Fundamentals Adaptive Quizzing

A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions?

"You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying anti-embolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets

2 The prescribed dose is 0.22 g. The available medication is 110 mg/tablet. First, convert the prescribed dose in grams to the available medication in milligrams. Then, use the dimensional analysis and ratio and proportion methods to determine the appropriate number of tablets to be administered.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet?

Asking about what the client knows about the diet that was prescribed Asking about what the client knows about the prescribed diet may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.

A nurse delegates tasks to a hospital rescue team to provide care to a group of clients who survived an earthquake. Which type of leadership is reflected in the nurse's action?

Autocratic During autocratic leadership, the leader retains authority and responsibility. An autocratic leader places little trust and confidence in others during a natural disaster. Situational leadership requires flexibility on the part of the manager in adapting to the needs of the work group. Democratic leadership involves treating every staff member equally; this type of leadership is not appropriate in a crisis situation. Laissez-faire leadership involves delegating decision-making to the group.

Which type of home health agency is supported by fees from limited sources?

Official An official home health care agency is supported by fees from limited sources; state, local, or county revenues; grants; and charitable contributions. Hospital and voluntary home health agencies receive fee support from all sources. Proprietary agencies receive fees from most of the sources.

Which type of temperature measurement is contraindicated in clients with shaking chills?

Oral Oral temperature measurements are contraindicated in clients with shaking chills. Rectal temperature measurements are contraindicated in clients who have a rectal disorder, such as a tumor or hemorrhoids. Axillary temperature measurements are not contraindicated in clients with shaking chills. Tympanic temperature measurements are not contraindicated in clients with shaking chills.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings?

Papules Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? Select all that apply.

Paramedics Nurses appointed to a field team Paramedics and nurses appointed to a field team are the EMS first responders who can perform triage during a mass casualty incident. Unlicensed assistive personnel can assist with providing client care in a hospital setting under the direction of a licensed practitioner. A physician who survives the incident can assist with treatment; however, this individual is not necessarily trained for triage. Community response team members can assist first responders; however, these individuals are not trained for triage.

Which responsibility of the nurse manager differs from the responsibilities of a nurse leader?

Planning the budget Budgeting is the responsibility of a nurse manager. The role of nurse leader is to motivate the nursing subordinates. Resolving conflicts is the responsibility of both the nurse leader and the nurse manager. Penalizing for poor performance is a behavior of transactional leadership.

A county-based visiting nurse association receives funds from charitable contributions that provide pneumonia vaccination to a community. Which type of health agency is this association?

Pneumonia vaccinations are given as part of community health. A combination health agency provides community health services and is supported by charitable contributions. A hospital agency gets fees from all sources and provides limited community health services. A voluntary health agency is supported by tax-deductible contributions. A proprietary health agency does not receive charitable contributions or provide community health services.

The rehabilitation team members on a hospice unit are caring for a client. One of the team members provides spiritual guidance to the client. Which team member plays this role?

A chaplain plays the role of a spiritual consultant, providing spiritual support and guidance to clients. A clinical psychologist plays the role of an emotional evaluator by assessing the client's disposition on the mental health continuum. A speech-language pathologist is responsible for designing the rehabilitation communication program and for helping the client to regain communication skills. A vocational rehabilitation counselor plays the role of a vocational planner, helping the client obtain training for current employment.

Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply.

Administering oral hypoglycemic agents Administering intramuscular medications Licensed vocational nurses and licensed practical nurses are authorized to administer drugs through oral and intramuscular routes. Analyzing vital signs should be performed by the registered nurse. Hygiene maintenance can be delegated to unlicensed nursing practitioners (UNP). Administering intravenous drugs should be done by the registered nurse.

What does the ethical principle of justice mean in the context of nursing?

All clients have the same right to nursing interventions In the context of nursing, the ethical principle of justice means that all clients have the same right to nursing interventions. The ethical principle of autonomy states that the nurse does not have the authority to make decisions for the client. The principle of nonmaleficence states that the nurse has a duty to do nothing that has a harmful effect on the client. The principle of beneficence states that the nurse has a duty to protect life and promote the well-being of all clients.

Which health care organization was renamed the National League for Nursing Education?

American Society of Superintendents of Training Schools The American Society of Superintendents of Training Schools was renamed the National League for Nursing Education. Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers who lived in rural Kentucky. The Council of Practical Nursing Programs is an accreditation service provided by the Department of Practical Nursing Programs. The American Nurses Association is an organization with the mission of advancing and protecting the profession of nursing.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply.

Pregnancy Drug abuse Sexual orientation Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

Which individual would be an appropriate member of a critical incident stress debriefing (CISD) team for a group of staff nurses? Select all that apply.

Staff nurse Physician trained in critical debriefing Advanced practice mental health nurse The critical incident stress debriefing (CISD) team includes a peer member of the group being debriefed. For this group, the CISD team would include a staff nurse. The team may include a physician trained in critical debriefing. The team leader would be someone with a background in mental or behavioral health. This role would be appropriate for the advanced practice mental health nurse. The chaplain and the media representative are not identified as being appropriate for the CISD team.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?

Teach the client how to exercise the legs The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.

A nursing student learns about the different health belief systems likely to be encountered while working with clients. Which characteristics would a nursing student recognize as belonging to a folk health belief system? Select all that apply.

Treatment involves rituals or repentance Illnesses or diseases are classified as natural or unnatural. A folk health belief system classifies illnesses and diseases as natural or unnatural. Natural events are associated with a higher power; unnatural events are not associated with a higher power or deity. Treatment involves carrying out rituals or repentance or giving in to a supernatural force's wishes. In a holistic health belief system, anointing the sick may be seen as a preparation for death and may also be performed in the hope of a miracle; treatment is designed to restore balance with the physical, social, and metaphysical worlds. In an alternative or complementary belief system, the whole client is considered; symptoms are viewed as the tip of the iceberg and as the body's means of communicating to the mind that something needs to be changed, removed, or added to one's life.

Atenolol 150 mg by mouth is prescribed for a client with hypertension. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number. ____________tablet(s)

3

A registered nurse is teaching a nursing student about Erikson's theory of psychosocial development. To which age group does Industry versus Inferiority apply?

6-11 years

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

With the help of another staff member, use a drawsheet when lifting the client in bed.

A leader should have time-management skills. Arrange the principles of time management in order.

1. Goal setting 2.Time analysis 3.Priority setting 4.Interruption control 5.Evaluation

A client with gastroesophageal reflux is to receive metoclopramide 15 mg orally before meals. The concentrated solution contains 10 mg/mL. How much solution should the nurse administer? Record your answer using one decimal place. _____ mL

1.5

Experimental use of which substance often directly or indirectly leads to interpersonal violence among teenagers?

Alcohol Experimental use of alcohol among teenagers is often directly or indirectly tied to interpersonal violence among teenagers. While teenagers may also experiment with steroids, tobacco, and cannabis, these substances have less of a relationship with interpersonal violence.

In which phase does cell division begin?

Anaphase In anaphase, the cell starts dividing. In prophase, the formation of chromatids and spindle fibers occurs. In telophase, the two nuclei appear, and the chromosomes disperse. In metaphase, the nuclear membrane and nucleolus disappear.

What should a nurse recommend to help a client best during the period immediately after a spouse's death?

Bereavement counseling Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

Which religious group may refuse autopsy?

