by law

Approaches to Ethics

Deontology--defines actions as right or wrong based on their adherence to rules and principles such as fidelity to promises, truthfulness, and justice -Utilitarianism: the value of someting is determined by its usefulness Casuistry: case-based reasoning Feminist ethics ethics of care types of ethical problems - ethical dilemma: 2 opposing courses of action can both be justified by ethical principles - moral distress: instead of competing options for aciton, the nurse feels the need to take a specific action while believing that action to be wrong

The school nurse is about to teach a freshman-level high-school health class about nutrition. Which instructional approach ensures that the students meet the learning outcomes? - Provide information using a lecture - Use simple words to promote understanding - Devleop topics for discussion that require problem solving - Complete an extensive literature search focusing on eating disorders

Develop topics for discussion that require problem solving. Rationale: Adolescents learn best when they are able to use problem solving to help them make choices.

Which action would the nurse take for a patient who agrees with the nurse that expected outcomes were met? - modify the care plan - revise the plan of care - discontinue the care plan - continue with the plan of care

Discontinue the care plan

A paraplegic patient is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment? Do you have a carbon monoxide detector? Do you have a plan to exit the home in case of an emergency? Where are your medications stored? Do you have a fire extinguisher?

Do you have a plan to exit the home in case of an emergency? Asking about a home exit plan in case of emergency is important for all patients, but it is extremely important for patients with limited mobility, as they may not be able to exit the home quickly in the event of a fire or other emergency.

Prior to discharge, the nurse reviews prescribed medication side effects and discusses conditions with the patient that should be reported to the health care provider. Which nursing role do these actions represent? Delegator Leader Educator Manager

Educator The nurse is educating the patient by reviewing medication side effects and discussing conditions that need to be reported. These actions represent the role of educator because they address the learning needs of the patient.

Building an empowered nursing team starts with the nurse executive. Which responsibility lies with the nurse executive in this process? - prvide traning to the nursing staff - maintain the pt's record in a systematic way - teach the pts about the health and well-being - establish a philosophy for nursing staf to provide quality nursing care

Establishing a philosophy for nursing staff to provide quality nursing care

Which method refers to the use of proof to guide clinical decision-making? Evidenced-based practice Clinical research Nursing process Research study

Evidenced-based practice The term evidence-based practice indicates that proof in the form of evidence is used to guide clinical decision-making.

A nurse is discussing the advantages of exercise with a patient with limited mobility. What benefit should the nurse include in the discussion to help facilitate normal movement? Exercise promotes muscle strength. Exercise minimizes joint flexibility. Exercise stimulates bone reabsorption. Exercise improves mood.

Exercise promotes muscle strength. Exercise promotes muscle strength and helps prevent the negative impacts of immobility. This is the most important aspect to include in the discussion.

Which of Paul's critical thinking skill will the nurse use when developing a care plan for a newly admitted patient? select all that apply - Experience - Reasoning - Proficiency - Observation - deduction

Experience Reasoning Observation observation--seen/heard/notice

A nursing care plan to promote the immobilized patient's involvement in his or her care includes what nursing action? Encourage the patient to read a book. Encourage family and friends to visit. Offer spiritual support. Explain all procedures to the patient.

Explain all procedures to the patient. Explaining all procedures to the patient will promote the patient's involvement in his or her care, and help with coping.

Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? - Provide a written document that contains the necessary instructions - Tell the patient that a relative will be taught how to take care of the wound - Explain and demonstrate the necessary action to the patient - Inform the patient that it will be explained later during discharge

Explain and demonstrate the necessary action to the patient

Which nursing action exemplifies cultural openness? Taking continuing education courses in pediatrics and geriatrics Asking a co-worker about her religious beliefs Exploring one's own self-awareness Making a concerted effort to eliminate disparaging thoughts about those of other cultures

Exploring one's own self-awareness Cultural openness involves cultural self-awareness as well as lifelong honing of transcultural skills

What psychosocial alteration is a consequence of bed rest and manifests in the patient becoming lonely or depressed? Feelings of isolation Alteration in self-concept Sensory deprivation Anxiety

Feelings of isolation Feelings of isolation are a consequence of bed rest and can manifest in the patient becoming lonely or depressed.

A nurse is caring for a patient and conducts rounds. The patient states that his spouse will be back in the room in 45 minutes and would like to speak with the nurse. The nurse promises to return at the agreed upon time to meet with family. When the nurse returns as promised, she is demonstrating which ethical concept? Fidelity Justice Veracity Confidentiality

Fidelity Fidelity refers to keeping promises or agreements with others.

Educating patients about electrical cord safety is important in preventing what home safety hazards? Fires and falls Falls and outdoor safety hazards Chemical and carbon monoxide poisonings Fires and medication safety hazards

Fires and falls Educating patients about electrical cord safety is important in preventing fires and fall hazards, as frayed electrical cords can start fires and electrical cords in walking areas are trip hazards.

Who made a significant contribution to nursing by authoring Notes on Nursing? - Florence Nightingale - Clara Barton - Leah Higbee - Virginia Henderson

Florence Nightingale Florence Nightingale, considered the founder of modern nursing, was the author of Notes on Nursing.

Which early nursing leader made significant contributions to the field of epidemiology? Florence Nightingale Dorothea Dix Bridget Mason Linda Richards

Florence Nightngale

Which place is appropriate to document urine output in the patient's chart? - Admission sheet - Operative report - Physician's prescription sheet - Flow sheet

Flow Sheet A flow sheet is utilized when repeated observations are to be recorded in a quick and accurate manner. The information from a flow sheet is retrieved quickly, too. An admission sheet is used to record the detailed initial assessment at the time of admission. An operative report records the summary of the client's surgery, complications, and preoperative and postoperative diagnoses. The physician's order sheet contains the information of the physician's orders for treatment and medications with date, time, and signature.

Which is a defining characteristic of public health nursing that distinguishes it from community-based nursing? · Focus on populations · Concern with disability as well as acute disease · Importance of collaboration · Commitment to patient-centered care

Focus on populations The primary characteristic of public health nursing is its population focus. Community-based nursing care, on the other hand, is individual or family focused. Thus, population focus is the defining characteristic that distinguishes the two

Which nursing action demonstrates altruism? Accepting responsibility for decisions Focusing on service to others Obtaining an advanced degree Adhering to a code of ethics

Focusing on service to others A profession provides services needed by society. Altruism is public service over personal gain. Nurses recognize nursing as their life's work. It is an important component of their lives and clearly defines who they are. Nurses focus on service to their patients and the community

A parent reports concern that his or her preschool child has difficulty following directions. The nurse should recommend which actions by the parent to help the child with this task? · Giving the child specific direction · Telling the child he or she could do it better next time · Explaining the directions in more detail next time · Reminding the child that good children always listen

Giving the child specific direction The nurse should recommend the parent give specific direction because preschool children are often unable to follow directions unless they are given one step at a time.

What is the purpose of the Nursing Code of Ethics? Extending formal education Defining legal parameters Guiding nurse practices and conduct Directing cultural competence

Guiding nurse practices and conduct The Nursing Code of Ethics guides nurses in making decisions about issues involving nurse conduct, the suitability of that conduct, and practice issues.

A nurse is assessing a patient's perceptions about susceptibility and perceived severity for hypertension. Which model is the nurse using? Health Belief Model Holistic Health Model Health Promotion Model Hierarchy of Needs Model

Health Belief Model The Health Belief Model uses perceived susceptibility and perceived severity to determine motivation to change. Health Belief Model's Constructs Beliefs about the costs of taking action—Perceived barriers Beliefs about the seriousness of a disease—Perceived severity Beliefs about the chances of getting a disease—Perceived susceptibility Beliefs about the effectiveness of taking actin—Perceived benefits

Which statement describes the term health? Health is a process. Health is a state of being. Health is the absence of disease. Health is an absence of physical, mental, and social well-being.

Health is a state of being.

Which phrase describes the primary focus when viewing family as context? - Family members within a system - Family process and relationship - Family relational and transactional concepts - Health needs of an individual member

Health needs of an individual member When you review the family as context, the primary focus is on the health/development of an individual member existing w/in a specific environment (e.g., the pt's family). Although the focus is on the individual's health status, assessment is on how much the family provides the individual's basic needs

The nurse is tacing a group of patients the importance of using sunscreen. Which type of content is the nurse providing? - Simulation - Restoring health - Coping with impaired function - Health promotion and illness prevention

Health promotion and illness prevention

Which priority level would be assigned to the patient diagnosed with decreased gas exchange? - High - Low - Medium - Intermediate

High

The nurse is caring for a confused 69-year-old male patient, who recently had a seizure at home and hit his head, sustaining a subdural hemorrhage. He has an IV infusion and is receiving Dilantin to prevent further seizures. The patient is to unable stand without assistance. According to the Hendrich II Fall Risk Model, what is the patient's fall risk? High risk Moderate risk Low risk Scale not appropriate

High risk The patient is a high risk for falls: Confusion - 4; Depression - 0; Altered elimination - 0; Dizziness - 0; Gender - 1; Any antiepileptic agents (Dilantin) - 2; Any benzodiazepine medications - 0; Get Up & Go Test - 4 = 11. The Hendrich II Fall Risk Model - Confusion/disorientation/impulsivity - Symptomatic depression - Altered elimination - Dizziness/vertigo - Male gender - Any administered antiepileptic's - Any administered benzodiazepines - Get up and go test

A patient is diagnosed with a diabetic ulcer with gangrene to his foot. The health provider adnises surgery, but the patient refuses because removal of a body part is not permitted according to his or her religion. Which concept of justifies this scenario? - Marginalization - Iceberg analog - Intersectionality - Health disparity

Iceberg analog It helps in understanding the visual and virtual aspects of the way humans perceive things. The pt may have come to get relief from symptoms.

Which determination does an evaluative measure make? - If nursing education meets the standards of care - If nurses follow the nursing process - If nurses record the number of patient falls - If nursing care was effective for meeting expected outcomes

If nursing care was effective for meeting expected outcomes

Which cultural issue is the patient most likely to hide from the nurse? Food preferences Views on end-of-life care Illiteracy Role in the family

Illiteracy Many illiterate patients are ashamed they cannot read and may pretend to understand written materials

Which term describes people reacting in different ways because of attitudes about illness? - Health belief - Illness behavior - Health promotion - Illness prevention

Illness behavior

Which is a physiological as well as psychological response to sleep pattern disturbance? Immunosuppression Depression Pressure ulcers Deep vein thrombosis

Immunosuppression A physiologic response to sleep pattern disturbance is immunosuppression. Sleep naturally promotes the production of cytokines, which helps a person sleep and also helps with inflammation and infection. Sleep deprivation may decrease the production of cytokines.

What does paresis mean? Impaired mobility and movement Complete loss of movement Weakness on one side of the body Lower body paralysis

Impaired mobility and movement Impaired mobility and movement is paresis.

A mother of a 10-month-old comes to the nurse concerned that her child has had two upper respiratory infections in one month and asks if something is wrong with her child. How can the nurse respond? To prevent infection the infant will need prophylactic antibiotics. Infants have an immature immune system, which makes them susceptible to infections. An infant's immune system should be developed by 6 months and so the child needs further evaluation. The infant's infections are a sign that the child will develop asthma.

Infants have an immature immune system, which makes them susceptible to infections.

The nurse is observing a patient ambulate around the room and notes the patient has an unsteady gait. What action should the nurse take next? Initiate a fall prevention plan for the patient. Place the patient on complete bed rest. Start passive range-of-motion exercises twice a day. Make sure the patient only ambulates with a walker.

Initiate a fall prevention plan for the patient. An unsteady gait places the patient at risk for falling, and the nurse should initiate fall preventions measures to ensure the patient's safety.

What is the public health nurse primarily accomplishing when he or she invites two representatives from the local senior citizens' center to participate in meetings to plan a nutritional fair for the over 65 population? · Gaining community trust · Involving stakeholders · Promoting participation Ensuring volunteers

Involving stakeholders Involving two representatives from the senior center in the planning for a nutritional fair designed for seniors is involving key stakeholders in the planning process. Key stakeholders are those individuals or groups with an investment or significant interest in a topic. Inclusion of key stakeholders helps ensure cooperation and compliance thus increasing the likelihood that the plan will work and the goal will be achieved.

A Haitian patient is admitted to the hospital for arthritic pain. During the nursing assessment, the nurse learns that the patient is using a therapy called cupping for palliation of pain along with traditional Western medicine. Cupping involves placing heated cups on the skin. Which is the MOST appropriate action by the nurse? - Ask the pt to stop this therapy immediately - Ignore this information and continue with Western medicine - Learn about this therapy and avoid imposing own beliefs - Ask the pt to select either Western medicine or cupping therapy

Learn about this therapy and avoid imposing one's own beliefs.

A nurse taking continuing education classes is an example of which professional nursing criteria? Altruism Body of knowledge Accountability Licensure

Licensure

The nurse is caring for a 68-year-old female patient who recently underwent colon surgery. The patient is awake and alert. She has a saline lock and is receiving oral pain medications. The patient is ambulatory and able to push up to get out of the chair easily. According to the Hendrich II Fall Risk Model, what is the patient's fall risk? High risk Moderate risk Low risk This scale is not appropriate for this patient

Low risk The patient is a low risk for falls: Confusion - 0; Depression - 0; Altered elimination - 0; Dizziness - 0; Gender - 0; Any antiepileptic agents - 0; Any benzodiazepine medications - 0; Get Up & Go Test - 1 = 1. The Hendrich II Fall Risk Model - Confusion/disorientation/impulsivity - Symptomatic depression - Altered elimination - Dizziness/vertigo - Male gender - Any administered antiepileptic's - Any administered benzodiazepines - Get up and go test

In which health care setting would completion of an OASIS (outcome and assessment information set) form be essential? - For-profit rehabilitation facility - State-funded health department clinic - Medicare-certified home care agency - Grant-funded ambulatory care unit

Medicare-certified home care agency The Outcome and Assessment Information Set (OASIS) is a comprehensive patient assessment tool which must be completed by nurses working for Medicare-certified home health agencies (Centers for Medicare and Medicaid Services, 2010b).

When preparing a research project, which level of evidence is highest for a scientific study? - Single non-experimental cohort study - Controlled without randomization - Systemic review of a qualitative study - Meta-analysis of a randomized clinical trial

Meta-analysis of a randomized clinical trial

Which outcome is an effect of stereotyping when planning care for a patient? · Misperceptions about the patient, resulting in a unsuitable plan of care · Development of a plan of care that is holistic. · Development of a culturally-sensitive plan of care Simplification of the care planning process

Misperceptions about the patient, resulting in a unsuitable plan of care Stereotyping can adversely affect the plan of care, b/c it allows for misperception about the pt

What nursing action should be included in the plan of care for a patient with sequential compression devices? Ensure the fit of the sleeves is tight. Roll the sleeves inside out to apply them. Monitor the patient's toes for impaired circulation. Activate the heating function once a shift.

Monitor the patient's toes for impaired circulation. As sequential compression devices can impair circulation if too tight, it's important to check the patient's circulation to the toes.

The nurse is incorporating the patient's religious dietary preferences into the care plan. Which step of the LEARN mnemonic is the nurse applying? - Explain - Negotiate - Recommend - Acknowledge

Negotiate

Which theory explains a patient newly diagnosed with diabetes who becomes stressed and eats more carbohydrates? - Neuman's - Orem's - Peplau's - Leininger's

Neuman's This pt is newly diagnosed with diabetes and is under stress. The pt responds to stress by eating too many carbohydrates. this process is explained by Neuman's theory, which focuses on stress and the reaction of pts to that stress Orem's theory focuses on the self-care needs of the pt Peplau's theory focuses on the nurse-pt interpersonal relationship Leininger's theory focuses on providing culturally competent care

Electrical impulses from nerves to muscles are communicated by what? Motor fibers Neurotransmitters Ligaments Proprioceptors

Neurotransmitters Neurotransmitters communicate electrical impulses from nerves to muscles.

Signs and symptoms of death:

No heartbeat or respirations Involuntary release of stool and urine No verbal response or response to tactile stimuli Decrease in body temperature Eyes may stay open, jaw will drop with the mouth open Color of skin pales and then turns bluish as blood settles Rigor mortis, or stiffening of the joints, after a period of time

Benner's stage of nursing proficiency Novice Advanced beginner Competent Proficient Expert

Novice (Learner)--beginning nursing student Advanced beginner--a nurse who has had some level of experience with the situation Competent (kowledge)--a nurse who has been in the same clinical position for 2-3 years Proficient--a nurse with mroe than 2-3 years of experience in the same clinical position Expert--a nurse with diverse experience who has an intuitive grasp of an exisitng or potential clinicla problem

Which factor differentiates research use from evidence-based practice (EBP)? Focus on theoretical as opposed to clinical application Number of studies from which evidence is drawn Need for collaboration before implementation Size of the patient population involved in the study

Number of studies from which evidence is drawn Research use differs from evidence-based practice in that it is narrower in scope than EBP. EBP also integrates theoretical background, clinical judgement, and pt preferences. Research use is a subset of EBP Research use is a subset of EBP. It is the direct application of findings from a single study, one or two studies, or a very small group of studies, to patient care. EBP involves reviewing the literature and comparing evidence from a large number of studies, or all known studies within the study subject or category, to determine which evidence is the best evidence.

Institute of Medicine (IOM) Professional standards review organization (PSROs) Utilizaiton reveiw (UR) committees Prospective payment system (PPS) Diagnosis-related groups (DRGs)

Nurses need to be transformed by o Practicing to the full extent of their training o Achieving higher levels of education through an education system that provides seamless progression o Becoming full partners with physicians and other health care providers in redesigning the health care system o Improving data collection and the information infrastructure for effective workforce planning and policy making PSROs - review the quality, quantity, and cost of hospital care provided thorugh medicare and medicaid - responsible for reviewing the medicla necessity and appriateness of inpateint admissions to hopsitals and length of patient stays UR committees review admissions, diagnostic testing, and treatments ordered by physician who cared for pts reciving medicare PPS a mehtod of reimbursement in whihc Medicare payment is made based on a predetermined, fixed amount DRGs a classificaiton system (referred to as DRGs) for inpatient discharges and adjust payments

A nurse is caring for a patient with osteoporosis. In which type of patient is this condition most prevalent? Adult African-American female Adult male Middle-age Caucasian female Older Asian female

Older Asian female Osteoporosis is more prevalent in the older adult population and in Caucasian and Asian women.

What nursing intervention can assist the patient with maintaining a normal sleep-wake cycle? Encouraging contact with family and friends. Providing a clock in the patient's room. Opening the window blinds during the day. Allowing access to the radio.

Opening the window blinds during the day. Opening the window blinds during the day can assist the patient with maintaining a normal sleep-wake cycle.

The nurse alerts the health care provider about a female patient's cultural preference for only female health care providers for examination. Which cultural behavior is being demonstrated by the nurse? Openness Stereotype Awareness Gender bias

Openness The nurse is demonstrating cultural openness, a lifelong stance that promotes continuing development of transcultural skills

Order the stage of psychosexual development as they occur in chronological order Oral stage—infancy Phallic stage—pre-school Anal stage—toddlerhood Puberty—adolescence Latency stage—school-age

Oral stage—infancy Anal stage—toddlerhood Phallic stage—pre-school Latency stage—school-age Puberty—adolescence

An older adult male is on prolonged bedrest, related to lower extremity trauma. Which cardiopulmonary condition is a concern in this patient? COPD HF PVD DM

PVD PVD is a disturbance in the venous system caused by venous stasis, immobility, inflammation, and prolonged bedrest.

Which characteristic reflects a common physical change that occurs during older adulthood? Pallor in the absence of anemia Loss of eyebrow hair in men Decrease in anteroposterior diameter of thorax Elevation in blood pressure

Pallor in the absence of anemia Pallor even in the absence of anemia is an expected assessment finding in the older adult

Which phrase best describes the relationship between the nurse and the patient in the community-based setting? Participatory and collaborative Authoritarian and caring Paternalistic and facilitating Permissive and enabling

Participatory and collaborative

Which section of the traditional source record does the nurse use to record patient demographic information? - Nurse's notes - Patient care summary - Graphic sheet and flow sheet - Nurse's admission assessment

Patient care summary

The nurse is caring for four patients on a medical unit. Which patient has developed a health care-associated infection? Patient who was admitted with pneumonia and placed on ventilator. Patient who was admitted with pancreatitis and an infected venous stasis ulcer. Patient who was admitted with a stroke and then developed constipation and a fecal impaction. Patient was admitted for surgery, had a urinary drainage catheter placed, and then developed a urinary tract infection.

Patient was admitted for surgery, had a urinary drainage catheter placed, and then developed a urinary tract infection. A urinary tract infection associated after placement of a urinary drainage catheter is considered a health care-associated infection.

Which expected outcome is written in measurable terms? - Patient will be pain free - Patient will have less pain - Patient will take pain medication every 4 hours - Patient will report pain acuity less than 4 on a scale of 0 to 10

Patient will report pain acuity less than 4 on a scale of 0 to 10

The nurse is caring for four different patients with immobility. Which patient would the nurse place in the supine position? - Pt with pressure ulcer - Pt with respiratory distress - Pt with deep vein thrombosis - Pt with musculoskeletal complications

Patient with musculoskeletal complications Patients with musculoskeletal complications would benefit from being placed in the supine position. Patients with pressure ulcers would benefit from being placed in the lateral side-lying position. Patients with deep vein thrombosis should be placed in supported Fowler's position. Patients with respiratory distress would benefit from being placed in the prone position because it helps improve oxygenation.

A patient asks the nurse how often deep breathing exercises should be performed. What is the appropriate response from the nurse? Perform 5 to 12 deep breaths in a row and repeat them every hour. Perform 3 to 5 deep breaths in a row and repeat them 10 times per hour. Perform 2 to 3 deep breaths in a row and repeat them every 2 hours. Perform 10 deep breaths in a row and repeat them 5 times per hour.

Perform 3 to 5 deep breaths in a row and repeat them 10 times per hour. Deep breathing exercises should be performed 3 to 5 times in a row and repeated 10 times per hour.

After questioning a patient, the nurse realizes the patient does not speak or understand English. How should the nurse proceed with the patient assessment? Place a request for a professional interpreter. Contact a member of the patient's family. Find an online interpreter software program to use. See if a nurse who speaks the language is present.

Place a request for a professional interpreter.

Which method is appropriate for the nurse to dispose of printed patient information? - Rip several times and place in a standard trash can - Place in the patient's paper-based chart - Place in a secure cainster marked for shredding - Burn the documents

Place in a secure canister marked for shredding.

A 50 year-old construction worker arrives at the hospital complaining of stomach cramps and states that he has been unable to hold anything down for two weeks. He smokes a pack of cigarettes day and lives near a landfill. Which environmental factor would most likely be affecting this patient's safety? Age Workplace Lifestyle behaviors Place of residence

Place of residence The patient's place of residence is an environmental factor that is possibly the reason for his current condition.

What is the main goal of the Quality and Safety Education for Nurses (QSEN) project? Prepare future nurses to advance quality and safety. Allocate resources for safety program implementation. Minimize the risk of harm to older adult patients by injury. Assist nurses to educate patients about safety concerns.

Prepare future nurses to advance quality and safety. In 2005, the Robert Wood Johnson Foundation funded the Quality and Safety Education for Nurses (QSEN) project with a goal of preparing nurses of the future with the knowledge, skills, and attitudes needed to advance quality and safety on the job in their health care settings.

Types of nursing diagnostic statements

Problem-focused identify an undesireable human response to existing problems or concerns of a pt Risk diagnosis apply when there is an inreased potential or vulnerability for a pt to develop a problem or complication Health promotion identify the desire or motivation to improve health status through a positive behavioral change use the nusring diagnostic process: critical thinking/knowledge/experience attitudes/intellectual standards use of nursing diagnosis in practice - concept mapping cultural releavance in diagnostic: pt's cultural diversity--ethnicity, values, beliefs, language and health practices

The nurse is caring for a young adult male in the emergency department. The patient was involved in a motorcycle crash and is now unable to move any of his extremities. What is the expected documentation of this condition? Ischemia Hemiparesis Paraplegia Quadriplegia

Quadriplegia Quadriplegia is an inability to move all four extremities.

Implementation Process

Reassessing a pt - continuous process each time you interact with the pt Reviewing and revising the existing nursing care plan - revise assessment data to reflect current status/revise nursing diagnosis, goals, outcomes/select or revise specific interventions -choose methods of evaluation to determine whether outcomes were met Preparing for implementation - Time management - Equipment - Personnel - Enviornment - Patient implementation skills - cognitive skill - interpersonal skills - psycomotor skills

What step is the nurse least likely to take while providing culturally congruent care to the patient? - Taking care of any discomfort related to the pt's religious beliefs - Trying to bridge religious gaps to provide meaningful and supportive care - Combining knowledge about a religion with an attitude of helpfulness and flexibility - Recognizing that his or her religious preference automatically applies to all patients

Recognizing that his or her religious preference automatically applies to all patients

A patient diagnosed with end-stage renal disease is undergoing dialysis. The nurse asks the patient about the patient's values and beliefs regarding end-of-life care and death. The patient's beliefs are a perception of what is ______. Select all that apply. Right True False Real Timely

Right True Real Beliefs are a perception of what is right, what is true, what is real

Which theory states that the patient adapts to changes in physiological needs, self-concept, and interdependent domains during health and illness? - Roy's - Orem's - Peplau's - Henderson's

Roy's Roy's theory explains the adaptation model and considers the patient to be an adaptive system—according this theory, the pt adapts to changes in physiological needs, self-concept, and interdependent relations during health and illness Roy Adaptation Model, which states that the goal of nursing care is to promote patient adaptation. Her model asks questions about the person who is the focus of nursing care, the target of that care and when that care is indicated.

When caring for a toddler in the hospital, which nursing intervention is most developmentally appropriate? Not allowing the child to have a pacifier while in the hospital. Allowing the child to decide if the nurse can perform a procedure. Asking the parents to leave the room when performing an assessment. Scheduling evening medications to follow the toddler's bedtime routine

Scheduling evening medications to follow the toddler's bedtime routine The toddler may experience distress when a routine is not followed. The nurse can provide care in the hospital that helps support routines, if possible.

The nurse is caring for a Korean woman who has just delivered her first baby. Which soup would the nurse anticipate the family to provide as the first meal to the woman? - Tomato soup - Sweet corn soup - Seaweed soup - Hot garlic soup

Seaweed soup

The nurse is teaching a student nurse how to properly apply wrist restraints. Which student action would indicate effective teaching? Securing the restrains with a square knot. Securing the restraints to the tops side rails. Securing the restraints with a quick release tie. Securing the restraints to the bottom side rails.

Securing the restraints with a quick release tie. This nursing action shows that teaching has been effective. Restraints should be secured to the bed with a quick release mechanism such as a quick release tie or buckles.

Which research topic is probable for a group of researchers conducting a study on patients with diabetes based on Orem's theory? - Self-administration of insulin - Effective nurse-patient communication - Pathological process in diabetes - Medications for diabetes

Self-administration of insulin

The nurse is positioning a postoperative patient to place the major portion of the body weight on the hip and shoulder. In which position does the nurse place the patient? - Sims' - Prone - Side-lying - Supported Fowler's

Side-lying

Which developmental theorist explained the behavior of a 4-year-old who fantasizes about the parent of the opposite sex? - Sigmud Freud - Arnold Gesell - Erik Erikson - Jean Piaget

Sigmud Freud Sigmud Freud—psychoanalytical model of personality development—based on the principle that each stage of development is characterized by sexual pleasures in different body parts—3-6 years fantasizes about the parent of the opposite sex - Arnold Gesell—based on the principle that each person's development is directed by genetic activity - Erik Erikson—focuses on psychosocial stages - Jean Piaget—cognitive thinking According to Freud, there are different components in human personality that develop in stages. These components include the id, ego, and superego. The id is defined as the basic instinctual impulse drive to achieve pleasure. The ego mediates conflicts btw the environment and the forces of the id. The 3rd component, the superego, regulates, restrains, and prohibits actions

Increased cervical flexion is observed when the patient is placed in which position? - Sims' position - Prone position - Side-lying position - Supported Fowler's position

Supported Fowler's position cervical flexion--bending the head forward towards the chest

Which nursing intervention would increase the risk of joint dislocaiton in a patient with hemiplegia who is immobile for an extended period? - Supporting the pt by holding the arm - Supporting the pt with assistive devices - Lowering the pt to the floow if he or she faints - Instructing the pt to use a cane while walking

Supporting the patient by holding the arm

a head nurse is teaching the physiology of fight-or-flight responses to student nurses. Which system is responsible for these phenomena? - renine-angiotension - respiratory - sympathetic nervous - parasympathetic nervous

Sympathetic nervous rationalePeople experience stress in day-to-day activities. Stress stimulates thinking processes and helps people to be alert. The fight-or-flight response helps a person to prepare for action. These responses occur because of the arousal of the sympathetic nervous system. The renin-angiotensin system helps in maintaining electrolyte and fluid balance. The respiratory system does not initiate fight-or-flight responses. The parasympathetic system counteracts the action of the sympathetic nervous system.

Which word does the S in PES stand for? - Situation -Symptoms - Sensitivity -Separation of date

Symptoms

The nurse is teaching a patient coughing techniques. What instruction should be part of that education? Take two deep breaths in and out to start. Inhale through the nose as deeply as possible. Inhale slowly through the mouthpiece of the spirometer. Fully exhale between coughs.

Take two deep breaths in and out to start. Taking two deep breaths in and out is part of the instructions for teaching coughing techniques. deep-breathing--inhale through the nose as deeply as possible

Because of the number of accidents involving cyclists and motor vehicles, a public health nurse initiates a safety education program in her town. Which term can most appropriately be used to describe cyclists in this scenario? · Target population · Interest group · At-risk individuals · Client population

Target population Target population refers to groups of public health clients within a community that are the focus of public health nursing interventions. Cyclists constitute a group for whom a public health nursing intervention is initiated so they are a target population.

When unit staffing includes assitive personnel (AP), which scenario is characteristic? - the AP hae formal training and are able to function independently - the AP do not have clinical duties on a patient care unit - the registered nurse (RN) is accountable for the tasks delegatd to the AP - delegating tasks to the AP is not the scope of th RN's practice

The registered nurse (RN) is accountable for the tasks delegated to the AP.

What is the primary goal of patient-centered care? - To provide care that fits a pt's own values, beliefs, and traditions - To help recognize biases, prejudices, and assumptions about other people - To provide individualized care and restore an emphasis on personal relationships - To assess social, cultural, and biophysical factors that influence pt treatment and care

To provide individualized care and restore an emphasis on personal relationships The primary goal of pt-centeredness is to provide care, restore an emphasis on personal relationships The goal of transcultural nurisng is to provide care that fits with the pt's own values, beliefs, traditions Culture awareness would help in recognizeing biases, prejudices, assumptions about other people cultural skills help assess social, cultural, biophysicla factros that influence pt tx and care

The nurse is studying the Emergency Medical Treatment and Active Labor Act. What is the meaning of the term patient dumping? - transferring a pt from a private to a public hospital on a pt's reqest - transferring a pt from a private to a public hospital after the pt is stabilized - transferring a pt from a private to a public hospital on consent of the health care provider - transferring a pt from a private to a public hospital without appropriate screening and stabilization

Transferring a patient from a private to a public hospital without appropriate screening and stabilizationPatient dumping refers to transferring a patient from a private to a public hospital without appropriate screening and stabilization. The Emergency Medical Treatment and Active Labor Act was established to reduce the incidence of patient dumping. According to this act, patients can be transferred from a private to public hospital on their own request, after being stabilized, or by consent of a healthcare provider.

Bill was in a car accident over a week ago and is currently on life support. As one of his nursing diagnoses he has impaired physical mobility. To whom would the nurse most likely delegate care such as turning the patient every two hours to maintain skin integrity and range of motion? Unlicensed assistive personnel Speech therapist Health care provider Dietitian

Unlicensed assistive personnel Unlicensed assistive personnel provide hands-on care for the patient as directed by the primary nurse under supervision.

Lack of proper body alignment can lead to what condition? Enhanced coordination Decreased falls Unsteady gait Decreased pain

Unsteady gait Lack of proper body alignment can lead to an unsteady gait.

Quality and Safety Education for Nurses (QSEN) project is increasing emphasis for patient safety. In what way has it impacted actual initiatives and regulations? Implementing new job descriptions for safety nurses Requiring all newly licensed RN's to take a safety test Requiring newly licensed nurses to petition their senator for support on patient safety Using national resources for professional development to focus attention on safety in hospital settings

Using national resources for professional development to focus attention on safety in hospital settings As an education driven strategy for nurses, they can teach nurses nationally and help implement new standards in the local hospital setting.

Which is a method whereby a person can discover his or her own values by assessing, exploring, and determining what those personal values are and how they affect personal decision-making? Self-awareness Values clarification Values system Zero-order belief

Values clarification Values clarification is a method whereby a person can discover his or her own values by assessing, exploring, and determining what those personal values are and how they affect personal decision-making.

A nurse in the emergency department is helping with a blood transfusion for a gunshot victim with the same blood type as herself, and hopes the blood she is transfusing is from her own donation. When she discovers that the injury occurred when the patient was attempting to steal a wallet, the nurse feels horrified that it may be her blood being transfused into the thief. What is the nurse experiencing? · Self-reflection · Values clarification · Self-awareness Values conflict

Values conflict The nurse has felt the emotion of sympathy with the patient before finding out about his past, and disgust after finding out he was trying to rob someone. This is a classic example of values conflict.

The nurse explained the need for, and advantage of, receiving pain medication before ambulating to a patient who is first day post-operative from abdominal surgery. Whose theory did the nurse exhibit with this patient? · Rosemarie Rizzo Parse · Virginia Henderson · Hildegard Peplau · Jean Watson

Virginia Henderson Humane/Holistic Care for patients theory focuses on helping pts become as independent as possible. by addressing the pt's pain, the pt will be able to ambulate and more quickly become independent

Which finding indicates a risk factor for development of heart disease in a patient? · Becomes a nonsmoker · Is of average height and weight · Watches television five hours per night · Has started walking in the evenings

Watches television five hours per night

Which question does the nurse ask a patient to assess the beliefs and practices of the patient? - What caused your problem? - What is your main source of income? - What do you do to keep yourself well? - How should we address you or what should we call you?

What do you do to keep yourself well? Asking the pt about what he or she does to keep well indicates that the nurse is assessing the beliefs and practices of the pt. asking the pt what caused the problem indicates assessment of bicultural ecology—questioning the pt about the main source of income indicates assessment of socioeconomic status. Asking the patient how to address him or her indicates that the nurse is assessing language and communication

Which example describes discrimination? Classifying all homeless people as "crazy" Assuming a male patient is "stoic" because the patient is Hispanic Stating all white people are "superior" Withholding pain medication from a drug addict

Withholding pain medication from a drug addict The practice of treating members of a particular group less fairly than others

Which skills from Paul's Critical Thinking Theory do nurses use when caring for patients? Select all that apply. a. Analyze data b. Establish patient goals c. Develop a plan of care d. Revise nursing diagnoses e. Evaluate the patient care plan

a c e

Which statements are true of advanced practice registered nurses (APRNs)? Select all that apply. a. APRNs provide at least some level of direct patient care. b. Collaboration is a core competency for APRNs. c. NPs treat primarily complex patient health care problems. d. DNP is the entry level for APRN specialty practice. e. APRNs have acquired theoretical research-based and practical knowledge

a/b/e

Which activity is within the LPNs/LVNs scope of practice? Select all that apply. a. Administer intramuscular medications b. Initiate the patient's plan of care c. Provide patient teaching d. Update nursing diagnoses e. Collect patient data

a/e

A woman who is a Jehovah's Witness has severe life-threatening injuries and is hemorrhaging after care accidnet. The health care provider prescribed 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood. Which action is the nurse's responsibility? - obtaining a court order to give the blood - coercing the husband into giving the blood - calling security and have the husband removed from the hospital - abiding by the husband's wishes and informing the health care provider

abiding by the husband's wishes and informng the health care provider RationaleAdult patients such as those who are Jehovah's Witnesses are able to refuse treatment for personal religious reasons.

Florence Nightingale

adaption to the environment allow for healing

Which feature is true about standing orders? -meet instrumental activities of daily living - ensure familiarity with evidence-based guidelines for nursing care -allow a quick response to a rapidly changing clinical situation - minimize documentation issues for nurse

allow a quick response to a rapidly changing clinical situation

Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe? - anxiety - glucose control - diabetes - risk of toe infection

anxiety

Which technique would the nurse use to communicate actively with a terminally ill patient? - asking closed-ended question - sympathizing with the pt - avoiding sensitive issues - asking open-ended questions

asking open-ended questions Rationale: Asking open-ended questions helps patients expand their thoughts and tell their stories.