Christian Science Families of Christian Science clients may refuse an autopsy due to their beliefs. Baptists, Mormons, and Christian Science clients are less likely to be opposed to it.

The nurse is caring for a client with a closed soft tissue injury. What does the nurse describe the injury as?

Contusion Closed wounds are considered contusions and hematomas because the skin is not broken. Abrasions, lacerations, and avulsions are considered open because there is a break in the skin integrity.

Which are the functions of skeletal muscle? Select all that apply.

Eye movements Movement of bones The skeletal muscles help in eye and bone movements. Cardiac muscles help in contraction of the heart. The smooth muscles change the diameter of the pupils and help in the movement of substances along the ducts.

Which is the main function of a joint?

Facilitation of movement Joints help facilitate movement in the body. The function of the integumentary system is to synthesize chemicals. Regulation of body temperature is the function of the integumentary system. The function of the lymphatic system is to produce various blood cells.

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is: "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use?

Focusing Focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. Exploring permits the nurse to delve deeper into the subject when the client tends to stay on a superficial level. Accepting is a technique used to understand and demonstrate regard for what the client stated.

Which two groups of American women have the highest breast and cervical cancer mortality rates?

Hispanic and African American Hispanic and African American women have the highest breast and cervical cancer mortality rates. The breast and cervical cancer mortality rates for Native American and Asian American women are lower.

Which religion recommends circumcision before puberty?

Islam Circumcising the foreskin of the penis before puberty is a cultural recommendation in the Islam community. The Mormon, Eastern Orthodox, and Disciples of Christ communities do not have specific recommendations on circumcision.

The nursing staff complains about confusion at the work place due to the nurse leader's habit of avoiding responsibility and asking the staff to self-schedule client care assignments. Which type of leadership does the leader exhibit?

Laissez-faire leadership In laissez-faire leadership, the leader completely relinquishes control. He or she avoids responsibility by delegating all the decision-making to the group. In autocratic leadership, the leader retains all authority and responsibility and would assign client-care assignments without input. Democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members. Situational leadership is a comprehensive approach that takes into account the style of the leader, the group being managed, and the situation at hand.

Which member of the rehabilitation team would work with the rehabilitation nurse to help the client perform the action depicted in the image?

Physical therapist In the given image, the client is ambulating. The rehabilitation nurse and the physical therapist would help the client with gross motor skills like walking. The chaplain would provide spiritual support and guidance. The therapeutic recreation therapist promotes the client's interest in activities. The vocational rehabilitation counselor would help the client obtain training for new or current employment.

Which drug is available in an injectable form?

Pitocin Pitocin is available in an injectable form. Misoprostol and methylergonovine are available as oral medications. Dinoprostone is available as a topical gel for self-administration in the vagina.

What is the goal of a rehabilitation organization?

To restore the client's level of functioning Rehabilitation centers focus on restoring a client's psychological, social, and physical functioning. The goal of a psychiatric organization is to control and restore a client's behavior. Long-term care facilities focus care on the client who is unable to manage self-care. Transitional and subacute facilities provide intermediate levels of care to the client upon discharge from the hospital.

Which religious group practices infant baptism?

United Church of Christ The United Church of Christ religious group practices infant baptism. Jehovah's Witness, Seventh-Day Adventist, and the Church of the Brethren clients do not practice infant baptism.

Which team members are members of a primary hospice team? Select all that apply.

Volunteer coordinator Bereavement coordinator A volunteer coordinator and a bereavement coordinator are members of a primary hospice team. A social worker, a medical director, and a spiritual coordinator would be members of a core interdisciplinary hospice team.

A terminally ill client appears happy and tells a nurse a joke about the situation despite becoming sicker and weaker. What is the nurse's most therapeutic response?

"Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always telling jokes?" is confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear?" is confrontational and is an assumption by the nurse. The response "The one who laughs on the outside cries on the inside" is judgmental and is an assumption and a stereotypical response.

A nurse is to administer 5000 units of heparin to a prenatal client on prolonged bed rest. The label indicates that there are 20,000 units of heparin in each milliliter of solution. How much solution should the nurse give the client? Record your answer using two decimal places and include a leading zero if applicable. ___ mL

0.25

Which team member of the hospice interdisciplinary team helps the clients and their families handle grief issues?

A social worker will evaluate a client's psychosocial needs, serve as a resource for potential community services, and counsel the client with grief issues. A hospice aide administers personal care and assists with bathing. The medical director medically certifies the client's eligibility for hospice care and mediates between the hospice interdisciplinary team and the health care providers. A nurse coordinator admits the client to the hospice program and manages the client's care.

In SOAPIER charting format, which word represents the potential diagnosis of the cause of the client's problem?

Assessment In SOAPIER (Subjective, Objective, Assessment, Planning, Intervention, Evaluation, Revision), "Assessment" refers to potential diagnosis of the cause of the client's problem. "Planning" refers to the general statement of the plan of care to be given or action to be taken. "Objective" refers to information that the nurse can measure or factually describe. "Evaluation" refers to an appraisal of the response and effectiveness of the plan.

Which temperature measurement site is least accurate?

Axillary Measuring the temperature using the axillary route provides the least accurate readings.

How can a nurse best evaluate the effectiveness of communication with a client?

Client feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

The registered nurse (RN) is caring for a client who was admitted to the hospital due to severe diarrhea. The RN assigns the unlicensed assistive personnel (UAP) to check on the client hourly and perform hygiene care as needed. Which concept best explains this situation?

Delegation Delegation involves transfer of responsibility for the performance of tasks and skills for the ultimate outcome. Here the registered nurse (RN) is delegating a task to the unlicensed assistive personnel (UAP). Supervision involves directing, guiding, and influencing the outcome of an individual who performs the task. Assignment mostly happens in professional staff members such as RNs because it involves transferring responsibility and accountability.

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?

Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.

Which skills would be essential for an effective nurse manager to develop and improve collaboration with others? Select all that apply.

Flexibility Ability to listen to others Ability to share information and ideas In order to collaborate effectively, the nurse should be flexible, must be willing to listen to others, and must share information and ideas with others. The nurse manager should plan a thoughtful response, consider others' perspective first, and not react hastily. The nurse manager should not share his or her own anger or frustration with other staff.

A client is diagnosed with terminal breast cancer. The primary health-care provider confirms that the life expectancy of this client is six months. Which organizational care suggested by the primary health-care provider is most appropriate for the client?

Hospice Hospice care would be appropriate for a client with a terminal illness and life expectancy of six months. Palliative care is available to clients at any time and any stage of illness. Subacute care is designed to transition a client out of acute care. Long-term care is provided to clients with chronic illnesses or disabilities.

Which type of home care agency uses fees from all sources?

Hospital A hospital-based home health agency receives fees from all sources. An official home health agency receives fees from limited sources: state, local, or county revenues; grants; and/or support from charitable contributions. A proprietary home health agency receives fees from most sources, but may or may not participate in Medicare-Medicaid. A combination home health agency receives support and fees from limited sources: state, local, or county revenues; grants; and/or support from charitable contributions.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls?

Instructing the client to call the nurse before going to the bathroom. Statistics indicate that the most frequent cause of falls in hospitalized clients is getting up or attempting to get up to the bathroom unassisted. Although moving the bedside table closer to the bed is helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it does not reduce the incidence of falls.

Which condition in the client may produce subnormal temperature?

Hypothyroidism In clients with hypothyroidism, a subnormal temperature may be found. In clients with hypertension, elevated body temperature may be found. Increased body temperature may lead to hypovolemia. Increased body temperature may be found with hypertension. Elevated body temperature is associated with hyperpnea.

While serving as leader, a nurse tells the group, "You should make all decisions concerning the client." Which leadership style is the nurse using?

Permissive Permissive leadership (also known as laissez-faire or free-run leadership) involves a leader avoiding responsibility and delegating all decision-making to the group. An autocratic leader makes all decisions. Situational leadership gives the manager flexibility in handling decisions. In democratic leadership, the leader and the group are equally involved in decision-making.

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's initial reaction, what is the best indication that the nurse-client interaction has been therapeutic?

Relaxation of tensed muscles Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

Which epithelial tissue is only involved in absorption by osmosis?

Simple squamous Simple squamous epithelial tissue is only involved in absorption by osmosis. The function of simple columnar epithelial tissue is involved in protection, secretion, and absorption. Stratified squamous epithelial tissue and stratified transitional epithelial tissue are involved in protection.

A registered nurse has obtained a certification in Advanced Disaster Life Support training. Which organization provided this training?

The National Disaster Life Support Foundation offers Core, Basic, and Advanced Disaster Life Support training courses. The courses include all essential aspects of disaster response and management. The Hospital Incident Command System (HICS) is a facility-level organizational model for disaster management, which is a part of the National Incident Management System. The Federal Emergency Management Agency (FEMA) provides numerous online resources, including Community Emergency Response Team (CERT) training to enable more self-sufficient responses to incidents and hazard situations in communities.

A nurse is caring for a client with advanced-stage oral cancer who has just undergone surgery. The health-care provider prescribes a combination of chemotherapy and radiation therapy. What does the nurse understand to be the reason behind this intervention?

To make the client more comfortable A combination of chemotherapy and radiation therapy may be administered to a client with advanced-stage oral cancer after surgery to make the client more comfortable. Radiation therapy may be used before or after surgery to shrink the tumor. Clients who have undergone radical neck dissection may have drains in their incision sites that are connected to suction to aid healing and reduce hematoma development. A percutaneous endoscopic gastrostomy (PEG) tube may be inserted to permit adequate nutritional intake in clients who have difficulty swallowing.

What is the first strategy for burnout prevention that deliberately reflects on the nurse's stress?

Awareness Awareness is the first strategy of burnout prevention because it deliberately reflects on the stress in one's life. Focusing on the goals to be achieved with full energy and the ability to make choices and prioritize are helpful, but these are not the first strategies. The important step next to awareness is to prevent or deal with burnout for restoring balance in one's life.

The client is about to leave the hospital, with home health nursing. Where should the nurse document the physiologic status of the client?

Discharge and transfer forms The nurse should document the physiologic status of the client in discharge and transfer forms. The nurse documents the client's laboratory and radiology results in flow sheets. The nurse documents the functional status of the client in progress notes. Judgment related to the nursing diagnosis of the client should be documented in the client care plan.

The licensed practical nurse (LPN) instructs a nursing student to avoid using generalized phrases in documents. What is the concern behind this instruction?

Overlooking the actual content of the report. Use of generalized phrases in documents can lead to overlooking the actual content of the report, presuming it to be a generalized statement. An inappropriate recording may result in the occurrence of errors. Confidentiality can be maintained by keeping documents and passwords confidential. Misinterpretation of the records is possible when the records entered are illegible.

Which statement about palliative care needs correction?

Palliative care is aimed at improving comfort and prolonging life at all costs Palliative care is intended to improve comfort, not prolong life. It may be started earlier in the dying process; can serve as a bridge between curative care and hospice care; and provides psychological, social, and spiritual assistance.

Which statement is true regarding laissez-faire leadership?

"Laissez-faire leadership involves completely relinquishing control." Laissez-faire leadership involves the leader completely relinquishing control. He or she chooses to avoid responsibility by delegating all decision-making to the group. In an autocratic leadership, the leader retains all authority and responsibility. He or she is primarily concerned with goal accomplishment. This leadership is important in certain situations where immediate decisions are required, and there is not enough time for group decisions. In such leadership, one-way communication with the group is established. A democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members.

Which is a requirement for admission to a hospice care facility?

A client's informed consent is required for the admission into a hospice care facility. A physician's order (not a nurse's order), a diagnosis of a terminal (not initial) stage of disease, and a diagnosis of less than 6 (not 3) months to live are also required for admission to a hospice care facility.

Which type of leadership gives all authority and responsibility of tasks and goal accomplishment to a leader?

Autocratic leader In an autocratic leadership, decisions are made only by the leader.

A child belonging to a strict religious faith is brought into the emergency department following an accident. The child has suffered massive blood loss and needs an immediate blood transfusion. The parents refuse to let their child have the blood transfusion because it is against their religious practices, but the health-care provider goes ahead with the blood transfusion anyway. Which is the primary ethical principle that has guided the health-care provider's decision?

Beneficence The principle of beneficence means doing good or acting for someone's good. In the context of health care, this means all health-care providers have an ethical duty to protect life and promote the well-being of all clients. By giving the child blood transfusion he urgently needed, the health-care provider followed the ethical principle of beneficence even though it is against the health practices of the parents. Since the child is a minor and not legally able to make a decision for him or herself, the hospital is legally able to disregard the family's wishes in this case. The principle of fairness or justice means that all clients have the same right to nursing interventions. While this principle implies that the child in question has the right to a blood transfusion, it is not the primary ethical principle that guided the health-care provider's choice. Autonomy refers to freedom of personal choice and implies that the health-care providers do not have the right to make decisions for the client. Legally, this client is not autonomous, so this is not the ethical principle that guided the health-care provider's decision. The ethical principle of truthfulness involves declaring the truth to the client; this principle is relevant in this situation but not relevant to the health-care provider's decision.

Nurses know they have an ethical duty to protect life and promote the well-being of all clients. Which ethical principle best describes this concept?

Beneficence The principle of beneficence means doing good or acting for someone's good. This is associated with the concept of all nurses having an ethical duty to protect life and promote the well-being of all clients. The principle of justice is associated with the concept of what is fair. Autonomy refers to freedom of personal choice. Nonmaleficence means to do no harm.

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity?

Blowing the nose Patients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the patient to avoid blowing their nose as this activity can increase the risk of bleeding. The following activities are not contraindicated with thrombocytopenia: ambulation, visiting with children, and semi-Fowler's position.

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what?

Breach of confidentiality The release of information to an unauthorized person or gossiping about a client's activities constitutes a breach of confidentiality and an invasion of privacy. Libel occurs when a person writes false statements about another that may injure the individual's reputation. Negligence is a careless act of omission or commission that results in injury to another. Defamation of character is the publication of false statements that injure a person's reputation.

Which are the most likely physical findings to be seen in a client who is the victim of intimate partner violence? Select all that apply.

Burns Abrasions Human bites Physical findings such as burns, abrasions, and human bites are often seen in victims of domestic violence. Abrasions and hematomas are more often seen in abused older adults.

How should nurses provide effective nursing care to clients from different cultural backgrounds?

By providing care that fits the clients' cultural beliefs When providing care to clients from different cultural backgrounds, nurses should be careful to provide care that fits the client's cultural beliefs. It helps provide effective nursing care to the satisfaction of the client. Advising clients against their cultural practices may offend them and should be avoided. Organization policies should be made flexible to incorporate cultural aspects of care. Ignoring the cultural aspect of client care may result in ineffective nursing care.