For a student to avoid a data collectioin error, the student should - assess the pt and, if unsure of the finding, ask a facult member to assess the pt - review his or her own comfort level and competency with assessment skills - ask another student to perform the assessment - consider whether the diagnosis should be acutal, potential, or risk

assess the pt and, if unsure of the finding, ask a facult member to assess the pt data collection is an art that the nurse gets better at with experience, so asking for assistance from a colleague to help with an unsure finding can ensure that the diagnostic statement is correct

Which action would the nurse take when the patient asks for a bedpan as the nurse is reassessing the patient? - call the assistive personnel (AP) and ask him or her to bring a bedpan for the patient - Assist the patient onto the bedpan - Quickly finish the reassessement - Reassure the patient that an AP will bring a bedpan soon

assist the patient onto the bedpan

Which element of the leadership qualify of decision-making gives the registered nurse the legitimate power to give commands and make final decisions specific to a given position? - authority - autonomy - respnosibility - accountability

authority

The nurse is caring for a patient with cancer and who wants to request comfort measures from the physician. The family wants to do "everything possible". What does the nurse promote when including patients in care-planning decisions? · Accountability · Autonomy · Beneficence · Responsibility

autonomy A nurse promotes patient autonomy when including patients in care planning decisions. A nurse shows personal autonomy when standing up for his or her own beliefs.

ethical concepts in nursing autonomy accoutability advocacy responsibility beneficenc

autonomy--self-determination accountability--is willingness to accept responsbility for one's action/admit mistakes and accepts consequence advocacy isthe support or promotion of the interests of others or of a cause greater than self/stand up for the right of the pt responsility--is the concept of being dependable and reliable beneficence--involves doing good for others

Which facts must the public health nurse consider when determining any public health goal? Select all that apply. a. Progress reports need to be scheduled monthly b. Goals need to be population focused c. Community leaders need to review goal d. Goals need to be measurable e. Stakeholders need to have input

b/d/e

How does an organization define its own health? By goals and objectives By ways of living and experiences By diseases cured and satisfaction By own personal values and beliefs

by goals and objectives Organization/business define health in the context of their goals/objectives

Which risk is reduced by taking annual Papanicolaou (Pap) tests and mammograms? - Cancer - Arthritis - Dementia - Hypertension

cancer Pap is a method of cervical screening used to detect potentially precancerous and cancerous process in endo-cervical canal of the female—mammogram is an x-ray image of the human breast

In which role is the home care nurse predominantly functioning when he or she arranges for delivery of a hospital bed and commode to a patient newly discharged from the hospital to home care? · Palliative care provider · Nurse consultant · Case manager · Patient advocate

case manager

Which directional pattern of growth is seen in early infant development? Dorsolateral Ventromedial Ventrolateral Cephalocaudal

cephalocaudal head (cephalo) to tail (caudal)

The nurse has placed a patient in the Sims' position. Which areas would bear the maximum weight of the body? - Elbow - Knees - Ankles - Clavicle

clavicle Rationale: In the Sims' position, the major portion of weight is placed on the clavicle and humerus. Pressure points such as the elbows are unprotected in the supine position. The knees are unprotected pressure points in the prone position. The ankles are unprotected pressure points in the side-lying position.

Matching individuals receiving care with health and social services available in the community is a primary concern for which nurse? · Long-term care facility nurse · Community-based nurse · Public health nurse · Acute care facility nurse

community-based nurse One of the most important responsibilities of community-based nurses is to maintain current information about health and social services available within the community and match patients with services in-line with the patient's unique needs and preferences.

other ethical concepts in nursing confidentiality fidelity nonmaleficence justic veracity

confidentiality--limits sharing private pt info fidelity--to keeping promises or agreements made with others nonmaleficence--first, do no harm/provide compassionate care justice--do we implement justic when choosing which pts receive organ transplants/treat all people fairly veracity--truthfulness/honesty A nurse is ethically required to advocate for the rights of all patients, including those who are unable to express themselves and those with whom the nurse disagrees philosophically.

Which priority action would the nurse take before administering a new drug? -confer with a colleague before giving the medication - consult with a pharmacist to obtain knowledge about the medication - ask the patient about the medication -administer the medication as prescribed and on time

consult with a pharmacist to obtain knowledge about the medication

Which factor affecting growth and development is defined as the sum of beliefs and values shared and transmitted from generation to generation? Social Family Culture Physiological Psychological

culture

A nurse is assessing an eight-year-old girl in the hospital for tonic-clonic seizures. In speaking with the parents through the couple's ten-year-old son who is interpreting for them, the nurse is not sure that they understand the provider's orders for the medication the girl is supposed to receive for her epilepsy. What is the most appropriate reason the family is not compliant with the prescribed medication? Values Paradigm Beliefs Culture

culture The nurse and the girl's family have a different language, and probably a different culture. It is likely they are immigrants, given that their son knows English at least well enough to be their main communicator with the nurse, even though they do not speak the language. It is not clear whether their limited understanding of English is the only reason that prevents them from following the treatment for their daughter, but it is clear that the language difference, which is a part of culture, is a contributing factor for the lack of treatment for the daughter's seizure disorder

As a science, which component does nursing rely on? - Current research - Experience of the nurse - Unique caring relationships - Clinical knowledge

current research As a science, the field of nursing relies on knowledge gained through current research. Nursing is both a science and an art. The experience of the nurse, the unique caring relationships, and clinical knowledge are components of the art of nursing, not the science of nursing As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, nursing relies on experimental research/non-experimental research/research from other disciplineq

A patient is admitted to the hospital with SOB. As the nurse assesses this pt, the nurse is using the process of - evaluation - data collection - problem identification - testing a hypthessis

data collection assessment is the first stage of the nursing process, and is the process of gathering data to formuate the nurisng daignosis and care plan Data Clustering: a set of assessment findins/defining characteristics/compare a pt's data with info that is consistent with normal/helath pattersn Data interpretation: involves palcing a label on your data pattern or cluster to clearly identify a pt's repsonse to health problems

Which finding is an expected physical change during older adulthood? Increased peristalsis Increased skin elasticity Decreased sense of taste Enhanced light reflex in eyes

decreased sense of taste

Which term describes a transient, generally reversible and treatable cause of cerebral dysfunction? Delirium Depression Vascular dementia Alzheimer's disease

delirium

Which hormone increases blood glucose levels during physiological stress? - aldosterone - parathyroid - epinephrine - antidiuretic hormone (ADH)

epinephrine

The nurse is caring for a Muslim patient who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month, in which Muslims fast during daylight for 28 days. The nurse understands that a good diet is important for the patient's wounds to heal. What should the nurse do when planning the patient diet? - Reschedule meals - Ask the pt's closest kin to ask him not to fast - Start enteral tube feedings if the pt refuses to take food orally - Respect the cultural beliefs and assure the pt that medical needs will be taken care of - Try to convince the pt not to fast b/c it will affect recovery

eschedule meals. Respect the cultural beliefs and assure the patient that medical needs will be taken care of.

Which type of grief is exemplified when the survivor of a motor vehicle accident attempts suicide because of feeling responsible for the friend's death? - delayed - masked - exaggerated - ambiguous

exaggerated

Which criterion is used to evaluate efficacy of interventions? - consultation - critical thinking - communication -expected outcome

expected outcome

The foundation or the basis of an individual's belief system based on direct experience is what order of belief system? · Zero-order · First-order · Higher-order · Tertiary-order

first-order First-order beliefs are conscious, typically based on direct experiences and are the foundation or the basis of an individual's belief system.

Maslow's Hierarchy of Needs

from bottom to top physioloical: oxygen, fluid, shelter, food.. safety and security: pysical and psychologicla Love and belonging need Self-esteem Self actualization

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done: - logically - hapazardly - independently - systematically

hapazardly critical thinking should be done using a systematic approach, using knowledge and experience to formulate an opinionin a manner lacking any obvious principle of organization.

Factors influencing loss and grief

human development personal relationships nature of the loss coping strategies socioeconomic loss culture spiritual and religious beliefs

Which describes an example of an interpreting error in nursing diagnostics? - inaccurate data - disorganization - failure to seek guidance - inaccurate understanding of cues

inaccurate understanding of cues

A patient complains of feeling that the room is spinning when she turns her head to the side, even though she is in a prone position. What is the suspected source of this complaint? Low blood sugar Low heart rate Inner ear fluid Nasal congestion

inner ear fluid Inner ear fluid would cause balance disturbance when the head is moved quickly.

if the family of a dying patient is highly emotional and critical of the nursing care, which action by the nurse would be appropriate? - listen to concern - explain interventions in technical terms - request that the nursing supervisor talk to the family - avoid the patient's family to reduce confrontations

listen to concern

A mother finds her 26-year-old daughter unconscious at home. She is taken to the hospital by ambulance while the mother and her 1-year-old granddaughter follow. Who would be the primary source of information in this case? - Mother - Daughter - Granddaughter - Both mother and daughter

mother

When assessing a patient for stress, which symptoms might the nurse expect to see? Select all that apply. Nervousness Irritability Muscle tension Increased concentration Weight loss

nervousness irritability muscle tension weight loss

the point of the ehtical principle to do no harm is to reassure the public that, in all ways, the health care team not only works the heal patients but agree to do this in the least painful and harmful way possible. Which principle describes this agreement? - beneficence - accountability - nonmaleficence - respect for autonomy

nonmaleficence Nonmaleficence is an important concept, but can be difficult to grasp at first. It refers to the balancing the risks and benefits of care while doing least amount of harm and suffering.

Which population group is at greatest risk for opportunistic infections? · Teenagers · Young adult males · Middle-aged women · Older adults

older adults Older patients are at the greatest risk for opportunistic infections caused by harmless organisms that become pathogenic; older adults have decreased immune system function as a result of the aging process.

Which overlapping phases are concepts included in Hildegard Peplau's Theory of Interpersonal Relations? Select all that apply. Independence Orientation Resonancy Working Resolution

orientation working resolution

Which attribute reflects a change in the cardiovascular system of the older adult? Blood pressure is elevated. Orthostatic hypertension is common. Peripheral pulses are difficult to palpate. Lower extremities are colder, especially during the day.

orthostatic hypertension is common

Which chronic condition are older adults at higher risk for due to age-related changes in the musculoskeletal system? Injury Pneumonia Osteoporosis Chronic obstructive pulmonary disease Decreased bone density and bone demineralization increase the risk of osteoporosis as people age

osteoporosis

Where does the nurse access the information to contact the guardian of a patient? - Discharge summary - Nurse's admission assessment - Nurse's note - Patient care summary

patient care summary

If a child begins to make judgments and his or her thinking becomes more logical, Piaget would suggest the child is at which stage of cognitive development? Sensorimotor Preoperational Formal operational Concrete operational

peroperational During the period of preoperational thought, language becomes increasingly useful to children. Children are able to make judgements and thinking becomes more logical

Which gland in the patient's body will initiate general adaptation syndrome (GAS)? - paroitid - pituitary - pineal - adrenal

pituitary RationaleThe general adaptation syndrome is a three-stage reaction that describes how the body responds to stressors through different stages. When the body encounters a physical demand such as an injury, the pituitary gland initiates the GAS. The parotid gland secrets saliva and is not related to the GAS. The pineal and adrenal glands do not initiate the GAS.

You have finished wit several nurisng interventions to evaluate interventions, you need to examine the: - appropriateness of the interventions and the correct applicaiton of the implementation process - nursing diagnoses to ensure that they are not medical diagnoses - care planning process for errors in other health care team members' judgements - interventions of each nurse to enable the nurse manager to correctly evaluate performance

ppropriateness of the interventions and the correct applicaiton of the implementation process

A nurse in an assisted living facility is training a group of nursing students about the older adult population. She explains that sometimes as people live together in a group after living only with family for their whole lives, conflicts can arise. Some people have a preformed opinion, usually an unfavorable one, about an entire group of people that is based on insufficient knowledge or irrational feelings. What term is the nurse referring to? · Prejudice · Stereotype · Perception Observation

prejudice A prejudice is a preformed opinion, usually an unfavorable one, about an entire group of people that is based on insufficient knowledge or irrational feelings

Which pattern of development growth can be described as "from the center outward"? Mediolateral Ventrolateral Proximodistal Coronal to sagittal

proximodistal Proximo refers to an anatomical area toward the center of the body or midline/distal refers to an area away from the center of the body or midline

Critical thinking in setting goals and expected outcomes

pt collaboration is needed to better prioritize goals of care/develop a realistic and relevant plan of care interprofessional team collaboration--more complex need with chronic dz./involve complexity of skills/comprehensive care to pts/specialization expected outcomes - writing goals and expected outomes - specific/mesurable/attainable/realistic/times SMART

Which behavior is commonly exhibited by young children experiencing a stressful situation such as hospitalization? Regression Repression Sublimation Rationalization

regression Regression is a reaction where a child reverts to an earlier form of behavior due to a stressful situation

According to the philosophy of the ethics of care, which aspect is most important when solving ethical dilemmas? - pts - relationships - ethical principles - code of ethics for nurses

relationships

Patient Self-Determinant Act Omnibus Budget Reconciliation Act

requires health care institutions to provide written info to pts concerning thier rights to make decision about their care, including the right to refuse treatment, durable power of attorney for health care (DPAHC), living wills, DNR OBRA one change focused on the use of restraints intended to change older adult behavior, addressed the use of both pysicla and chemical restraint us

Which quality is most helpful in a nurse interacting with patients with different backgrounds? · Values · Self-awareness · Beliefs - Culture

self-awareness Self-awareness is the conscious knowledge of one's own character, feelings, motives, and desires. This is crucial for a nurse to establish respect for diverse patients.

Freud suggested parts of the body assume psychological significance as the focus of which type of energy? Sexual energy Sensorimotor energy Preoperational energy Formal operational energy

sexual energy

While positioning a patient with pressure ulcers, the nurse observes lateral flexion of the neck and internally rotated shoulder and hip joints. Which patient positioing would have caused the patient's position? - Prone position - Supine position - Side-lying position - Supported Fowler's position

side-lying position A 30-degree side-lying position is recommended for patients with pressure ulcers. Some trouble points are common in the side-lying position, such as lateral flexion of the neck and internally rotated shoulder and hip joints. Placing patients in the prone position may cause neck hyperflexion and hyperextension of the lumbar spine. Placing the patient in the supine position may cause extended elbows and externally rotated hips. When the patient is placed in the supported Fowler's position, he or she may suffer from increased cervical flexion and external rotation of the hips.

The nurse is caring for different patients. Which patient's condition may benefit from logrolling? - Head injury - Hand fracture - Spinal cord injury - Abdominal surgery

spinal cord injury

which statement is true about the primary nursing model? - the model has no hierarchy of communication - the model allows lateral communicaiton from nurse to nurse - the model allows a mix of communication channels - the model allows every staff member to communicate with everyne else

the model allows lateral communication from nurse to nurse The primary nursing model of care delivery was developed to place registered nurses (RNs) at the bedside and improve the accountability of nursing for patient outcomes. This model involves lateral communication from nurse to nurse. The model has a hierarchy, but the nurse can communicate with other nurses, and the caregiver can communicate with other caregivers. The model does not allow a mix of communication channels. If every team member communicated with everyone else, there would likely be miscommunication.

Delegation

the process of assigning part of your responsibility effective delegation results in the achievement of quality/safe pt care/improved efficiency/increased productivity/empowered staff/skill development Five rights of delegation - right task/circumstance/person/directions or communication/supervision or evaluation Tips for effective delegation - assess the knowledge/skills of the person - match tasks to the person's skills - communicate clearly: task, outcome, time - listen attentively - provide feedback

A pt is suffering from SOB. The correct goal statement would be written as: - the pt will be comfortable by the morning - the pt will breath unlabored at 14-18 breaths per minute by the end of the shift - the pt will not complain of breathing problems within the next 8 hours - the pt will have a respiratory rate of 14 to 18 breaths per minute

the pt will breath unlabored at 14 to 18 breaths per minute by the end of the shift critical thinking in planning nursing care -types of interventions nurse-initiated Health care provider-initiated other provider-initiated selection of interventions - desired pt outcomes -characteristics of diagnosis - research base knowledge - feasibility doing intervention - acceptability ot the pt - own competency

Which is an appropriate task for the nurse to delegate to a nursing assistant? - checking a health care provider's new prescriptions - chaning a patient's wound dressing - toileting a pt on a bladder-training regimen - taking the blood pressure of a pt who has fallen

toileting a pt on a bladder-training regimen

Which action indicates that the nurse is using physical care techniques? - meeting the patient's expressed needs - performing indirect care measure - using safe patient-handling procedures - providing a hand-off report

using safe patient-handling procedures

The belief that an object can exist even when you cannot see or hear it is which category of belief? Zero-order First-order Higher-order Tertiary-order

zero-order - Zero-order beliefs, most of which are unconscious, such as object permanence/ A zero-order belief is so foundational that a person cannot stop believing it, even with much effort. - First-order beliefs, which are conscious, typically based on direct experiences - Higher-order beliefs, which are generalizations or ideas that are derived from first-order beliefs and reasoning

Which question should the nurse ask the family of a dying parent to assess anticipatory grief? · "When dealing with your parent's illness have you been able to continue with your other life responsibilities?" · "Are you having difficulty making decisions?" · "What are you doing to care for yourself?" · "Do you feel capable to continue caring for your parent at home?"

· "Are you having difficulty making decisions?"

A nurse is measuring the height and weight of a 4-year-old child during the well-child visit. The child's parents comment that they are concerned that the child's growth seems to have slowed down since the child was a toddler. The nurse knows that this is because of which factors? · The child may be neglected at home. · The child likely has a growth disorder. · Normal growth slows down in this age group. · The child isn't taking in enough calories for their age.

· Normal growth slows down in this age group. It is normal for children to have slowed patterns of growth between age 2 and the onset of puberty. Rapid growth tends to occur during infancy/toddlerhood and puberty.

A nurse is teaching a student nurse about toxins in the home. Which statement shows a need for further teaching? "Mix household chemicals in a well ventilated area." "Wear protective clothing when spraying pesticides." "Open the windows when using household chemicals." "Poisonous chemicals should always be kept in their original containers."

"Mix household chemicals in a well ventilated area." This statement shows a need for additional teaching. Mixing household chemicals can result in toxic fumes.

A nurse is caring for a patient on bed rest. The patient does not wish to wear the sequential compression sleeves and asks the nurse why they are so important. What should the nurse say to the patient? "You need to wear them because the practitioner ordered them." "You don't have to wear them all the time, just when you are sleeping to prevent leg cramps." "They help prevent blood clots in your legs, which puts you at risk for a pulmonary embolism." "They prevent clots from traveling to your pulmonary artery, which is fatal."

"They help prevent blood clots in your legs, which puts you at risk for a pulmonary embolism." This is the correct statement. Sequential compression sleeves help prevent deep vein thromboses from forming in the legs and decrease the risk of a pulmonary embolism.

Which is the best response to a parent's concern that his 6-year-old frequently lies to get out of trouble? · "Children this age are aware of rules and should not lie." · "This is normal and you can set an example for what is right." · "Lying is expected for children this age and should be ignored." · "A school-age child may tell lies to avoid embarrassment. Strict punishment should be enforced."

"This is normal and you can set an example for what is right." The parent should be informed that lying is normal at this age and should be encouraged to set an example in order to instill values in the child.

Which statement indicates that the nurses understand the major advantage of using computerized provider order entry (CPOE)? - Transcription errors are reduced when using CPOE - The use of CPOE reduces the amount of time it takes health care providers to write prescriptions - Health care providers can write prescriptions from any computer that has internet access - CPOE reduces the time nurse use to communicate with health care providers

"Transcription errors are reduced when using CPOE."

Vulnerable populations

- Individuals living in poverty - Older adults - People who are homeless - Immigrant populations - Individuals in abusive relationships - Substance abusers - People with severe mental illnesses Pt who are abused—physical/emotional/sexual abuse/neglect are major public health problems that often affect older adults/women/children

Which statements describe the cognitive difference in regard to object permanence between a 6-month-old and a 9-month-old? Select all that apply. 1. A 6-month-old will not notice if you hide a toy. 2. A 9-month-old will look for a toy if it is hidden from view. 3. A 6-month-old will look for a toy if it is hidden from view. 4. A 6-month-old will look for the toy and will likely show no interest once the toy is found. 5. A 9-month-old will ignore the toy if it is hidden and immediately seek another object of interest.

1 2 8-9 months—will actively search for object when hidden from view (object permanent)/at 6 months the cognitive development of the child will not be mature enough to understand that the object still exists if it is hidden from view/9-months—the development of object permanence occurs in children around the age of nine months and therefore a child at this age will look for a toy if it is hidden from view

The registered nurse is teaching a nursing student about the interventions to be performed when the patient avoids moving. Which statement by the nursing student indicates a need for further learning? select all that apply 1. I should consult an occupational therapist 2 I should increase the frequency of turning 3. I should allow the pain medication to take effect 4. I should administer analgesics if the pt is in pain 5. I should educate the pt about the benefits of moving

1 2 When there is a critical situation, such as worsening of joint contractures; the nurse should consult an occupational therapist. Consulting an occupational therapist is not a correct intervention if a patient avoids moving. The nurse should increase the frequency of turning or repositioning the patient to decrease the erythema and breakdown of the skin, not if the patient avoids moving. When the patient avoids moving, the nurse should allow the pain medication to take effect before providing other treatment options. The nurse should administer analgesics if the patient is in pain, as ordered by the primary health care provider, to ensure the patient's comfort before moving. The nurse should also educate the patient about the benefits of moving if the patient is avoiding moving.

The progression of function in infants can be described by which patterns of growth and development? Select all that apply. 1. Simple to complex 2. General to specific 3. Complex to simple 4. Specific to general 5. Functional to nonfunctional

1 2 e.g., as a child develops language, their vocabulary becomes more detailed and enhanced, and similarly, an infant holds a toy in his or her hand before he or she picks up a small object with pincer grasp—simple to complex/general to specific—describes responses of infant body systems, e.g., myelination of the peripheral nerves in the neurological system becomes more developed as the infant grow, allowing the infant to crawl before walking

which common response is associated with general adaptation syndrome (GAS)? select all that apply 1. alarm 2. resistance 3. exhaustion 4. helplessness 5. intrusive recollection

1 2 3 The alarm stage: responses of fight or flight with adrenal hormones. Resistance: where the patient will show a response due to the parasympathetic nervous system. Exhaustion: may lead to stress-induced illness or death.

Which of these conditions may be mistaken for poisoning? Select all that apply. 1. Stroke 2. Seizure 3. Infection 4. Insulin reaction 5. Fatigue

1 2 4

Which factors can affect older adults' living arrangements? Select all that apply. 1. Health 2. Social roles 3. Perception of sexuality 4. Changing life circumstances 5. Family and social responsibilities

1 2 4 5

Which area of the patient would bear weight when palced in the side-lying position? select all that apply 1. Hip 2. Heel 3. Ileum 4. Shoulder 5. Humerus

1 4

Which may occur when a patient falls out of bed? Select all that apply. 1. The nurse will have to report the fall. 2. The patient's family may sue the hospital. 3. The nurse will physically restrain the patient. 4. The patient may experience significant injuries. 5. The hospital may not be reimbursed for the care the patient receives after the fall.

1 4 5 Centers for Medicare and Medicaid Services (CMS) no longer makes payments to hospitals for the cost of additional care resulting from patient falls because they are considered reasonably preventable.

Which tenets promote patient-centered care based on knowledge of the patient's culture, according to Leininger (2002)? Select all that apply. 1. Cultural maintenance 2. Cultural fixation 3. Cultural immersion 4. Cultural care accommodation 5. Cultural care repatterning

1 4 5 Madelein Leininger-Planning culturally competent care 3 types of professional action, decision-making strategies that promote pt care based on a nurse's knowledge of a pt's culture - cultural maintenance (maintain their sense of well-being) - Cultural care accommodation or negotiation--helps people of diverse cultures adapt to or negotiate with others for beneficial or satisfying health outcomes) - cultural care re-patterning or restructuring (respects the pt's cultural values/beliefs while helping pts reorder, chagne or modify their lives and adopt new and different health care patterns

A mother has brought in her infant for the infant's 6-month well-child checkup. You notice the infant's left eye intermittently not aligning with the right eye and an inability to focus both eyes on the same spot. What is the appropriate response? Select all that apply. 1. Ensure the infant's "red reflex" is normal. 2. Place the infant in isolation as this can be a sign of conjunctivitis. 3. Do nothing, as infants do not gain extraocular eye coordination until 9 months of age. 4. Stress the importance of eye exercises to help prevent worsening of the condition. 5. Notify the child's provider, as extraocular eye alignment should be achieved by 6 months of age.

1 5

Which musculoskeletal diseases are more prevalent in the older population? Select all that apply. 1. Osteoporosis 2. Rheumatoid arthritis 3. Cerebral palsy 4. Muscular dystrophy 5. Osteoarthritis

1 5

Which nursing intervention would be beneficial for older-adult patients who are diagnosed with chronic obstructive lung disease (COPD)? Select all that apply 1. Assessing for bacterial infection 2. Monitoring blood pressure frequently 3. Placing a feather pillow under the head 4. Monitoring changes in peripheral pulses 5. Monitoring respirations and breath sounds

1 5

Math the period of cognitive development with the appropriate characteristic 1. Egocentric view of the world 2. thiking is magical and dominated by perception 3. thinking becomes logical 4. situations can be analyzed a. formal operational b. peroperational c. sensorimotor d. concrete operational

1-c 2-b 3.-d 4.-a

Match the example to the correct Right of Medication Administration. 1. Nurse checks to see when the medication was last given 2. Nurse ensures the administration of the medication sublingually 3. Nurse checks the name of the person on the medication container 4. Nurse reviews the prescription to see how much medicine patient receives a. right pt b. right dose c. right time d. right route

1-c 2-d 3-a 4-b

Match the risk factor with the musculoskeletal system condition. 1. Aging 2. Disease 3. Genetic disorders 4. Developmental disorders a. muscular dystrophy b. rheumatoid arthritis c. cerebral palsy d. osteoporosis

1-d 2-b 3-a 4-c

Civil War to the Beginning of the Twentieth Century 1. Clara Barton 2. Mother Bickerdyke--Mary Ann Bickerdyke 3. Harriet Tubman 4. Mary Mahoney 5. Lillian Wald and Mary Brewster 6. Lenah Higbee 7. Mary Adelaide Nutting

1. American Red Cross Founder 2. a hospital administrator for Union Soldiers during the Civil War and a lifelong advocate for veteran--influenced nurisng during Civil War 3. American abolitionist and pilitical activist 4. firts African American to study and work as a professionally trained nurse 5. public health nursing, Hery Street Settlemtn 6. U.S. Nave Nurse Corps 7. Army and Navy Nurse Corps

The nurse is conducting a health interview for a patient. Which assessment question is an example of an open-ended question? Select all that apply 1. Did you have this problem before? 2. What do you think caused your illness? 3. How do you want us to help you with your problem? 4. How different is this problem from the one you had previously? 5. Is there someone whom you want us to talk about your care?

2 3

What are the most appropriate ways that a nurse can promote safety for a patient? Select all that apply. 1. Contact the social worker. 2. Assess risk factors. 3. Educate the patient. 4. Examine environmental concerns. 5. Contact The National Center for Health Statistics.

2 3 4

Which is an example of a ritual (normal)? Select all that apply. 1. Enculturation 2. Meditation 3. Socialization 4. Fasting 5. Reading the Bible

2 4 5

Identify the gross motor capability of the toddler. Select all that apply. 1. Riding a bicycle 2. Ascending the stairs 3. Jumping over objects 4. Hop on one foot 5. Throwing a ball overhand

2 5

A family includes a mother, stepfather, two teenage biological daughters of the mother, and a biological daughter of the father. This family belongs to which category? - A nuclear family - A blended family - An extended famil - An alternative family

A blended family A nuclear family—consists of 2 adults/one or more children - An extended family—aunts/uncles/grandparents/cousins - An alternative family—multiple-adult households/grandparents caring for grandchildren, nonfamilies/cohabiting partners

Growth and Development of the Toddler

A toddler who was 33 inches in height on his or her second birthday would be expected to measure approximately 36 inches in height on his or her third birthday. The average toddler grows approximately 3 in. (7.62 cm) each year. The toddler would therefore be expected to be 36 inches (33 + 3) on his or her third birthday A toddler who weighs 22 lbs at 1 year of age would be expected to weigh approximately 32 lbs by the third birthday. The average weight gain is 5 lb (2.26 kg) per year. Therefore, a toddler weighing 22 pounds at 1 year of age would be expected to weigh approximately 32 pounds (22 + 5 + 5) by the third birthday

Which intervention is classified as an active strategy of health promotion? - Fortification of milk with vitamin D - Fluoridation of municipal drinking water - A weight reduction program for obese people - Fortification of cereals with vitamin A

A weight reduction program for obese people

A nurse is caring for a pt who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: - living wills - assisted suicide - passive euthanasia - advance directives

Advance directives advance directives are written documents that outlay the pt's wishes, should he or she become incapacitated

Which entity publishes and updates the Standards of Nursing Practice? American Nurses Association Each state or jurisdiction International Council of Nurses National League for Nursing

American Nurses Association The Standards of Nursing Practice are published and updated by the American Nurses Association to ensure quality care, and serves as legal criteria for adequate patient care.

When does the anterior fontanelle close? - Btw 1-6 months - Btw 6-12 months - Btw 12-18 months - Btw 18-24 months

Btw 12-18 months Before 12 months, the skull bones and sutures are too tender to ossify and close. By 18 months of age, the skull bones usually ossify, and it is too late for a fontanelle to close after that. The posterior fontanelle closes by the endo of the second or third month

What is the process of physical growth in boys and girls from early school-age to age 12? By age 10 boys are heavier and taller than girls. By age 12 girls are taller and heavier than boys. Boys are shorter than girls during early school-age but are the same weight. Girls are heavier than boys during early school-age but are the same height.

By age 12 girls are taller and heavier than boys.

Which action should the nurse take to incorporate QSEN's guidelines into patient care while providing tertiary prevention? Coordinate a flu shot clinic for patients of all ages Collaborate with patient, family, and health care team to develop a care plan Ensure sensitivity to the patient's needs while providing individualized screening Base a patient's physical and emotional care solely on the primary care provider's orders

Collaborate with patient, family, and health care team to develop a care plan

Which factor is an essential requirement for implementing evidence-based (EBP) in personal practice or within the health care department or organization? Interdisciplinary education Self-regulation Self-evaluation Collaboration

Collaboration

Which nursing proficiency is defined as being able to anticipate nursing care and establish long-range goals? Expert Competent Advanced beginner Proficient

Competent The competent nurse is one who has been working in the same clinical position for 2-3 years/Competent nurses are able to anticipate nursing care and establish long-range goals.

You are caring for a pt who is depressed b/c the only child has gone away to college. The nurse will assess this type of depression as A. acutal loss B. perceived loss C. situation loss D. mautraitonal loss

D

A patient has been admitted after falling at home and breaking an arm. When asked about the trip and fall hazards in the home, the patient states the home has hardwood flooring and area rugs in the main rooms. What additional question should the nurse ask to ensure the flooring is safe? Do you have nightlights in all your hallways? Are there handrails on the stairs? Do the area rugs have rug pads underneath them? Is there adequate lighting by the stairs?

Do the area rugs have rug pads underneath them? It is essential to ascertain if the area rugs in the patient's home have non-slip rug pads beneath them.

Which one of the following developmental characteristics explains why a toddler frequently uses the words me, I, and mine? Animism Ritualism Negativism Egocentrism

Egocentrism Egocentrism is when a toddler views everything in relation to self and is unable to consider another's point of view, and it explains why the predominant words in the toddler's language are me, I, and mine

Regardless of how it is defined, nursing is described as which kind of profession? Holistic Compassionate Collaborative Feeling

Holistic Regardless of who or which entity defines nursing, nursing is described as a holistic profession that addresses the many dimensions necessary to fully care for patients.

What is meant by "Magnet status"? Agency recognized by the Centers for Medicare and Medicaid Services as a Center of Excellence Hospital which has met a set of criteria that measures the quality of nursing care Facility that is fully staffed with a nurse-patient ratio of 1 to 4 or better Institution that attracts and retains highly-qualified professional staff

Hospital which has met a set of criteria that measures the quality of nursing care Magnet status refers to a hospital that has met a set of criteria developed by the American Nurses' Credentialing Center, which measures the strength and quality of nursing and has been awarded Magnet recognition as a result.

The nurse is caring for an older female patient with recent stroke. In the shift report, the nurse learns that the patient has right-sided hemiparesis. What does this mean? Impaired movement of the right side No movement of the either side No movement of the right side Impaired movement of the left side

Impaired movement of the right side Right-sided hemiparesis is impaired movement of the right side, and is a result of brain injury of the left side of the brain.

Which symptom is present in the patient with Presbycusis? - Impairment in the ability to hear high-pitched sounds - Difficulty in distinguishing between dark colors such as blue and black - Difficulty in vision when moving from bright to dark environments - Decline in the ability of the eyes to accommodate from near to far vision

Impairment in the ability to hear high-pitched sounds Difficulty in vision when moving from bright to dark environments—reduced ability to adapt to abrupt changes from dark to light areas - Decline in the ability of the eyes to accommodate from near to far vision—presbyopia

Which is a preventative measure to ensure child safety? Store bullets with the firearm. Use helmets while riding in the car. Secure netting above a trampoline. Keep firearms locked in a secured location.

Keep firearms locked in a secured location. Firearms should be unloaded and locked in a secured location.

Which caring process would be included in Swanson's theory? - Bias - Knowing - Doing for - Being with - Randomization

Knowing Doing for Being with The caring processes of Swanson's theory of caring include knowing, doing for, and being with. Knowing helps to understand an event and adds meaning to life. Doing for a patient is comforting to the patient. Being with a patient provides emotional support to the patient. Bias and randomization are not part of Swanson's theory

Which statement about Kohlberg's theory of moral development is accurate? - Stage 3 and 4 are found in the Postconventional level - The theory expands upon Freud's psychoanalytic theory - Kohlberg identified six stages of moral development under three levels - This theory is especially useful for understanding children under the age of 4

Kohlberg identified six stages of moral development under three levels Pre-conventional level conventional level Post-conventional level Moral development—Kohlberg's six stages o From Jean piaget Stage 1: obedience and punishment Stage 2: self-interest Stage 3: interpersonal accord and conformity (not get involve, want others see she is a good girl) Stage 4: authority and maintaining social order—teacher sees the group fighting, he immediately steps in and shouts: "STOP." Stage 5: social contract—he punched a young girl form grade one. She asks herself: Does a rule truly serve all members of the community? Stage 6: universal ethical principles

Which factor, aside from educational level and socioeconomic status, affects a pt's compliance w/a prescribed course of therapy? - Gender - Lifestyle - Motivation - Family history

Motivation However, motivation can be influenced by a variety of factors, including age, experience, family history, social support, and pressure from health care providers

What important parental guidance advisory needs should caregivers be reminded of when discussing motor development in the toddler? Encourage the toddler to walk because he or she will fall down when running. Keep the toddler in a crib until 3 years of age, even if he or she tries to climb out. As motor development increases, allow the toddler to use a toothbrush unsupervised. Motor development in this age group is far ahead of development of judgment and perception.

Motor development in this age group is far ahead of development of judgment and perception.

What is the Subjective Global Assessment (SGA) tool used to predict? Protein calorie needs Nutrition-related complications Optimal weight ranges Body mass index

Nutrition-related complications The SGA tool predicts nutrition-related complications.

The nurse is caring for four patients with immobility from different conditions.Which patient would the nurse place in the side-lying position? Patient A: pressure ulcers Patient B: Respiratory distress Patient C: Deep vein thrombosis Patient D: Musculoskeletal complications

Patient A

The nurse is assisting a patient in the supported supine position. Which nursing action would the nurse implement reduce the rotation of the hip? - Placing pillows under teh upper shoulders - Placing pillows under the pronated forearms - Placing small rolled towel under the lumbar area of back - Placing trochanter rolls parallel to the lateral surface of the thighs

Placing trochanter rolls parallel to the lateral surface of the thighs

The nurisng student is performing range-of-motion (ROM) exercises for a patient who has been immobile for an extended period. Which action performed by the nursing student needs correction? - Performing ROM exercises when the pain score is 2 - Performing ROM exercises 5 times during a session - Performing ROM exercises from smaller joints to larger joints - Performing ROM exercise by extending the joint as much as possible

ROM exercises from small joints to larger joints The nurse should perform the ROM exercises from larger joints to smaller joints. Because a pain score of 0 is not possible, a pain score 2 is considered as a minimum in which ROM exercises can be performed. The movements should be repeated 5 times during each session. The joint can be extended as much as possible, but it should not be extended beyond resistance, and force should not be applied to perform the ROM exercises.

Which is true of racism? · Racists are individuals who fight against discrimination and persecution. · Research has demonstrated that some races are culturally superior to others. · Scientific evidence suggests that some races are psychologically inferior, but adaptations can be learned. · Racism is the belief that one race is superior or inferior to another.

Racism is the belief that one race is superior or inferior to another.