A nursing student is learning about various health belief systems. Which characteristics describe the holistic health belief system? Select all that apply.

Circumcision may be viewed as a religious practice Healing powers may be ascribed to animate or inanimate objects. Treatments are designed to restore balance with the physical, social, and metaphysical worlds. Under the holistic health belief system, religion dictates social, moral, and dietary practices designed to assist an individual in maintaining a healthy balance. In this system, circumcision is sometimes viewed as a religious practice. In this system, healing powers may be ascribed to animate or inanimate objects. Also in this system, treatments are designed to restore balance with the physical, social, and metaphysical worlds. The alternative or complementary belief system sees the mind and body as a single unit. In the folk health belief system, treatments involve rituals or repentance or giving in to the wishes of a supernatural force.

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller than 5 mcg, such as measles, chickenpox (varicella), or pulmonary TB. Droplet precautions are used for droplets larger than 5 mcg and being within 3 feet of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immune system to protect them from incoming pathogens.

The nurse is caring for a client who requires an intravenous infusion. The nurse explains the reason for the procedure while assembling the kit for the infusion. What is the role of the nurse in this situation?

Educator The nurse assumes the role of educator when explaining to the client the need for an intravenous infusion. The nurse as a manager oversees the budget of a specific nursing unit or agency and is also responsible for coordinating the activities of the staff providing nursing care. As an advocate, the nurse protects the human and legal rights of the client. The nurse empowers the client with information required to make important health care decisions. The nurse is a caregiver when helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.

When caring for a client with pneumonia, which nursing intervention is the highest priority?

Employ breathing exercises and controlled coughing For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered his or her regular diet as tolerated.

What is the role of a vocational rehabilitation counselor who is caring for a client in a rehabilitation center?

Helps the client obtain training for new employment The vocational rehabilitation counselor helps the client obtain training for new employment. The therapeutic recreation therapist promotes the client's interest in activities. The clinical psychologist assists the client in developing realistic positive attitudes. The rehabilitation registered nurse educates the client and family concerning the rehabilitation process.

Which intervention is used to measure axillary temperature?

Inserting a probe into the center of the axilla While measuring the axillary temperature, the nurse should insert the probe into the center of the axilla. The nurse should assist the client to regown rather than just instructing the client. The client should be in sitting, supine, or side-lying position. The axillary area should be clean and dry.

After explaining the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of what conflict, according to Erickson?

Integrity versus despair According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generatively versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.

What are the benefits of palliative care? Select all that apply.

It allows clients to make more informed choices. It allows clients to achieve better alleviation of symptoms. It allows clients to have more opportunity to work on issues of life closure. Palliative care allows clients to make more informed choices, achieve better alleviation of symptoms, and have more opportunity to work on issues of life closure. It does not help cure serious illnesses. Physical care allows clients to fulfill their physical needs.

What is the main focus of a nurse caring for a client with liver carcinoma?

Keeping the client as comfortable as possible The main focus of a nurse while caring for a client with liver carcinoma is keeping the client as comfortable as possible. The nurse should promote adequate rest, administer antiemetics as ordered, and provide a diet high in carbohydrates and low in fats to clients who have imbalanced nutrition resulting from hepatitis.

Which healthcare team member would the nurse expect can be delegated with the task of administering oral medication to a client per the functional model?

Licensed practical nurse The licensed practical nurse can give oral medication to a client. The registered nurse gives IV medication to a client. Patient care associates assist and monitor vital signs. Unlicensed assistive personnel perform all hygienic tasks.

A nurse takes the rectal temperature of a client with an electronic thermometer. What should the nurse do to ease the insertion?

Lubricate one inch of the thermometer tip Lubricating one inch of the thermometer tip will ease the insertion of the instrument into the rectum. Assisting the client into Sims position will ensure the thermometer's placement. Holding the electronic probe until an audible signal occurs will ensure an accurate reading. Sliding a disposable plastic cover over the thermometer probe will help to prevent the spread of microorganisms.

Which insurance plan became effective in 1966 by an act of legislation that revolutionized home care?

Medicare The Medicare insurance plan became effective in 1966 by an act of legislation that revolutionized home care. Medicaid is a federal insurance plan that pays for home care services to indigent and low-income clients of all ages. Preferred provider organizations (PPOs) and health maintenance organizations (HMOs) are prepaid health plans operated independently or through employer groups.

Which organization established the Department of Practical Nursing Programs and developed the accreditation service called the Council of Practical Nursing Programs?

National League for Nursing The National League for Nursing established the Department of Practical Nursing Programs and developed the accreditation service called the Council of Practical Nursing Programs. Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers in rural Kentucky. The Association of Practical Nurse Schools was organized to address the needs of practical nursing education. The National Federation of Licensed Practical Nurses has set standards for practical and vocational nursing practice to promote and protect the interests of licensed practical nurses and licensed vocational nurses and to educate and inform the general public about practical and vocational nursing.

What is a function of a bereavement support group?

Providing families who have lost loved ones a chance to communicate and share their feelings A bereavement group provides families who have lost loved ones the chance to communicate and share their feelings. Filing insurance papers is administrative and therefore not a function of bereavement groups. Drug consultation is done by pharmacists, not bereavement groups. Social workers, not bereavement groups, help resolve any problems between a caregiver and client.

A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care?

Put the client in a high-Fowler's position. Putting the client in the high-Fowler's position will help to expand lungs and decrease severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period for at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition such as shortness of breath and take care of this immediate client need prior to continuing the hygiene activities.

Which therapy may be used as a palliative measure to decrease tumor mass and temporarily relieve obstruction in clients with stomach cancer?

Radiation therapy Radiation therapy may be used as a palliative measure to decrease tumor mass and temporarily relieve obstruction in clients with stomach cancer. A combination of chemotherapy and radiation therapy is sometimes used in clients who are at high risk for disease recurrence after surgery for stomach cancer. Oxygen therapy is used in the management of low oxygen levels. Photochemotherapy is used in the management of psoriasis.

Which healthcare professional does the nurse know is authorized to delegate work to other healthcare members?

Registered nurse (RN) Delegating work is the most effective professional management strategy that an RN can implement in clinical practice to improve the safety and quality of client care. RNs can delegate work to LPNs, UNP, or UAP.

In a rehabilitation care center, a team member assists the coordinator in the development and implementation of a care plan. Which team member is involved in this situation?

Rehabilitation licensed practical nurse A rehabilitation licensed practical nurse is responsible for assisting the client in creating and implementing a treatment plan. A rehabilitation physician is a team member and coordinator of the program. A rehabilitation registered nurse provides support and educates the client and family about the rehabilitation process. A vocational rehabilitation counselor helps the client obtain training for new or current employment.

A client with a fractured tibia and fibula is being discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, what teaching should the nurse include?

Remove loose rugs from the environment Loose rugs can interfere with crutch walking and cause a fall; they should be removed to prevent further injury. Calcium is encouraged to enhance bone healing. It is not within the legal role of the nurse to encourage the client to increase the dose of any medication without a health care provider's prescription. The client may shower if the cast is protected from becoming wet. Decisions regarding weight bearing are a medical, not a nursing, responsibility.

Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction?

Restraints can be used anytime without a written order from the healthcare provider. Restraints can be used only on the written order of a healthcare provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents.

Which is known as the chemical messenger in the protein synthesis process?

Ribonucleic acid (RNA) Ribonucleic acid is the chemical messenger. This is because the DNA encodes RNA as a message for protein synthesis and sends RNA to the ribosomes in the cytoplasm where protein synthesis occurs. Ribosomes are known as protein factories. Lysosomes are small sac-like structures that contain enzymes. Deoxyribonucleic acid is known as the chemical blueprint.

What are the primary goals of most health care organizations in the 21st century? Select all that apply.

Safety Equitability Efficiency As health care changes, safety, equitability, and efficiency have become the primary stated goals for health care organizations in the 21st century. While still important, teamwork and efficiency are not as much of a priority in the changing landscape.

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP makes which statement?

Saying that everything will be fine provides false hope. Agreeing with the client is an example of offering approval. Commenting on how a client should feel is an example of being judgmental. Implying that the problem is minor is an example of minimizing.

Which position is appropriate for measuring rectal temperature?

Sims The Sims position with upper leg flexed is appropriate for measuring rectal temperature. The sitting, supine, or side-lying positions can be used to measure oral, tympanic, or axillary temperatures.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The health care provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse?

Sit down quietly next to the bed and allow her to cry. Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion made without enough information.

Which services in home health nursing are directly reimbursable by Medicare? Select all that apply.

Skilled nursing Physical therapy Speech language therapy Skilled nursing, physical therapy, and speech language therapy are directly reimbursable by Medicare. Respite care and homemaker services are not directly reimbursable by Medicare.

A client in the terminal stage of cancer is being admitted to the hospice care unit. One member of the interdisciplinary team assists the client and family in filling out insurance papers. Which team member would be assisting?

Social worker A social worker would assist in filling out insurance papers and supporting the client and caregiver with grief issues. A primary nurse serves as a liaison among the client and caregiver, health care providers, and the interdisciplinary team. A spiritual coordinator serves as a liaison between the client and the spiritual community. A volunteer coordinator recruits and trains volunteers.

Which staff members are part of a core interdisciplinary hospice team? Select all that apply.

Social worker Medical director Nursing coordinator A core interdisciplinary hospice team includes the social worker, medical director, and nursing coordinator. A hospice pharmacist and a volunteer coordinator are members of a primary hospice team.

For which health care team role are the principles of the delegation process outlined according to the American Nurses Association (ANA)?

The ANA has outlined the principles of the delegation process for registered nurses. Licensed practical nurses, licensed vocational nurses, and unlicensed nursing personnel are the delegatees and do not manage the delegation process.

A new mother returns home 24 hours after delivery. Which reimbursement source would help the mother to pay the cost of home care services?

Third party A third party pays for posthospitalization recoveries, which include home health services of a mother who returned home within 24 hours of delivery. Private pay involves payment directly from an individual to receive home care services. Preferred provider organizations (PPOs) and health maintenance organizations (HMOs) provide prepaid health plans that are operated independently or through employer groups.

What is the goal of the American Hospital Association (AHA) with respect to clients' rights?

To promote clients' knowledge regarding their rights as consumers of health care One goal of the American Hospital Association (AHA) is to promote clients' understanding of their rights and responsibilities as consumers of health care. The AHA does not provide federal funding. The Health Insurance Portability and Accountability Act states that it is the duty of the health care provider, not the AHA, to protect the confidentiality of client health information. The Patient Self-Determination Act states that institutions providing health care, not the AHA, should maintain written policies and procedures regarding advance directives.

A nursing instructor explains to a nursing student that the nursing student is using ethnic stereotyping in her beliefs about a particular culture. Which of these beliefs are likely held by the nursing student? Select all that apply.

"All the people who belong to this ethnic group are violent and have criminal tendencies." "I feel that clients who are originally from a certain part of the world usually aren't compliant with the norms of the biomedical health system." An ethnic stereotype is a fixed concept of how all members of an ethnic group act or think. A nursing student may demonstrate ethnic stereotyping if she believes that all people belonging to a particular ethnic group are violent and have criminal tendencies or believes that clients who are originally from a particular part of the world are not compliant with the norms of biomedical health systems. A nurse should accept that it is not possible to act the same with all clients and still render effective, individualized holistic care. The belief that the practices of one's own culture are best is called ethnocentrism. The nurse should learn to value the beliefs of others and realize that practices of other cultures can be valuable in health care.

The nursing leader is teaching the newly hired nurse about the use of computerized provider order entry (CPOE). Which statement by the new nurse indicates effective learning? Select all that apply.

"CPOE will provide clinical warnings. "CPOE will provide legible medication orders." "CPOE will give automatic order notifications. CPOE will alert the provider for allergies, pertinent laboratory data, drug-drug and drug-food interactions and supports decision and clinical warnings. It will provide legible, accurate, and complete order sets. It will provide automatic order notification. It will decrease variations in practice. It will take less time for clarifying orders.

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How should the nurse respond to the technician?

"I can't receive them right now. Please wait a few minutes or come back." The transfer of controlled substances from one authorized person to another must occur according to protocol. In this situation the controlled substance must be returned to the pharmacy and delivered at a later time. The controlled substances cannot be left unattended. The nurse cannot delay the securing of controlled substances; if time is not available when the medications are delivered, they must be returned to the pharmacy. The UAP does not have the authority to receive controlled substances.

The registered nurse (RN) is caring for an older client who has been admitted to the hospital. The RN allocates several tasks to the unlicensed nursing personnel (UNP). In order to evaluate the understanding of the UNP, the RN asks the UNP to describe which tasks have been allocated. Which responses given by the UNP indicate effective understanding of the tasks? Select all that apply.

"I must assist the client with oral care. I must give a sponge bath to the client every morning." "I must monitor the blood pressure of the client at regular intervals." The registered nurse allocates the tasks to the UNP based on the capabilities and skills of the UNP. The UNP can perform tasks that involve basic hygiene and activities of daily life, such as oral care, toileting, bathing, and eating. The UNP can also perform tasks to monitor vital signs, such as blood pressure readings and temperature measurement. Assessment of the client's health status and intravenous drug administration are within the scope of practice of registered nurses, not UNP.

A nursing student is learning about cultural competence. Which statement by the nurse reflects ethnocentrism?

"I sincerely believe that the beliefs and practices of the culture I was born into are the best." Ethnocentrism is the belief by an individual that that the beliefs and practices of his or her particular culture are best. An individual who learns to value the beliefs of others and realizes that practices of other cultures can be valuable in health care is not ethnocentric. Cultural influences vary with the individual; the belief that all members of an ethnic group act or think the same way is called ethnic stereotyping. The awareness of one's own cultural beliefs and practices and their relation to differing cultural beliefs is known as cultural competence.

A nurse manager is selecting direct care nurses for a client-care project. The manager asks a direct care nurse about treatment priorities. Which answer provided by the direct care nurse would be

"I will give preference to the problems that have the greatest urgency." The preference for treatment should be always given to problems that have the greatest urgency such as life-threatening conditions. Secondary preference should be given to problems that are encountered first, problems that appear to be easiest to resolve, and problems that take the shortest amount of time to resolve.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

"It is performed routinely starting at your age as part of an assessment for colon cancer." The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

A home health nurse checks the client's vital signs and completes a follow- up visit. After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response?

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. It is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.

The nurse manager is teaching newly assigned delegators about the limitations of delegation. Which statements made by the delegators indicate effective teaching? Select all that apply.