What should the nurse wear when working with patients with radioactive implants? Padded mitts Sterile gown and gloves Radiation-monitoring badge Personal protective equipment

Radiation-monitoring badge All personnel who work with radiation should wear a radiation-monitoring device to monitor cumulative radiation exposure. Staff should wear lead shields and patients should also be shielded, except for those areas that are purposely exposed for radiological examination. Staff should be kept as far as possible from the radiation source and the length of exposure limited. Health Care professionals working with radiation should wear a radiation-monitoring device that is periodically checked for cumulative radiation exposure level.

Which indoor environmental factor can negatively affect a person's health? Radon exposure Absence of gang activity Nonsmoking household Municipal waste disposal practices

Radon exposure Radon exposure is an indoor environmental factor that can negatively affect a person's health by increasing the likelihood of respiratory illnesses

How can the parent-infant attachment be strengthened immediately after birth? The mother needs to have time alone to ensure she does not overwhelm the child. A mother should cuddle with the baby but allow the child to cry alone if the baby is upset. The mother should give the infant some space to allow for natural biological development. Reciprocal interactions that include holding the child, touching the child, and speaking gently to the child.

Reciprocal interactions that include holding the child, touching the child, and speaking gently to the child. This is an example of how the parent-infant interaction can be strengthened after birth and therefore a lot of positive physical and emotional interactions btw the parent and child should be encouraged

Which statement describes research use in nursing? Research evidence from one or two studies is applied to clinical nursing care. Data from related research studies are compiled to guide nursing care. Practicing nurses are involved in the development of research studies focusing on clinical questions. Findings from multiple studies serve as the basis for standardized clinical procedures.

Research evidence from one or two studies is applied to clinical nursing care. Research use in nursing is the application of evidence from a single study, one or two studies, or a very small group of research studies to the provision of clinical nursing care.

The nurse is providing care to a newborn whose sibling passed away during infancy due to unknown causes. Which nursing diagnosis related to the newborn's safety should the nurse include in the plan of care? Risk for Aspiration Compromised Family Coping Dysfunctional Family Processes Risk for Sudden Infant Death Syndrome

Risk for Sudden Infant Death Syndrome Risk for Sudden Infant Death Syndrome is an appropriate nursing diagnosis for the newborn that lost an older sibling in death from unknown causes during infancy.

Which is the primary category of home care nursing intervention being addressed when the nurse suggests that throw rugs be removed from an older adult patient's home? Patient education Risk management Service coordination Disease management

Risk management Implementation and evaluation—interventions commonly implemented in home care nursing include pt assessment, education, risk management, disease management, referrals, and coordination of services btw agencies Throw rugs are a safety hazard particularly for older adults, who frequently have some eyesight impairment, and difficulty with balance and walking. Thus, suggesting removal of throw rugs, which increase the risk of tripping and falling, is a risk management intervention.

Children in which age-group are in the industry versus inferiority stage of Erikson's psychosocial development? - Toddler - Adolescents - School-age children - Preschoolers

School-age children Toddler—autonomy stage of Erikson's psychosocial development/develop autonomous behavior - Adolescents—use cliquish behavior/may be intolerant of differences - School-age children--industry vs. inferiority - Preschoolers—tend to learn new things/take the initiative

A nurse has been caring for a patient on bed rest for the last several days. The patient has been calm and cooperative. Today, however, the patient is angry and upset about being woken up every night. The nurse suspects the patient may be developing which problem? Sensory deprivation Sleep pattern disturbance Feelings of isolation Confusion

Sleep pattern disturbance The patient is probably developing sleep pattern disturbance, due to disruptions to the patient's sleep for care and treatments at night.

Lee tells his instructor about this issue. His instructor advises him that the ethics committee would be a good place to share this issue. What is the purpose of the ethics committee within a health care organization? (Select all that apply.) A. Ethical case consultation B. Recommendation of policies and procedures related to ethics C. Provision of multidisciplinary input D. Reprimanding of caregivers in ethical issues

a b c an ethics committee is an advisory committe that reviews, on request, ethical or moral questions that may come up during a pt's care. Committe members include doctors, nurses, social workers, an attorney, a chaplain

Which essential functions of public health nursing are directly or indirectly involved when a public health nurse speaks to members of the city council about the need for, and benefits of having parks and playgrounds within the city limits? Select all that apply. a. Education b. Promotion of healthy lifestyles c. Coordination of services d. Consultation with public entities e. Participation in regulation

a/b/d

Which basic components are included in the EBP process? Select all that apply. A. Assessing the need for change B. Critically appraising the evidence C. Determining a plausible hypothesis D. Identifying applicable variables E. Designing change for practice

a/b/e Assessing the need for change and identifying a problem/Linking the problem with interventions and outcomes by formulating a well-built question to search the literature: P-population, I-Intervention, C-Compare to another intervention or standard of care, O-outcome/Identifying articles and other evidence-based resources that answer the PICO question/Critically appraising the evidence/Synthesizing the best evidence/Designing a change for practice/Implementing and evaluating the change by applying the synthesized evidence/Integrating and maintaining change while monitoring processes and outcomes by reevaluating the application of evidence and assessing areas for improvement.

Concept mappin is one way to - a connect concepts to a cetnral subject - relate ideas to pt health problems - challenge a nurse's thinking about pt needs and problem - graphically display ideas by organizing data - all of the above

all of the above concept mapping helps the busy nurse, with numerous pts, focus on healing pts on an individual basis

Which descriptive phrase best fits the role of the registered nurse in home health care? · Completely supervisory · Essentially autonomous · Basically consultative · Primarily advisory

essential autonomous

Ethical dilemma often arise over a conflict of opinion. Which action is the critical first step in negotiating differences of opinion? - consult a professional ethicist to ensure that the steps of the process occur in full - gather all relevant info regarding the clinical, social, and spiritual aspects of the dilemma - ensure that the attending physician or health care provider has written an order for an ethics consultation to support the ethics process - list the ethical principles that info the dilemma so negotiations agree on the language of the discussion

gather all relevant info regarding the clinical, social, and spiritual aspects of the dilemma

the nursing process organizes your approach to delivering nursing care. To provide care to your pts, you will need to incorporate nursing process and - decision making - problem solving - interview process - intellectual standards

interview process this is an integral part of pt-centered care, and is continuous throughout pt interaction, regardless of the stage of the nursing process Assessment process -data collection: use info aobut pt's needs to adapt your data collectioin - interpretation critically interpret assessment data to determine whether abnormal findings are present cues/inferences -validation: coomparison of data with another source to determine data accuracy

which principle of health ethics refers to the avoidance of harm or hurt? - justcie - autonomy - beneficence - nonmaleficence

nonmaleficence Nonmaleficence is the act of avoiding harm or hurt to the patient. Justice refers to the promotion of open discussion whenever mistakes occur, or nearly occur, without fear of recrimination. Autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient's independence. Beneficence refers to taking positive actions to help others

Types of assessments

pt-centered interveiw (history) periodic assessment (during ongoing contact w/pts) physical examination (during nursing hx/at any time a pt presents a symptom) types data - subjective: pt's verbal/self-reported symptoms -objective: labs, exam etc. data sources: pt/family/caregivers/medical records/health care team/scientific literature/nurses' experience communication skill: courtesy/comfort/connection/confirmation

In which stage of mourning described by Bowlby's attachment theory does a person accept change, acquire new skills, and build new relationships? - numbing - reorganization - yearning an dsearching - disorganization and despair

reorganization In the reorganization stage of mourning, the person accepts change, acquires new skills, and builds new relationships. In this stage the person is trying to create separation from a lost relationship. In the numbing stage, the person feels unreal. In the yearning and searching stage, the person experiences an inner and intense yearning for the lost person. In this stage the person also shows some physical symptoms. In the disorganization and despair stage, the person extends blame and expresses anger towards anyone who is responsible for the loss.

Which characteristic may help an individual identify with a particular ethnic group? · Gender · Socioeconomic status · Skin color · Birth place

skin color An individual may identify with a particular ethnic group based on skin color b/c membership often is based on national origin

Erikson viewed development as a lifelong series of conflicts affected by which factors? Social and cultural Ecological and physical Biological and psychological Educational and environmental

social and cultural Development is a lifelong series of conflicts affected by social/cultural factors and that each conflict must be resolved for the child and adult to progress emotionally Stage of development according to Erikson with the corresponding age group Trust vs. mistrust—infancy Autonomy vs. shame—toddlerhood Initiative vs. guilt—preschool age Industry vs. inferiority—school age Cognitive development according to Piaget with the corresponding age group Birth-2 years—sensorimotor 2-7 years—per-operational thought 7-11 years—concrete operations 11 years-adulthood—formal operations

Which positioning aid prevents external rotation of the hips when the patient is in the supine position? - Thin pillow - Thick pillow - Trapeze bar - Trochanter roll

trochanter roll Rationale: A trochanter roll prevents external rotation of the hips when a patient is in the supine position. A thin pillow or thick pillow would not be helpful for preventing the external rotation of the hips, but may lead to increased flexion when the appropriate pillow size is not taken. The trapeze bar allows the patient to raise the upper extremities to raise the trunk off the bed, which helps in decreasing the shearing action from sliding across or up and down the bed.

A patient who received penicillin developed a rash on the right hand. The patient asked the nurse why the rash developed. How would the nurse explain this to the patient? - Create his or her own explanation - Inquire why the patient is concerned - Use previous knowledge - Find out which health care provider prescribe the drug

use previous knowledge

A typical dietary pattern for optimal growth and development includes which proportions of fat, carbohydrate, and protein? · 20% fat, 50% carbohydrate, and 30% protein · 50% fat, 30% carbohydrate, and 20% protein · 15% fat, 35% carbohydrate, and 50% protein · 40% fat, 40% carbohydrate and 20% protein

· 20% fat, 50% carbohydrate, and 30% protein

What is descriptive epidemiology? · Descriptive epidemiology is concerned with the causes of disease. · Descriptive epidemiology is the study of the "who, when, and where" of disease occurrence. · Descriptive epidemiology determines how to limit disease in a specific population. · Descriptive epidemiology is concerned with hypotheses about why a disease is occurring in a population.

· Descriptive epidemiology is the study of the "who, when, and where" of disease occurrence.

A nurse is attempting to prepare a patient for a procedure that the patient does not wish to proceed with. Which response demonstrates advocacy? · Reporting the patient to his family. · Informing the physician that the patient does not wish to proceed. · Have the patient sign consent, but inform the next nurse that the patient is unsure. · Tell the patient that failure to perform the procedure will result in denial of payment by insurance.

· Informing the physician that the patient does not wish to proceed.

Which statement reflects a child's ability to develop autonomy according to Erikson? · The child learns to do chores. · The child is able to pour milk from a cup. · The child speaks in an appropriate tone of voice. · The child no longer cries when taken from the mother.

· The child is able to pour milk from a cup. Erikson suggested that, for a toddler, one important developmental task is to acquire a sense of autonomy rather than a sense of shame and doubt.

Which statement by a student demonstrates accurate understanding of a "competent" nurse, according to Benner's Novice to Expert Model? "A role model with a vision of what is possible" "The nurse who doesn't need rules or guidelines" "One who can use experiences to make decisions" "A nurse who uses more analytical thinking

"A nurse who uses more analytical thinking" The nurse who uses more analytical thinking describes the competent nurse, according to Benner's theory.

A nurse is teaching a student nurse about The Joint Commission's National Patient Safety Goals. Which statement shows further teaching is needed? "Before administering medication, I will ask for the patient's name." "Prior to surgery, I will mark the patient's body where surgery is to be completed." "I will label all unlabeled medications in the medication supply area before a procedure." "Remind patients to bring their up-to-date medication list every time they visit their health care provider."

"Before administering medication, I will ask for the patient's name." This statement shows that further education is necessary. Nurses should always properly identify patients by asking them for two forms of identification, such as their name and their date of birth, to ensure that each patient gets the correct medicine and treatment.

A parent reports concern that her preschool child is not as coordinated at sports as other children. Which statement by the nurse is most appropriate to address this concern? "All children should be at the same level by 4 years old." "Children develop differently and practicing will help." "This sounds like a balance problem that needs follow-up." "Your child should be able to throw and catch a ball by now."

"Children develop differently and practicing will help." This is the most appropriate statement to address the parent's concern because as long as the child has met critical motor milestones, other motor skill ability varies widely among children and practice may improve skills.

Which question should the nurse ask a teenager that shows she understands the unique risk factors for this age group? "Do you text while driving?" "Do you know how to swim?" "Do you work in a dangerous environment?" "Does your home contain furniture with sharp corners?"

"Do you text while driving?" One of the greatest risk factors for teenagers is motor vehicle accidents are related to distracted driving.

Which statement by the nurse when giving report on a Middle Eastern patient shows cultural competence? "He missed breakfast and I offered him a sausage biscuit." "You'll notice that he doesn't tell his wife anything about his illness; I think they are having problems." "He doesn't wear deodorant but he has a fever, so you may notice a slight odor despite his morning bath." "He doesn't talk much; he usually just nods to let you know he understands."

"He doesn't wear deodorant but he has a fever, so you may notice a slight odor despite his morning bath." Middle Eastern individuals may recognize natural body odor as normal and avoid wearing deodorant mask them

Which report by a parent would indicate normal social development of the 2-year-old patient? "He doesn't care at all when I leave him." "He only talks to himself, and not to me." "I never really know what he is saying to me." "He will play next to another child and watch the child, but won't interact with the child."

"He will play next to another child and watch the child, but won't interact with the child." Playing beside other children, or parallel play, indicates normal social development of the toddler.

Which patient statement made in response to an assessment question about coping indicate the patient's ability to cope with a current stressor? "I love my new job but the commute is too long." "I am much more relaxed now that I am retired." "I have reached out to human resources to get information on flexible hours to help my commute at my new job." "I am falling behind on my work because of problems at home."

"I have reached out to human resources to get information on flexible hours to help my commute at my new job."

The nurse is educating a patient about fire safety in the home. Which response would indicate that the patient needs further education? "All the electrical outlets have covers on them." "I like to shave with my electric razor when I am in the tub." "There is a fire extinguisher in the kitchen." "I have smoke detectors in each room."

"I like to shave with my electric razor when I am in the tub." Using an electric razor while in the bath tub is an electrical safety hazard and the patient should be counseled not to use electrical appliances around water.

A bedridden patient is refusing to drink any fluids because of the fear they will have to use the bedpan. What should the nurse say to the patient? "I understand you don't like using the bedpan; however, if you don't drink anything, I will have to put an IV catheter in you." "I understand you don't like using the bedpan; however, drinking fluids helps prevent urinary tract infections and constipation." "I understand you don't like using the bedpan; however, drinking fluids is really important to prevent blood from pooling in your legs and clots from forming." "I understand you don't like using the bedpan, so let's see if you can use a bedside commode."

"I understand you don't like using the bedpan; however, drinking fluids helps prevent urinary tract infections and constipation." Acknowledging the patient's dislike of the bedpan is important, and explaining why the fluid is necessary allows the patient to make a better informed decision about drinking the fluids.

A student nurse is learning about fire emergency response using the RACE acronym. When asked about the action steps for the "C", which response by the student nurse indicates understanding of RACE? "I will control the fire with an extinguisher." "I will continue to rescue patients from the building." "I will confirm that there is a fire and confine the fire." "I will contain the fire by closing doors and confining the fire."

"I will contain the fire by closing doors and confining the fire." The "C" in the acronym RACE stands for contains the fire by closing doors, confining the fire, and preventing the spread of smoke. Rescue, Alarm, Contain, Extinguish

A nurse is teaching a nursing student about seizure precautions. When asked how to address a person having a seizure in the community, which response indicates that the nursing student understands the teaching? "I will go get professional medical help for the individual." "I will look for a medical ID bracelet with seizure instructions." "I will give other people standing around tasks to perform to help out." "I will wait for the person to recover from the seizure before calling for help."

"I will look for a medical ID bracelet with seizure instructions." Looking for a medical ID bracelet with seizure instructions is the appropriate response that indicates understanding of teaching.

While caring for a comatose patient, a nurse asks a new graduate nurse what the Braden Scale is used for. Which response indicates that the new nurse understands the purpose of the Braden scale? "It is an inexpensive tool that can predict nutrition-related complications." "It is a standardized tool used to identify protein-energy malnutrition." "It is a standardized tool used to identify patients at risk for pressure ulcers." "It is a numerical scale that assists the patient with identifying his or her level of pain."

"It is a standardized tool used to identify patients at risk for pressure ulcers." The Braden Scale is a standardized tool used to identify patients at risk for pressure ulcers.

A nurse is teaching a family about safety interventions for seizure patients. Which statement by a family member shows the need for further education? "Tight clothing must be loosened, especially around the neck." "Turning the person on their side prevents aspiration if vomiting occurs." "It is important to lay the person on the ground with a pillow under their head." "It is important to place something in the patient's mouth to prevent tongue swallowing."

"It is important to place something in the patient's mouth to prevent tongue swallowing." This statement shows a need for further education. Nothing should be inserted into the patient's mouth during a seizure as this action can damage the patient's teeth or obstruct the patient's airway. Fire alarm change every 6 months

A nurse is teaching a student nurse about safety concerns in communities. Which statement shows a misunderstanding? "Proper safety gear should be used when operating power tools." "Weather should be taken into consideration when riding a bicycle." "Risk of injuries can be minimized through education programs for skating." "Lawn mowers should only be operated while wearing steel-toed shoes."

"Lawn mowers should only be operated while wearing steel-toed shoes." This statement shows a need for additional education. Lawn mowers should be operated while wearing sturdy laced or Velcro non-slip shoes. Steel-toed shoes are not a requirement.

Which false assumption of childhood that adults need to resolve during their lifetime does Gould identify? "Death and evil are real." "Life is simple and I can control it." "Bad things do not happen to good people." "I will be able to live with my parents until I am financially stable."

"Life is simple and I can control it." Gould (1979) also identifies the following four false assumptions of childhood that adults need to resolve during their lifetimes: "I'll always live with my parents and be their child." "I'll always be there to help when my parents can't do things on their own." "Life is simple, and I can control it." "Death and evil are not real."

Which communication statement indicates a defensive response? - No one here would intentionally lie to you - This work is incomplete, and it's all your fault - Things are bad, and there's nothing I can do about it - How can you say you didn't sleep when I heard you snoring all night?

"No one here would intentionally lie to you."

A nurse is teaching a student nurse about medication administration errors. Which statement from the student nurse shows a need for further education? "Confusion between sound-alike or similarly spelled drug names cause many medication errors." "46% to 56% of medication errors occur during transfers from nurse to nurse across units and across settings." "Over half of all medication errors occur due to nurses being called away while preparing an insulin injection for a patient." "Nurses may miscalculate the number of tablets for a medication dose due to a patient's IV pump alarm beeping."

"Over half of all medication errors occur due to nurses being called away while preparing an insulin injection for a patient."

Which statement indicates prejudice (bias)? "People of Muslim background are terrorists." -as it devalues an entire culture "Asian people tend to be very stoic." "Patients are unhappy being hospitalized." "Hispanic people know more than Chinese people."

"People of Muslim background are terrorists." as it devalues an entire culture

Which instructions by the nurse would be appropriate for the school-age child who is active in sports? "As long as it isn't hot, you can play." "Rest often and drink plenty of water." "If you are sweating, then take a break." "Stop playing sports when you feel tired."

"Rest often and drink plenty of water." Resting and staying hydrated are important to prevent dehydration and would be appropriate instruction for the school-age child who is active in sports.

The nurse is asking the patient a series of questions about the patient's activities of daily living. The patient asks the nurse why that information is important. What is the nurse's best response? "The answers to these questions will help us determine if you need any assistance at home." "This information will help your provider determine if you need to be placed in a skilled nursing facility." "The questions are designed to get you to think about going home from the hospital." "We use this information to determine if you live in an unsafe environment."

"The answers to these questions will help us determine if you need any assistance at home." The purpose of the questions is to assess the patient's need for assistance at home and ensure the patient's safety.

Which responses would the nurse make to help a patient move through the stages of change when the patient states, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" - "Walking is okay, but I really think running is better because it burns more calories." - "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" - "Yes, I want you to begin walking. Walk for 30 minutes every day, and eat more fruits and vegetables." - "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes walking if you are going to do any good."

- "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?"

Which intervention performed by the nurse would require an order from a health care provider? select all that apply 1. Getting an x-ray of the chest to rule out pulmonary complications 2. Administering an antibiotic to prevent infection 3. Starting an intravenous (IV) infusion of normal saline 4. Instructing the patient to splint the incision when coughing 5. Teaching the patient about the side effects of the medication

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Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital? select all that apply - Check the hospital procedure manual to obtain more information - Request the unit manager assign the procedure to another student nurse - Ask an experienced nurse for supervision and guidance during the procedure - Verbalize the steps of the procedure with an instructor before performing it - Refuse to perform the procedure

- Check the hospital procedure manual to obtain more information - Ask an experienced nurse for supervision and guidance during the procedure - Verbalize the steps of the procedure with an instructor before performing it

Both pt-centered/cultural competence aim to improve health care quality Which student nurse statement regarding cultural competence indicates a need for further teaching? - Culturally competent organizations adapt diversity - Culturally competent organization conduct cultural self-assessment - Cultural competent organizations institutionalize cultural knowledge - Culturally competence organizations manage the dynamics of homogeny

- Culturally competence organizations manage the dynamics of homogeny NOT HOMOGENY a culturally competent organization adapts to diversity to provide meaningful and supportive care for all pts. it encourages the health care providers to conduct cultural self-assessment to understand pts' world views. It also institutionalizes cultural knowledge to gain sufficient comparative knowledge of diverse groups, including the values/health beliefs/care practices/world views/bicultural ecologies commonly found w/in each group

Three levels of prevention

- Primary o Goal to reduce/prevent disease § Immunization · Includes all health promotion efforts/wellness education activities that focus on maintaining or improving the general health of individuals/families/communiteis § Exercise plan to reduce cholesterol to prevent heart disease/safe water/safe food handling - Secondary o Prevent spread of disease, illness, or infection once it occurs § Annual screening for cholesterol, blood sugar/identify and screen high risk groups for exposure § E.g., identifying people who have a new case of a disease or following people who have been exposed to a disease but do not have it yet—including screening techniques/treating early stages of disease to limit disability by averting or delaying the consequences of advanced disease · E.g., a nurse screens a pt who is obese for diabetes. After gathering more info from the pt, the nurse provides health education about physical activity/preventing HTN - Tertiary o Reducing complication of long-term disease and disability through treatment and rehabilitation o It occurs when a defect or disability is permanent and irreversible § E.g., pt with a spinal cord injury undergoes rehabilitation to learn how to use a wheelchair/perform activities of daily living independently—this helps pts achieve as high a level of functioning as possible

General adaptation syndrome (GAS)

- alarm stage (fight or flight) - resistance stage - exhaustion stage - immune response - reaction to psychological stress: coping and defense mechanisms

The RN comes on shift and goes in to do primary assessment on the patient. The nurse assesses the patient with a history of multiple sclerosis lying in bed and notices a wheelchair at the bedside. The patient reports tiredness from physical therapy. Which nursing diagnoses could be identified from this assessment? Select all that apply. 1. Impaired Physical Mobility 2. Impaired Skin Integrity 3. Pain 4. Activity Intolerance 5. Constipation

1 2 The patient is always in bed or in a wheelchair with constant pressure on the coccyx, and is therefore at risk for pressure ulcers. The patient is restricted to the bed and requires assistance out of bed and with movement. The patient is also wheelchair-dependent when out of bed. Activity intolerance as evidenced by increased oxygen requirements or increased heart rate during activity was not reported or observed. The patient did not report any pain.

A nurse working at a rehabilitation center has a patient who is paralyzed from the waist down. The patient needs assistance with mobility, bathing, and other activities of daily living (ADLs). Which helpful resources related to safety and injury prevention will the nurse coordinate? Select all that apply. 1. Obtaining a health aide when family members are not available to assist to the patient 2. Ordering assistive devices such as a bath stool, hand held shower nozzle and grab bars for the patient 3. Discussing options available for handicap transportation services so that the patient can get to physical therapy and other appointments 4. Helping the family find a therapist to assist in the adjustment to the patient's injury 5. Preventing the patient from using anything that is sharp

1 2 Transportation services, while needed, are not related to patient safety and injury prevention. Preventing the patient from using sharp objects is unrealistic and is not age-appropriate.

A nurse is caring for a child who unintentionally came in contact with a poisonous plant. Which findings would be concerning during her assessment? Select all that apply. 1. A red, itchy rash 2. Nausea and vomiting 3. Swollen lips and tongue 4. No urine output for 2 hours 5. Crying when the nurse walks into the room

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The nurse, after administering antibiotics, is updating a patient's chart in the emergency department. Which element of the report does the nurse accurately document to limit nurisng liability in case of a legal claim? select all that apply 1. current medicaitn given 2. discountinued medications 3. drug allergies 4. name of drug manufacturer 5. size, shape, and color the pills

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Which action would the nurse take when the patient who is nothing by mouth (NPO) (no food or fluids allowed) develops an adverse reaction to a new intravenous (IV) drug? select all that apply 1. Record the reaction 2. Stop further administration of the drug 3. Notify the health care provider 4. Start oral medication 5. Stop the medication and administer it again after the reaction subsides

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Which disorders decrease the body's ability to deliver oxygen and nutrients to body organs? Select all that apply. 1. Heart failure 2. Peripheral vascular disease 3. Chronic obstructive pulmonary disease 4. Diabetes mellitus 5. Renal failure

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Which features describe the anticipated physical changes of older adulthood? Select all that apply. 1. Decreased sense of taste 2. Diminished sense of smell 3. Decreased rate of nail growth 4. Increased accommodation noted in eyes 5. Spotty pigmentation of skin, regardless of sun exposure

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Which musculoskeletal conditions does immobility predispose a patient to developing? Select all that apply. 1. Weakness 2. Decreased muscle tone 3. Decreased muscle mass 4. Increased bone mass 5. Decreased joint pain

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Which patient statement would lead the nurse to conclude that the patient has barriers to health care services? select all that apply 1. I live from paycheck-to-paycheck 2. I do not believe in insurance policies 3. I drive 40 minutes to the nearest hospital 4. I pay $15 for my co-pa to a doctor's office 5. I sell my primary care provider on a regular basis

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Which physical changes are experienced by girls during the adolescent years? Select all that apply. 1. Menarche 2. Pubic hair growth 3. Breast development 4. Formation of ovaries 5. Decrease in adipose tissue

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Which social/personal skills are milestones for the preschool child? Select all that apply. 1. Caring for a doll 2. Dressing oneself 3. Personal hygiene 4. Identifying the color blue 5. Naming four familiar pictures

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Which sources of internal conflict prevent adults from progressing through the developmental stages of Gould's transformation? Select all that apply. 1. Denial of reality to protect oneself from pain 2. Reluctance to fully commit due to fear of abandonment 3. Maintenance of work-life balance 4. Arguments with an unhappy colleague or supervisor 5. Economic pressures resulting in reduced hours due to a recession

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Which tasks describe nursing roles for an evidence-based approach to Grace's needs? Select all that apply. You are the family nurse assigned to assist Michael and Grace. 1. Reviewing clinical research on caregiver stress 2. Performing a self-assessment of nurse's clinical skills 3. Communicating with Grace about how she deals with stress 4. Discussing Grace's behavior with neighbors 5. Scheduling an intervention for Grace before discussions

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Which false assumptions of childhood that adults need to resolve during their lifetime did Gould identify? Select all that apply. 1. "Death and evil are not real." 2. "Life is simple, and I can control it." 3. "I'll always live with my parents and be their child." 4. "I don't need to be there to help my parents when they can't do things on their own." 5. "My parents will always be available to help me fix any situation that comes up that I can't handle on

1 2 3 Gould (1979) also identifies the following four false assumptions of childhood that adults need to resolve during their lifetimes: "I'll always live with my parents and be their child." "I'll always be there to help when my parents can't do things on their own." "Life is simple, and I can control it." "Death and evil are not real."

Which questions should be asked during assessment, based on Galanti's 4 Cs of culture? Select all that apply. 1. "How do you cope with your condition?" 2. "What do you think caused your problem?" 3. "What do you call your problem?" 4. "Who have you consulted regarding your condition?" 5. "Can you communicate clearly about your problem?"

1 2 3 Call What do you call your problem Cause What do you think caused your problem Cope How do you cope with your condition Concerns What converns do you have regarding your condition

Which is true regarding methicillin-resistant Staphylococcus aureus (MRSA)? Select all that apply. 1. It may lead to sepsis. 2. It is resistant to common antibiotics. 3. It is associated with infections of the skin. 4. It generally affects the weakest patients in the hospital. 5. It commonly enters the body through invasive procedures.

1 2 3 Drug resistant vancomycin-resistant enterococcus (VRE) rather than MRSA generally affects the sickest patients in the hospital. Drug resistant vancomycin-resistant Staphylococcus aureus (VRSA) commonly enters the body from catheters, surgery or invasive procedures.

The RN has just received a post-surgical hip patient from the PACU who is restricted to bed rest. The patient is lying supine in the bed and reports pain 8/10, for which the nurse medicates the patient with narcotic pain medication. What types of nursing diagnoses should the nurse assign based on this initial assessment? Select all that apply. 1. Impaired Physical Mobility 2. At Risk for Constipation 3. Impaired Skin Integrity 4. Social Isolation 5. Impaired Ambulation

1 2 3 Impaired Ambulation is unable to be evaluated at this time because the patient is on strict bed rest

The cardiopulmonary system is responsible for supplying the rest of the body with what? Select all that apply. 1. Nutrients 2. Chemicals 3. Fluids 4. Neurotransmitters 5. Cartilage

1 2 3 Neurotransmitters communicate electrical impulses from nerves to muscles, assisting movement. Cartilage is connective tissue that cushions joints.

Which statement describes how nurses can use Piaget's theories in a pediatric setting? Select all that apply. 1. Nurses can use the theories to develop teaching plans for children. 2. Nurses can use the theories to predict health outcomes in children. 3. Nurses can use the theories to understand the cognitive basis of fears. 4. Nurses can use the theories to understand the physiological basis for disease. 5. Nurses can use the theories to understand psychosexual stages of development.

1 2 3 Nurse can understand the cognitive development of children at specific ages, which can help to educate children in an age-appropriate and developmentally appropriate way/understand a child's ability to cope and therefore can help to predict health outcomes in children/use Piaget's theories to help children in a pediatric setting

Decreased physical exercise contributes to what symptoms? Select all that apply. 1. Bone fragility 2. Deterioration 3. Loss of strength 4. Hypertonicity 5. Spasticity

1 2 3 Spasticity is related to cerebral palsy. Decreased physical exercise and lack of weight-bearing exercise contribute to bone fragility, deterioration, and loss of strength. Flaccidity or hypotonicity (lack of muscle tone) may result from lack of physical activity, injury, or neurologic impairment.

The nurse is planning to discharge a patient home on a new medication. Which statements are important to emphasize in the discharge paperwork? Select all that apply. 1. Never take larger or more frequent doses of medications. 2. Do not refer to medication as "candy" which can entice children. 3. Read over directions in direct light, and follow all directions on medication label. 4. Dispose of used needles in a plastic container to avoid needlestick injuries. 5. Make sure the primary care provider sets refill orders for the medication.

1 2 3 Used needles should be disposed of in red sharps containers to avoid needlestick injuries.

Questions about which health-related factors should be included in the nurse's assessment of a dying patient's caregiver? Select all that apply. 1. Normal daily dietary intake 2. Sleep hygiene 3.Formal and informal support systems 4. Childhood illnesses 5. Activities of daily living and mobility

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Identify fine motor capabilities for the toddler. Select all that apply. 1. Drawing a circle drawing loops/lines (scribbling) 2. Stacking blocks or toys building a tower of blocks 3. Drinking from a sippy cup 4. Using a spoon without difficulty 5. Drawing a person with several body parts

1 2 3 is a fine motor skill capability of the toddler--drawing is a fine motor skill capability of the toddler--stacking by 12-18 months, the toddler should have mastered the use of a sippy cup/can use an adult cup w/out much spilling

A nurse is teaching a student nurse what The Joint Commission (TJC) might do while at a hospital renewing their accreditation. Which statements made by the student nurse demonstrates that the teaching has been effective? Select all that apply. 1. "The surveyor may observe and talk to patients." 2. "It is likely that the surveyor will interview the staff." 3. "During an on-site survey, the surveyor will trace patient care." 4. "A hospital's information and documentation is reviewed during accreditation." 5. "The surveyor will provide a final accreditation decision at the closure of the on-site survey."

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A patient who has been immobile at home for the last three months is admitted to the hospital. Which problems should the nurse anticipate finding when the patient is examined? Select all that apply. 1. Atrophy of the muscles 2. Contractures 3. Pain with joint movement 4. Joint stiffness 5. Increased range-of-motion

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What should the nurse do to ensure accurate order interpretation? Select all that apply. 1. Clarify orders that are lacking critical information. 2. Understand the purpose of a medication prior to administration. 3. Know the common dose of a medication prior to administration. 4. Evaluate whether the amount of medication prescribed is safe for the patient. 5 Use clinical judgment when delegating administration of a medication to another nurse.

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Which factors has been linked to intimate partner violent (IPV)? Select all that apply 1. alcohol abuse 2. pregnancy 3. unemployment 4. drug use 5. religion

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Which important anticipatory guidance would parents need to learn prior to the development of the infant's pincer grasp (around 9 months of age)? Select all that apply. 1. Electrical outlets should be covered with socket safety panels. 2. Parents should place stove pot handles away from the child's reach. 3. Parents should keep unsafe objects locked out of reach of the infant. 4. The infant's food items should be cut into small, manageable pieces. 5. Parents should place hand protectors on the child to help protect them from injury.

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Which questions should the nurse ask to assess the effect of the patient's activity level on body systems? Select all that apply. 1. What is the frequency of bowel movements? 2. Do you become short of breath when completing your activities of daily living? 3. Are you experiencing any pain with movement? 4. What is your appetite? 5. Do you have any environmental allergies?

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With whom might the nurse discuss potential interventions when planning care for patients of diverse cultures? Select all that apply. 1. Patient 2. Extended family members 3. Boyfriend or girlfriend 4. Cultural healers 5. Patient's former spouse

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Which attributes are risk factors for delirium during older adulthood? Select all that apply. 1. Pain 2. Old age 3. Polypharmacy 4. Hospitalization 5. Cerebral dysfunction

1 2 3 4 Delirium—decrease attention span, confusion, memory loss; old age, polypharmacy, pain, and hospitalization—risk factors

Monitoring the patient for urinary and gastrointestinal alterations related to immobility includes which observations? Select all that apply. 1. Urinary frequency 2. Fluid intake 3. Food intake 4. Bowel frequency 5. Food allergies

1 2 3 4 Assess intake and output, the concentration and odor of urine, and the frequency of urination. This is manifested by decreased bowel sounds on auscultation and by constipation. Assess the abdomen by auscultating bowel sounds in all four quadrants and palpating the abdomen for distention and discomfort. Assess patients' dietary intake for adequate fiber and fluid volume while on bed rest. Assess and record the frequency of bowel movements to avoid a potential fecal impaction (buildup of hardened feces in the lower intestine).

Which behavior observed by the nurse represents normal social development of the preschool child? Select all that apply. 1. The child steals a toy from another child. 2. The child is playing a game with another child. 3. The child is arguing about the rules of the game. 4. The child blames a mess on an imaginary friend. 5. Plays alone, away from other children in the group.

1 2 3 4 Although preschoolers may begin to play with other children, they are still primarily egocentric and have difficulty understanding the morality of right and wrong—steals/ Cooperative play is a normal social development of the preschool child—game/ Arguing about the rules of a game represents normal social development of the preschool child because preschool children will become more argumentative as they become secure in their group—imaginary

Which cognitive developmental changes are expected in the school-age child? Select all that apply. 1. Organizing toys by size 2. Starting a new leaf collection 3. Telling jokes to make others laugh 4. Understanding the idea of volume and mass 5. Believing their magic wand makes the sun set

1 2 3 4 Placing toys in order from smallest to largest is part of classification and is an expected cognitive developmental change in the school-age child/Collecting items is part of classification and is an expected cognitive developmental change in the school-age child/Understanding humor is an expected cognitive developmental change in the school-age child/Understanding conservation is an expected cognitive developmental change in the school-age child.

Which cellular changes are characteristic of aging? Select all that apply. 1. Atrophy 2. Diminished function 3. Altered protein homeostasis 4. Decrease in number of cells 5. Increased capacity to divide

1 2 3 4 Specific cellular factors appear to be significant in the aging process: Increased cell damage, Decreased capacity to divide, Diminished ability to repair damaged DNA, and Altered protein homeostasis (Huether, McCance, Brashers, & Rote, 2017).

Miyoko follows which steps to objectively evaluate the degree of success in achieving outcomes of care for Mr. Mashoud? select all that apply 1. identify the exact desired pt behavior 2. evaluate the pt's acutal behavior 3. compare the outcome criteria with the actual behavior 4. assess the desired behavior and anticipated outcome 5. judge the degree of agreement btw the outcome criteria and the actual behavior

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The nurse is educating a student nurse on the initiatives that guide nurses to ensure safety for their patients and environment. Which statements made by the student nurse demonstrates that the education has been effective? Select all that apply. 1. "The QSEN project will continue to guide improvements and recommend safe practice." 2. "The Joint Commission continues to re-evaluate and recommend new safety goals each year." 3. "The National Center for Health Statistics continues to examine injury and report patterns so we can work toward prevention." 4. "QSEN recommends hospitals install improved ventilation and water systems in health care settings." 5. "The Joint Commission (TJC) recommends that acute care hospitals enact a no-lifting policy and provide patient lifting equipment."

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When caring for patients with more than one chronic disease, the nurse recalls that they are likely to experience which event? select all that apply 1. Frequent health care visits 2. Increased health care expenses 3. Multiple medications 4. Increased depression 5. Greater changes in the ability to perform daily activities

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Which are examples of the essential functions of the community-based nurse? Select all that apply. 1. Arranging for Meals-on-Wheels for a patient 2. Performing a routine pre-high school checkup 3. Managing care of a chronic skin ulcer 4. Teaching bike safety to fifth grade classes at the local school 5. Administering pain medication to a dying person

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Which behaviors are expected in the toddler? Select all that apply. 1. Throwing tantrums 2. Crying when the toddler's parent leaves for work 3. Developing a sense that bad behavior is punished 4. Insisting on same book being read every morning 5. Feeling guilty when they steal a toy from another child

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Which can influence the development of both speech and language in infants? Select all that apply. 1. Anatomical defects children w/cleft lip/palate e.g., may have difficulty reaching normal language milestone 2. Genetics/family history genetics/family histories will always be a consideration when evaluating a child's speech/language millstones 3. Sociodemographic factors 4. Lack of access to television and computers 5. Quality of communication in the environment such as in a home where family members place a high value on education, with family members who

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Nursing observations regarding a patient's nutritional needs include which items? Select all that apply. 1. Food intake 2. Food preferences 3. Changes in weight 4. Hair analysis 5. Physical status

1 2 3 5 Nurses need to have close contact with patients and their families to make observations about physical status, food intake, food preferences, weight changes, and response to therapy in order to determine nutritional alterations.

Which developmental milestones are normal for a 10-year-old child? Select all that apply. 1. Back-talking to parents 2. Interest in the opposite sex 3. Interest in getting a cell phone 4. Unwillingness to venture too far from the home 5. Being upset when artwork does not look like others

1 2 3 5 Rebellion is normal at age 9-11 and may include back-talking to parents as the child begins to assert independence—back-talking/At 9-11 years of age, boys tease girls, and girls may become interested in boys—opposite/9-11-year-olds begin to talk to friends on the phone and may want to have their own cell phone/By 9-11 years, children are critical of their own work and may be upset if they do not feel their work measures up to personal standards

Which items would the home health nurse observe for when assessing an older adult patient's home for safety? Select all that apply. 1. Scatter of area rugs 2. Working fire alarms 3. Telephone within reach 4. Types of refrigerated foods 5. Bath tub grab bars 6. Number and type of stairs

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The nurse is caring for 50-year-old Hindu, Asian male patient with diabetes who is hospitalized after an incidence of high blood pressure. The nurse reviews the data and concludes that the pt's health care needs conflict with his health care practices. His cultural practices do not help him maintain normal blood pressure and manage his diabetes. How should the nurse implement culturally congruent care? Select all that apply 1. Negotiate for a change in the pt's cultural practices 2. Preserve the pt's values relevant to maintaining his health 3. Develop a standard care plan that is used for every patient 4. Modify the pt's lifestyle to develop a beneficial health care plan 5. Explain that his cultural practices are unhealthy and need to change

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What contributes to helping an infant to fight infection within the first year of life? Select all that apply. 1. Breast milk 2. Vaccinations 3. Fully functional respiratory system 4. The mother's transplacental antibodies

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Which action by the nurse would not require permission from the patient? select all that apply 1. Touching the pt's arms 2. Patting the pt's back 3. Holding the pt's wrist 4. Patting the pt's shoulders 5. Touching the pt's feet

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Which topics are key issues in social and community context as a social determinant of health? Select all that apply. 1. Incarceration 2. Discrimination 3. Housing stability 4. Civic participation 5. Crime and violence

1 2 4 SDOH includes key issues such as poverty, employment, food security, and housing stability Education=Language and literacy Economic stability = Access to healthy foods Health and health care = Access to primary care Neighborhood and built environment= Rehabilitation care center

The ANA Standards of Professional Performance for Home Care require home care nurses to evaluate their own nursing practice in relation to which factors? Select all that apply. 1. Relevant statutes and regulations 2. Professional practice standards 3. Employing organization guidelines 4. Scientific evidence 5. Personal goals

1 2 4 The Standards of Professional Performance for Home Care Nursing require home health care nurses to evaluate their own nursing practice in relation to professional practice standards, scientific evidence, and relevant statutes and regulations.

A 40-year-old patient has poorly controlled hypertension. The dietitian recommended several dietary modifications to the patient. Whcih technique would the nurse use during teh orientation phase of this helping relationship? Select all that apply 1. Closely observe the patient's behavior 2. Prioritze the patient's problems and identify goals 3. Review the patient's medical history 4. Begin the conversation wit hwarmth and empathy 5. Work to understand the patient's behavior 6. Choose a quiet and private location for hte interaction

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The nurse is planning care for an adult heart transplant patient who is about to be discharged from the hospital. Which essential members of the collaborative health care team should the nurse include in the discharge planning conference to minimize safety issues for this patient? Select all that apply. 1. Patient and family 2. Transplant care coordinator 3. Nurse's aide assist with the patient 4. Pharmacist who has helped adjust medication doses 5. Primary health care provider who will continue to provide care

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The nurse provides care for a patient with a chronic illness who does not adhere to the prescribed treatment plan. The nurse identifies that the patient is a at risk for which occurrence? select all that apply 1. Increased mortality 2. Increased morbidity 3. Increased depression 4. Increased hospital admissions 5. Increased health care expenses

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Which actions by a home health nurse indicate respect for the patient's resources? Select all that apply. 1. Guarding against accidental scratching of eyeglasses 2. Protecting furniture from soil or spills 3. Asking permission to use the bathroom 4. Avoiding waste of wound care supplies 5. Turning off unnecessary lights

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Which extrinsic factor increases the risk of falls among older adults? Select all that apply 1. poor lighting 2. inappropriate footwear 3. adverse medication reactions 4. improper use of assistive devices 5. unfamiliar environment of a hospital room

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Which series of activities best reflects the motor development of an infant from 1 month of age to 4 months? Select all that apply. 1. At 4 months, the rooting reflex disappears. 2. At 1 month, the child will hold a fist tightly clenched. 3. At 3 months the child will be able to crawl a minimal distance. 4. At 3 months the child will be able to lift the head 90 degrees from a prone position. 5. At 4 months the child can hold the head steadily erect in a sitting position.

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Which toy is appropriate for an infant? Select all that apply—play is an important activities/allows better cognitive/physical growth—toys for infants promote development of milestones 1. Rattles 2. Wooden blocks 3. Video games 4. Plastic stacking rings 5. Squeezable stuffed animal

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Patients on bed rest are at risk for which problems? Select all that apply. 1. Increased venous return 2. Decreased lung expansion 3. Decreased cardiac workload 4. Atelectasis 5. Pneumonia

1 2 4 5 Patients on bedrest are at risk for increased venous return, due to supine positioning. atelectasis Patients on bedrest are at risk for atelectasis, due to dependent positioning and limited lung expansion. an abnormal condition characterized by the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and oxygen in a part of the lungs. Symptoms may include diminished breath sounds, or aspiratory crackles, a mediastinal shift toward the side of the collapse, fever, and increasing dyspnea.

A nurse is teaching a new class of nursing students about the different orders of belief. She asks them to explain the types of belief. Which answers by the students are correct? Select all that apply. 1. Higher-order beliefs are derived from a combination of first-order beliefs and logic. 2. A zero-order belief is a foundational belief, such as knowing "I am a person different from you." 3. A tertiary-order belief begins in childhood and is based on the presumptions children assume from their parents. 4. A higher-order belief is arrived at once a person can directly experience things, such as believing that all men wear hats, if all men that the person knew at the age of deciding this did wear hats. 5. A first-order belief can be developed into adulthood based on knowledge a person gathers, such as choosing a major based on gender stereotyping, even though the person might be interested in a different major.

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Which activities correspond to normal motor development during the first year of life? Select all that apply. 1. 10-12 months: can stand alone 2. 8-9 months: sits steadily, unsupported 3. 1-2 months: can roll from front to back 4. 4-5 months: turns from back to abdomen 5. 6-7 months: sits and leans forward on both hands

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Which are examples of external factors which may affect safety? Select all that apply. 1. Residing in a high-crime area 2. Living with an abusive, alcoholic father 3. Developmentally performing below one's age level 4. Being diagnosed with a disease at a very young age 5. Becoming a member of a gang in your neighborhood

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Which information would the nurse include in a hand-off report at the end of shift? select all that apply 1. The pt's name, age, and admitting diagnosis 2. Allergies to food and medications 3. Personal evaluation that the pt is "needy" 4. How much the pt ate for breakfast 5. That the pt's pain rating went form an 8 to a 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen

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Which statement describes the purpose of the incident report? select all that apply 1. Identifies loopholes in the operation of the health care system 2. Provides good, quality health care 3. Documents a pt's negative feedback related to the health care deliverd 4. Determines the severity of the punishment to be delivered 5. Identifies the need to change a procedure or policy

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Which are the major psychosocial developments that should occur during adolescence? Select all that apply. 1. Becoming independent 2. Determining gender identity 3. Increasing desire to please others 4. Developing a sense of industry 5. Solidifying future plans for an occupation

1 2 5 Becoming independent is a major psychosocial development that should occur durign adolescenc determining sexual identity, including gender identity, is a major psychosocial development that should occur during adolescence forming vocational identiy is a major psychosocial development that should occur during adolescence

A 6-month-old infant is brought to the clinic and after assessing the child's head circumference, the nurse notes that the head circumference for this baby has gone from the 50th percentile to 10th percentile since the 2-month visit. What might this indicate? Select all that apply. 1. A delay in skull growth 2. A below-normal intelligence 3. Disturbances in nutrition intake 4. A problem with brain development Issues with physical development 5. issues with physical development

1 3 4 Frequent head growth measurements can provide information on the growth of an infant's skull. Suture closure may occur at inappropriate times and therefore affect skull growth—a delay in skull growth/A lack of proper nutrition can impede growth and development in children including head growth. This can indicate failure to thrive in an infant—disturbances in nutrition intake/Since the skull grows to accommodate the developing brain, head circumference measurements can provide information on brain development—a problem w/brain development

A postpartum mother will require education regarding newborn care prior to discharge. The priority nursing diagnosis for this mother is Knowledge Deficit. What kind of support should the nurse include in the plan of care related to newborn injury prevention and safety promotion? Select all that apply. 1. Bathing techniques 2. Handling a crying baby 3. Feeding techniques (breast versus bottle) 4. Caring for the breasts to avoid engorgement 5. Sleeping practices (the Safe to Sleep® campaign)

1 2 5 Sleeping practices (the Safe to Sleep® campaign) should be included in the plan of care for Knowledge Deficit related to newborn injury prevention and safety promotion. Newborns are susceptible to drown injuries if left unattended during bathing. While it is important to provide information related to breast and bottle feeding this is not a topic the nurse includes in the plan of care for Knowledge Deficit related to newborn injury prevention and safety promotion. While it is important to provide information related to caring for the breasts to prevent engorgement this is not a topic the nurse includes in the plan of care for Knowledge Deficit related to newborn injury prevention and safety promotion.

The nurse is caring for a pregnant woman who is in labor. When the nurse asks the woman if she wants her husband to be near when she is delivering, the patient strongly objects. People of which culture are likely to react in this way? Select all that apply 1. Hindus 2. Mexicans 3. Muslims 4. Filipinos 5. Roman Catholics

1 3

Which positive health habit may prevent the development of chronic illness later in life? 1. Routine screening and diagnostic tests 2. Unprotected sexual activity 3. Regular exercise 4. Excessive alcohol consumption 5. Driving without a seat belt

1 3

What ambulation aid provides a base of stability for patients with weakness or balance problems? Select all that apply. 1. Walker 2. Crutches 3. Canes 4. Transfer belts 5. Knee walker

1 3 A walker provides a base of stability for patients with weakness or balance problems, allowing the patient to lean heavily on the walker to avoid falls. A cane provides a point of stability for patients with weakness or balance problems.

A nurse is caring for a patient with nervous system impairment. What symptoms may be associated? Select all that apply. 1. Poor balance 2. Circulatory stasis 3. Involuntary movement 4. Decreased muscle tone 5. Tissue ischemia

1 3 Decreased muscle tone is associated with impairment of the musculoskeletal system. Circulatory stasis is an effect of immobility on the cardiopulmonary system.

The registered nurse is evaluating the student nurse for the teach-back technique. Which statement made by the student nurse indicates the need for further teaching? Select all that apply 1. I should avoid using models during the teaching process 2. I should use charts to facilitate pt understanding 3. I should ask the pt whether he or she understood th teaching 4. I should let the pt ask question during the course of teaching 5. I should teach the pt again after finishing the 1st round of teaching

1 3 Use model is one such method the nurse can employ/the nurse should not ask whether the pt has understood but should instead

A diminished ability to speak can lead to which consequence? select all that apply 1. Anxiety 2. Stomach pain 3. Social isolation 4. Ineffective coping 5. Difficulty in movement

1 3 4

A nurse is caring for a comatose patient and is concerned that the patient may develop a urinary tract infection. Which items should be included in the nurse's assessment? Select all that apply. 1. Fluid intake and output 2. Peripheral pulses 3. Concentration and odor of urine 4. Urinary frequency 5. Serum albumin levels

1 3 4

Which are effective methods to incorporate the patient's beliefs and values system in their care to promote wellness? Select all that apply. 1. Asking relevant questions 2. Telling the patient the correct beliefs to adopt 3. Actively involving the patient in establishing goals and outcomes 4. Involving the patient in determining which interventions will be implemented 5. Providing swift care directly from the physician, without tedious explanations about the procedures

1 3 4

Which characteristics are a component of critical thinking? select all that apply 1. open-mindedness, continual inquiry, and perseverance 2. reliance on laboratory reports and diagnostic results to assess patients 3. recognition of an issue, analysis of related information, and formation of conclusions 4. imagination and exploration of alternatives, consideration of ethical principles, and informed decision-making 5. low consideration of what the patient says, preference for diagnostic tests and scientific data

1 3 4

Which descriptive phrases apply to hospice care? Select all that apply. 1. End-of-life care for the terminally ill 2. Care at any stage of a serious disease 3. Symptom relief 4. Grief support for families 5. Supports curative therapy

1 3 4

Which findings would be expected when assessing a patient at the end of life? Select all that apply. 1. Apnea 2. Increased blood pressure 3. Increased heart rate 4. Decreased urine output 5. Well-perfused extremities

1 3 4

Which nursing actions should take place immediately prior to ambulation of a patient who has been immobile to prevent injury to the patient? Select all that apply. 1. Assess the patient for dizziness. 2. Perform passive range-of-motion exercises. 3. Assess the patient's ability to stand unassisted. 4. Dangle the patient's legs on the side of the bed. 5. Perform active range-of-motion exercises.

1 3 4

Which quality is desired in an entry-level nurse? select all that apply 1. an understanding of the environment of care 2. the ability to provide care single-handedly 3. respect for the rights, beliefs, and values of patients 4. knowledge of the roles and responsibilities of a nurse 5. the ability to lead management of pt care as needed

1 3 4

Which questions would be appropriate to ask when assessing a patient's coping mechanisms? Select all that apply. 1. "How have you dealt with stressful situations in the past?" 2. "Are you experiencing feelings of anxiety or nervousness?" 3 "Were these techniques of handling stress effective?" 4. "Whom can you ask for assistance from during stressful times?" 5. "Have you experienced any changes in your life recently?"

1 3 4

While placing a patient in the prone position, the nurse supports the lower legs with pillows to elevate the toes. Which reason explans this nursing action? select all that apply 1. Prevent footdrop 2. Improve breathing 3. Reduce external rotaiton of the hips 4. Eliminate mattress pressure on the toes 5. Reduce hyperextension of the crevical vertebrae

1 3 4

Tom is being discharged from the hospital after a fall at home, and the nurse is providing education for Tom before he leaves. What reminders should the nurse include in his education? Select all that apply. 1. The home should be free from clutter. 2. Make sure the windows are open. 3. Do not get up to walk right away if you are dizzy. 4. Make sure to maintain a nutritious diet. 5. Make sure to perform activities independently while recovering.

1 3 4 The patient will want to ask for help during recovery to prevent the possibility of reinjuring himself while at home.

Which motor skills should be developed in the preschool child? Select all that apply. 1. Playing hopscotch 2. Cutting paper using safety scissors 3. Drawing a picture of his or her home and pets 4. Balancing on each foot for one second 5. Riding a bicycle without training wheels

1 3 4 The preschool child can hop on one foot and jump forward, two skills used in hopscotch/ Drawing objects that resemble familiar objects is a motor skill that should be developed in the preschool child/ Balancing on each foot for one second is a motor skill that should be developed in the preschool child

Which trouble point would the nurse anticipate while positioning the patient in the Sims' position? select all that apply 1. Lack of foot support 2. Increased cervical flexion 3. Lateral flexion of the neck 4. Lack of protection for pressure points 5. Pressure on posterior aspects of knee

1 3 4 The trouble points that are common in the Sims' position are lack of foot support, lateral flexion of the neck, and lack of protection for pressure points. Increased cervical flexion and pressure on posterior aspects of the knee are the common trouble areas in the supported Fowler's position.

Which characteristics are typical of the toddler's physical appearance? Select all that apply. 1. Leaner loss of adipose tissue 2. Knees curved inward 3. Flattened plantar arch toddler's feet seem flat 4. Inward curve of the spine 5. Mature abdominal muscles

1 3 4 as the toddler becomes more active is typical of a toddler's appearance--leaner b/c of a plantar fat pad that disappears around 2 years of age. This is typical of a toddler's appearance an exaggerated lumbar curve is typical of a toddler's appearance

A patient is on a large number of medications and the nurse is concerned about the patient's ability to manage all the medications at home. Which of the following questions should the nurse ask to assess the patient's potential safety risk? Select all that apply. 1. Do you take your medications consistently? 2. Do any young children live in the home? 3. Do you know how to take your medications? 4. Do you know when to take your medications? 5. Do you know why you take all these medications?

1 3 4 5

Which risks are unique for an infant or toddler? Select all that apply. 1. Choking on grapes 2. Drowning in swimming pools - school age 3. Strangulation from blind cords 4. Dehydration from sitting in a hot car 5. Accidental ingestion of grandmother's medication

1 3 4 5

Which statements reflect the impact of genetics on aging? Select all that apply. 1. Genes play a role in repair of cells. 2. Inherited genes have little effect on life span. 3. Genetic factors are involved in cell maintenance. 4. Genetic factors lead to altered cell functioning. 5. Mutations that influence aging are either inherited or occur after birth.

1 3 4 5

Why is an understanding of motor development important for keeping a child safe when an infant's mobility increases around 10 months of age? Select all that apply. 1. The child has no understanding of consequences. 2. The child has a clear understanding of boundaries. 3. The child now has an increased ability to move about. 4. The child now has a naturally increased level of curiosity. 5. The child now has an increased ability to reach for objects.

1 3 4 5

Which are areas of assessment data on the OASIS Data Set? Select all that apply. 1. Living arrangements 2. Usual social activities 3. Therapy needs and schedules 4. Plan of care management 5. Activities of daily living capability

1 3 4 5 Nurses use OASIS (outcome and assessment information set) to assess home care pts - Current/pat medical/surgical hx/influenza and pneumococcal vaccination status/living arrangement and activities-of-daily-living capability/sensory status and neurologic, emotional, and behavioral status/integumentary status/respiratory and cardiac status/elimination status/therapy needs and schedule/plan of care management/medication regimen and pt and caregiver understanding of required meds and schedule

Which factors are integrated in evidence-based practice (EBP)? Select all that apply. 1. Research findings 2. Patient insurance protocols 3. Delivery of quality, cost effective care 4. Clinical nursing expertise 5. Patient preferences 6. Medicare and Medicaid guidelines

1 3 4 5 EBP entails nurses addressing pt problems by reviewing research/clinical guidelines/other resources to determine best practice—clinical nursing expertise/pt values and needs/delivery of quality, cost-effective health care

Which are characteristics of culture? Select all that apply. 1. Symbolism 2. Inherited 3. Learned 4. Shared 5. Integrated

1 3 4 5 integrated--joined SLSI

Which milestones associated with fine/gross motor control are achieved by the adolescent? Select all that apply. 1. Driving a car 2. Jumping in place 3. Playing an agility sport 4. Texting on a smart phone 5. Playing a complex musical instrument

1 3 4 5 Adult fine motor control; early growth-related awkwardness develops into coordinated muscle control. A female patient who experienced her first period on her 13th birthday can expect her peak height to be achieved by 15 age . 15 Height in female adolescents increases rapidly until it reaches its peak height at 2 to 2½ years after menarche. Therefore, the female patient who experienced menarche at age 13 would stop growing by age 13 + 2.5 = 15.5, or age 15.

To assist with determining the patient's risk for injury and issues requiring further evaluation, the patient assessment should include which items? Select all that apply. 1. Subjective data related to the patient's symptoms 2. Patient's family history 3. Focused assessment of the affected body systems. 4. Patient's history of exposures to environmental hazards. 5. Subjective data related to the patient's chief complaint

1 3 4 5 Collecting subjective data related to the patient's symptoms and chief complaint. Reviewing the patient's history of exposures to environmental hazards. Forming an objective assessment focusing on the affected body systems.

Which questions show the nurse understands how body system integrity can affect individual safety? Select all that apply. 1. "Are you having difficulty with your memory?" 2. "Have you had a sudden increase in your blood pressure?" 3. "Have you experienced any alterations in your vision recently?" 4. "Has your physician documented any changes in your cognitive abilities?" 5. "Do you take any long term medication that may affect your kidneys or liver?"

1 3 4 5 Detoxification and excretion of medications occurs in the renal and hepatic systems. Impairment of these systems can lead to symptoms of toxicity, which can include cognitive and physical changes.

What is true regarding safety promotion? Select all that apply. 1. Implementing community outreach programs that provide instruction about safety, aids the nurse in promoting safety. 2. Nurses must protect their own safety first, then that of their patients. 3. Nurses must use strategies to reduce the risk of harm to others. 4. Valuing their role in preventing errors in the health care setting is important for nurses in promoting safety. 5. Assisting the patient, the patient's family, and the community is important in promoting safety.

1 3 4 5 In addition to promoting safety for patients, nurses must ensure their own safety in the working environment. The nurse demonstrates safety by using strategies to reduce the risk of harm to self and others and by valuing the nurse's role in preventing errors.

Which goals are appropriate for the nurse to include in the plan of care for a patient who suffered a hip fracture, and subsequent total hip replacement, related to injury prevention and safety promotion? Select all that apply. 1. Patient will experience no injuries during the remainder of the hospital stay. 2. Patient will consent to a living will while hospitalized. 3. Patient will consent to having grab bars installed in the home bathroom. 4. Patient will experience pain relief within one hour of prescribed intervention. 5. Patient will consent to have safety hazards (area rugs) removed from the home

1 3 5

The nurse is caring for a patient with PVD. Which nursing interventions are expected to be included in the plan of care? Select all that apply. 1. Ambulation 2. Bedrest 3. Coughing and deep breathing exercises 4. Lower extremities elevated 5. Pursed lip breathing

1 4

Which complication would the nurse have to monitor for when using the supported Fowler's position? select all that apply 1. Pressure on the posterior aspect of the knees 2. Excessive lateral flexion of the spine 3. Hyperextension of the lumbar spine 4. Increased shearing force on the back 5. Unprotected pressure points at the ileum

1 4 In the supported Fowler's position, pressure is applied on the posterior aspect of the knees, decreasing circulation to the feet. Increased shearing force on the back may be due to the supported Fowler's position. Excessive lateral flexion on the spine is due to the side-lying position. Hyperextension of the lumbar spine may be due to the prone position. Lack of protection for pressure point at the ileum is due to the Sims' position.

The nurse has an assignment today with a family who is very nervous about being in the hospital. Their father was admitted the previous evening with a stroke and serious deficits. The nurse has assessed the patient and began talking with the family. What are some interventions the nurse can anticipate during his care of this patient and family? Select all that apply. 1. Education about the diagnosis of stroke 2. Evaluation of the education given during care 3. Neurological assessments as ordered by the health care provider 4. Pain management, as needed by the patient, per health care provider order 5. Performing range of motion and positioning the patient so he is comfortable

1 4 5

Which behavior fosters the development of trust? select all that apply 1. Answering the nurse call system promptly 2. Calling the pt by his or her first name unless he or she requests otherwise 3. Completing all care as quicky as possible and leaving the room so the pt can rest 4. Ansering quesitons honestly 5. Demonstrating competence when implementing treatments

1 4 5

Which family function is important? Select all that apply 1. Providing care and protection 2. Creating an insecure environment 3. Developing conflict and using power 4. Cooperative meeting financial needs 5. Socializing and nurturing relationships

1 4 5

Which primary mode encompasses stress intervention? select all that apply 1. increase the resistance to stress 2. identify the triggers to stress 3. isolate oneself form other to de-stress 4. decrease the number of situations that produce stress 5. learn skills to reduce the body's response to stress

1 4 5

Which response is a sign or symptom of the alarm reacton stage of general adaptation syndrome? select all that apply 1. increased heart rate 2. low blood pressure 3. constricted pupils 4. increased blood glucose levels 5. increased mental alertness

1 4 5

Which statements are true about unintentional and intentional injuries? Select all that apply. 1. Accidents are also referred to as unintentional injuries. 2. Unintentional injuries typically result from deliberate acts of violence. 3. Unintentional injuries are the second leading cause of death in the United States. 4. The risk factors for intentional injuries are better understood than those of unintentional injuries. 5. Patterns of unintentional injuries are often predictable and preventable.

1 4 5

Which statements by a patient indicate social cohesion? Select all that apply. 1. "I feel safe in my community." 2. "There are several gangs in the area." 3. "Most people stay in their own houses." 4. "My neighbor watches my house when I am traveling." 5. The state's legislators make decisions that will positively affect the future."

1 4 5 A cohesive society is defined by the United Nations as a society in which individuals are protected against life risks, trust their neighbors and the institutions of the state, and can work towards a better future (United Nations, 2012)

Which activity is classified as an instrumental activity of daily living (IADL)? select all that apply 1. Shopping 2. Getting magnetic resonance imaging (MRI) 3. Ambulating 4. House cleaning 5. Preparing meals

1 4 5 An IADL, or Instrumental Activity of Daily Living, are more complex sets of skills we need in order to live independently. These skills are: using the telephone, shopping, preparing meals, housekeeping, using transportation, taking medication(s), and managing finances, balance checkbook

Which action is an example of an independent nursing intervention? select all that apply 1. Provide health education 2. Start intravenous (IV) fluids 3. Administer a hypertension agent 4. Assist with daily activities 5. Reposition a patient

1 4 5 § Independent nursing interventions—initiated and conducted by the nurse § Dependent nursing interventions—initiated by a provider in the form of an order, and conducted by the nurse § Collaborative nursing interventions—initiated by the nurse or though consult w/other healthcare team members, and conducted by other healthcare team members

A 5-year-old who steals money from his or her mother's purse and does not understand consequences is likely at which stage of morality? Select all that apply. 1. Premorality/preconventional morality 2. Morality of conventional role conformity 3. Morality of self-accepted moral principles 4. Morality of nonconventional role conformity 5. Instrumental hedonism and concrete reciprocity

1 5 At this level a child does not have a developed conscience. Right or wrong is determined by physical consequences: "If I get caught and punished for doing it, it is wrong. If I am not caught or punished, then it must be right."—premorality/Preconventional morality/This is another stage found within the level of premorality, when the child will not understand the difference between right and wrong. The conscience is not fully developed at this stage. The child thinks at this stage, "If you do something bad to me, then it's OK if I do something bad to you."—instrumental

A 5-year-old who steals money from his or her mother's purse and does not understand consequences is likely at which stage of morality? Select all that apply. 1. Premorality/preconventional morality 2. Morality of conventional role conformity 3. Morality of self-accepted moral principles 4. Morality of nonconventional role conformity 5. Instrumental hedonism and concrete reciprocity

1 5 Premorality and preconventional morality--right or wrong is detemined by physical consequences: If I get caught and punished for doing it, it is wrong; if I am not caught or punished, then it must be right Instrumental hedonism and concrete reciprocity--the child thinks at this stage, "If you do something bad to me, then it's OK if I do something bad to you

Match the milestone with the corresponding age group

1-2 months (gross motor)—may lift head when held against shoulder 3 months (gross motor)—can lift head off bed when in prone position 4-5 months (gross motor)—bears weight when held in a standing position 4-5 months (fine motor)—begins reaching and grasping with palm

A nurse is preparing to teach clients. Which client findings will cause the nurse to postpone a teaching session? Select all that apply 1. The client is hursing 2. The client is fatigued 3. The client is febrile (elevated temperature) 4. The client is midly anxious 5. The client is asking questions 6. The client is teh acceptance phase

1. 2 3

In which order would the nurse proceed to reach a clinical decision through evidence-based practice (EBP)? Ask a clinical question Collect evidence from databases Critically appraise the evidence Evaluate the practice decision

1. Ask a clinical question 2. Collect evidence from databases 3. Critically appraise the evidence 4. Evaluate the practice decision/IntegrationEvaluation

What sequence is correct when conducting a randomized controlled trial (RCT)? - The researchers measure both groups for the same outcomes to see if there is a difference - The researchers determine if the intervention leads to better outcomes than the standard of care - Participants are randomly assigned to either the control or treatment group - The treatment group receives the experimental intervention; the control group receives the standard of care

1. Participants are randomly assigned to either the control or treatment group 2. The treatment group receives the experimental intervention; the control group receives the standard of care 3. The researchers measure both groups for the same outcomes to see if there is a difference 4. The researchers determine if the intervention leads to better outcomes than the standard of care

Health care settings and services

1. Preventive Care reduces/controls risk factors a. Adult screenings for blood pressure, cholesterol, tobacco use, and cancer b. Pediatric screenings for hearing, vision, autism, and developmental disorders, HIV screening for adults at higher risk, immunizations, diet counseling 2. Primary care (Health Promotion) focuses on improved healht outcomes/collaboration a. Diagnosis and treatment of common illness, ongoing management of chronic health problems, prenatal care, well-baby care, family planning 3. Secondary Care (Acute care) diagnosis and tx of diseases a. Urgent care, hospital emergency care, acute medical-surgical care: ambulatory care, outpatient surgery, hospital, radiological procedures 4. Tertiary Care diagnosis and tx of diease a. Highly specialized—intensive care, inpatient psychiatric facilities, specialty care (such as neurology, cardiology, rheumatology, dermatology, oncology) 5. Restorative care a. Rehabilitation programs (such as cardiovascular, pulmonary, orthopedic), sports medicine, spinal cord injury programs, home care 6. Continuing Care regulated by Omnibus Budget Reconciliation Act of 1987 a. Long-term care—assisted living, nursing centers, psychiatric and older-adult day care--hospice, adult day care center, respite care, long-term facility Magnet recognition program--evaulation of hospital pt care Healthy People 2020 GOALs: increase life expectancy and quality of life, and to eliminate health disparities through improved delivery of health care services health services (social factor)--Health people list 5 determnants - sex/age/alcohol usedrug use/sex/smoking/discrimination/income/genderwhere a person lives/crowding condition/access to quality care/health insurance

At which age should a parent discuss sexual intercourse, reproduction, and sexually transmitted infections with their child? - 8 years of age - 10 years of age - 13 years of age - 15 years of age

10 years of age—menstruation/sexual intercourse/reproduction/sexually transmitted infections 8 years of age—may not be mature enough to understand sex education

A new mother at the clinic asks at what age her baby will be able to actively participate in a game of pat-a-cake with her. Which would be the correct response from the nurse? 4 months 6 months 9 months 12 months

12 months

The activity with the age at which it is first exhibited

15 months— walking independently 18 months— turning the pages as they are read to 24 months— dressing themselves 36 months— stacking multiple blocks to build towers

What happens to the musculoskeletal system when injury or disease occurs? Select all that apply. 1. Increased lung capacity 2. Increased flexibility 3. Impaired mobility 4. Decreased capacity for exercise 5. Coordinated body movement

3 4

The nurse is caring for a patient with hemiplegia. While assessing the patient's condition, the nurse observes erythema and breakdown the skin. Which nursing intervention would be correct in this condition? select all that apply 1. Allowing pain medicaiton to take effect 2. Placing a turning schedule above the pt's bed 3. Placing the pt on a pressure -relieving mattress 4. Increasing the frequency of turning and repositioning 5. Ensuring that the range-of-motion exercises are implemented consistently

2 3 4

The nurse is learning about nursing malpractice. Which statement would the nurse consider as good nursing practice? select all that apply 1. nursing notes can be illegible as long as the nurse can read them 2. nursing notes should be maintained properly 3. nursing records should be properly preserved 4 institutions should maintain complete nursing records 5. only basic duties should be recorded in nursing records

2 3 4

The registered nurse is teaching a nursing studetn the steps of planning for moving and postioning patients. Which statement by the nursing student indicates the need for further learning? select all that apply 1. I should perform hand hygiene 2. I should place all pillows on the bed 3. I should collect appropriate equipment 4. I should explain the procedure to the patient 5. I should keep the level of the bed in a low position 6. I should close the room door and bedside curtains

2 5

In a hospital, there is an acute shortage of nurses because of retirements. Which action would the remaining nurses take? Select all that apply. One, some, or all responses may be correct. 1. Hurry through the patient care assignments 2. Use patient contact time efficiently 3. Use the patient contact time professionally 4. Only treat the same number of patients as treated before the retirements 4. Eliminate assessment aspects of patient care to make more time

2 3

The nurse is providing care to a child who is the victim of physical abuse. When planning collaborative care for this patient to enhance safety, which providers should the nurse include? Select all that apply. 1. Pharmacist 2. Psychologist 3. Social worker 4. Physical therapist 5. Occupational therapist

2 3

The nurse uses a trochanter roll or a sandbag when performing which intervention? select all that apply 1. Placing the pt in the prone position 2. Placing the pt in the supported supine position 3. Placing the pt in the supported Fowler's position 4. Assisting the pt to sleep in the 30-degree lateral position 5. Assisting the pt in moving up in bed using a friction-reducing device

2 3

What is safety? Select all that apply. 1. Resistance against attack 2. Having no physical harm or injury 3. Being comfortable in an environment 4. Being free from psychological harm and injury 5. Having the ability to speak and act without hindrance

2 3

The nurse is positioning a patient with hemiplegia to a supported Fowler's position. While positioning, the nurse uses a pillow to support the arms and hands of the patient. How will this help the patient? select all that apply 1. It increases comfort 2. It prevents shoulder dislocation 3. It prevent flexion contractures of the arm and wrists 4. It supports the cervical vertebrae 5. It prevents occlusion of the popliteal artery

2 3 Using a pillow to support the arms and hands of the patient will help to prevent shoulder dislocation and flexion contractures of the arm and wrist. Elevation of the head of the bed helps to increase patient comfort. Resting the head on a small pillow will help to support cervical vertebrae. Occlusion of the popliteal artery can be prevented by placing a small pillow under the thigh.