"Personal hygiene activities can be delegated to unlicensed assistive personnel (UAP)." "Administration of oral medication can be delegated to the licensed practical nurse (LPN). Tasks related to caring for clients in a hospice care setting can be delegated to licensed vocational nurses (LVNs)." Activities related to client hygiene can be delegated to unlicensed assistive personnel (UAP). Administration of oral medication can be done by the licensed practical nurse (LPN). Licensed vocational nurses (LVNs) can care for the clients in a hospice care setting. Administration of intravenous medication cannot be done by LPNs as they are not eligible. Diabetic clients cannot be cared by UAP as this group does not have sufficient knowledge about how to care for clients with diabetes.

Which statement is true regarding autocratic style leadership?

"This leadership style involves establishing one-way communication with the group." In autocratic style leadership, the leader retains all authority and responsibility. The leader is primarily concerned with task and goal accomplishment; he or she establishes one-way communication with the group. In laissez-faire leadership, the leader completely relinquishes control and delegates all decision-making to the group. Democratic style leadership is a people-centered approach that allows employees to have more control. The leader encourages individual participation in the decision-making process.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?

"Wash your hands before performing the procedure." To avoid transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2 to 3 hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. _____ mL

0.2 The prescribed dose is 2 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer.

A client has been diagnosed as "brain dead". What does the nurse understand that this means?

A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of "brain dead."

A client with a terminal illness creates a legal document that requests that he not be given intravenous nutrition and hydration if he becomes permanently unconscious. What is this document known as?

A living will is a type of advance directive that a client can formulate that is a written document that directs treatment in accordance with a client's wishes in the event that the client becomes unable to make a conscious decision about his or her own care. A "tail" agreement is a type of individual professional liability insurance coverage purchased by a nurse that offers extended coverage; it is not a document made by a client. The doctrine of informed consent refers to full disclosure of the facts the client needs to make an informed decision before any invasive treatment or procedure is performed. A durable power of attorney for health care designates an agent, surrogate, or proxy to make health care decisions on the client's behalf based on the client's wishes.

Which rehabilitation team member designs a client's exercise program?

A physical therapist has the role of designing an exercise program with which to perform therapy. A clinical psychologist assesses the client's mental health. An occupational therapist assesses the client's independent living needs. A rehabilitation registered nurse is the primary coordinator and educator on the team.

A client who sustained a minor hand fracture 2 months ago arrives at the physician's office for a follow-up visit and is provided with a brace. Which health care professional would help to restore the client's musculoskeletal function?

A physical therapist helps restore the client's musculoskeletal function. A speech therapist helps the client deal with disorders that affect oral communication. An occupational therapist helps the client learn to perform the activities of daily living. A clinical nurse specialist consults the nursing staff on appropriate nursing interventions to provide appropriate client care.

A licensed practical nurse delegates tasks to the team members based on their knowledge and qualifications. Which task can the nurse delegate to the unlicensed assistive personnel?

A skill that is repetitive According to the five rights of the delegation, a task that can be delegated to the unlicensed assistive personnel (UAP) should be a skill that is repetitive and requires little supervision. Noninvasive processes that pose minimal risk to the client can be delegated to UAP. The UAP should be assigned to perform skills used during a crisis or skills that facilitate goal accomplishment.

Which hospice team member can assist in solving any conflicts between a caregiver and client?

A social worker is trained to assist in solving any conflicts between a caregiver and client. The other team members have other primary responsibilities. A hospice nurse is involved in coordinating the team. The medical director certifies the client's eligibility for hospice care. A nurse coordinator performs the initial assessment and helps implement the plan of care.

Which component of delegation is retained while the delegator is delegating the client's care task to the nursing aide?

Accountability Accountability is retained by the delegator while delegating a client's care task to the nursing aide. Every individual on the healthcare team has authority for the delegated task. The nursing aide is just responsible for the delegated task, so the delegator retains the accountability. Supervision is a right of delegation.

In nursing education, which health care organization-run process signifies that a program has met a higher set of standards?

Accreditation Accreditation is the process by which a health care organization decides whether a program has met a higher set of standards. Advancement is a process by which an individual nurse may choose to build his or her career. Articulation allows programs to build their curricula collaboratively, allowing one program to be the foundation for another. Approval is the process by which a program has established that it has met the state's minimum baseline standards.

In DARE charting format, which word represents the combination of planning and implementation?

Action In DARE (Data, Action, Response and evaluation, Education and patient teaching), "action" is a combination of planning and implementing. "Data" is both subjective and objective and is equivalent to the assessment step of the nursing process. "Response and evaluation" of the client is the same as evaluation of effectiveness. "Education and patient teaching" refers to providing educational material to the client or more advanced instruction.

After cataract surgery, a client reports feeling nauseated. How can the nurse help relieve the nausea?

Administer the prescribed antiemetic drug An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Providing some dry crackers for the client to eat, explaining that this is expected following surgery, and teaching how to breathe deeply until the nausea subsides. are unsafe; vomiting increases intraocular pressure, and aggressive intervention is required.

Which statement about family violence is true?

Alcohol and substance abuse can lead to family violence. Alcohol and substance abuse are among factors that contribute to family violence. The incidence of family violence increases, not decreases, with pregnancy. Sexual abuse occurs equally across all socioeconomic classes. Although abuse may end when one leaves a particular family environment, negative long-term physical and emotional consequences often persist.

Which of the following are features of a transdisciplinary rehabilitation team? Select all that apply.

Allows for the blurring of boundaries between different disciplines. Uses cross-training and flexibility to minimize the duplication of effort toward individual goal attainment. A transdisciplinary rehabilitation team is distinguished from multidisciplinary-model and interdisciplinary-model teams by their blurring of boundaries between different disciplines. This type of team also uses cross-training and has flexibility to minimize the duplication of effort toward individual goal attainment. While communication is important for team members to have success, their cross-training and overlapping of boundaries allow them not to have to rely on it solely. The interdisciplinary rehabilitation team, not the transdisciplinary team, collaborates to identify individual goals of different disciplines with a problem solving approach.

Which health belief system addresses the whole client by viewing symptoms as the tip of the iceberg and as the body's means of communicating to the mind?

Alternative or complementary belief system An alternative or complementary belief system addresses the whole client by viewing symptoms as the tip of the iceberg and as the body's means of communicating to the mind that something needs to be changed, removed, or added to one's life. Treatment in the folk health belief system involves carrying out rituals or repentance. Treatment in the holistic health belief system is designed to restore balance with the physical, social, and metaphysical worlds. Treatment in the biomedical health belief system is focused on the use of physical and chemical interventions.

A client of which culture is most likely to interpret eye contact as hostility or aggressiveness?

Appalachian Prolonged eye contact indicates hostility or aggressiveness among some Appalachian people. Direct eye contact between the sexes in Middle Eastern cultures is sometimes forbidden except between spouses. Some Native Americans consider eye contact impolite or an invasion of privacy. Direct eye contact in European American cultures is a sign of honesty and truthfulness.

The health care provider suggests a client be admitted to a long-term care facility. Which organization developed a document that provides clarity regarding the needs and rights of this client?

American Hospital Association The American Hospital Association developed the Resident's Bill of Rights, a document that was developed to provide clarity regarding the needs and rights of the individual who is residing in a long-term care environment. The American Nurses Association, National League for Nursing, and the Department of Practical Nursing Programs have developed other stances and documents related to nursing and client care.