A male patient underwent a prostatectomy and expresses that he is experiencing some pain and discomfort. The nursing student examines the patient's wound. Which describes a good critical thinker? select all that apply 1. Diagnostic 2. Analytic 3. Systematic 4. Inquisitive 5. Overconfident

2 3 4

A nurse is caring for a patient in the telemetry unit who is complaining of a recent decrease in her ability to perform activities of daily living (ADLS) and routine exercise. Which conditions are possible contributing factors? Select all that apply. 1. Cerebrovascular accident 2. Heart failure 3. Peripheral vascular disease 4. COPD 5. Renal failure

2 3 4

A nurse is developing a plan of care for a patient who identifies with both his native country of origin's culture as well as American culture. Which nursing action indicates cultural competence? Select all that apply 1. Ignoring cross-cultural learning 2. Inquiring about the patient's health beliefs 3. Self-understanding of the nurse's own culture 4. Assessing cultural and biophysical factors that influence treatment 5. Practicing w/in the cultural limitations of the pt's native culture

2 3 4

A patient is being transferred from bed to stretcher. Which precausiton would the nurse take to ensure patient safety during transfer? select all that apply 1. Release the brakes of the bed ot allow movement 2. Raise the bed to the level of the stretcher 3. Cross the pt's arms on chest while transferring 4. Involve multiple caregivers for safe transfer 5. Unlock the stretcher's wheels once it is in place alongise the bed

2 3 4

Ethnocentrism can pose a serious ethical concern for health care professionals. Which actions can the nurse take to prevent this from happening? Select all that apply. 1. Point out to a patient's family when their uncommon beliefs are rooted in ignorance. 2. Recognize that one's own cultural beliefs are not necessarily superior. 3. Refrain from thinking of another person's ideas as inferior. 4. Be culturally sensitive and culturally competent. 5. Use one's own values as criteria to evaluate the validity of other's beliefs

2 3 4

The nurse educator provides teaching for a group of nurses who work in a pediatric office. The educator emphasizes the importance of early detection of disease and encourages which simple screening measure? Select all that apply 1. Blood glucose 2. Blood pressure 3. Weight 4. Height 5. Oxygen saturation

2 3 4

The nurse is assessing patients from different cultural backgrounds. Which action should the nurse perform to obtain a systematic cultural assessment? Select all that apply 1. Overlook pts' beliefs about health care 2. Establish trusting relations with pts 3. Obtain information by asking open-ended questions 4. Gather area demographic information form census data 5. Obtain information about economic backgrounds

2 3 4

The nurse is learning about the effect of different cultures on nursing. Which is a benefit of culturally congruent care? Select all that apply 1. It will help the nurse interact with different people in their language 2. It will help the nurse interpret the needs of the patient who belongs to a different culture 3. It will help the nurse identify the similarities and differences of various patients across different cultures 4. It will help the nurse deliver the specific kind of health care that is expected from patients who belong to a different culture 5. It will help the nurse deliver different remedies for an illness as practiced in the pt's culture

2 3 4

Which professionals would be involved in the collaboration of care for a patient with decreased movement and immobility needs? Select all that apply. 1. Dietitian 2. Physical therapist 3. Nurse 4. Unlicensed assistive personnel 5. Housekeeping

2 3 4

Which activities experienced by older adults improve their psychosocial health activities? Select all that apply. 1. Exclusion from social roles 2. Implementation of a life review 3. Active involvement in community activities 4. Opportunity to share wisdom gained from life experience 5. Spending time alone following retirement from a fulfilling job

2 3 4 2-reminiscence-life review 3-—adults experience improved psychosocial health when they are able to remain active in social events

Which body system changes are expected in the school-age child? Select all that apply. 1. Skeletal muscles fully develop. 2. Enlarged tonsils and adenoids. 3. Lungs and alveoli fully develop. 4. Development of frontal sinuses. 5. Eustachian tubes angle upward.

2 3 4 School-age children appear thinner and more graceful than do preschoolers. Musculoskeletal growth leads to greater coordination and strength. The muscles are still immature, and thus, can be injured from overuse. As the facial bones grow, the eustachian tube assumes a more downward and inward position, resulting in fewer ear infections than in the preschool years. Lymphatic tissues such as adenoids and tonsils continue to grow until about age 9 years. During the school-age years, the lungs and alveoli develop fully, and fewer respiratory infections occur. Enlarged tonsils and adenoids are an expected body system change in the school-age child as the lymphatic tissues grow and are not always indicative of an infection. A 7-year-old child who is 48 inches is expected to be approximately 52 inches at age 9. (48 + 4)

Which obstacles prevent evidence-based practice (EBP) from being implemented in a health care facility? Select all that apply. 1. Specialty focus with limited research 2.Slow dissemination of findings 3. Staff lack of knowledge 4. Inadequate resources 5.Large volume of literature

2 3 4 5

Which outcome is expected after effective documentation? select all that apply 1. Redution of the level of care required 2. Facilitation of proper insurance reimbursement 3. Efficient use of time 4. Enhanced continuity of care 5. Protectin for the nurse form legal recourse

2 3 4 5

Which parts of the nursing process provide the framework for patient safety goals? Select all that apply. 1. Charting 2. Assessing 3. Evaluating 4. Diagnosing 5. Interventions

2 3 4 5

Which aspects influence the understanding of sexuality as a fundamental human need in older adulthood? Select all that apply. 1. Legal 2. Moral 3. Social 4. Biological 5. Psychological

2 3 4 5 2-sexuality is a fundamental human need w/moral/social/biological/psychological

Monitoring the patient for psychosocial alterations related to immobility includes observing for which changes? Select all that apply. 1. Equilibrium 2. Rest patterns 3. Mood 4. Behavior 5. Sleep patterns

2 3 4 5 assess for changes in mood, behavior, and sleep patterns. Interviewing patients regarding their typical hours and nature of sleep is important to establish a baseline.

A nurse is working with a student nurse who asks about orthostatic hypotension. The nurse responds that it occurs when the patient stands up and experiences a sudden change in vital signs. Which changes in vital signs are indicative of orthostatic hypotension? Select all that apply. 1. Increase in heart rate of 10 beats/min 2. Drop in systolic blood pressure of 20 mm Hg 3. Increase in heart rate of 20 beats/min 4. Drop in systolic blood pressure of 10 mm Hg 5. Drop in diastolic pressure of 10 mm Hg

2 3 5

As a home care nurse, when would the nurse complete the OASIS data set? Select all that apply. 1. After each home care visit 2. On admission to home care 3. Every two months during homecare 4. Every six weeks during homecare 5. Upon discharge from homecare

2 3 5

What factors make children more vulnerable to environmental exposures? Select all that apply. 1. Small body surface area 2. Large body surface area 3. Increased metabolic rate and growth 4. Slow and gradual developing tissue in many body systems 5. Immature and rapidly developing tissue in multiple body systems

2 3 5

When should a nurse evaluate a patient's risk for falls? Select all that apply. 1. After a patient falls 2. On admission 3. Every day 4. Per provider orders 5. With any change in the patient's condition

2 3 5

Which are characteristics of palliative care? Select all that apply. 1. End of life care for the terminally ill 2. Care at any stage of a serious disease 3. Focused on symptom relief 4. Supports families during grieving 5. Provides non-curative therapy

2 3 5

Which individuals are more likely to be involved in an intentional injury? Select all that apply. 1. A young female with a history of falling 2. An adolescent female with severe depression 3. A young adult male with a history of violence 4. An older adult male diagnosed with dementia 5. A middle-aged female who is a known child abuser

2 3 5

Which instructions could the nurse provide to parents to encourage self-esteem of the school-age child? Select all that apply. 1. Complete her homework so she can get good grades. 2. Tell her "I love you" and give her a hug before leaving. 3. Give her a chore chart with things she can do each day. 4. Encourage her to do better by pointing out all mistakes. 5. Allow her to solve problems and make responsible choices.

2 3 5

Which patient statement describes the concept of ethnicity? Select all that apply. 1. "My mother taught me how to make enchiladas just like my grandmother made." 2. "My skin is lighter than most, but I am African American." 3. "I think Chinese people are smarter than Hispanic people." 4. "I like to pray every day because it makes me feel good." --rituals 5. "My long black hair resembles my Native American grandmother's"

2 5 1--culture 3--enthnocentrim 4--ritual (custom)

Which measure taken by the health care organizations would create an inclusive environment for patients belonging to the LBGTQ+ (lesbian, gay, bisexual, transgender, queer, questioning, asexual, and others) community? Select all that apply 1. Identify them on the basis of their appearance 2. Make sure that they have access to unisex bathrooms 3. Ensure the gender-inclusive language is used while talking 4. Avoid enquiring about their gender to avoid discomfort 5. Ensure that gender-inclusive information is asked on the hospital forms

2 3 5

The nurse is assessing an Asian patient in a day care center. The nurse is developing a transcultural care plan for the patient who identifies both with his native culture and the American culture. Which component should the nurse incorporate to provide culturally congruent care? Select all that apply 1. Ignoring biophysical differences of pts from different cultures 2. Obtaining knowledge of the pt's health beliefs 3. Self-examining the nurse's own culture 4. Working in another country to learn new nursing practices 5. Being open and accepting of cultural differences

2 3 5 The goal of transcultural nurisng is to provide care that fits with the pt's own values, beliefs, traditions

Which physical changes are experienced by boys during the adolescent years? Select all that apply. 1. Thelarche 2. Increased height 3. Growth of sexual organs 4. Increased fat deposits 5. Growth of pubic hair

2 3 5 the first sign of puberty in girls is thelarche, with development of breast tissue. On average, thelarche occurs between the ages of 8 and 13 years. A female patient who experiences menarche at age 12 would be expected to reach reproductive maturity by no later than 17 age . Females are expected to reach reproductive maturity 2 to 5 years after menarche. If a patient experienced menarche at age 12, maturity would be expected by 12 + 5 = 17 years of age.

Which two influences on growth and development increase the risk of occurrence of multifactorial birth defects? Select all that apply. 1. If the child is female, the risk for multifactorial birth defects will increase. 2. If one close relative has a severe form of the defect, then the risk for multifactorial birth defects increases. 3. A risk for multifactorial birth defects increases if the mother has gestational diabetes. 4. If several close relatives have the defect, whether mild or severe, it will increase the risk for multifactorial birth defects. 5. If the mother is exposed to harmful chemicals during pregnancy, then the child is at increased risk for multifactorial birth defects.

2 4

An older adult stroke patient with limited mobility is being discharged to home. What interventions should be included in the home care plan for this patient? Select all that apply. 1. Place a throw rug outside of the shower. 2. Maintain walkways so they are free of debris. 3. Keep a cellphone near the sink in case help is needed. 4. Install handrails and grab bars around the tub and toilet. 5. Store frequently used items away in closets and cabinets.

2 4 The goal is to prevent an injury from occurring and keeping a cellphone near the sink will not address this issue. The goal is to prevent an injury from occurring and storing frequently used items away in closets and cabinets will cause the patient to reach or stoop, which can lead to injury.Match the type of exercise with an example. Isotonic Isometric Aerobic Anaerobic

The nurse attends to an Asian male patient at a clinic who is joined by his family. The nurse finds that the patient speaks a different language and determines that he needs an interpreter. A male interpreter is appointed, as preferred by the patient. How should nurses communicate with this patient. Select all that apply 1. Direct the questions to the interpreter 2. Introduce themselves to the pt 3. Introduce the interpreter to the pt before introducing themselves 4. Observe the pt's nonverbal and verbal behaviors 5. Request the interpreter to ask the pt for feedback and clarification

2 4 5

Which physical changes are normally seen as an infant transition into a toddler? Select all that apply. 1. Cherub appearance 2. Protruding abdomen 3. Increased adipose tissue 4. Excessive curve of the back 5. Wide gap between knees when standing erect

2 4 5

Which professional permitted to perform a prenatal assessment of a pregnant woman? Select all that apply 1. Lay doula 2. Obstetrician 3. Registered nurse 4. Certified midwife 5. Nurse practitioner

2 4 5

Which screenign tool can be used to test literacy? select all that apply 1. The Joint Commission's (TJC's) Speak Up Initiatives 2. Wide RAnge Achievement Test (WRAT 3) 3. National Assessment of Adult Literacy Survey (NAALS) 4. Cloze test 5. Rapid Estimate of Adult Literacy in Medicine (REALM)

2 4 5

Which newly acquired cognitive/language milestones are achieved by the adolescent? Select all that apply. 1. Understanding conservation 2. Arguing a hypothesis 3. Reversing a math problem 4. Expressing abstract concepts 5. Planning for college

2 4 5 Hypothesizing several solutions to a problem is a cognitive/language milestone that is achieved by the adolescent—hypothesis/The ability to think and reason abstract concepts is a cognitive/language milestone that is achieved by the adolescent—concepts/Becoming future-oriented is a cognitive/language milestone that is achieved by the adolescent—planning

Which hallmark of emotional health indicates successful maturation in young adult? 1. Sensitivity to criticism 2. A sense of meaning and direction in life 3. Unrealistic fears 4. Satisfaction with friendships 5. Generally cheerful attitude 6. Attainment of several long-term goals

2 4 5 6

What are the uses of the OASIS (outcome and assessment information set) data set? Select all that apply. 1. Supervise homemaker activities 2. Evaluate the clinical performance of home care agencies 3. Coordinate home health aide assignments 4. Document the plan of care 5. Note patient characteristics

2 4 5The Outcome and Assessment Information Set (OASIS) is a comprehensive patient assessment tool which must be completed by nurses working for Medicare-certified home health agencies (Centers for Medicare and Medicaid Services, 2010b).

A stuff nurse is interested in participating in a unit research study regarding the use of nursing interventions to decrease the patient's risk for impaired skin integrity. Based on the current review of the literature, which should be the focus of the research in the prevention of pressure ulceration? Select all that apply. 1. Using transfer gait belts appropriately 2. Determining the most effective positions 3. Managing the use of transfer-assist devices 4. Teaching the proper use of positioning devices 5. Establishing protocol for the frequency of repositioning

2 5

Which factor is essential to a philosophy of care? select all that apply 1. management of pt care 2. selection of proper interventions 3. selection of the management structure 4. selection of a nursing care delivery model 5. knowledge of roles and responsibilities of a nurse

3 4 Rationale: A philosophy of care helps support professional nursing care. Selection of the management structure and selection of a nursing care delivery model are essential to the philosophy of care. These factors help provide quality nursing care. Management of patient care is a skill required in an entry-level nurse; it is not related to the philosophy of care. Selection of proper interventions is essential for delivering patient care; it is not a factor in a philosophy of care. The knowledge of roles, responsibilities, and functions of a nurse is something nurses should possess.

Which cognitive skills are milestones for the preschool child? Select all that apply. 1. Being able to tell time on a clock 2. Naming five different colors correctly 3. Knowing what tired and hungry mean 4. Knowing what a fork and blanket are used for 5. Speech being understandable 15% of the time

3 4 Understanding the meaning of two adjectives is a critical cognitive milestone of the preschool child/ Knowing the use of two objects is a critical cognitive milestone of the preschool child.

How is cultural competence different from patient-centered care? Select all that apply 1. Cultural competence involves individualized care 2. Cultural competence improves health care quality 3. Cultural competence aims to increase health equity 4. Cultural competence emphasizes reducing disparities 5. Cultural competence concentrates on disadvantaged groups

3 4 5

Which actions illustrate the focal points of family-centered nursing practice? Select all that apply. 1. Renewing nursing licensure 2. Reading the latest nursing journals 3. Connecting family members with community resources 4. Listening to family members' concerns about caregiving 5. Educating family members to assist with healthy meal preparation

3 4 5

Why was The National Center for Injury Prevention and Control established? Select all that apply. 1. To increase HCAPS scores. 2. To gain repeat business. 3. To decrease the mortality rate. 4. To reduce cost associated with injuries. 5. To reduce the number of patients on disability.

3 4 5

Which tasks demonstrate a nursing role in family caregiving? Select all that apply. 1. Creating a strict care routine for all skills 2. Sharing the birth of a new family member 3. Asking family members about their openness 4. Educating family members about healthy eating 5. Allowing a family caregiver to perform skills they are trained in

3 4 5 Assessing family dynamics is an essential nursing role; open communication leads to better family outcomes/ The nurse as a family educator is essential in preventing illness and promoting wellness/ Assessing family skills and allowing family members to participate in care are family-centered approaches to caregiving.

As per the Culturally and Linguistically Appropriate Standards (CLAS), what point is covered under communication and language assistance? 1. Communicate the organization's progress 2. Offer language assistance to individuals at a low cost 3. Provide easy-to-understand print and multimedia materials 4. Ensure the competence of individuals providing language assistance 5. Inform pt's of language assistance services verbally and in writing 6. Offer language assistance to individuals who have limited English proficiency

3 4 5 6

As per the Culturally and Linguistically Appropriate Standards (CLAS), what point is covered under communication and language assistance? Select all that apply 1. Communicate the organization's progress 2. Offer language assitance to individuals at a low cost 3. Provide-easy-to-understand print and multimedia materials 4. Ensure the competnece of indivuduals providing language assistance 5. Inform patients of language assistance services verbally and in writing 6. Offer language assistance to individuals who have limited English proficiency

3 4 5 6

A girl in Tanner stage 3 would be expected to exhibit which characteristics regarding breast development? Select all that apply. 1. Breast mound elevation 2. Mature nipple projection 3. Lack of contour separation 4. Areola forming secondary mound 5. Breast and areola enlargement

3 5

Which assessment data would support the nursing diagnosis of Risk for Poisoning for a pediatric patient receiving home health care? Select all that apply. 1. Stairwell carpeting that is loose 2. Bucket of water left in the kitchen 3. Access to unlabeled cleaning chemicals 4. Bicycle use without proper safety equipment 5. Prescription medications within reach of the child

3 5

Which information would the registered nurse (RN) include regarding learning in the nursing plan? select all that apply 1. Learning involves setting an appropriate pace 2. It requres the educator to be knowledgable about subject matter 3. Learning includes both understanding and applying newly acquired concepts 4. Learning involves imparting knowledge through a series of directed activities 5. It is the acquisition of new knowledge, behaviors, and skills through an experience

3 5

Which parameter helps assess the structure of the community? select all that apply 1. Government 2. Educational system 3. Economic status 4. Growth trends 5. Water and sanitation

3 5

Which model is applied when the nurse assesses the coping strategies of a patient from a different culture? King's model Self-Care Theory Sunrise model 4 C's of culture

4 C's of culture Call What do you call your problem Cause What do you think caused your problem Cope How do you cope with your condition Concerns What converns do you have regarding your condition Galanti's C's

The nurse is observing a mother who is interacting with her infant and notices the infant trying to imitate the sounds that the mother is making. The nurse knows that the child must be at least what age? · 3-4 months · 4-6 months · 6-8 months · 1-3 months

6-8 months an infant who is 6-8 months of age will be able to imitate the sounds the mother is making and therefore the nurse knows the patient must be at least this age

Which individual is in the stage of transformation identified by Gould as "getting into the adult world"? An 18 year old heading off to college A 22 year old who accepted a new job A 30 year old who bought a new house A 32 year old who established a 5-year career plan

A 22 year old who accepted a new job

Which statement corresponds to Freud's puberty stage of psychosexual development? A child who places an object in his or her mouth A child who tries to control body functions A child who experiences personal and family turmoil A child who begins to develop a conscience and feelings of guilt

A child who experiences personal and family turmoil (turbulence) Child is stimulated by increasing hormone levels/sexual energy wells up in full force, resulting in personal and family turmoil

Which collaborative member of the health care team should the nurse include as a priority to enhance safety for a patient who is recovering from a hip fracture? An occupational therapist to assess the patient's needs while eating A pharmacist to assess the patient's needs related to pain medication A physical therapist to assess the patient's needs for a walker A social worker to assess the patient's home environment

A physical therapist to assess the patient's needs for a walker After a hip fracture it is important that a patient's gait and stability is assessed and if needed an assistive device such as a walker is given to the patient to help prevent further falls and injuries.

A confused older-adult client is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? - Allow time for the client to respond - Focus on tasks to be completed - Limit conversation with the client - Use gestures and other nonverbal cues

Allow time for the client to respond

A student nurse employed as a nursing assistant may perform care: A. as learned in school B. expected of a nurse at that level C. identified in the hospital's job description D. requiriing technical rather than professional skills

C. student nurses should never perform a task that is not in the job description of the facility with which they work

A female patient has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the patient into the proper position and offers support during the biopsy. The nurse is demonstrating A. Enabling B. Comforting C. A sense of presence D. Maintaining belief

A sense of presence

Which definition relates to family durability? - The uniqueness of each family unit - The ability of a family to cope w/expected and unexpected stressors - The interactions btw family members that are affected by a family's makeup and function - A system of support and structure w/in a family that extends beyond the walls of the household

A system of support and structure w/in a family that extends beyond the walls of the household

Which initiative demonstrates the commitment of Magnet hospitals to evidence-based practice (EBP)? Establishing unit-based interdisciplinary care teams Allowing nurses autonomy in using evidence to improve quality of care Signing a clinical affiliation agreement with a college nursing program Supporting staff participation in continuing education

Allowing nurses autonomy in using evidence to improve quality of care Allowing nurses autonomy in using evidence to improve quality of care is a characteristic of an EBP environment.

Which action is involved in the characterizing level of affective learning? - acting and responding with a consistent value system - listening to a process and responding verbally or nonverbally - developing a value system by organizaing values according to their worth - paying attention to the process of learning while receiving information

Acting and responding with a consistent value system Affective learning involves the expression of feelings and development of values, attitudes, and beliefs. It may include value clarifications as an example. Characterizing is the most complex behavior of affective learning. It involves an action and response with a consistent value system. The responding level of affective learning involves active participation through listening along with a verbal or nonverbal response. The organizing level requires the development of a value system by organizing values according to their worth. At the receiving level, the learner is passive and simply takes in information by paying attention.

Define illness prevention. - Actions that motivate a patient to strive for optimal health - Conditions that increase a patient's vulnerability to illness - Activities that protect a patient from actual or potential health threats - Behaviors that balance a patient's physical, emotional, social, spiritual, and intellectual well-being

Activities that protect a patient from actual or potential health threats Prevention of disease—Primary/detection of a hidden disease—Secondary/treatment for a diagnosed disease—Tertiary

A post-surgical patient has been out of bed once. The patient experienced increased heart rate and increased oxygen requirements. What nursing diagnosis would the primary nurse identify for this patient? Social Isolation Risk for Falls Imbalanced Nutrition Activity Intolerance

Activity Intolerance The patient is exhibiting signs of deconditioning as a result of bed rest after surgery, such as pulse rate above 100 with activity, increased oxygen requirements, and shortness of breath.

Patient reports shortness of breath and fatigue while performing activities of daily living are indicative of which problem? Orthostatic hypotension Deep vein thrombosis Activity intolerance Cerebellar problems

Activity intolerance Patient reports of shortness of breath and fatigue while performing activities of daily living are signs of activity intolerance.

Which statement describes the relationship between illness and aging in older adulthood? - Disease is an expected outcome of aging. - Acute illness increases risk for chronic health conditions. - Illness and disease seen in older adults are unique to this group. - The strengthened immune system protects older adults against infectious disease.

Acute illness increases risk for chronic health conditions.

Which is an example of community-based nursing practice? Testing vision of first grade students at a local school Testifying at a government hearing on fluoridation of the city water supply Administering IV antibiotics to a patient at home Developing a brochure on immunizations

Administering IV antibiotics to a patient at home Community-based nursing care is focused on the individual or individual family, and occurs outside the traditional acute or ambulatory care settings. Settings in which community-based care are provided include the home, schools, camps, and correctional facilities.

Which nursing intervention is an example of primary prevention? Providing discharge teaching Obtaining a fecal occult blood test Administering a pneumonia vaccine Scheduling a mammogram screening

Administering a pneumonia vaccine Instill hope for the future—spiritual well-being/emphasize the importance of education—intellectual well-being/provide alternatives for substance abuse—physical well-being/allow family members to participate in care—social well-being

Which intervention will the nurse implement to provide secondary prevention? - Encouraging the patient to use seatbelts - Helping the patient adjust to an incurable disease - Administering a purified protein derivative (PPD) skin test to a patient - Facilitating genetic screening for a patient and significant other

Administering a purified protein derivative (PPD) skin test to a patient

Which intervention will the nurse implement to provide secondary prevention? Encouraging the patient to use seatbelts Helping the patient adjust to an incurable disease Administering a purified protein derivative (PPD) skin test to a patient Facilitating genetic screening for a patient and significant other

Administering a purified protein derivative (PPD) skin test to a patient

A mother is concerned she won't be able to ask questions of her child's health care provider before she leaves for work. The nurse assures the mother the questions will be asked and recorded in writing at the child's bedside. Which role is the nurse demonstrating? Educator Leader Advocate Manager

Advoate The nurse demonstrated the role is advocate by assuring the mother that her questions will be asked, even though she cannot personally communicate with the health care provider. The nurse records the questions so the mother is confident the nurse will communicate her questions to the health care provider.

The mother of a newborn child enquires about having her child's hearing checked. What is the best response by the nurse? All newborns should be screened before 1 year of age. At 6 months you can return and we will screen your infant. Your newborn will be screened at the four-month well-baby visit. All newborns should be screened for hearing before one month of age.

All newborns should be screened for hearing before one month of age. Stating that the child will be screened for hearing before one month of age is accurate and therefore this is the best response for the nurse to make

Which core principle is a component for the National Action Plan to Improve Health Literacy? Jargon and problematic terms should be reduced to improve comprehension. Staff should be trained to use plain language when they communicate with the public. All people have the right to health information that helps them make informed decisions. The profession must work together in a coordinated manner to provide understandable health information.

All people have the right to health information that helps them make informed decisions.

Which nursing diagnosis is definitively related to a public health problem? · Compromised Family Coping related to temporary family role changes as evidenced by the significant person withdrawing from the client. · Altered Health Seeking Behaviors related to discontinuation of senior bus services as evidenced by canceled clinic visits related to lack of transportation. · Frail Elderly Syndrome related to chronic illness as evidenced by social isolation. · Caregiver Role Strain related to family member with significant care needs as evidenced by disturbed sleep and difficulty performing required tasks.

Altered Health Seeking Behaviors related to discontinuation of senior bus services as evidenced by canceled clinic visits related to lack of transportation. The focus of this nursing diagnosis is the senior citizens in the community who are dependent on senior bus transportation to the clinic. This is a population-focused public health problem.

Which term describes nurses who engage in selfless acts? Competent Autonomous Altruistic Fair

Altruistic Engaging in selfless acts is known as altruism. A selfless nurse is altruistic. Selfless acts provide a service to society, which is a defining criterion for a profession.

A cephalocaudal pattern of growth is seen in which aspect of motor development? An infant will be able to roll front to back before he or she can crawl. An infant can use their upper limbs before he or she is able to use their lower limbs. An infant will be able to point to a moving object before they can bat the object. An infant will be able to lift the head before they demonstrate tripod sitting.

An infant can use their upper limbs before he or she is able to use their lower limbs. The cephalocaudal pattern of growth is seen as infants learn to use their upper limbs before they are able to use their lower limbs

What question should the nurse ask to assess a patient's understanding of the risks related to poisonous substances? Do you have injuries that place you at risk for drowsiness? Do you know why you take your current set of medications? Are separate cutting surfaces used for cutting raw fish and meats? Do you have any safety concerns at home or work?

Are separate cutting surfaces used for cutting raw fish and meats? Asking about separate cutting surfaces for meat and fish assesses the patient's understanding of food safety and the prevention of food poisoning.

A patient had high blood sugar when the nurse tested it previously, but the patient says the blood sugar was normal when tested at home right before coming to the clinic. Which action would the nurse take next? - Ask the patient if he or she would like a consult to another endocrinologist - Advise the patient to change the type of insulin - Advise the patient to decrease the dose of insulin - Ask the patient to show the technique for checking blood sugar levels

Ask the patient to show the technique for checking blood sugar levels

The nurse at an outpatient clinic asks a Chinese American patient with newly diagnosed hypertension if he is limiting sodium intake as directed. The patient nods his head but does not make eye contact with the nurse. Which action would the nurse take next? - Ask the pt how much salt he is consuming each day - Discuss the health implications of sodium and hypertension - Remind the pt that many foods such as soy sauce contain hidden sodium - Suggest some low-sodium dietary alternative

Ask the pt how much salt he is consuming each day In Asian cultures, spoken messages often have little to do with their meanings—nurse should clarify how much salt the pt is consuming in his diet

A nurse is working with a female patient who has a distended abdomen and has not been able to urinate for 24 hours. After catheterizing the woman, a large amount of clear urine collects in the urine bag. The patient asks for her 32-ounce cup to be filled with water for her to drink right away. The cup is marked with the logo of a local weight loss group. The nurse asks the woman who does not look overweight once her distended bladder is relieved, if she is drinking water to try to lose weight. Sharing this information later with the health care provider, an order for electrolyte testing as part of blood work is put in. What is the best explanation for what has occurred? Values clarification process Asking relevant questions Listening to the patient Establishing goals

Asking relevant questions The nurse asked why the woman was drinking an unusual amount of water, given that she already had dilute urine and difficulty urinating. The nurse was probably aware of the danger of drinking too much water that could upset electrolyte balance. Therefore asking relevant questions is the best answer.

The practitioner has ordered a nasogastric feeding tube for a patient. The nurse knows that improper insertion places the patient at risk for what complication? Malnutrition Constipation Aspiration pneumonia Urinary tract infection

Aspiration pneumonia Aspiration pneumonia is associated with improper placement of a nasogastric feeding tube due to tube feeding entering the lungs.

Which is an example of a patient-centered care nursing skill, as defined by the QSEN project? Assess and treat pain and suffering in light of patient values, preferences, and expressed needs. Empower contributions of others who play a role in helping patients and families achieve health goals. Develop guidelines for clinical decision making regarding departure from established standards of care. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team.

Assess and treat pain and suffering in light of patient values, preferences, and expressed needs. This is an example of a patient-centered nursing skill as defined by QSEN.

What intervention facilitates early identification of pressure ulcers? Turn and reposition the patient frequently. Maintain clean, dry, wrinkle free bed linens. Ensure patient has adequate nutritional intake. Assess the patient's skin with a skin assessment tool.

Assess the patient's skin with a skin assessment tool. Using a skin assessment tool regularly can facilitate the early identification of the development of a pressure ulcer.

The nurse enters a room and notices that the patient's bed is very high up off the ground, posing a safety risk. What step in the nursing process is this? Diagnosis Assessing Evaluation Intervention

Assessing The nurse is assessing safety risks as during an initial look at the room.

An Arab woman is admitted to the hospital. A male nurse is assigned to examine this patient. The patient is uncomfortable and expresses displeasure at being assigned a male nurse. What should the nurse manager do? - Ask the male nurse to go ahead with the examination - Assign a female nurse to carry out the examination - Remain in the room when the male nurse is examining the pt - Explain to the pt that the hospital is short on staff and that she has cooperate

Assign a female nurse to carry out the examination

The nurse is caring for a patient whose daughter wishes to pursue a career in nursing. The daughter wants to enroll in a program that is of short duration and makes her eligible to take the nursing licensure examination. Which educational program would the nurse recommend to this student? - Baccalaureate degree program in nursing - Associated degree program in nursing - Professional doctoral program in nursing - Master's degree in nursing

Associated degree program in nursing U.S., a student can take the NCLEX-RN nursing licensure examination after completing either the associate or the baccalaureate degree program in nursing (2 years and 4 years)

Which teaching tool is beneficial for patientswith reading comprehension problems and visual deficits? - Graphs - Physical objects - Audiovisual materials - Computer instruction

Audiovisual materials Audiovisual materials include slides, audiotapes, television, and videotapes used with printed material or discussion. This teaching tool is effective for patients with reading comprehension problems and visual deficits. Graphs are visual presentations of numerical data. They help learners grasp information quickly about single concepts. This teaching tool may not be beneficial to patients with visual deficits. Likewise, using physical objects such as actual equipment, objects, or models to teach concepts or skills may not be beneficial to patients with visual deficits. The computer instruction method requires reading comprehension, psychomotor skills, and familiarity with computers.

How can a nurse develop cultural knowledge? - Become self-aware of personal biases - Understand the forces that influence one's own world view - Avoid unwarranted generalization about any particular group - Engage in an in-depth self-examination of one's own background

Avoid unwarranted generalization about any particular group The nurse should approach each person individually and ask questions to gain a better understanding of the person's perspective/needs to gain sufficient comparative knowledge of diverse groups/including the values/health beliefs/care practices/world views/bicultural ecologies

To enhance cultural awareness, which should the nursing students include in their self-examination? - Motivation/culture/commitment to caring - Social/cultural/biophysical factors - Engagement in cross-cultural interactions - Background/personal biases/prejudices

Background/personal biases/prejudices Cultural awareness involves an in-depth self-examination of one's own background, recognizing biases and prejudices and assumptions about other people The primary goal of pt-centeredness is to provide care, restore an emphasis on personal relationships The goal of transcultural nurisng is to provide care that fits with the pt's own values, beliefs, traditions Culture awareness would help in recognizeing biases, prejudices, assumptions about other people cultural skills help assess social, cultural, biophysicla factros that influence pt tx and care

The nurse is caring for a patient with trauma to the cerebellum. What problem should the nurse anticipate when getting the patient out of bed? Planter flexion contractures of both feet Muscle atrophy and weakness of the arms Pathologic bone fractures of the lower legs Balance and stability issues

Balance and stability issues The nurse should anticipate balance and stability issues in the patient with cerebellar problems, as the cerebellum assists with equilibrium.

Which factor would the nurse consider when communicating with adolescents? - Be alert for clues to their emotional state - Ask closed-ended questions to get straight answers - Avoid looking for meaning behind adolescents' words or actions - Avoid discussing sensitive issues such as sex and drugs

Be alert for clues to their emotional state

Which option is available to nurses who want to expand their practice, but do not desire to return to formal education? Move to a higher level area of practice. Become certified in current practice area. Join a second professional organization. Take online continuing education courses.

Become certified in current practice area Specialty certification allows nurses to excel and demonstrate excellence in their practice without having to return to formal education to obtain a higher degree.

What measure is essential for effective family caregiving as a family member transitions to continuing care? Continuing the restrictiveness of continuing care Suggesting that family members will have less interaction Being flexible about family care changes postdischarge Being open and explaining that caregiving will be needed for the remainder of the family member's life

Being open and explaining that caregiving will be needed for the remainder of the family member's life Openness and communication needs in family caregiving are always essential; providing information and explaining the continued needs for family members are essential for positive outcomes.

What measure does the nurse outline for providing culturally competent care? - Less diversity among health care provider - Better communication between health care providers and patient - In-depth self-examination of one's own background to recognize biases - Treating all pts uniformly regardless of cultural and racial associations

Better communication between health care providers and patient

Gesell's theory of development is based on which principle? - Moral development - Psychosocial development - Psychosexual development - Biophysical development

Biophysical development Gesell's theory focuses on biophysical development and states that an individual's development is determined by genetic activity. Moral development—Kohlberg's six stages o From Jean piaget Stage 1: obedience and punishment Stage 2: self-interest Stage 3: interpersonal accord and conformity (not get involve, want others see she is a good girl) Stage 4: authority and maintaining social order—teacher sees the group fighting, he immediately steps in and shouts: "STOP." Stage 5: social contract—he punched a young girl form grade one. She asks herself: Does a rule truly serve all members of the community? Stage 6: universal ethical principles - Psychosocial development—Erikson's theory Stage 1: Trust vs. Mistrust Stage 2: Autonomy vs. Shame and Doubt Stage 3: Initiative vs. Guilt Stage 4: Industry vs. Inferiority Stage 5: Identity vs. Confusion Stage 6: Intimacy vs. Isolation Stage 7: Generativity vs. Stagnation Stage 8: Integrity vs. Despair - Psychosexual development—Freud' theory

After a health care provider informed a patient that he has colon cancer, the nurse enters the room find the patient gazing out the window in thought. Which response would the nurse provide first? A. "Don't be sad. People live with cancer every day. "B. "Have you thought about how you are going to tell your family?" C. "I can sit with you for a while, if you would like to talk." D. "I know another patient whose colon cancer was cured by surgery."

C. "I can sit with you for a while, if you would like to talk." RationaleAsk the patient if he would like you to sit down for a few minutes so he can talk. Asking an open-ended question and providing an opportunity for the patient to talk allow the nurse to assess the patient's perception of the situation, which is of utmost importance. Test-Taking Tip: Look for answers that allow the patient to express feelings.

The nurse is floated to work on a nursing unit where the assignment is beyond the nurse's capability. Which action would the nurse take? - call the nursing supervisor to discuss the situation - discuss the problem with a colleague - leave the nursing unit and go home - say nothing and begin work

Call the nursing supervisor to discuss the situation

The nurse is caring for a patient with a nasogastric tube who is also NPO. The practitioner places an order for a medication but fails to specify if the route is by mouth or by the nasogastric tube. Which action by the nurse is appropriate? Administer the medication orally. Call the practitioner to clarify the correct route. Call the pharmacist and ask which route is appropriate. Administer the medication via the patient's nasogastric tube.

Call the practitioner to clarify the correct route. The nurse should always clarify orders missing critical information with the practitioner.

Which clinical feature is associated with delirium? - Lasts for months to years - Minimal impairment of attention - Onset is slow and often unrecognized - Calls out repeatedly with the same phrase

Calls out repeatedly with the same phrase

The nurse gently touches the shoulder of a patient lying with his eyes closed. When the patient opens his eyes, the nurse smiles and asks how he is feeling. Which kind of touch is this? - Caring - Protective - Task-oriented - Healing touch

Caring

A male adult who previously enjoyed running 5-6 miles per day now complains of a "grinding" sensation in the knee when he runs. He states that this has been a gradual problem which seems to be increasing in frequency. What could be responsible for this problem? Muscle Tendon Ligament Cartilage

Cartilage Cartilage is within the joint to provide cushion. Lack of cartilage would create a "grinding" sensation as there is no cushion in the joint space.

Which outcome does the nurse understand to be a normal result of the aging process? Cellular atrophy Cell function increases Cell damage decreases Number of cells increases

Cellular atrophy Cellular changes such as atrophy are characteristic of aging

The rehabilitation nurse is caring for a patient with inability to move all four extremities. What type of injury is related to this? Ischemia Head injury Lower spinal cord trauma Cervical spinal cord trauma

Cervical spinal cord trauma Cervical spinal cord trauma is related to quadriplegia.