Which organization's goal was to set educational standards for nurses?

American Society of Superintendents of Training The primary goal of the American Society of Superintendents of Training was to set educational standards for nurses. Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers in rural Kentucky. A health maintenance organization provides health care to members for a fixed prepaid rate. The Association of Practical Nurse Schools was organized to address the needs of practical nursing education.

Which statement regarding leadership is true?

An autocratic leader stresses prompt and orderly performance. An autocratic leader retains all authority and responsibility and stresses prompt and orderly performance of tasks. Successful organizations require both leadership and management. The autocratic leader is useful in times of natural disaster. The most commonly used styles of leadership are autocratic, democratic, and laissez-faire.

At 10 AM the nurse hangs a 1000-mL bag of D5W with 20 mEq of potassium chloride to be administered at 80 mL/hr. At noon the healthcare provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion to use the circulatory access for the secondary infusion of the antibiotic?

An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. One quarter, half, and three quarters of an hour are incorrect calculations.

A client says, "I won't touch my wife until she bathes herself in a mikvah after her period." To which religion does the client belong?

An observant Orthodox Jew will not touch his wife until she bathes in a pool called a mikvah after menses. A Muslim woman will exempt herself from prayers while menstruating. There are no such specifications regarding menstruation for women of Lutheran and Jehovah's Witness faiths.

What are the signs of elevated body temperature? Select all that apply.

Anorexia Glassy eyes Elevated respiratory rate Anorexia, glassy eyes, and elevated respiratory rate along with warm skin and elevated pulse rate are the signs of elevated body temperature.

Which therapies may be considered palliative in the end stage of HIV disease? Select all that apply.

Antibiotics Blood transfusions Intravenous therapy Antibiotic use, blood transfusions, and intravenous therapy help keep clients with HIV disease comfortable and help maintain quality of life; therefore they may be considered palliative in the end stage of HIV disease. Photochemotherapy is used for the management of psoriasis. Monoclonal antibody therapy may be used to treat metastatic breast cancer in women who overexpress a breast cancer cell antigen called HER2.

When suctioning a client with a tracheostomy, what is an important safety measure for the nurse?

Apply suction only as the catheter is being withdrawn Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the trach tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

Which statements are true about practical nursing education? Select all that apply.

Articulation allows nursing programs to plan their curricula collaboratively. Education programs today offer various creative approaches to the education of licensed practical nurses and licensed vocational nurses. Articulation allows nursing programs to plan their curricula collaboratively. It reduces the duplication of learning experiences and supports a process of progressive buildup. Education programs today offer various creative approaches to the education of licensed practical nurses and licensed vocational nurses that involve the combination of practical and vocational nursing programs. The length of a practical nursing school program is 12 to 18 months. A combination vocational and practical nursing education with a degree is available in two-year colleges. After completion of the first academic year, not just the first 6 months, the nursing student can take the licensure examination for either practical nursing or vocational nursing.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client's condition every hour A restraint impedes the movement of a client; therefore, a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally do not need to be documented as frequently as every two hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.

The nurse plans to provide a back massage to a client. What should the nurse do first in this situation?

Assess the client's preference for touch and massage. The nurse should first assess the client's preference for touch and massage when planning to give a back massage. The nurse can assist the client into an appropriate position, but only after assessing the client's preference for touch and massage. The nurse can start the massage, but only after knowing the client's perspective on touch. The nurse can provide information regarding the massage, but only after assessing the client's preferences.

What is the responsibility of a bereavement coordinator on a hospice care unit?

Assessing the client and the caregiver at the time of admission A bereavement coordinator assesses the client and the caregiver on admission. A hospice aide assists the client with light housekeeping. A primary spiritual leader supports the client and caregiver in coping with their fears. The primary nurse provides emotional support to the client and caregiver.

Which part of the nursing process is documented in discharge and transfer forms?

Assessment The assessment findings of the client are documented in the discharge and transfer forms, progress notes, and flow sheets of the client. The treatment plan required for the client is documented in the client care plan, protocols, progress notes, and client's problem lists. The diagnostic details of the client are documented in the client care plan, protocols, progress notes, client problem lists, and admission sheets. The implementation of the care plan of the client is documented in the progress notes of the client, critical pathways, and protocols.

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake?

Assessment The documentation of the client's information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the doctor understand the client's history a make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client's problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client's problems and then the plan is implemented.

Which condition is associated with unevenly curved surfaces of the client's cornea?

Astigmatism Astigmatism is a refractive error caused by unevenly curved surfaces on or in the eye, especially of the cornea. These uneven surfaces distort vision. Myopia (nearsightedness) occurs when the eye overbends the light, and images converge in front of the retina. Hyperopia (farsightedness) occurs when the eye does not refract light enough; as a result, images actually converge behind the retina. Emmetropia is the perfect refraction of the eye, in which light rays from a distant source are focused into a sharp image on the retina.

A primary healthcare provider notes that all conventional treatment procedures have proved to be ineffective in managing a client's disorder. The primary healthcare provider decides to try an experimental treatment. The nurse ensures that the client has understood the implications of the new treatment plan thoroughly and then signs the client's consent form as a witness. Which basic healthcare ethic does the nurse follow in this situation?

Autonomy Autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent. This ensures that the client is involved in the decision-making process appropriately. Justice refers to fairness. The given situation does not deal with fairness. Beneficence refers to taking positive actions to help others. This involves keeping the interests of the client before self-interest. Nonmaleficence is the avoidance of harm or hurt. Weighing the pros and cons of the new treatment plan would involve nonmaleficence.

Which act enacted by the United States Congress imposed new limits on home health care payments?

Balanced Budget Act (BBA) Congress imposed new limits on home health care payments through a provision of the Balanced Budget Act of 1997 (BBA) in an effort to control home health expenditures. The Social Security Act includes two enactments (Medicare and Medicaid) that directly impact how home health care provides health care to members for a fixed prepaid rate. The Prospective Payment System Act (PPS) was enacted by Congress as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement. The Health Care Financing Administration (HCFA) implemented a new payment system for home health agencies to increase payment to clients.

A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent?

Battery Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary healthcare provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.

The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The nurse draws up the prescribed dose and then requests that another nurse witness wasting of the remaining medication. The second nurse states that there is no time to observe the wasting of the medication, enters the identification to serve as the witness, and leaves the area. What is the appropriate action for the first nurse to take?

Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication. According to hospital policy the wasting of the excess opioid solution must be monitored by two nurses. This provides for client safety and protects the nurse legally. It is unsafe for the first nurse to proceed without a second nurse performing observation and documentation. Asking another nurse to observe the wasting of the excess solution but not to serve as the documented witness is a violation of the policy. Documenting something that was not performed is unethical. Insisting that the second nurse interrupt another pressing responsibility may result in jeopardizing another client.

A medical-surgical unit is expecting a large volume of client admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit?

Charge nurse A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual client; therefore, it is this member of the team that will prioritize care for the clients who are being admitted. The nurse supervisor may be in charge of assigning the trauma clients to individual units. The licensed practical nurse will receive a client assignment on the unit but will not prioritize care for the unit. The unlicensed assistive personnel will be delegated tasks by other members of the nursing team.

What intervention should the nurse implement when caring for a client 24 hours postthyroidectomy?

Check the back and sides of the operative site Bleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period, except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually and frequent rest periods encouraged.