Clara Barton Linda Richards Lenah Higbee

Clara Barton, founder of the American Red Cross. The first nurse in America was Linda Richards, who graduated from Boston's Women's Hospital in 1873. Lenah Higbee—the U.S. Navy Nurse Corps--Superintendent of the U.S. Navy Nurse Corps

The nurse states to a patient, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations? Whcih therapeutic communication technique does this illustrate? - Providing information - Calrifying - Focusing - Paraphrasing

Clarifying

Clinical Care coordination Team Communicaiton

Clinical Care coordination clinical decisions/priority setting/organizational skills/use of resources/time management/evaluation Team Communication - Effective communication is critical to all teams: use open/professional communication - respect one another's ideas/share info - understand the roles and responsibilities of everyone on eht health care team - the two-challenge rule allows concerns about safety to be voiced twice - situation-background-assessment recommendation (SBAR)

What describes an early care responsibility within the stages of family approaches to caregiving? Listening to family health care complaints Palliative care for end-stage renal disease Clinician discussion related to diabetes care Allowing family members to support themselves

Clinician discussion related to diabetes care Early stages of caregiving include the responsibility of communication between the family and health care professions.

Which aspect of Florence Nightingale's work set the stage for evidence-based practice (EBP) in nursing? Concern with the impact of the environment on health Close monitoring of the effectiveness of interventions Collaboration with government officials Focus on nutrition and basic hygiene

Close monitoring of the effectiveness of interventions EBP integrates the best available research evidence with clinical expertise. When Ms. Nightingale monitored and recorded patient responses to interventions and treatments and then used this information in subsequent patient care, she was beginning to accumulate and use research data.

Which action should the nurse take to incorporate QSEN's guidelines into patient care while providing tertiary prevention? - Coordinate a flu shot clinic for patients of all ages - Collaborate with patient, family, and health care team to develop a care plan - Ensure sensitivity to the patient's needs while providing individualized screening - Base a patient's physical and emotional care solely on the primary care provider's orders-

Collaborate with patient, family, and health care team to develop a care plan The six major QSEN competencies developed for pre-licensure and graduate nursing programs include patient-centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement (QI), safety, and informatics (QSEN, n.d.).

Which scenario is an example of primary prevention? - Conducting a lead screening program targeted at pre-school age children - Providing directly observed drug therapy for clients with active tuberculosis - Collaborating in the development of a citizen emergency preparedness plan - Asking about abuse as part of routine health assessment

Collaborating in the development of a citizen emergency preparedness plan Primary prevention is focused on the prevention of disease or disability. Developing a citizen emergency preparedness plan is designed to prevent disease and disability and, therefore, is an example of primary prevention.

Bethany, a registered nurse (RN) works on a busy surgical unit. One of Bethany's patients, 65-year-old Dale, is recovering from a radical prostatectomy due to prostate cancer. Dale is scheduled to be discharged soon. He lives alone and is unable to drive due to poor vision. Dale's neighbor, John, agreed to help him with his catheter care and medications. As Bethany is reviewing the treatment plan, Dale informs her that his financial situation has caused him concern over the past few weeks and he is feeling hopeless about his situation. Bethany enlists the help of a social worker to connect Dale to provide information about community programs that can help him obtain this medications and supplies. She also calls the chaplain to talk with Dale and offer some words of encouragement. Which nursing role did Bethany's actions depict in this scenario? Collaborator Educator Leader Change agent

Collaborator Bethany's actions demonstrated the role of collaborator. Collaboration is the process by which two or more people work together toward a common goal. In this situation, Bethany, the social worker, and the chaplain are working together to ease Dale's concerns about his situation.

Which Standard of Professional Performance is the home care nurse modeling when he or she contributes to the professional development of a peer? Quality of care Education Collegiality Collaboration

Collegiality companionship and cooperation between colleagues who share responsibility.

Which concept best encompasses all areas of nursing practice outside the acute care setting? Outpatient Clinic Nursing Community-based nursing Community health nursing Public health nursing

Community health nursing Community-based nursing focuses on providing direct nursing care for individuals in a community setting, such as in a home, school, or workplace. It does not include care of populations.

Which area of nursing practice is defined as provision of direct care to individuals in a community setting? Community-based nursing Palliative care nursing Public health nursing Chronic care nursing

Community-based nursing

According to the World Health Organization (WHO), what is the definition of health? - Being free from illness or injury - Complete physical, mental, and social well-being - Absence of signs and symptoms with normal laboratory reports - Total absence of all disease, disorders, and syndromes

Complete physical, mental, and social well-being

Which intervention should the nurse use as an alternative to patient restraints? Enhance environment stimuli such as lights. Avoid patient distractions such as the television. Cover drainage tubes and intravenous access devices. Limit visitors and the time they can spend with the patient.

Cover drainage tubes and intravenous access devices. Covering drainage tubes and intravenous access devices is an effective alternative intervention for restraints. Restraint can often be avoided by: Orienting the patient to surroundings and explaining interventions Using bed alarms and moving the patient near the nurse's station for closer observation Encouraging family/caregivers to spend time with the patient Minimizing environmental stimuli (noise, lights) Providing distraction (TV, music) Identifying sources of agitation (hunger, pain, need for toileting) Obtain order for a 24-hour sitter Cover tubes, IVs, equipment to decrease agitation Used padded mitts as opposed to wrist restraints that do not allow movement. Side rail use - Often use top two side rails for turning and positioning; however, when all four side rails are raised—it is considered a form of physical restraint

The nursing process organizes your approach while develiverin nursing care. To provide the best professional care to pts, nurses need to incorporate nursing process and: - decison making b. problem solving c. intellectual standards d. critical thinking skills

Critical thinking skills Critical thinking synthesis - critical thinking/the nruisng process go hand-in-hand in making quality decsions about pt-centered care. the nursing process cannot be completed w/out critical thinking in forming nursing diagnoses/setting goals/interventions/evaluation

The nurse is caring for a Native American patient newly diagnosed with lung cancer, who smokes his own tobacco. Which of the Leininger's strategies is most recommended for the nurse? Cultural care accommodation Cultural care restructuring Cultural care negotiation Cultural maintenance

Cultural care restructuring Cultural care re-patterning or restructuring respects the pt's cultural traditions while pts changes their lives and adopt new, beneficial health care patterns. This will best help the pt stop smoking

The nurse, while caring for a patient of a different cultural background, learns about the patient's cultural practices that affect health. The nurse uses these facts to plan the patient's care. Which component of Campinha-Bacote's model of cultural competency is reflected in this scenario? - Cultural skill - Cultural desire - Cultural encounter - Cultural knowledge

Cultural encounter Cultural knowledge-—knowledge of diverse groups, including the values/health beliefs/care practices/world views/bicultural ecologies cultrual desire-motivation/commitment to care for pt Campinha-Bacote's model of cultural competency includes interrelated components. Cultural encounter involves the cross-cultural interactions between the nurse and the patient that provide opportunities to learn about other cultures and develop effective intercultural communication.

Which statement is true regarding culturally congruent care? - Culturally congruent care has predetermined criteria from which patterns of life and the system of meaning are generated - Culturally congruent care bridges gap to provide supportive care for pts from certain cultures - In culturally congruent care, transcultural nursing enables health care providers to deliver uniform services irrespective of health beliefs - Culturally congruent care sometimes diverges from the values of the professional health care system

Culturally congruent care sometimes diverges from the values of the professional health care system

During their clinical post-conference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that a patient was homeless. Which difference was being describe between the student and the patient? - Ethnicity - Culture - Heritage - Religion

Culture Culture is the context in which groups of people interpret and define their experiences relevant to life transitions, such as being homeless versus coming from a middle-class family

A nurse is caring for a pt who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss? A. living wills B. assisted suicide C. passive euthanasia D. Advance directives

D advance directives are written documents that outlay the pt's wishes, should he or she beocme incapacitated

The nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. In which option does the nurse avoid an error? - Data collection - Data clustering - Data interpretation - Making a diagnostic statement

Data interpretation Data Interpretation is the process of making sense out of a collection of data that has been processed.

Impending death is manifested by these symptoms:

Decrease in urine output Cold and mottled extremities Vital sign changes: Blood pressure decreases and pulse often increases, but can also decrease Changes in breathing patterns: periods of apnea that increase with time Respiratory congestion or 'death rattle' from the inability to swallow secretions

While positioning a patient in the 30-degree lateral position, the nurse rolls the patient towards his or her side. Which rationale explains this nursing action? - Decrease internal rotation - Decrease trauma to tissues - Provide comfort to the patient - Reduce pressure on trochanter

Decrease trauma to tissues Rationale: Rolling a patient toward the nurse side while positioning in a 30-degree lateral position decreases trauma to the tissues. Positioning both arms of the patient in a slightly flexed position decreases internal rotation and adduction of the shoulder. Lowering the head of the bed completely provides comfort to the patient. Placing the nurse's hands under the patient's hips during positioning reduces pressure on the trochanter.

What nutritional alteration is associated with immobility? Decreased basal metabolic rate Positive nitrogen balance Enhanced appetite Increased serum albumin levels

Decreased basal metabolic rate Immobility is associated with a decreased metabolic rate, due to a diminished activity level.

What complication can develop as a result of circulatory stasis and weakened calf muscles? Edema Gait disturbances Permanent plantar flexion Deep vein thrombosis

Deep vein thrombosis Circulatory stasis and weakened calf muscles can lead to the development of deep vein thrombosis.

When the nurse collaborates with the dietary department to provide a kosher meal for a patient, which professional criterion does this action support? Diversity Trust Leadership Autonomy

Diversity

The nurse is caring for a patient who is being treated for an inner ear infection. What is an expected assessment finding? Headache Visual disturbance Numbness of fingers Dizziness

Dizziness Equilibrium is related to the cerebellum and inner ear so an infection may cause the person to feel dizzy.

The nurse is concerned about the fire hazards associated with home oxygen therapy for a patient being discharged to home with oxygen. What education should be included when teaching this patient? Have a fire escape plan. Do not allow trash to accumulate. Do not start a fire in the fireplace. Ensure circuit breaker boxes work properly.

Do not start a fire in the fireplace. Patients on home oxygen therapy should be instructed not to smoke or have open flames in a fireplace.

The registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient? - What are your dietary preferences? - What time do you typically go to bed? - Do you bathe and use deodorant more than 1 time a week? - Do you have any health issues that we should know about?

Do you bathe and use deodorant more than 1 time a week?

The Domain of Nursing types of theory

Domain the persepctive or territory of a profession or discipline, allows nurses ot identify, treat pts' health care need in all settings Paradigm a pattern of beliefs used to describe the domain of a discipline, conceptual framework a way to organize major conepts and visualize the relationship among phenomena Nursing metapradigm-person, health, evnironment and situation, nursing it allows nurse to understand and explain what nursing is, does, most abstract level of knowledge Theory 1. grand: broad in scope/complex 2. middle-range--limited in scope and less abstract 3. practice--narrow in scope and focus (easier to understand) 4. Descriptive--describe phenomena and identify circumstances in which phenomena occur 5. Prescriptive--address nursing interventions for a phenomenon, guide practice change, and predict the conseuqneces

Which example is a passive strategy for health promotion? Drinking fluoridated tap water Meditating every morning before work Participating in a smoking cessation program Attending an exercise program three days a week

Drinking fluoridated tap water With passive strategies of health promotion, individuals gain from the activities of others without acting themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with vitamin D are examples of passive health promotion strategies.

Which assessment finding alerts the nurse that the patient lives in a food desert? · Obtains vegetables from a roadside stand · Eats at a restaurant five miles away from home · Drives three miles to the closest supermarket · Does not eat the recommended daily servings of fruit

Drive 3 miles to the closest supermarket More than 23 million Americans, including 6.5 million children, live in low-income urban and rural neighborhoods that are more than a mile from a supermarket. These communities are known as "food deserts" since they lack access to affordable, nutritious food.

The nurse implements several pain relieving interventions, teaches relaxation techniques, re-evaluates the patient's pain throughout the shift, and revises the plan of care as needed. Which nursing roles do these actions demonstrate? Select all that apply. Educator Leader Care provider Manager Collaborator

Educator Care provider The nurse demonstrated care provider by assessing, implementing, evaluating, and revising the patient's plan of care/The nurse demonstrated the role of educator when teaching the patient relaxation techniques

a homeless man enters the emergency department seeking health care. the health care provider indicates that the patient need to be transferred to the city hospital for care. Which law does this action most likely violate? - Health Insurance Portability and Accountability Act of 1996 (HIPPA) - American With Disabilities Act (ADA) - Patient Self-Determination Act (PSDA) - Emergency Medical treatment and Active Labor Act (EMTALA)

Emergency Medical Treatment and Active Labor Act (EMTALA)

Federal Stutory Issues in Nursing Practice

Emergency Medical Treatment and Active Labor Act-pt presents to ED--they must treat Health Insurance Portability and Accountability Act (HIPAA)--privacy of their health care infor/records Health Info Technology Act: nurses must ensure PHI is protected American with Disabilities Act (ADA)-protects rights of ppl with physical or mental disabilities Mental Health Parity and Addiction Equity Act--provide coverage for mental health and substance used disorder (SUD) treatment Patient Self-Determination Act--provide written info to pts concerning rights to make decision about their care, including the RIGHT TO REFUSE TX and to formulate an adance directive/DURABLE POWER OF ATTORNEY FOR HEALTH CARE (DPAHC)/LIVING WILLS/DNR The Omnibus Budget Reconciliation Act (1987)--older adults - focused on pt right/quality of life, quality of care, and the physical environment in which pt lived. OBRA 1987 addressed the use of BOTH PHYSICAL AND CHEMICAL RESTRAINT us

Which strategy would the nure use to assist the patient newly diagnosed wiht colon cancer who is withdrawn? - obtain a RX for a psychiatirc evaluation - encourage the pt to identify fears and verbalize feelings - allow the pt to remain withdrawn to avoid drawing attention to this behavior - explain to the pt that newer treatments permit many people to survive colon cancer

Encourage the patient to identify fears and verbalize feelings. The nurse recognizes that the patient could be expressing feelings of grief. The nurse should encourage the patient to verbalize feelings and identify fears. This would help the patient to move through the phases of the grief process. The patient does not need a psychiatric evaluation, as this is a normal grief process and not a psychiatric disorder. The patient should not be left alone because the patient needs support to cope with the illness. Explaining newer treatment options may not affect the grief process.

A nurse is meeting with a family whose father is being admitted to the hospital for infection due to radiation for the treatment of stage IV lung cancer. The nurse uses the values clarification process. What application of the values clarification process is most likely to occur? · End of life care · Financial decisions · Family involvement · Living arrangements

End of life care The most helpful application of the values clarification process occurs when the nurse assists a patient or family making a decision regarding end of life care.

Which is an appropriate nursing action when caring for a terminally ill patient? Share personal beliefs about end-of-life care. Engage the patient to defend his or her values. Advise the patient on making choices about care. Ensure the patient has reached an informed choice.

Ensure the patient has reached an informed choice While helping pts with values clarification/care decisions, nurse must be aware of the potential influence of their professional nursing role on pt decision making/A nurse has a professional responsibility to provide information so a patient can make an informed decision.

Which values does the Nursing Code of Ethics address? Select all that apply. Equal treatment Nurse achievement Professional experience Patient advocacy Commitment to others

Equal treatment Patient advocacy Commitment to others The nurse holds in confidence personal information and uses judgment in sharing information about a patient. The nurse acts as an advocate for the patient and has the best interests of the patient in mind at all times. Nurses treat all patients equally regardless of socioeconomic background, religious beliefs, race, religion, or sexual orientation. Nurses recognize nursing as their life's work, being an important component of their lives and clearly defining who they are. Nurses focus on service to their patients and the community. Commitment to others

What is the primary goal of health care professionals who specialize in epidemiology? -Track the incidence and prevalence of communicable disease to identify vulnerable groups -Improve morbidity and mortality rates by identifying patterns of disease -Establish programs to prevent the development of disease and control its spread -Design strategies to monitor the effectiveness of treatment on limiting the prevalence of disease

Establish programs to prevent the development of disease and control its spread Public health professionals who specialize in epidemiology study factors that influence the frequency and distribution of disease, injury, and other health-related events and their causes within a population. The purpose of their work is to establish programs to measure and prevent disease and control its spread.

A nurse in a skilled nursing facility is meeting her patient for the first time, a woman who is 92 years old and a retired nurse herself. The older woman says she has a Do Not Resuscitate order in her chart, and wishes to have "DNR" written on her chart by her door, in case she should pass away. The intake nurse says, "You were a nurse, too. How can you not allow me to care for you in every instance? You might change your mind later, if I were to bring you back." What kind of dilemma best describes the intake nurse's position? Ethical Legal Scope of practice Spiritual

Ethical The intake nurse is identifying with the retired nurse and perhaps this caused her to think more deeply about this issue. Clearly, the intake nurse thinks that a nurse should want to be resuscitated when in a medical facility such as the skilled nursing facility. Also clearly, she sees that this is not the older woman's wish. The intake nurse is expressing an ethical dilemma.

Which fundamental skill is required of the nurse for safe and effective evidence-based practice (EBP)? Prepare clear, useful practice guidelines. Evaluate the strength and relevance of research findings. Coordinate and conduct research projects. Assign and delegate patient care appropriately.

Evaluate the strength and relevance of research findings. EBP is the integration of best research evidence with clinical nursing expertise, patient values and needs, and the delivery of quality, cost-effective health care. To determine the best evidence, the nurse must be able to evaluate the strength and relevance of research findings.

During the 12-hour shift, a patient had 40 mL of drainage in the surgical drainage collection device. The nurse refers to the written plan of care and notes that the health care provider should be informed when drainage in the device exceeds 100 mL for the day. Which type of action is the nurse performing when observing the drainage volume in the device to determine if it has exceeded the prescribed daily maximum? - Planning - Evaluation - Intervention - Daignosis

Evaluation Evaluation is the type of action the nurse is performing when observing the volume in the surgical drainage collection device to determine if it has exceeded the health care provider's prescribed maximum goal of less than 100 mL for the day. The patient's baseline wound drainage volume was 40 mL, which is the nurse's initial assessment of the patient's wound condition. The nurse is evaluating the amount of drainage to determine if there has been any change since the last shift and if the total drainage volume meets the health care provider's prescribed goal in the plan of care, which indicates how well the wound is healing.

The nurse implemented strict infection control procedures for an immunocompromised patient. Whose theory did the nurse exhibit when caring for this patient? · Jean Watson · Florence Nightingale · Hildegard Peplau · Virginia Henderson

Florence Nightingale

A nurse is selecting written materials on wound care for a patient. Which patient evaluation is a priority for the nurse to determine before providing the materials? · Writing skills · Abstract thinking · Grade level completion · Functional literacy level

Funtional literacy level Functional literacy level is the priority when providing written materials about wound care. Low functional language and literacy skills limit the ability of individuals to read and comprehend health education and illness prevention materials, resulting in worse health outcomes.

The nurse is working with a patient who has a history of falls and is displaying generalized weakness and requires some assistance with ambulation. The patient has not used an ambulation aid in the past. Which aid would be the best choice for the nurse to use with this patient at this time? Gait belt Cane Walker Crutches

Gait belt A gait belt provides a grasp point for caregivers to support ambulation of a patient with an unsteady gait or generalized weakness, and would be appropriate for use with this patient.

The nurse assesses a patient who comes to the pulmonary clinic: "I see that it has been more than 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from you last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following this plan?" The nurse's assessment covers which of Gordon's Functional Health Patterns? -Value-beliefs - Cognitive-perceptual - coping-stress tolerance - health perception and management

Health perception and management The nurse's assessment covers the health perception- health management pattern, which is a patient's self-report of how he or she manages his or her health and his or her knowledge of preventive health practices. The coping-stress tolerance pattern includes questions focused on how a patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs, and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient's language adequacy, memory, and decision-making ability.

An aging patient is admitted to the hospital under the guardianship of his daughter, who does not agree with his belief in alternative medicine. When the patient's daughter leaves the room, he consults the nurse for advice. Using the values clarification process, what should the nurse do? · Tell the patient to leave the hospital. · Tell the patient to find alternative treatment. · Help the patient by sedating him long enough to treat him. · Help the patient make an informed decision about next steps.

Help the patient make an informed decision about next steps. The best way to approach the values clarification process is to provide the patient with ample information so he can make an informed choice/decision about how he would like to proceed.

The nursing mentor observes that a nursing student is deficient in communication skills but is good at understanding nursing theories. How would the mentor intervene with respect to this student? - Help the student build communication skills - Use the student's services for patient education and rehabilitation - Use the student's services for coordinating and managing patient care - Consider the lack of communication skills unimportant because sound knowledge ensures a good patient-nurse relationship

Help the student build communication skills

The nurse is caring for a 72-year-old female patient who is on bed rest following hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. She has an IV infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient's fall risk?

High risk The patient is a high risk for falls: History of Falls - 25; Secondary diagnosis - 15; Ambulatory aid - 0; IV/Heparin lock - 20; Gait/transferring - 0; Mental status - 15 = 75 points. Morse fall scale - Hx of fall (y or n), existence of secondary diagnosis, use of ambulatory aids (type and number), use of IV line or saline lock (y or n), gait (normal, weak, impaired), mental status (orientation, forgetfulness)

An older adult patient is admitted with heat exhaustion. The nurse is concerned that the patient's home environment contributed to the problem. What question should the nurse ask the patient to obtain information about this issue? How do you cool your home? Do you use space heaters? Do you check for frays on electrical cords? Do you use an oven?

How do you cool your home? The nurse should ask how the patient keeps his or her home cool, as heat exhaustion is evidence of an overly warm environment.

Which question does the nurse ask the patient with a renal disorder while selecting nursing diagnoses relevant to the patient's culture? - How often do you visit your health care setting? - How does this health problem affect you and your family? - What should you know before signing an informed consent? - Do you know about the side effects of the medications that you are using?

How does this health problem affect you and your family?

What is a basic tenet of Leininger's Theory of Cultural Care Diversity and Universality? Biology, emotions, and other dimensions are fragmented and separated. Humans are inseparable from their cultural backgrounds and social structures. Gender, race, age, and class are separate from social structure. The child patient is the best explainer of his cultural needs.

Humans are inseparable from their cultural backgrounds and social structures A basic tenet of Leininger's theory is that human begins are inseparable from their cultural backgrounds and social structures

Which statement made by a young adult patient with an amputation indicates a problem with body image? - I just don't have any energy to get out of bed in the morning - I've been attending church regularly with my wife since I got out of the hospital - My wife has taken over paying the bills since I've been in the hospital - I don't go out very much because everyone stares at me

I don't go out very much because everyone stares at me

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning? - I should raise the side rail on the opposite side of the bed from where I'm standing - I should evaluate the pt for correct body alignment - I should determine the type of assistance required for safe positioning - I should arrange the positioning equipment as close as possible to the pt's bed

I should arrange the positioning equipment as close as possible to the patient's bed

Based on the Transtheoretical Model of Change, which response would a nurse make to a patient who states? Me, exercise? I haven't done that since junior high gym class, and I hated it then?" - I don't exercise either because I hate it, too, and I don't think it's helpful - I want you to walk 3 miles four times a week, and I'll see you in 1 month - I understand. Can you think of one reason why being more active would be helpful for you? -I would like you to ride your bike three times this week and then four times by next week

I understand. Can you think of one reason why being more active would be helpful for you?

The nurse and patient worked together to facilitate communication when the patient was unable to communicate verbally. Whose theory did the nurse exhibit when caring for this patient? · Imogene King · Betty Newman · Jean Watson · Rosemary Rizzo Parse

Imogene KIng his general system framework, the nurse and pt work together to achieve desired pt goals Betty Nuwman--basic survivial Jean Watson--preserving the dignity and wholeness of humans Rosemary Rizzo Parse--views pts as constantly changing person

Miranda is a new patient on the orthopedic floor. She is currently on post-op day three from a total knee replacement. Physical therapy and nursing staff have been encouraging Miranda to walk frequently, but she is still rating her pain 7/10 with movement. Her nurse has written a care plan and reevaluated based on today's assessment. Which nursing diagnosis fits Miranda's current situation most accurately? Imbalanced Nutrition Constipation Activity Intolerance Impaired Mobility Related to Pain

Impaired Mobility Related to Pain Miranda is experiencing pain, which is deterring her from progressing on her physical rehabilitation, which would increase her ability to move independently.

Patients who are on prolonged bed rest should be encouraged to make what dietary choices? Include lean protein in their diet. Eat two large meals a day. Eat more polyunsaturated fats. Include more fats in their diet.

Include lean protein in their diet. Patients who are on prolonged bed rest should be encouraged to include lean protein in their diet. The Dietary Guidelines for Americans recommend that the daily intake of protein be 0.8 gram per kilogram of ideal body weight.

The patient recently diagnosed with iron-deficiency anemia reveals that he has trouble swallowing pills and cannot take his iron supplements. He is also a vegetarian and cannot consume red meat, which is a good source of iron. What should the nurse do to support the patient? · Tell him that vegetarianism is an unhealthy way to live. · Independently decide what the patient's course of action should be moving forward. · Include the patient in determining what intervention should be implemented. · Ask the attending provider to prescribe the patient iron supplements because he needs them

Include the patient in determining what intervention should be implemented

What action does the nurse perform upon admission to create an accepting environment for the transgender patients? - Calling the patient by his or her birth name - Using pronouns that match the patient's birth sex - Showing the patient where the restroom for his or her birth sex is - Including changing the mother/father option to parent/guardian on the assessment form

Including changing the mother/father option to parent/guardian on the assessment form

A patient on bed rest is concerned about developing constipation. What actions should the nurse take to prevent this from happening? Increase the frequency of the patient's active range-of-motion exercises. Decrease the patient's food intake and increase the patient's fluid intake. Complete the Mini Nutritional Assessment tool on the patient. Increase the patient's dietary fiber and fluid intake.

Increase the patient's dietary fiber and fluid intake. The patient's dietary fiber and fluid intake should be increased to prevent constipation in the immobile patient.

A community nurse is working toward achieving Healthy People 2020. Which aim would be the goal? - Assess the number of new diseases per 1000 per year - Increase the quality of life through better health care services - Discover a vaccine for acquire immunodeficiency syndrome (AIDS) - Train nurses to give better health care services to rural people

Increase the quality of life through better health care services One of the goals of Healthy People 2020 is to improve life expectancy and quality of life. Another goal is to eliminate health disparities through an improved delivery of health care services.

Which statement about culture is true? Members are delineated by geographic boundaries. Individual thinking is influenced by cultural beliefs. Groups identify themselves based on similar traits. Practices remain stable and rarely change over time.

Individual thinking is influenced by cultural beliefs. delineat--defined A person's culture influences the way a person thinks and makes decisions; it also impacts the patterns of actions the person takes

At which age should infants achieve proper eye coordination? Infants should achieve proper eye coordination by 2 weeks to 1 month. Infants should achieve proper eye coordination by 1-2 months. Infants should achieve proper eye coordination by 2 to 4 months. Infants should achieve proper eye coordination by 4 to 6 months.

Infants should achieve proper eye coordination by 4 to 6 months.

Which element is described when the researcher provides complete information about the purpose of the study and gives patients the choice to participate or not participate in the study? - Bias - Anonymity - Confidentiality - Informed consent

Informed consent The process of informed consent includes providing research subjects full disclosure about the study and provides the subject the opportunity to participate or note participate in the study

State Statutes Impacting Nursing Practice

Informed consent and health care acts - know the right to refuse/explanation of the procedure or treatment - Good Samaritan Laws limit liability and offer legal immunity if a nurse helps at the scene of an accident - Public health laws laws affect individuals, population, and communities--to improve the health of people - The Uniform Determinatioin of Death Act determines acutal death--cardiopulmonary standard requires irreversible cessation of circulatory and respiratory fx

What are foundational elements that keep a culture strong? Select all that apply. Infrastructure Educational structure Social structure Interpersonal resonance World view

Infrastructure Social structure World view An infrastructure is part of the foundational structural elements of a culture b/c it provides the basic necessities of life/a social structure that determines how people interact with one another/a world-view that provides a belief system that helps people identify themselves, their society

Which is an example of a community health care service focused on tertiary prevention? - Initiating an occupational therapy referral for a patient recovering from a stroke - Counseling new mothers on the use of infant car safety seats - Screening adolescent girls for scoliosis - Contacting persons exposed to tuberculosis

Initiating an occupational therapy referral for a patient recovering from a stroke Tertiary prevention involves interventions for those already experiencing symptoms of disease or disability. It focuses on maintenance or restoration of health, and rehabilitation. Occupational therapy referral for a patient who has already had a stroke is aimed at rehabilitation and is an example of tertiary prevention.

A nurse is caring for a patient with complaints of balance problems. What could be the source of this abnormal finding? Eye infection Sinus infection Inner ear infection Tonsillitis

Inner ear infection Balance depends on the cerebellum and inner ear.

Which nursing action prevents machine-related intravenous therapy flow rate errors? Inspecting for kinks in IV tubing. Checking to see if the alarms are correctly set. Seeking assistance if equipment is new or unfamiliar. Asking another nurse to double check all machine settings.

Inspecting for kinks in IV tubing. Inspecting for kinks in the IV tubing is a nursing action to prevent a machine-related error as kinks may be prevent the pump from working properly.

An adolescent boy is brought to the ER after consuming a bottle of his mother's sleeping pills. A suicide note was left beside his bed. What type of injury is this? Accidental Unintentional Routine Intentional

Intentional The patient left a suicide note, which is evidence that he intentionally wanted to harm himself. Therefore, this is an intentional injury.

Which organization's definition of nursing includes the autonomous role of nurses? International Council of Nurses (ICN) American Nurses Association (ANA) State Board of Nursing (SBN) National League for Nursing (NLN)

International Council of Nurses (ICN) The ICN definition discusses the autonomous role of nurses. ICN also discusses other nursing roles including promoting a safe environment, research, and participation in shaping health policy and education.

While caring for an immobile patient, the nurse notes the patient has a poor appetite. What action should the nurse take to encourage the patient's nutritional intake? Monitor the patient's serum albumin. Assess the patient' nutritional intake. Interview the patient for food preferences. Weigh the patient at routine intervals.

Interview the patient for food preferences. The nurse should interview the patient for food preferences as this information can be used to adjust the patient's diet more to the patient likes.

What is the most important symbolic aspect of a culture? Clothing Tools Flags Language

Language Language is the most important symbolic aspect of a culture

A nurse is going over suggested dietary items for a patient who has just been diagnosed with oxalate kidney stones. The patient is anxious to eliminate the painful condition from persisting, but the diet appears to be restrictive of some of his favorite foods. The patient sees cherries and cantaloupe on the low oxalate list the nurse provides, and notes that they are his favorite fresh fruit, but they are expensive and out of season. The nurse suggests that he think of them as his special daily treat, and compare the costs to those of his favorites he is giving up. What is the most important aspect of what the nurse has been doing with the patient? · Listening to the patient · Drawing up a diet for him · Asking relevant questions · Involving the patient in establishing goals

Involving the patient in establishing goals Involving the patient in establishing goals allows the nurse and patient to jointly develop goals and identify support options to meet the stated goals and outcomes that take into account the patient's values and beliefs into the plan of care.

Why is the process of assimilation (adaptation) important to understand when working with recent immigrants? It facilitates the adaptation to life in a new county. It allows families to remain together once they enter the country. It prevents cultural imposition from occurring. It allows the group to maintain its cultural identify.

It facilitates the adaptation to life in a new county.

The nurse is asking the patient about how far the patient walks each day. The patient asks the nurse why that information is important. What is the nurse's best response? "Your practitioner asked me to obtain the information." "It gives us information about your activity and agility." "It helps us determine what you will be allowed to do while in the hospital." "We need to make sure you can walk without assistance."

It gives us information about your activity and agility." The question provides data about a patient's activity and agility.

Which offers the best definition of enculturation? It is a process in which culture is passed from generation to generation. It only occurs unconsciously through interactions with family members. It is an interactive process that begins as soon a child is able to verbalize understanding. It is a process in which culture is directly taught to a child.

It is a process in which culture is passed from generation to generation.

The nurse is caring for a comatose patient who is at high risk for skin breakdown. The practitioner orders PRAFO boots for the patient. The patient's spouse asks what a PRAFO boot is. What is an appropriate response from the nurse? It is a tubular shaped boot made of foam used to cushion the heels. It is a cloth-covered boot made of sheepskin used to prevent friction between the patient's heels and the bed sheets. It is rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels. It is a rigid aluminum-framed lower leg boot that keeps the knee, ankle, and foot in proper alignment.

It is rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels. A PRAFO boot is a rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels.

Which description is applicable to therapeutic communication? - It provides sensory stimulation - It focuses on an older adult recalling the past - It accepts time descriptions as stated by an older adult - It provides care by meeting a pt's expressed or unexpressed needs

It provides care by meeting a pt's expressed or unexpressed needs It provides sensory stimulation—may be provided through touch therapy - It focuses on an older adult recalling the past—characteristic of reminiscence (Reminiscence therapy is a treatment that uses all the senses — sight, touch, taste, smell and sound — to help individuals with dementia remember events, people and places from their past lives) - It accepts time descriptions as stated by an older adult—part of validation therapy

The nurse facilitated extended visiting hours and offered additional support to the family of a dying patient. Whose theory did the nurse exhibit when caring for this family? · Sister Callista Roy · Rosemarie Rizzo Parse · Betty Newman · Jean Watson

Jean Waston Human Caring Theory is based on caring for the patient or family while the nurse functions to preserve dignity and wholeness in health, or while the pt is peacefully dying

Which condition is observed by placing the patient in the Sims' position? - Excessive lateral flexion - Increased cervical flexion - Lateral flexion of the neck - Plantar flexion of the ankles

Lateral flexion of the neck Patients positioned in the Sims' position may suffer from lateral flexion of the neck. Excessive lateral flexion of the spine may occur if a patient is positioned in a side-lying position. Patients positioned in the prone position may experience plantar flexion of the ankles. Increased cervical flexion is observed in patients positioned in the supported Fowler's position.

The rehabilitation nurse is caring for a patient with a history of cerebrovascular accident. The MRI revealed that the injury occurred on the right side of the brain. What are the expected impairments? Right-sided hemiparesis Left-sided hemiparesis Lower body paralysis Inability to move all four extremities

Left-sided hemiparesis Right-sided brain injury would cause left-sided hemiparesis.

Which reason is the most common for grandparents to raise their grandchildren? - Single parenthood - Legal interventions - Dual-income families - Increased divorce rate

Legal interventions This new parenting responsibility is caused by a number of societal factors: the increase in the divorce rate, dual-income families, and single parenthood. But most often, it is a consequence of legal intervention when parents are unfit or renounce their parental obligations

Which nursing model or theory holds the basic tenet that people are connected to their cultural backgrounds, social constructs, world-views and environmental context? Galanti's 4 Cs of culture Leininger's sunrise model Giger and Davidhizar's transcultural assessment model Orem's self-care theory

Leininger's sunrise model Leininger's sunrise model's basic tenet is that human beings are inseparable from their cultural/educational/economic backgrounds as well as their social structures/world-view/history/environmental context

A child prefers to be with friends rather than with parents. The child is demonstrating which of Kohlberg's levels of morality? The level of premorality (stage 1) The level of premorality (stage 2) Level of conventional role conformity Level of self-accepted moral principles

Level of self-accepted moral principles This is a stage that reflects a time when a child is social and will want to be with friends. The individual will develop a conscience at this stage. This stage is usually experienced by adolescents who will be social and want to spend time with friends rather than with parents.

Which qualification must an individual have in order to provide skilled home health care services reimbursable by Medicare? License as a health care professional Home care certification Minimum of 12 months experience Completion of an approved orientation

License as a health care professional

Which perspective is based on the principle that individuals develop new abilities to compensate for some of their decreased physical abilities as they age? - Life span approach - Stage-crisis theory - Piaget's theory - Temperament theory

Life span approach Stage-crisis theory—based on developmental tasks that evolve form physical maturation/personal values/pressures from society - Piaget's theory—cognitive thinking Sensorimotor stage: birth to 2 years Preoperational stage: ages 2 to 7 Concrete operational stage: ages 7 to 11 Formal operational stage: ages 12 and up - Temperament theory—the behavior of individuals and has 3 classes based on temperament

The nurse is caring for a 50-year-old male patient with a bowel obstruction. The patient has orders to be out of bed in a chair. He is alert and oriented with no prior medical history. The patient has an IV and nasogastric tube. According to the Morse Fall Scale, what is the patient's fall risk? High risk Moderate risk Low risk Scale not appropriate

Low risk The patient is a low risk for falls: History of Falls - 0; Secondary diagnosis - 0; Ambulatory aid - 0; IV/Heparin lock - 20; Gait/transferring - 0; Mental status - 0 = 20 points Morse - Hx of fall (y or n), existence of secondary diagnosis, use of ambulatory aids (type and number), use of IV line or saline lock (y or n), gait (normal, weak, impaired), mental status (orientation, forgetfulness)

The rehabilitation nurse is caring for a patient with loss of sensation to the lower extremities. What type of injury is related to this? Ischemia Head injury Lower spinal cord trauma Cervical spinal cord trauma

Lower spinal cord trauma Paraplegia and loss of sensation are most commonly associated with lower spinal cord trauma.

A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity Which nursing theorist used anthropology to form a theory of universality? - Madeleine Leininger - Callista Roy - Imogene King - Dorothea Orem

Madeleine Leininger Leininger used her background in anthropology to form her theory of cultural care diversity and university—identified types of demands placed on the pt, assessed adaptation to demands, and help the pt with adaptation.

Which intervention should be implemented to prevent falls in the hospital? Check on the patient frequently. Place patient near the nurse station. Make sure wheelchair brakes are locked. Keep the call light within the patient's reach.

Make sure wheelchair brakes are locked. Making sure wheelchair brakes are locked prior to transferring a patient in or out of the chair will prevent falls.

The charge nurse is authorized to make changes in the number of staff members who work that shift, based on the number and acuity of patients on the unit. Within which nursing role is the charge nurse functioning? Leader Manager Collaborator Delegator

Manager The nurse in this instance is functioning as manager by efficiently and effectively managing a hospital unit, which includes determining the number of staff members according to patient census.

The nurse is caring for a 65-year-old male patient who was admitted with pancreatitis with no prior medical history. The patient keeps getting out of bed to go to the bathroom despite being repeatedly told to call for assistance. He has an IV infusion and nasogastric tube and is receiving opioids for pain. According to the Johns Hopkins Fall Assessment Tool, what is the patient's fall risk? High risk Moderate risk Low risk Tool not appropriate

Moderate risk The patient is at moderate risk for falls: Age (60-69 years) - 1; Fall history - 0; Elimination (urgency or frequency) - 2; Medications (opioids) - 3; Patient care equipment (IV infusion and nasogastric tube) - 2; Mobility (requires assistance for mobility) - 2; Cognition (impulsivity/poor safety judgment) - 2 = 12 points; - Age (60-69, 70-79, 80+) - Fall hx (one fall w/in past 6 months; no falls) - Elimination, bowel and bladder concerns (none to incontinent) - Medications (prescribed one high risk fall drug to sedation) - Pt care equipment that tethers (presence of one to many) - Mobility (requires assistance to visual/auditory impairment) - Cognition (alterations to lack of understanding)

The nurse is caring for an 85-year-old female patient who was admitted with constipation. The patient has a history of hypertension controlled with medications. She is alert and oriented, is receiving laxatives, has an IV infusion, and is ambulatory without assistance. According to the Johns Hopkins Fall Assessment Tool, what is the patient's fall risk? High risk Moderate risk Low risk Tool not appropriate

Moderate risk The patient is at moderate risk for falls: Age (80+ years) - 3; Fall history - 0; Elimination - 2 (incontinence); Medications (laxative and antihypertensive) - 5; Patient care equipment (IV infusion) - 1; Mobility - 0; Cognition - 0 = 11 points. Moderate risk is 6-13 points. - Age (60-69, 70-79, 80+) - Fall hx (one fall w/in past 6 months; no falls) - Elimination, bowel and bladder concerns (none to incontinent) - Medications (prescribed one high risk fall drug to sedation) - Pt care equipment that tethers (presence of one to many) - Mobility (requires assistance to visual/auditory impairment) - Cognition (alterations to lack of understanding)

The nurse asks an 80-year-old patient a quesiton while washing hands across the room. The patinet does not answer. Which action would the nurse take next? - Leave the room quietly, b/c the pt evidently does not want to be bothered right now - Repeat the question in a loud voice, speaking very slowly - Move to the pt's bedside, get her attention, and repeat the question while facing the pt - Bring the pt a communicaiton board so she can experss her needs

Move to the patient's bedside, get her attention, and repeat the question while facing the patient.

Tara Collins is a nurse working with a patient who was admitted to the medical unit after passing out on the job. Howard Duncan is a 52- year- old male who works for a construction company that specializes in tree-trimming. Howard is obese with a history of smoking since age 25. He has never been treated for any chronic illnesses. He only sees a physician when he has an acute illness, which is typically once or twice a year. When Howard was found semi-conscious at work and brought to the hospital, laboratory values revealed a blood sugar level over 450mg/dl in addition to abnormal chemistry panel. Upon further review, he stated that he had been having increased thirst and hunger, but thought it was related to working outside. Mr. Duncan was treated with insulin initially and started on oral antihyperglycemic agents after his blood glucose stabilized. He was diagnosed with Type II diabetes and informed that changes to diet and lifestyle must be made to prevent the need for insulin. Tara is preparing Mr. Duncan for discharge and educating him about the need to exercise, stop smoking, and change to a prescribed diabetic diet. As Tara prepares discharge education for Mr. Duncan, which topic addresses his lowest level of needs according to Maslow's hierarchy? Nutrition education Family support Reportable symptoms Stress management

Nutrition education

What nursing activity starts the assessment of a patient's mobility? Assessing the patient's sleep patterns Asking the patient's family about the patient's activities Asking the patient questions Observing the patient

Observing the patient Assessment of the patient's activity level starts with observing the patient. Assessment of a person's level of activity, and the possible effects of immobility, begins with observing and continues by asking a variety of questions. A

Which patient is displaying health protection behaviors? · Reduces stress · Exercises regularly · Obtains immunizations · Maintains good sleep habits

Obtain immunizations Obtaining immunizations is health protection; health protection includes intentional behaviors aimed at circumventing illness.

The senior nurse observes that a newly appointed nurse is having trouble relating to a patient fom a different culture. What advice can the senior nurse give this nurse to enhance cultural competency? - Obtain in-depth knowledge about medical concepts/nursing care - Learn at least three foreign languages - Obtain sufficient knowledge about a pt's cultures and beliefs - Learn about various dialects prevalent in the country

Obtain sufficient knowledge about a pt's cultures and beliefs

The nurse is caring for patient on prolonged bed rest who is refusing to eat. The patient states he has no appetite. What modification should the nurse make to the plan of care to address this issue? Change the patient to a soft diet. Offer the patient smaller, more frequent meals. Call the practitioner and obtain an order for tube feedings. Encourage the patient to include more whole grains with their meals.

Offer the patient smaller, more frequent meals. Patients with a decreased appetite should be offered smaller, more frequent meals.

Under supervision of the registered nurse, a nursing student is caring for a patient from a different cultural background. Which action performed by the student nurse indicates the need for further teaching on transcultural nursing? - Asking the pt open-ended questions - Advocating for the pt considering his or her world view - Offering generalized opinions during the assessment of the pt's world view - Speaking to pt's family members about cultural aspects

Offering generalized opinions during the assessment of the pt's world view Nurse should avoid stereotypes or unwarranted generalizations to obtain an accurate assessment of the pt's unique characteristics and world view The goal of transcultural nurisng is to provide care that fits with the pt's own values, beliefs, traditions

Miyoko is a nursing student assigned to Mr. Mashoud, a 48-year-old Arab admitted to the hospital with kidney stones upone Mr. Mashoud's admission to the emergency department (ED) this morning, he was experiencing excrubiating pain. The treatment plan for Mr. Mashoud includes keeping him in the hospital until he passes the stone and adjusting his pain mediacation as needed Miyoko evaluates Mr. Mashoud;s response to the medication therapy to update his care plan. Miyoko assesses Mr. Mashoud's pain before NSAID administration and then approximately one hour after administration : Miyoko knows that evaluation is an ___ process that occurs whenever contact with a pt occurs

Ongoing Miyoko determines the pt outcomes for Mr. Mashoud based on his reaction to the medicaiton regimen. which of the following is an end result that translates into observable pt behaviors that are measurable and desirable? - unexpected outcome - expected outcome - sensitive outcome - accomplished outcome expected outcome

Which is an appropriate primary goal for a home care patient with a nursing diagnosis of Nutrition Imbalance: Less Than Body Requirements related to inability to obtain access and prepare food as evidenced by 20-lb weight loss in 1 month? Patient will drink a nutritional supplement midafternoon and at bedtime. Patient will gain 1 lb by the next visit in 10 days. Patient will ask neighbors to help with food shopping. Patient will eat at least 75% of each meal.

Patient will gain 1 lb by the next visit in 10 days.

Which is an appropriate goal for a home care patient with a nursing diagnosis of Impaired Physical Mobility related to decreased endurance as evidenced by inability to walk further than the bathroom adjoining the bedroom without complaints of weakness and general discomfort? Patient will walk about the house without complaining of weakness. Patient will have less discomfort when walking beyond the bathroom. Patient will report being free of weakness or other discomfort after walking to the living room. Patient will gradually increase distance walked.

Patient will report being free of weakness or other discomfort after walking to the living room. This is a measureable goal. It specifies the distance the patient will walk and asks for the patient's report of subjective symptoms.

The community health nurse is conducting a program on health and fitness awareness for medically underserved people. Who would be categorized as medically underserved? - People belonging to a different culture - People of a poor socioeconomic status - People who are not willing to be treated for their illnesses - People who use complementary and alternative treatments for their illnesses Medically underserved people are those who lack the financial resources required for proper health care.

People of a poor socioeconomic status Medically underserved people are those who lack the financial resources required for proper health care. Unemployment/low-paying jobs/rising health care costs have all increased the population of medically underserved people in the U.S.

A nurse is caring for a woman in her 20s recovering from a mastectomy after cancer was detected. The woman's twin sister is visiting and they are discussing whether the twin should get regular mammograms. The patient says that her early mammogram saved her life. The twin sister says that she does not want to live life worrying about what can go wrong, and that the medical evidence for cancer of the type removed by the surgery indicates the same mortality whether a mastectomy is done or not. Which best explains the differences the twins are showing in their attitude? Beliefs Culture Paradigms Personal values

Personal values

__________________ include the life principles that are most important to people and shape their thoughts, feelings, and, ultimately actions. Beliefs Cultures Paradigms Personal values

Personal values Personal values include the life principles that are most important to an individual and shape that person's thoughts, feelings, and ultimately, actions Most important principles that shape one's thoughts, feelings, and actions—values Conscious knowledge of one's own character, feelings, motives, and desires—self-awareness Perception of what is right, true, and real—beliefs Way of life for a group of people—culture

A school-age child asks the school nurse about sexual development, which indicates that the child is in which Freudian stage of development? Anal stage Latency stage Genital stage Phallic or Oedipal/Electra stage

Phallic or Oedipal/Electra stage During this stage the genitals become the focus of sexual curiosity, the superego (conscience) develops, and feelings of guilt emerge. Children at this stage are school age and often ask many questions.

When defining nursing as a holistic profession, which dimensions are necessary to fully care for patients? Select all that apply. Physical Mental Emotional Educational Financial

Physical Mental Emotional Nursing definition—reflected the idea of nursing as a holistic profession that addressed the many dimensions necessary to full care for a patient, including the pt's physical/emotional/mental needs

Which member of the health care team should the nurse collaborate with when providing care for a hospitalized patient who is at Risk for Falls related to the use of a walker? Hospital physician Physical therapist Occupational therapist Unlicensed assistive personnel

Physical therapist The nurse collaborates with the physical therapist related to safety concerns for a hospitalized patient who is using a walker.

The primary nurse is advocating for the patient. In order to properly evaluate and treat a nursing diagnosis of impaired mobility, the nurse would contact the provider and ask for which order? Dietitian consults to evaluate nutritional needs. Speech therapy consults to evaluate swallowing. Physical therapy consults to evaluate and treat mobility. Chaplain for spiritual guidance.

Physical therapy consults to evaluate and treat mobility. A physical therapist manages mobility and would be able to properly conduct an evaluation and then work with the nurse to come up with a patient-centered treatment plan.

According to Maslow's Hierarchy of Needs, a patient who is unable to show affection toward his wife or accept her reassurances must have which needs met before love and belonging needs can be addressed? Select all that apply. Self-esteem Physiologic needs Love and belonging Safety and security Self-actualization highest level need

Physiologic needs safety and security from bottom to top 1. physiological 2. safety 3. love/beloning 4. esteem 5. self-actualizationf

A nurse is using the Hierarchy of Needs Model to plan care. Which principle should the nurse remember? · Health promotion will be a priority over basic needs. · Application of a fixed hierarchical order is always the most accurate method to use. · Physiologic needs are more immediate and of greater importance for survival. · Higher needs should continually be met before needs at lower levels can be addressed.

Physiologic needs are more immediate and of greater importance for survival. The Hierarchy of Needs Model implies that basic physiologic needs are more immediate and therefore of greater importance in terms of survival than needs related to health promotion and illness prevention.

The registered nurse is supervising a nursing student who is using positioning aids with a patient. Which nursing action may lead ot skin and tissue damage caused by pressure? - Applying the positioning boots - Placing a thin pillow under the bony prominences - Placing the pillow under the knees by slight elevation - Using rolled washcloths as hand rolls in trochanter rolling

Placing a thin pillow under the bony prominences Placing a thin pillow under bony prominences may lead to skin and tissue damage due to pressure. Positioning boots are applied to reduce the risk of foot drop. Placing a pillow under the knees with slight elevation increases the peripheral circulation. Rolled washcloths should not be used as hand rolls because they do not keep the thumbs well abducted.

As per Yura and Walsh, which describes a component of the nursing process? select all that apply - Planning - Evaluation - Assessment - Implementation - Nursing diagnosis

Planning evaluation assessment implementation

The nurse is using the teach-back technique to evaluate a patient after teaching about medication adherence. Which question by the nurse is appropriate to verify the patient's understanding? - Did you understand - Do you have any questions? - Was this information useful to you - Please review what we talked about. How will you make it work at home?

Please review what we talked about. How will you make it work at home?"

Which option is health problem that may be more common in older adults? Select all that apply. One, some, or all responses may be correct - Polypharmacy - dementia - Sexually transmitted infections - Viruses - Chronic physical illness

Polypharmacy dementia Chronic physical illness

The nurse received a hand-off report from the night shift nurse at the change of shift in the conference room. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the aassigned patients and lists the nursing care information for each patient on each individual patient's message board in the patients' rooms. The nurse also lists the patient's medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which aciton violates the Health Insurance Portability and Accountability Acto fo 1996 (HIPPA)? - discussing pt ocnditions in th enursing report room at the change of shift - allowing nursing student to review pt charts before caring for pts to whom they are assigned - posting medial info about a pt on message board in the pt's rooms - releasing pt info regarding terminal illness to family when the pt has given permission for imfo to be shared

Posting medical information about the patient on a message board in the patient's room

Which factor is a key issue for a social determinant of health that increases a patient's health risk? · Age · Gender · Poverty · Genetics

Poverty

The nurse is caring for an immobile patient who refuses to turn on his side and lays on his back most of the time. Due to the patient's position, the nurse is most concern that this behavior will contribute to the patient's development of what complication? Edema Constipation Pressure ulcer Deep vein thrombosis

Pressure ulcer A patient who lays most of the time on his or her back is at risk for developing pressure ulcers, due to pressure on the bony prominences.

A travel nurse has taken a ssignemt at a health care facility where nurses assume responsibility for a caseload of pts over a period of time. This type of nursing exemplifies: - team nursing - primary nurisng - functional nurisng - decentralized managment

Primary nurisng decision making staff involvement - transformational leadership 1. problem-solving committees or shared governance councils 2. interprofessional collaboration 3. interprofessional runding 4. staff communication 5. staff education important leadership skills to learn include: clinical care coordination, team communication, delegation, knowledge building

Sarah is a post-op total hip replacement patient. She is receiving very good care by a team of professionals in the hospital. Ultimately, which provider is primarily responsible for this patient's care? Chaplain Her sister Primary nurse Health care provider

Primary nurse The primary nurse assigned to this patient has ultimate responsibility for the coordination of care for this patient.

While manning a booth at a community health fair, a public health nurse is asked what is meant by primary prevention. Which would be a correct response? -Primary prevention focuses on restoration of health and rehabilitation. -Primary prevention is concerned with early identification and treatment of an illness to limit its effect. -Primary prevention consists of strategies whose goal is to avoid recurrence of disease. -Primary prevention refers to interventions designed to prevent disease or disability.

Primary prevention refers to interventions designed to prevent disease or disability.

When is the best time to teach deep-breathing techniques to a surgical patient? The day after surgery. Immediately after surgery. Prior to surgery. Either before or after surgery.

Prior to surgery. The best time to teach deep breathing techniques is prior to surgery to maximize the patient's understanding while not impaired by the effects of medication. Education about these exercises is included as part of preoperative teaching to maximize understanding on the part of the patient when not impaired by the effects of medication.

Planning

Priority setting - problem-focused diagnoses/problems take priority over wellness/establish priorities in relation to their ongoing clinical importance Emthods for prioritizing - high: nurisn diagnoses that, if untreated, result in harm to pt or other/Maslow's hierarchy of needs - intermediate--nonemergent and not life-threatening -low: not always directly related to a specific illness or prognosis but affect a pt's future well-being review prioritie each time you see the pt

The nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. The nurse uses a finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells the nurse the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? - Agenda setting - Problem focused - Objective - Use of a structured database format

Problem focused The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient's report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment.

Which is the most important group a nurse can join to gain support and foster growth within the profession? Ethics committee Hospital nursing team Shared governance committee Professional organization

Professional organization

According to Benner's Novice to Expert Model, a nurse who sees situations holistically and perceives deviations from normal is at which level of clinical nursing practice? Expert Novice Competent Proficient

Proficient The nurse is this description sees situations holistically and perceives deviations from normal. This describes the proficient nurse according to Benner's model.

What is the goal of evidence-based practice (EBP)? Promote positive patient outcomes Lower the incidence of errors in patient care Increase the speed of patient recovery Decrease the need for readmissions

Promote positive patient outcomes The goal of EBP is to produce positive patient outcomes through the integration of best research evidence, clinical expertise, and patient preferences.

The nurse is caring for a patient with acute repiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patinet positioning would likely have caused this condition? - Sims' position - Prone position - Side-lying position - Supported Flower's position

Prone position Prone positioning is most suitable for patients with acute respiratory distress syndrome and acute lung injury. The potential trouble points with patients in the prone position include hyperextension of the lumbar spine and neck hyperextension. The trouble points of the Sims' position and the side-lying position are lateral flexion of the neck and lack of foot support. The trouble points of the supported Fowler's position are increased cervical flexion and pressure on the posterior aspects of the knee.

You are the family nurse assigned to assist Michael and Grace. Which of these tasks would be an inappropriate nursing responsibility from a family-centered approach? Provide a predetermined plan of care for Michael. Assess family resources related to the long-term care facility. Discuss communication methods with Michael, Grace, and their children. Determine family member caregiving skills in caring for Michael and Grace.

Provide a predetermined plan of care for Michael. Predetermining a plan of care is counterproductive to family dynamics. Nurses should allow the family to participate in how the plan of care should be approached.

An elderly patient has been put on a potentially toxic drug for treatment of arthritis. The patient and family have expressed concern about the drug. What is the nurse's responsibility in this particular situation? - Give the drug in a very low dose - Obey the health care provider's instruction - Do not speak out against policies or actions - Provided information so the patient can decide whether to accept or refuse the treatment

Provided information so the patient can decide whether to accept or refuse the treatment

A nursing instructor asks a nursing student, "How can health care providers help reduce health disparities? Which response indicates a need for further teaching? - Providing compartmentalized care - Providing culturally competent care - Improving the quality of health care - Helping patients get access to language services as needed

Providing compartmentalized care Compartmentalizing care with fragmented delivery is a contributing factor in health disparities—fragmented delivery lacks coordination and results in inefficient allocation of resources, resulting in poor health outcomes

Which task demonstrates a family-centered nursing role? · Providing education to family members on healthy dietary approaches to wellness based on clinical research · Developing an educational program for healthy eating based on personal weight loss program · Assigning caregiving tasks to family members based on needs · Suggesting the family restrict communication with each other to reduce potential for stress

Providing education to family members on healthy dietary approaches to wellness based on clinical research Education is a cornerstone in family-centered care. Using clinical evidence to provide a wellness approach to eating benefits all members of the family.

A community-based nurse notices an increased prevalence of pertussis infection in children. Which preventive care service would the nurse implement to address this problem? - Mass administration of antibiotics - Provision of prescribed effective immunizations - Prompt referral to tertiary care centers - Effective and extensive use of cough suppressants

Provision of prescribed effective immunizations

Parent--infant attachment is the most important association for which type of development? Biological Physiological Psychosocial Sociocultural

Psychosocial Examples of psychosocial issues paramedics have encountered include loneliness, anxiety, fear, grief, depression, neglect, abuse, self-care issues

when performing an assessment of a cancer survivor, you need to explore A. Nutrition problems B. Psychosocial problems C. Mobility problems D. Economic problems

Psychosocial problems

Federal Statues Impacting Nursing Practice

Pt Protection and Affordable Care Act (PPACA) - Affordable Care Act (ACA)-name change 1. Consumer rights and protections--pt's bill of rights: prohibits being denied health care coverage for prior existing conditions 2. Affordable health care coverage 3. increased access to care 4. Quality of care that meets the needs of patients

While performing an assessment, the nurse notes that a patient has developed redness, warmth, and swelling in the right lower leg. What complication does this place the patient risk for? Pulmonary embolism Pathologic bone fractures Orthostatic hypotension Joint damage

Pulmonary embolism Redness, warmth, and swelling in an extremity is indicative of a deep vein thrombosis, which places the patient at risk for developing a pulmonary embolism.

When a hospital is awarded Magnet status, what is being recognized? High levels of patient satisfaction Quality nursing care Health care team collaboration Patient-centered care focus

Quality nursing care Magnet status is the highest credential for nursing facilities in the United States and around the world.

A nursing instructor asks a nursing student about factors that contribute to health disparities. Which answer indicates a need for further teaching? - Health insurance - Quality of health care - Quantity of health care providers - Poor access to health care organizations

Quality of health care Health care providers are striving to provide equal health care quality to everyone, so this should not contribute to health disparities

What action can the nurse take to prevent a medication error? Contact the pharmacist to calculate all drug dosages. Prepare all the medications and then distribute them to the appropriate nurse for administration. Question unfamiliar or unknown abbreviations and know standard medication abbreviations. Return to a patient's room to ensure all oral medications were ingested after leaving them at the bedside.

Question unfamiliar or unknown abbreviations and know standard medication abbreviations. The nurse should know standard medication abbreviations and question unfamiliar or unknown abbreviations.

The nurse wants to assess health literacy in a group of patients. Which measure does the nurse use to evaluate word recognition? - Calm-Listen, Affirm, Respond, Add (C-LARA) - Test of Functional Health Literacy in Adults (TOFHLA) - Rapid Estimate of Adult Literacy in Medicine (REALM) - Culturally and Linguistically Appropriate Services (CLAS)

Rapid Estimate of Adult Literacy in Medicine (REALM)

A patient with mouth cancer is advised to undergo radiation therapy. However, the patient refuses to do so. The health care provider gives the patient and family other treatment options. Which step of the LEARN mnemonic is the health care provider performing? - Listen - Explain - Negotiate - Recommend

Recommend The recommend step involves making suggestions to the pt and/or the family members when appropriate. As the health care providers is involving the pt and the family members, he or she is performing the recommend step of learn mnemonic

Based on Lewin's change theory, when a new mother accepts responsibility for the care of her infant and reports comfort with her role, which change step occurred? · Unfreezing · Stability · Moving · Refreezing

Refreezing Refreezing is the third step when the change is completed and accepted. At this point, the mother is comfortable with the change

Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis? - Data cluster - Concept map - Related factors - Defining characteristics

Related factors Related factors are data that appear to show some type of patterned relationship with a nursing diagnosis. Data clusters are meaningful and usable patient data that are organized at the initial stage of analysis and interpretation of assessment data. A concept map helps the nurse think critically about the diagnosis of a patient. Defining characteristics of a patient involves observable assessment cues such as patient behavior and physical signs that support each problem-focused diagnostic judgment.

Which term describes the adaptive function allowing older adults to recall the past and assign new meaning to past experiences? Recall Recollection Remembering Reminiscence

Reminiscence Reminiscence, also called life review, is an adaptive function allowing older adults to recall the past and assign new meaning to past experiences. It is a natural way that older adults can establish order and meaning to their past, enhancing well-being and improving quality of life

Which action should the nurse take first when discovering a fire in a patient's room? Extinguish the fire. Give patients an Ambu bag. Remove the patient from the immediate area.

Remove the patient from the immediate area Removing the patient from the immediate area is the first action a nurse should take when discovering a fire in the patient's room.

According to systems theory, which information is considered input from the patient with a urinary tract infection? - Reports difficulty with urination - Voids normally after treatment - Thanks the nurses for their help - Is given a diuretic to assist with urination?

Reports difficulty with urination

Which describes the ability of a family to cope with expected and unexpected stressors? - Love - Integrity - Resiliency - Hardiness

Resiliency Love—feeling of attachment toward family/other people - Integrity—the feeling of oneness among family members - Resiliency - Hardiness—is the internal strengths and durability of the family

A patient who was hopitalized for a smoking-related illness tells the nurse, "I am ready to accept responsiblity for learning, and I need your help." Which stage of psychosocial grief is refelcted in this statement? - Anger - Disbelief - Resolution - Bargaining

Resolution It is difficult for a patient to accept a temporary or permanent loss of health. The process of grieving provides time to adapt psychologically to the emotional and physical implications of their illnesses. In the resolution stage, the patient begins to sense a need for help, is ready to accept responsibility for learning, and begins to express his or her emotions openly. The stage of anger is reflected when the patient direct anger towards the nurse or others.The stage of disbelief would be characterized by the patient avoiding discussions about illness. The bargaining stage would be indicated by the patient offering to live a better life in exchange for the promise of better health.

An older Chinese woman is admitted to the hospital after a hip fracture. Once the fracture has healed, the nurse encourages the patient to walk around the room. The patient refuses to walk without her son. What should the nurse do this scenario? - Leave the patient alone but understand that the patient has no self-confidence - Respect the patient's wish and ask her to walk when her son is present - Explain the patient calmly that she cannot be dependent on her son - Tell the patient that she needs to walk now, and that it is inappropriate to be dependent on her son

Respect the patient's wish and ask her to walk when her son is present

Which action by the nurse indicates cultural sensitivity? Allowing privacy when a Sudanese patient slaps his adolescent son Explaining the medical reasons for consuming the protein found in meat to a Seventh Day Adventist patient Calling an on-staff rabbi to speak with a Jewish patient who wishes to leave against medical advice Respecting a Muslim patient's request to have same-gender caregivers Fulfilling a culturally-based patient request demonstrates cultural sensitivity

Respecting a Muslim patient's request to have same-gender caregivers

The nurse is caring for a patient who has suffered multiple fractures after a motor vehicle accident. What assessment finding would be most critical? Respiratory distress Elevated heart rate Pain Decreased mobility

Respiratory distress Respiratory distress following multiple fractures would be the most critical finding, particularly if there are rib fractures, as the ribs protect vital organs

The nurse is positioning a patient in supported Fowler's position. Which action would the nurse perform to prevent flexion contractures of the cervical spine? - Place a small pillow under the thigh - Position a small pillow at the lower back - Elevated the head of the bed to 50 degrees - Rest the head of the patient against the mattress

Rest the head of the patient against the mattress while positioning a patient in the supported Fowler's position, the nurse should rest the patient's head against the mattress or on a small pillow to prevent flexion contractures of the crevical vertebrae with a pt in the supine positon, the nurse elevated the head of the bed from 45-60 degrees to increase pt comfort and to improve ventilation. To prevent hyperextension of the knee, the nurse should place a small pillow undre the thigh positioning a small pillow at the lower back helps support hte lumbar vertebrae and decrease the flexion of the vertebrae

When a public health nurse screens for hearing loss, which level of prevention is being addressed? Primary Primary transitional Secondary Tertiary

Secondary Screening is aimed at early detection and treatment of disease, and is an example of secondary prevention

Which task demonstrates the school-age child has progressed from intuitive thought to concrete operational stage? Retracing steps without getting lost Guessing the answer after a few tries Stating the sidewalk caused the accident Chooses favorite toy as a gift for another child

Retracing steps without getting lost Children in the concrete operations stage grasp the concept of reversibility. They can mentally retrace a process, a skill necessary for understanding mathematic problems (5 + 3 = 8 and 8 - 3 = 5). The child can take a toy apart and put it back together. Reversibility also enables a child to anticipate the results of actions-a valuable tool for problem solving. The understanding of time gradually develops during the early school-age years. Children can understand and use clock time at around age 8. Although 8- or 9-year-old children understand calendar time and memorize dates, they do not master historic time until later. Retracing steps, or reversibility, demonstrates the school-age child has progressed from intuitive thought to concrete operational stage.

Which teaching method has the nurse employed when showing a patient how to use a sphygmomanometer to record blood pressure and asking the patient to perform the procedure to confirm understanding? - Practice - Demonstration - Independent projects - Return demonstration

Return demonstration Psychomotor learning involves acquiring motor skills that require coordination. It includes integration of mental and physical movements. With the return demonstration method of teaching, the nurse encourages the patient to use newly learned skills under the nurse's observation. The practice method of teaching involves the nurse providing a controlled environment for the patient to perform skills. With the demonstration method, the nurse provides presentations of the procedures or skills the patient should learn. An independent project involves a teaching method that promotes adaptation and origination of psychomotor learning. It also permits the learner to use new skills.

Which is the priority nursing diagnosis related to safety when planning care for a pediatric patient with burns on over 50 percent of the body? Acute Pain Risk for Infection Disturbed Body Image Risk for Ineffective Renal Perfusion

Risk for Infection The patient is at Risk for Infection due to the burn injury threatening the patient's safety; therefore, this is the priority nursing diagnosis for this situation.

During a routine prenatal assessment, the nurse notices that the patient has bruises on the face, arms and back. When the nurse asks about the bruises the patient looks away and says, "I fall a lot." Which is the priority nursing diagnosis related to patient safety to add to the plan of care? Risk of Falls Risk for Injury Risk for Suicide Risk for Impaired Physical Mobility

Risk for Injury Risk for Injury is an appropriate nursing diagnosis based on the bruising and the patient's behavior during the assessment as abuse is suspected.

The new graduate nurse attending the hospital's orientation session is an example of which process? Becoming competent Vision development Character shaping Role socialization

Role socialization Orientation sessions address the role of nurses at that particular institution or facility. This is an example of the process of the role socialization for the nurse.

A patient who is physically stable and healing is withdrawn and refusing treatment following an auto accident in which he suffered an amputated limb. Which theory would be beneficial if applied to this patient's care? Rosenstock Erikson Maslow Imogene King

Rosenstock Rosenstock's Health Belief Model focuses on possible reasons why a patient may not comply with recommended health promotion behaviors. For example, this patient may perceive of too many barriers to adjusting to the loss of his limb.

What do state nurse practice acts define for nurses residing or working in that state? Select all that apply. Scope of practice Quality of care Protocols for care Legal practice limits Professional performance

Scope of practice Legal practice limits Nurse Practice Acts (NPAs) are laws that set the legal limits of nursing practice and define the scope of practice within each state or jurisdiction. Advanced practice registered nurse (APRN) is a designation for an RN who has met advanced educational and clinical practice requirements.

Which statement reflects the relationship between living arrangements and psychosocial health of older adults? · Living arrangements do not affect psychosocial health. · Moving in with family members will improve psychosocial health. · Significant differences in psychosocial health can occur based on living arrangements. · Older adults seldom require support from family or friends when moving into a nursing home.

Significant differences in psychosocial health can occur based on living arrangements. Change in living arrangements for an older adult can be stressful and have a significant impact on psychosocial health

Which areas related to a patient's behavior-specific knowledge and affect will the nurse assess when using the Health Promotion Model? Select all that apply. Behavioral outcomes Situational influences Perceived self-efficacy Basic and higher needs Perceived benefits of action

Situational influences Perceived self-efficacy perceived benefits of action Situational influences are a subcomponent of behavior-specific knowledge and affect of the Health Promotion Model/Perceived self-efficacy is a subcomponent of behavior-specific knowledge and affect of the Health Promotion Model/Perceived benefits of action are a subcomponent of behavior-specific knowledge and affect of the Health Promotion Model.

There are how many stages in Kohlberg's theory of moral development? - Three - Four - Five - Six

Six Kohlberg's theory of moral development is an expansion of Piaget's theory—six stages of moral development in 3 levels—punishment and obedience orientation, instrumental relativist orientation, good-boy or nice-girl orientation, society-maintaining orientation, social contract orientation, and universal ethical principle orientation

Which portion of the musculoskeletal system contains both flat bones and immobile joints? Skull Vertebrae Rib cage Femur

Skull The skull contains both flat bones and fibrous or immobile joints.

A nursing instructor asks a nursing student to list the key concepts of intersectionality. Which answer indicates a need for further teaching? - Social equality - Marginalization - Matrix of domination - Overinclusion and under inclusion

Social equality Social inequality rather than social equality is one of the key concepts of intersectionality. Intersectionality also includes marginalization, which refers to the groups who are left out of the matrix of domination/another concept of intersectionality/overinclusion and under inclusion is the idea that various groups have been overlooked in the research and design of interventions

Social well-being physical well-being spiritual well-being emotional well-begin

Social well-being—communities and family Physical well-being—fitness and nutrition Spiritual well-being—Charity and Hope Emotional well-being—Crisis care and stress management

A child presents to the primary care provider's office after having an asthma attack. During assessment, the nurse observes that both mother and child are disheveled in appearance and learns that they are living out of a car. Which is member of the health care team would be a priority for the nurse to collaborate with when planning care for this patient related to safety? Pharmacist Social worker Physical therapist Occupational therapist

Social worker The social worker is needed to assist the family related to a safe living situation. This is the priority given the current situation.

The nurse observes a surgeon explaining a surgical procedure in English to a patient she knows to only understand Spanish and getting her to sign the consent form (written in English). What action should the nurse take based on this observation? Document her observations in the patient's chart. Recognize that obtaining consent is the responsibility of the surgeon, not the nurse. Speak with the surgeon and offer to find a Spanish interpreter. Ask the patient's English-speaking son to explain the procedure to the patient.

Speak with the surgeon and offer to find a Spanish interpreter.

Which describes the concept of a nursing discipline? - group of like-minded individuals - specific field of study or learning - social group with similar professional skills -theoretical base that reflects nursing practice

Specific field of study or learning

Components of critical thinking

Specific knowledge base Experience Competencies - Assessment - Daignosis - Planning - Implementation - Evaluation Attitudes Standards Specific critical thinking - diagnostic reasoning/inference - Clinical decision making: inductive reasoning: sepecific to ghe general; deductive reasoning: general to specific general critical thinkiing - sceintific method - Probme solving - decision making

Which situation best describes a 6-month-old's ability to maintain a standing position? The 6-month-old will kick slightly to avoid bearing weight. The 6-month-old will stand on his or her own and bear full weight. The 6-month-old can bear significant weight when held in a standing position. The 6-month-old's knees will bend and they will bear no significant weight.

The 6-month-old can bear significant weight when held in a standing position. The 6-month-old can bear significant weight when held in a standing position.

The Get Up & Go Test is part of what fall risk assessment tool? The Johns Hopkins Fall Assessment Tool - Category 1 The Johns Hopkins Fall Assessment Tool - Category 2 The Morse Fall Scale The Hendrich II Fall Risk Model

The Hendrich II Fall Risk Model The Get Up & Go Test is part of the Hendrich II Fall Risk Model.

Which statement differentiates APRNs from RNs? They are approved to practice in expanded roles. APRNs provide care for a variety of patients. They are licensed within in the state of practice. APRNs have passed the NCLEX-RN exam

They are approved to practice in expanded roles. APRNs are approved to practice in expanded and specialized roles. This characteristic differentiates APRNs from RNs.

Which toy is appropriate to encourage cognitive development in the toddler? Card game Board game Stacking cups One-hundred-piece puzzle

Stacking cups Stacking cups would encourage cognitive development. Cups are also safe and durable. This would be an appropriate toy.

Which statement about physical restraints is supported by evidence? Staff education can reduce the need for patient restraints. It is acceptable to use a vest restraint on a patient with a chest tube. Wrist restraints are less harmful and restrictive than vest restraints. A practitioner's order must be obtained prior to the application of restraints.

Staff education can reduce the need for patient restraints. Evidenced supports that staff education can reduce the need for patient' restraints.

Which patient behaviors observed during the health history interview suggest the patient should be further assessed for stress? Staring at the floor and responding with abrupt, monosyllable answers Sitting with crossed legs and taking notes Sitting upright and telling the nurse about a recently read novel Holding wife's hand and nodding

Staring at the floor and responding with abrupt, monosyllable answers

Which entity sets legal limits for nursing practice? State Board of Nursing American Nurses Association National League for Nursing International Council of Nurses

State Board of Nursing U.S, Nurse Practice Acts (NPA) are governed by each state's Board of Nursing—Nurse practice Acts regulated eh scope of nursing practice and protect public health/safety/welfare--Nurse Practice Acts, which are governed by each state's board of nursing, set the legal limits for nursing practice and provided the scope of practice for that state.

Which entity regulates prescriptive authority for advanced practice nurses (APRNs)? Employing agencies State boards of nursing ANA Standards of Practice for Nurses Medicare/Medicaid

State Boards of Nursing Each state or jurisdiction defines the scope of practice and grants prescriptive authority to APRNs within that state. States vary in regard to educational and other guidelines for prescriptive authority

What is a definition of health from an individual's perspective? - Absence of infirmity/illness - Process of making good decisions for oneself - State of complete physical, mental, and social well-being - Unidirectional force to stay strong and fit in all areas of life

State of complete physical, mental, and social well-being Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

Which describes the concept of generalization? · An end-point that is applicable to all individuals in a cultural group. · Used to anticipate certain behaviors in given particular situations. · A set of fixed ideas about members of a certain group. · Statements, ideas, or principles that have a broad application.

Statements, ideas, or principles that have a broad application.

Which focus by the nurse reflects a humanistic attitude? Strengths of a patient Mental disorder of a patient Reduction of a patient's welfare Patient's physiologic disease

Strengths of a patient A humanistic approach to health care focuses on strengths of individuals rather than weaknesses or illness eg., physiologic disease or mental disorder—Maslow

Which communicaiton technique is nontherapeutic? - Sympathizing - Focusing - Clarifying - Summarizing

Sympathizing Nurses may take patient feelings on as their own, which may hinder the nurse's ability to be objective and help the patient process their feelings. Focusing is a therapeutic communication technique that involves centering a conversation on key elements or concepts of a message. Clarifying is therapeutic communication technique to check whether you understand a message accurately by restating an unclear or ambiguous message to clarify the sender's meaning. Summarizing is a therapeutic communication technique that involves a succinct review of key aspects of an interaction.

The nurse skillfully inserts a Foley catheter in a patient. Which type of touch in this? - Caring touch - Protective touch - Task-oriented touch - Interpersonal touch

Task-oriented touch Nurses use task-orientated touch when performing a task or procedure. An expert nurse learns that any procedure is more effective when administered carefully/in considered of any pt concern Caring touch is holding a pt's hand, giving a back massage, gently positioning a pt, or participating in a conversation to enhance a pt's comfort/security, self-esteem, confidence in the caregivers, and mental well-being Protective touch protects the nurse and/or the pt to prevent physical or emotional harm

The registered nurse is teaching a patient of a different cultural background the procedure to self-administer insulin. After teaching, the nurse asks the patient to self-administer insulin. Which type of technique does the nurse use in this situation? - Teach-back - Health literacy - Cultural encounter

Teach-back

Which nursing action shows cultural competence? Giving a sponge bath to an American male with a broken femur Explaining to a Mexican patient's husband that the decision to have surgery is hers alone Discussing appropriate weight guidelines with an overweight African American woman Teaching an Asian male's adolescent daughter how to change his dressing

Teaching an Asian male's adolescent daughter how to change his dressing This culturally-competent nursing action is based on the knowledge that Asian men are frequently cared for by their wife and children when ill

Which teaching approach would be effective for informing a patient of an emergency appendectomy and the postoperative recovery he or she will experience? - Telling - Paricipating - Entrusting - Reinforcement

Telling The telling approach should be used for teaching when limited information is taught. It is more effective for the patient experiencing anxiety. Participating involves the nurse and patient working together to achieve learning objectives. Entrusting gives the patient the opportunity to manage self-care, and the patient accepts the responsibility. Reinforcement is using some stimulus to increase the probability of a response.

A pre-adolescent male can expect physical changes to occur in which order?

Testicular enlargement Growth of pubic hair Penile enlargement Deeper voice Axillary hair Facial hair

A nurse is teaching a new nurse about the difference between the Johns Hopkins Fall Assessment Tool and the Morse Fall Scale. Which statement indicates the nurse understood the teaching? The Morse Fall Scale contains more items than the Johns Hopkins Fall Assessment Tool. The Morse Fall Scale solicits information on the patient's age and gender, while the Johns Hopkins Fall Assessment Tool does not. Neither tool solicits information regarding the patient's prior history with falling. The Johns Hopkins Fall Assessment Tool solicits information about the patient's medications and elimination issues, while the Morse Fall Scale does not.

The Johns Hopkins Fall Assessment Tool solicits information about the patient's medications and elimination issues, while the Morse Fall Scale does not. The Johns Hopkins Assessment Tool solicits information about the patient's medications and elimination issues, while the Morse Fall Scale does not.

Which organization accredits hospitals while focusing on patient safety? The Joint Commission World Health Organization Center for Disease Control National Institute of Health

The Joint Commission The Joint Commission accredits hospitals and develops patient safety goals. The Joint Commission re-evaluates National Patient Safety Goals every 12 months.

How does the ability for a 24-month-old to build a two-block tower demonstrate a toddler's fine motor development? The ability to stack one block on top of another demonstrates an improvement in the toddler's balance. The ability to stack one block on top of another demonstrates an improvement in the toddler's autonomy. The ability to stack one block on top of another demonstrates an improvement in the toddler's visual acuity. The ability to stack one block on top of another demonstrates an improvement in a toddler's hand-eye coordination.

The ability to stack one block on top of another demonstrates an improvement in a toddler's hand-eye coordination.

Which common theme explains the aging process? The aging process is universal. (and inevitable) Deterioration of functioning occurs rapidly. Aging is an abnormal physiological process. Young adulthood marks the beginning of the aging process.

The aging process is universal. (and inevitable)

The nurse discusses economic losses caused by the costs of health disparities with a nursing student. What comment by the student indicates adequate learning? - The economy loses an estimated $309 billion per year b/c of the direct and indirect costs of disparities - The economy loses an estimated $509 billion per year b/c of the direct and indirect costs of disparities - The economy loses an estimated $709 billion per year b/c of the direct and indirect costs of disparities - The economy loses an estimated $909 billion per year b/c of the direct and indirect costs of disparities

The economy loses an estimated $309 billion per year b/c of the direct and indirect costs of disparities Recent analysis estimates that 30% of direct medical costs for African Americans, Hispanics, and Asian Americans are in excess b/c of health disparities

Which aspect of ear development leads to increased susceptibility to ear infections during the first two years of life? · The eustachian tube is short and horizontal. · The external acoustic meatus is short and vertical. · The auricle is narrow and can block the eustachian tube. · The outer tympanic membrane is porous and not highly vascularized. Bottle-fed cow's milk supplemented with Vitamins A, C, and D

The eustachian tube is short and horizontal.

What is a benefit of having a primary care provider as a regular source of care? Health care costs are increased. A supportive, short-term relationship is provided. Effective, cost-efficient emergency medical services are provided. The likelihood of receiving appropriate care is increased.

The likelihood of receiving appropriate care is increased. A primary care provider increases the likelihood that patients will receive appropriate care, which is a benefit.

A nurse is about to administer medication to a patient, when there is an emergency on the unit that she must attend to. Which action made by the nurse indicates a need for further learning regarding medication administration? The nurse leaves the medication unattended at the patient's bedside. The nurse refuses to delegate the medication administration to another person. The nurse does not let her coworker administer the medication on her behalf. The nurse lets the patient know that she will be back to continue the medication later.

The nurse leaves the medication unattended at the patient's bedside. Leaving medications at the patient's bedside is an unsafe practice and would indicate the nurse needs further instruction on how to safely administer medications.

Which situation is an example of ethnocentrism? The Chinese immigrant is absorbed into Western culture and loses aspects of her home culture. The Chinese immigrant seeks Western health care treatments in addition to traditional Chinese remedies. The nurse tells the patient that cupping will not help her get well because the only reliable treatment for her illness is antibiotics.

The nurse tells the patient that cupping will not help her get well because the only reliable treatment for her illness is antibiotics. The nurse assumes all Asian patients prefer Eastern medicine practices to Western medicine. Ethnocentrism is the belief that one's own culture is superior to that of another while using one's own cultural values as the criteria by which to judge others. The nurse tells the pt that her cultural practice will nto work, believing that only Western medicine will help her ethnocentrism: evaluation of other cultures according to preconceptions originating in the standards and customs of one's own culture.

Which observation made by the nurse while obtaining a health history signifies a patient may be actively stressed? The patient is sitting still and calm on the exam table. The patient is talkative and expressive during the assessment. The patient appears withdrawn and is unable to sit still in the exam room. The patient has a normal gait and adequate posture for age and height. Can the patient sit still? Is the patient experiencing tremors or muscle tension?

The patient appears withdrawn and is unable to sit still in the exam room A patient who is withdrawn and pacing or antsy in the exam room is most likely experiencing active stress, and this observation is important to note during the assessment.

The health care provider prescribes a clear liquid diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the n urse document this findings? - The patient had soup and tolerate it well - The patient had soup while watching a football game - The patient had 2 cups of soup, which was tolerated well - The patient had soup, 2 cp and was w.t., w.a.p.

The patient had 2 cups of soup, which was tolerated well

Which interpretation would the nurse make regarding a patient with pneumonia whose cough decreased and respiratory rate decreased from 33 to 25 breaths/min after nebulization treatments? - Discontinue the care plan - The patient can be discharged to home immediately - The patient needs continued neubulization therapy - Modify the care plan to include a transfer to the intensive care unit (ICU)

The patient needs continued nebulization therapy

In the communicaiton process, which person is the receiver of the message? -The person who encodes a message - The person who decodes a message - The person who delievers a message - The person who seeks feedback

The person who decodes a message The sender is the person who delivers and encodes the message.The sender also seeks both verbal and nonverbal feedback while the receiver provides feedback to the sender.

Which theme is found across all types of theories of aging? Aging is preventable. The process of aging begins at conception and ends at death. An acute deterioration of function is a hallmark of the aging process. Diseases commonly seen in older patients are the focus of the aging process. Aging is a complete biological process, beginning at conception and ending at death

The process of aging begins at conception and ends at death.

which term if often applied to people who find themselves balancing responsibilities related to employment, family life, care of children, and care of aging parents? - The sandwich generation - The millennial generation - Generation X - Generation Y

The sandwich generation The sandwich generation is the generation of people who care for their aging parents while supporting their own children. According to the Pew Research Center, just over one in every 8 Americans ages 40-60 is both raising a child and caring for a parent.

The nurse is evaluating an immobile patient. The nurse observes the condition of the patient and places the patient on a pressure-relieving mattress. Why did the nurse implement this intervention? - The pt avoids moving - Jont contractures are wrosening - The pt has difficulty moving - The pt has erythema and breakdown

The skin is showing areas of erythema and breakdown. When the skin shows erythema and breakdown, the nurse should place the patient on a pressure-relieving mattress. When the patient avoids moving, the nurse administers analgesia as ordered by the health care provider. When worsening joint contractures are observed, the nurse ensures that activity and range of motion are implemented consistently. When the patient has difficulty moving, the nurse consults the physical or occupational therapist.

A nurse is teaching a student nurse how to put on antiembolism stockings. Which action would indicate the student nurse understood the teaching? The student nurse bunches up the stockings and pulls them up the patient's leg. The student nurse makes sure the stockings are big enough to slip two fingers between the stocking and the leg. The student nurse leaves wrinkles behind the patient's knee to allow the patient to bend the leg. The student nurse checks the circulation in the patient's toes once the stockings have been applied.

The student nurse checks the circulation in the patient's toes once the stockings have been applied. The circulation in the patient's toes should be checked after the stockings are applied, and then routinely thereafter, to ensure the stockings are not constricting blood flow to the extremit

Which statement describes utilitarianism? - The value of something is determined by its usefulness to society - people's value are determined by religious leaders - the decision to perform a liver transplant depends on a measure of the moral life that the pt has led so far - the best way to determine the solution to an ethical dilemma is to refer the case to the attending physician or health care provider

The value of something is determined by its usefulness to society. Utilitarianism specifically refers to the greatest good for the greatest number of people, where goodness is determined primarily by usefulness. The concept is easier to apply in a community where shared values allow for agreement about a definition of usefulness. Utilitarianism is not when values are determined by religious leaders, does not take into account the patient's previous moral life, and does not argue that the best way to determine the solution is to refer the case to the provider.

Which nursing actions align with Leininger and McFarland's steps for the delivery of culturally congruent (consistent) and culturally competent care? Placing reliance on an interpreter when speaking with a non-English speaking patient Reading reliable literature about different cultures Reconfirming the meaning of the data provided by the patient Thinking "outside the box" when using assessment findings

Thinking "outside the box" when using assessment findings Leininger and McFarland suggest using assessment findings 1. gain knowledge of individual's culture from reliable literature and transcultural nursing course 2. Be familiar with one's own cultural heritage, patterns, biases that may interfere with assessment and undertanding of the pt 3. Use theory to guide cultural assessment 4. know some common phrases in the pt's language and work with qualified interpreters 5. Show respect and a genuine interest in teh pt's culture 6. Be observant of the environmental context in which the pt interaction takes place 7. as the pt shares emic or tic data 8. Make the pt an active co-participant in the assessmetn to collect credible and accurate data 9. Identify specific and general cutlura care values, beliefs, and needs related to generic (emic) and professional (etic) data 10. Use assessment findnings in sensitive, knowing, crative, and meaningful ways so that beneficial and satisfying

The public health nurse assesses the social, cultural, and ethnic traditions of a community for which reason? · This information is essential to the provision of patient centered care. · This information is necessary to establish a trusting relationship with community members. · It facilitates collaboration with community leaders. · It is needed to identify vulnerable groups

This information is essential to the provision of patient centered care. Within the domain of public health nursing, the patient is often the community as a whole. The preferences, needs, and values of that community are commonly tied to social, cultural, and ethnic traditions. This data is needed by the public health nurse if patient-centered care is to be provided to that community and the individuals within it.

A mother brings her 5-month-old infant to the clinic and is concerned that the child does not seem to smile as much as her niece, who is the same age. How will the nurse respond? This is normal as you can expect to see a smile at 6 months of age. All children start to smile at a different age, so be patient. There is no need to worry. This is a concern since the child should be showing a social smile by no later than 1 month of age. This is a concern since the child should be showing a social smile by no later than 3 months of age.

This is a concern since the child should be showing a social smile by no later than 3 months of age Since the child should be showing a social smile by no later than 3 months, this is the correct response that the nurse should make to this parent

Which goal is typical of Watson's theory? - To develop interaction between the nurse and patient - To promote self-healing using carative factors - To focus on unitary beings by expanding consciousness - To facilitate the reparative processes of the body by manipulating the patient's environment

To promote self-healing using carative factors Jean Watson's 10 carative factors are: (1) forming humanistic-altruistic value systems, (2) instilling faith-hope, (3) cultivating a sensitivity to self and others, (4) developing a helping-trust relationship, (5) promoting an expression of feelings, (6) using problem-solving for decision-making, (7) promoting teaching-learning, (8) promoting a supportive environment, (9) assisting with the gratification of human needs, and (10) allowing for existential-phenomenological forces.

What is the goal of culturally congruent care? - To provide care to fit a pt's own values/beliefs/traditions - To help recognize biases/prejudices/assumptions about other people—cultural awareness - To assess social/cultural/biophysical factors that influence pt tx and care--skills - To motivate the nurse to learn from others, accept the role as a learner, and be open to and accepting of cultural different—cultural desire

To provide care to fit a pt's own values/beliefs/traditions

While caring for a patient with immobility, the nurse positions the patient in the supported supine position. The nurse places pillows under the pronated forearms keeping the upper arms parallel to the patient's body. Which reason explains this nursing action? - To reduce extension of fingers - To maintain correct body alignment - To provide support to the lumbar spine - To reduce the internal rotation of shoulders

To reduce the internal rotation of shoulders

Which aspect will the nurse promote when teaching a patient about wellness? Wellness is the same as health. Wellness is the absence of disease. Wellness has many interrelated dimensions. Wellness has a focus on others' needs and choices

Wellness has many interrelated dimensions. Wellness is made up of many interrelated dimensions that contribute to health. Wellness is a process of self-care achieved by making choices leading to a healthy life.

Which topics will the nurse include when preparing a presentation about the leading health indicator topics within Healthy People 2020? Select all that apply. Tobacco Access to health services Heart failure prevalence Mortality rates for hospitals Injury and violence prevention

Tobacco Access to health services Injury and violence prevention tobacco is a leading health indicator topic within Healthy People 2020. The Healthy People 2020 initiative is designed to track over 10-year increments the risk factors and personal behaviors related to physical activity, access to health services, tobacco use, substance use, responsible sexual behavior, mental health, immunizations, and injury and violence prevention (U.S. DHHS, 2010). Access to health services is a leading health indicator topic within Healthy People 2020. The Healthy People 2020 initiative is designed to track over 10-year increments the risk factors and personal behaviors related to physical activity, access to health services, tobacco use, substance use, responsible sexual behavior, mental health, immunizations, and injury and violence prevention (U.S. DHHS, 2010)/Injury and violence prevention is a leading health indicator topic within Healthy People 2020. The Healthy People 2020 initiative is designed to track over 10-year increments the risk factors and personal behaviors related to physical activity, access to health services, tobacco use, substance use, responsible sexual behavior, mental health, immunizations, and injury and violence prevention (U.S. DHHS, 2010).

Nursing Care Delivery Methods

Traditional models - team and primary nursing Today's models - Patient- and family-centered care 1. dignity/respect 2. info sharing 3. participation 4. collaboration - case management Only RN can do admission assessment

Risk Factor Modification and Changing Health Behaviors

Trans-theoretical model of change—stages of health behavior change o Preconception—no intent to make changes w/in the next 6 months § May be defensive—There is nothing I really to change o Contemplation (observation)—considering a change w/in the next 6 months § Pt is thinking about making a change—I have a problem that I think I need to work on o Preparation—making small changes in preparation for a change in the next month § May have tied to make changes in the past but was unsuccessful—pt believes that advantages outweigh disadvantages of behavior change · I started running once, but I did not keep it up. I think I might try again in a few weeks o Action—actively engaged in strategies to change behavior—lasts up to 6 months § Committed to changes · I am really working hard to stop smoking o Maintenance—sustained changed over time—begins 6 months after action has started and continues indefinitely § Changes integrated into the pt's lifestyle/behaviors adopted to px relapse · I need to avoid people who smoke so I won't be tempted to start smoking again

Which model that consists of five stages of health behavior change would the nurse use to manage a patient who needs to exercise? - Health belief model - Holistic health model - Transtheoretical model - Maslow's hierarchy of needs

Transtheoretical model The transtheoretical model of change describes the five stages of health behavior change that a pt undergoes while trying to change a behavior—exercising—it helps the nurse understand the pt's beliefs/behaviors/perception of illness and plans to provide an appropriate intervention

Following surgery to repair a fractured femur, a patient is asking for something to help with repositioning in bed. Which device would be the most appropriate for this patient? Transfer board Friction-reducing sheet Mechanical lift Trapeze bar

Trapeze bar A trapeze bar would allow the patient to assist with repositioning, as the patient can grasp the bar to pull his own weight up when repositioning.

Which site is at risk of skin breakdown when the patient is int eh side-lying position? - Knees - Clavicle - Humerus - Trochanter

Trochanter

When a patient is in the supine position, where should a pillow be placed? Between the legs Under the calves Between the arms Under the scapula

Under the calves When a patient is in the supine position a pillow should be placed under the calves to alleviate pressure on the heels, preventing pressure ulcers.

According to Gordon's model, which health pattern describes the patient's spiritual attitude? - Value-belief pattern - Role-relationship pattern - Cognitive-perceptual pattern - Self-perception and self-concept pattern

Value-belief pattern The value-belief pattern describes a patient's spiritual attitude, the values and beliefs that guide the choices or decisions of the patient. The role-relationship pattern describes a patient's pattern of role engagements and relationships. The cognitive-perceptual pattern describes memory, decision-making ability, language adequacy, and sensory-perceptual patterns. A patient's concept of self or perception of self is described by the self-perception-self-concept pattern.

A nurse in the children's ward is caring for a boy with impetigo who is experiencing some discomfort. In a private moment with the father, the nurse is shocked to learn that the reason they did not give the boy antibiotics was that they did not want to kill the living bacteria causing the condition. Later, she still feels angry that the family would make their son suffer to save a colony of highly contagious bacteria. Which concept best explains why she feels the way she does? · Values · Values conflict · Ethics · Accountability

Values Values, or a personal belief about the worth of a given idea or behavior, cause the nurse to feel that the boy's discomfort was worth more than the family's wish to not kill a living thing

A nurse working in a pain management clinic is having a conversation with an older adult patient with bone cancer, who emigrated from Japan 60 years ago, and his 40-year-old son. The son asks why his father, who is obviously in great pain from his condition, has not received more pain medication. The father says he does not need the medicine and that bearing the pain without complaining is important to him and was how his parents acted when they lived in Japan. What kind of assessment is the best choice in this situation? Collaborative Intelligence Risk Values clarification

Values clarification Learning the patient's values and why he does not wish to seek drugs to lessen his pain is part of clarifying the differences in the values between the father and the son. The best choice is the values clarification assessment.

The nurse reflects which theory when helping the patient become as independent as possible before discharge from the hospital? Hildegard Peplau Virginia Henderson Rosemarie Rizzo Parse Martha Rogers

Virginia Henderson humane/holistic care for patients

Which theory states the body wears out from overuse and abuse and that the toxins in the diet, poor nutrition, and stressors contribute to wear and tear? Wear and Tear Theory Immunological Theory Neuroendocrine Theory Programmed Senescence Theory

Wear and Tear Theory The Wear and Tear Theory states the body wears out from overuse and abuse and that the toxins in the diet, poor nutrition, and stressors contribute to wear and tear. It is classified as a damage theory in which life span can be increased if a change is made to minimize damage.

a breastfeeding infant whose birth weight was 3000g now weighs 2700 g after 1 week. The concerned mother asks the nurse about the infant's weight loss. Which response by the nurse is appropriate? - Weight loss during this period is normal for an infant - The infant is dehydrated and needs fluid replenishment - Weight loss is caused by the infant's increased motor activity - You should stop breastfeeding immediately

Weight loss during this period is normal for an infant

The health care team is discussing safe patient handling. A team member asks about available evidence on the subject. Which statement would most accurately reflect current available evidence on safe patient handling? When moving patients, colleague assistance can reduce nurse injuries. Proper body mechanics prevents injury during patient transfers. Nurses should use assistive devices when lifting patients over 50 lbs. The use of lift equipment has not be shown to reduce staff injuries.

When moving patients, colleague assistance can reduce nurse injuries. Maximizing assistance when moving patients in can drastically reduce transfer- or lift-related injuries to the staff. The recommended maximum weight limit for lifting patients without an assistive device is 35 lbs.

Setting a time frame for outcomes of care determines which purpose? - The priority level - Time it takes to complete an intervention - How long the nurse is scheduled to care for a patient - When the patient is expected to respond in the desired manner

When the patient is expected to respond in the desired manner Time frames indicate when the patient is expected to respond in the desired manner. The time frame indicates when the nurse expects a response to nursing interventions. Time frames help organize priorities but do not indicate which problem has priority. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to how long the nurse is scheduled to care for a patient.STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the examination." Specify how many hours, what day and time, and what material you will cover.

Which are the best resources to find an appropriate growth chart in assessing growth for a 1-year-old child? · Food and Drug Administration growth chart · American Academy of Pediatrics growth chart · Center for Disease Control (CDC) growth charts for this age group World Health Organization (WHO) growth standards for this age group

World Health Organization (WHO) growth standards for this age group The CDC recommends that health care providers use the World Health Organization (WHO) growth standards to monitor growth for infants and children age 0-2 years of age and the CDC growth charts for children age 2 years and older.

A patient is scheduled for a Prostatectomy. The Patient is worried that he may not be able to have sex after surgery. Which response by the nurse is appropriate? - Oh! Who told you that? It is not true at all! - Don't worry; you will not have any problems with your sexual ability. - Yes, I am afraid this is true. You will never be able to have sex again. - Your surgeon will talk to you about the surgery. Don't be afraid to ask this question.

Your surgeon will talk to you about the surgery. Don't be afraid to ask this question.

_____ _____ beliefs are primarily unconscious thoughts. Zero-order First-order Second-order Higher-order

Zero-order Zero-order beliefs are primarily unconscious thoughts, such as object permanence/ Higher-order beliefs are generalizations or ideas that are derived from first-order beliefs and reasoning. They are not primarily unconscious/ Second-order is not a type of beliefs covered in this lesson.

Which assessment finding is indicative of death? · Absent apical pulse · Auscultated secretions in the airway · Low blood pressure · Irregular respiratory rate

absent apical pulse An absent heartbeat is an assessment finding that indicates death.

The nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risks and benefits of the surgery to the family and discusses the patient's wishes with the family. Which role is the nurse playing for the patient? - Educator - Advocate—recommend or support - Caregiver - Manager

advocate recommend or support

Which clinical feature is related to depression in older adults? - Apraxia - Agitation - Hypervigilance - Impaired orientation

agitation Impaired orientation--delirium Psychomotor disorientation, or agitation, is commonly seen in pts w/depression. Apraxia is a clinical feature associated with dementia but not depression/pt with delirium have increased alertness (hypervigilance)--however, the alertness in pts w/depression is usually normal

Nurisng diagnosis for stress

anxiety despair difficulty coping risk for post trauma response stress overload

Which description is accurate for a system warning alerting the nurse an intervention is inappropriate for a patient because of risk? - Electronic health record - Clinical documentation - Clinical decision spport system - Computerized provider order entry

clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user. Text Reference

Which teaching method does the nurse use for a patient newly diagnosed with diabetes who will be self-administering insulin? - simulation - demonstration - group instruction - one-on-one discussion

demonstration

A mother presents to the nurse and states, "just recently my child has developed a positive, 'can-do' attitude towards all of her tasks." Based on this comment the child has recently reached which stage of psychosocial development according to Erikson? · Initiative vs guilt · Trust vs mistrust · Identity vs role confusion · Autonomy vs shame and doubt

initiative vs. guilt The initiative vs guilt stage happens during the preschool years and is a time when a child will present with a "can-do" attitude.

What is a child at the concrete operational stage able to understand? · Fact vs. fiction · Socialized thinking · Abstract thinking · Far past and far future events

facts vs. fiction During the period of concrete operations, the child is no longer bound by perceptions and can distinguish fact from fantasy. The concept of time becomes increasingly clear during this stage, although far past and far future events remain obscure. Although reasoning powers increase rapidly during this stage, the child cannot deal with abstractions or with socialized thinking.

Florence Nightnglae Peplau Orem Leininger Watson Sister Callista Roy Betty Neuman Lewin's change theory Rosenstok

first practicing nurse epidemiologist orangized first school of nursing improved sanitation in battlefield hospitals practice remain basic part of nursing today She decribed concrete concepts such as physical condition and health care environments Her theroy was founded on her belief that nursing could improve a pt's environment to facilitate recovery and prevent complicaiton Peplau interperosnal theory--the mother of psychiatric nursing Orem's Self-Care Deficit Nursing Theory--self-care needs Leininger's Culture Care Theory integrates pt's cultural traditions, values, and beliefs into care plans - Caring is an essential human need Jean Wastson Transpersonal caring--promotes healing and wholeness Sister Callista Roy's--Adaptation Betty Neuman--holistic concept Erikson's psychosocial theory--Psychosocial Theory of Development and Socialization is based on individuals interacting/learning about their world—nurses use concepts from this developmental theory to care for their pts at various stages of life Lewin's change theory - 1st unfreezing, which is the process of overcoming inertia/changing one's mindset—right environment is created for change - 2nd moving or change, is the time of transition/confusion when change takes place—change is supported/implementation of the change occurs - 3rd refreezing. During this step the change is completed, reinforced/accepted Rosenstock developed the psychological Health Belief Model--used to predict more general health behaviors-- - perceived susceptibility to or risk of getting the condition - perceived severity of the seriousness of the condition and its potential consequences - perceived barriers of the influences that discourage adoption of the promoted behavior - perceived benefits of the positive consequences of adopting the behavior

Mr. Bagley is placed on Isolatin Precaustions. isolation precautions as a tx intervention are an example of which type of care? - direct - indirect - prevention - safety

indirect

a pt living in Oregon has been receiving hospice care in the home. one day the pt tells the nurse, "Dying takes forever. I hate it that I am a burden to my family. I can't stand this anymore. Can you help me take my life?" The nurse's personal ethical values do not include complying with this pt's request. Which is the nurse's BEST response? - let's talk a little more about your wanting to die. - I will inform your primary health-care provider of your desire to die - Your family members probably do not consider you a burden. - I can't help you b/c I do not believe in assisted suicide

let's talk a little more about your wanting to die.

Fear of punishment is the hallmark of which of Kohlberg's stages of moral development? Level of premorality Level of conventional morality Level of postconventional morality Level of self-accepted moral principles

level of premorality Children at this level have no real understanding of right and wrong. Children will do what they told to do rather than what is right—child will demonstrate acceptable behavior b/c of a fear of punishment

Which is the major differentiating factor between hospice care and palliative care? Acuity of the patient's illness Life expectancy of the patient Care requirements of the patient Patient care setting

life expectancy of the patient

Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the pt's only treatment choice. This example describes the ethical principle of: - autonomy - fidelity - justice - nonmalefinence

nonmalefince Nonmaleficence is the obligation of a physician not to harm the patient. values - a deeply held belief about the worth of an idea, attitude, custom, or object that affects choices and behaviors Values clarification - ethical dilemmas almost always occur in the presence of conflicting values - to resole ethical dilemmas, one needs to distinguish among values, facts, and opinion

which member of the nursing team is most likely to use transformational leadership for team development? - nurse manager - registered nurse (RN) - assistive personnel - Licensed practical nurse (LPN)

nurse manager

Evidence-based care

o Looks for the very best scientific and clinical evidence for treating and managing a problem § EBP enhances the pt experience/decrease cost/empowers clinicians/improves pt outcomes o Improves quality, safety, and pt outcomes o Increases nurse satisfaction o Reduces costs The best scientific evidence comes from well-designed, systematically conducted research studies fund in scientific, peer-reviewed journals Steps of EBP 1. Cultivate a spirit of inquiry (Promote)--cnostantly questioning current practices lead to consistent use of EBP 2. Ask of clinical quesiton in PICOT format - Patient population of interest - Intervention of interest - Comparison of interest - Outcome - Time Does the use of complementary therapies (I) compared with analgesics (C) lessen pain (O) in pts with osteoarthritis (P)? 3. Search for the best evidence - experts (nursing faculty/librarian/advanced practice nurses/staff educators/risk managers) 4. Critically appraise (evaluate) the evidence--synthesize or combine the findins 5. Integrate the evidence (particpate/involve new policy) 6. Evaluation the outcome of practice decision or changes 7. communicate the outcomes of the evidence-based practice decision

According to Piaget's cognitive theory, which concept is demonstrated by an infant looking for a pacifier that has fallen out of the crib? · Object permanence · Operational thought · Preoperational thought · Concrete operational thought

object permanence

a nurse is making initial rounds on pts. which interveniton for a pt with poor wound healing should the nurse perform First? - observe wound appearance and edges - perform the ordered dressing change twice daily - reinforce the wound dressing as needed with gauze - document wound characteristics

observe wound appearance and edges

The metaparadigm for nursing focuses on which concepts? Select all that apply. a. Person b. Environment c. Health d. Society e. Nursing

person environment health nursing

Which positioning aid increases cervical flexion? - Pillows - Arm splints - Trapeze bars - Trochanter rolls

pillows Rationale: When thick pillows are used under the patient's head, it increases cervical flexion. Arm splints help reduce musculoskeletal injuries. A trapeze bar helps patients perform upper arm exercises. Trochanter rolls prevent external rotation of the hips when a patient is in the supine position.

A child who acts in a way to avoid consequences rather than internal feelings of right and wrong is demonstrating which of Kohlberg's levels of moral development? Premorality Morality of conventional role conformity Morality of self-accepted moral principles Morality of postconvential role conformity

premorality At this level do not have a good understanding of right/wrong/will not feel guilty

Which physical factor is associated with the death rattle? · Uncontrolled seizure-like activity at the time of death · Increased respirations at the time of death · Trapped respiratory secretions at the time of death · Alternating periods of apnea and deep-breathing at the time of death

trapped respiratory secretion at the time of death Respiratory congestion or 'death rattle' from the inability to swallow secretions The death rattle refers to breathing sounds made by the dying patient as a result of accumulated secretions in the throat.

Which patient outcome about a wound would allow the nurse to measure a patient's response to care more precisely? - Will appear normal within 3 days - Will have less drainage within 72 hours - will reduce in size to less than 4 cm (1.5 inches) by day 4 - Will heal without redness or drainage by day 4

will reduce in size to less than 4 cm (1.5 inches) by day 4

How does Erickson's theory of child development influence pediatric nursing? · It provides a rationale for appropriate punishment of children. · It provides a theoretical basis for teaching children life skills for the future. · It provides a theoretical basis for the emotional care required for nursing. · It provides feedback for thoroughly understanding why children may get sick.

· It provides a theoretical basis for the emotional care required for nursing. Erikson's main contribution to the study of human development lies in his outline of a universal sequence of phases of psychosocial development influences. This information aids pediatric nursing by providing a framework for how to work with children of different ages and developmental levels.

Which is an example of a public health oriented nursing diagnosis? · Risk for Ineffective Childbearing Process related to domestic violence · Risk for Ineffective Relationship related to substance abuse · Risk for Contamination related to elevated lead levels in the public water supply · Risk for Ineffective Activity planning related to insufficient social support

· Risk for Contamination related to elevated lead levels in the public water supply This nursing diagnosis pertains to a population because it refers to the public water supply. Public health nursing is concerned with populations and public health nursing diagnoses reflect this focus.

Which nursing diagnosis could be appropriate for use by a home nurse, but inappropriate for use by a public health nurse? · Readiness for Enhanced Health Management among middle school children at Public School 102 as evidenced by asking how catching the flu can be avoided. · Deficient Community Health related to increased risk of polio as evidenced by inadequate immunization of children and adults in the community. · Frail Elderly Syndrome among residents of a senior citizen housing complex related to sedentary lifestyle as evidenced by activity intolerance. · Risk-Prone Health Behavior related to opioid abuse as evidenced by refusal to enter a rehabilitation program

· Risk-Prone Health Behavior related to opioid abuse as evidenced by refusal to enter a rehabilitation program This nursing diagnosis is focused on an individual; therefore, it would be appropriate for use by a home health nurse if the patient situation demanded it. It would not be appropriate as written for use by a public health nurse because public health nursing focuses on populations.

Which statement provides an example of considerations for older adults related to sexuality? · Safe sex practices are not important. · People participate in sexual activity primarily for the purpose of reproduction. · Individuals experiencing weakness or paralysis are not able experience sexual pleasure. · Sexuality should be discussed during visits with the health care team to promote psychosocial health

· Sexuality should be discussed during visits with the health care team to promote psychosocial health

The nurse is assessing a newborn and notes that the head circumference is 13 inches and the chest circumference is 11 inches. What conclusion can be made by the nurse about this ratio? · The newborn has a cardiovascular anomaly. · The newborn is presenting with a normal growth pattern. · The newborn is at risk of having microcephaly and neuro referral is needed. · The child may have a developmental delay as the head should be at least 17 inches at birth.

· The newborn is presenting with a normal growth pattern.

A nurse is helping a woman who is six months postoperative for a C-section, and experiencing belly pain and lumpiness below the skin. The nurse palpates the abdomen, and suspects that the lumpiness is due to postoperative adhesions of the peritoneal covering. The nurse offers a choice of using a hot compress on the knots, or else doing some self-massage. The patient opts for the hot compress. The nurse asks the patient what time of day she will use the hot compress. What is the best reason why the nurse pursued the questioning technique the way she did? · The nurse wanted to avoid using medical jargon. · The nurse wanted to distract the patient from her stressful conflict about her C-section. · The nurse wanted to use the choosing, prizing, actions framework to involve the patient in her own treatment. · The nurse wanted to treat the patient's psychological state of depression about her C-section.

· The nurse wanted to use the choosing, prizing, actions framework to involve the patient in her own treatment. The nurse did use the Choose (between hot compress and self-massage), Prize (did she feel relieved to have a course of action to take?), Action (what time of day will you use the hot compress?) method. This brought the patient in to the decision-making process, and allowed her to focus on the future instead of regrets about the past. Therefore this is the reason why the nurse pursued this questioning technique.

Which is a common physical growth pattern seen in infancy during the first to second month? · Upper limbs and head grow faster. · Lower limbs and GI tract develop faster. · Cardiovascular system and lower limbs develop faster. · Respiratory and immune systems develop at a rapid pace.

· Upper limbs and head grow faster.

Which is an example of a stereotype? · Frequently hospitalized patients are attention-seekers · Women tend to emotionally overreact. · Obese patients are lazy and do not watch their diet. · Health care workers enjoy their work.

· Women tend to emotionally overreact.