Which religious community seeks exemption from vaccinations?

Christian Science The Christian Science community is against vaccinations unless they are legally compulsory. The Islam, Eastern Orthodox, and Pentecostal communities allow vaccinations.

The nurse is caring for clients who were brought to the hospital following a large-scale disaster. Which client would be suitable for the nurse to triage with a green tag?

Client who is injured but is able to ambulate The nurse will triage the clients according to priority for providing care. The client who is injured and is able to walk may not require immediate treatment and would be issued a green tag. The client who is severely injured and who has no chances of survival is tagged black. The client who is stable and requires retriage after observation is tagged with a yellow tag, indicating that the client is not in immediate danger. A red tag issued to the client indicates that the client requires immediate care.

A nurse is caring for four different clients. Which client is the most likely recipient of Medicare?

Client with permanent kidney failure Medicare is a health insurance program administered by the U.S. government as part of the Social Security Act. Based on the disorders alone, a client with permanent kidney failure is the most likely to receive Medicare. Dementia, depression, and type 2 diabetes mellitus are considered lower-priority disorders in terms of Medicare eligibility.

Which client should be treated first, according to the disaster triage tagging system?

Client with red tag The red tag is applied to clients who require immediate treatment according to the disaster triage tag system, so client A requires immediate treatment. A black tag is applied to clients who are dead or expected to die and are not prioritized for immediate critical care. The green tags are applied to clients who can ambulate on their own, and there is no need of attending these clients first. The yellow tag is applied to clients who can wait a short duration for treatment and who can be treated after treating clients with red tags.

What is the most important skill of the nurse leader?

Clinical care coordination The most important leadership skill for a nursing student is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.

What is the role of unlicensed assistive personnel in intravenous (IV) therapy for a client?

Collecting the data to be used in the assessment of the IV site. The role of unlicensed assistive professional in IV therapy is to collect the data that can be used in the assessment of the IV site. Monitoring clinical manifestation is performed by the licensed practical nurse (LPN). Administering IV fluids and medications is done by a registered nurse or LPN. Evaluating the client for clinical manifestations is performed by the registered nurse.

The count of hydrocodone is incorrect. After several minutes of searching the medication cart and medication records, no explanation is found. Who should the primary nurse notify about the discrepancy?

Controlled substance issues for a particular nursing unit are the responsibility of that unit's nurse manager. Responsibility flows directly from the staff of a nursing unit to the nurse manager; the nurse manager reports to a nurse administrator. There is no direct flow of accountability from the primary nurse to the quality control manager. Healthcare providers are responsible for medical management issues, not issues associated with management of a nursing unit.

A nurse helps a client to clarify health problems and choose appropriate courses of action. What competency in community-based practice is the nurse exercising?

Counselor When a nurse is helping a client to identify and clarify health problems and choose appropriate courses of action to solve those problems, the nurse is acting as a counselor. The nurse acts as an educator by establishing relationships with community service organizations. The nurse acts as an epidemiologist when he or she is involved in case finding, health teaching, and tracking incident rates of an illness. The nurse acts as a caregiver when he or she provides appropriate, individualized nursing care for specific clients and their families.

What should the nurse do initially when obtaining consent for surgery?

Determine whether the client's knowledge level is sufficient to give consent. Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. Describing the risks involved in the surgery is not within nursing's domain. Although obtaining a signature is routine, explaining that obtaining the signature is routine for any surgery does not determine the client's ability to give informed consent. Although witnessing the client's signature will be done, the nurse first should assess the client's knowledge of the surgery.

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider?

Cultural background In the initial stage of grief the degree of anguish experienced is influenced by cultural background. Although personality traits factor into the grief process, they are not as important as culture. Educational level is not related directly to a grief response. While past experience is important, it is not as significant as culture.

The nurse leader is teaching the staff that the health care provider continuously strives to work effectively within the cultural context of a client. Which cultural principle is the nurse leader explaining?

Cultural competence Cultural competence is the process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of a client, individual, family, or community. Cultural diversity describes a vast range of cultural differences among individuals or groups. Cultural sensitivity describes the affective behaviors in individuals such as the capacity to feel, convey, and react to ideas, habits, and customs or traditions unique to a group of people. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for various reasons.

Which action of the nurse leader while preparing to share any information with followers is accurate?

Determining which information is to be shared The nurse leader should determine the information that has to be shared with followers, but should not give all information at once. The nurse leader should give only limited information; giving too much at once can create disinterest in the listeners. The nurse leader can share information through mail as it is a primary communication method. The nurse leader should use face-to-face communication over text messages.

Identify the risk factor for other-directed violence.

Difficulty managing anger Difficulty managing anger is a risk factor for other-directed violence. Headaches can be a result of posttraumatic stress disorder, but they are not risk factors for violence. Decreased concentration and difficulty sleeping may indicate problems with coping, but they are not necessarily risk factors for violence. Topics

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next?

Documenting the event on an incident report (Canada: adverse event) form provides a legal record and is critical in providing appropriate care and follow-up. Calling the family is the responsibility of the healthcare provider and nurse providing ongoing care. Reporting the incident to the nurse manager should be done, but it is not as critical as documenting the incident. Escorting the client to radiology is not the responsibility of the witnessing nurse. Once care is transferred to the emergency department nurse, it is the emergency department nurse's responsibility to arrange for or to escort the client to radiology.

What is the mental process most sensitive to deterioration with aging?

During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.

To decrease abdominal distention following a client's surgery, what actions should the nurse take? Select all that apply.

Encourage ambulation Auscultate bowel sounds Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.

Which nursing interventions are examples of the nurse as a caregiver? Select all that apply.

Encouraging the client to exercise daily Setting goals for the client to reduce weight Arranging for the client to meet a spiritual advisor The nurse acts as a caregiver by encouraging the client to exercise daily. The nurse's role as a caregiver involves helping the client to maintain and regain health. As a caregiver, the nurse also sets goals and helps the client and family to achieve them. The duties of a caregiver involve restoring a client's emotional, spiritual, and social well-being. Therefore the nurse arranges for the client to meet a spiritual advisor to meet the client's spiritual needs. The nurse as an educator evaluates the client's understanding of prescribed diet. As an educator, the nurse demonstrates the procedure for administering insulin injection. The nurse also reinforces and evaluates learning.

A nurse refuses to administer an analgesic to a young African American man with sickle cell anemia, because she believes young African American men abuse drugs. What is reflected in the nurse's action?

Ethnocentrism is the belief that one's own way of life is superior to that of others; this results in biases and prejudices that lead to negative associations with other groups, like that illustrated by the nurse who assumes the client would abuse analgesics. Enculturation is socialization into one's primary culture as a child. Cultural imposition is using one's own values and lifestyles as an absolute guide in dealing with clients and interpreting behavior. Cultural competence is having specific knowledge, skills, and attitudes that ensure the delivery of culturally congruent care.

A nurse in the health clinic is counseling a college student who was recently diagnosed with asthma. On what aspect of care should the nurse focus?

Evaluating whether the necessary lifestyle changes are understood. Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

What is evaluation in SOAPIER?

Evaluation is an appraisal of the response and effectiveness of the plan in SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision). Intervention or implementation is the specific care given or action taken in SOAPIER. Revision includes the changes that may be made to the original plan of care in SOAPIER. Planning includes the general statement of the plan of care to be given or action taken.

A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with?

Evidence-based practice The QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare.

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that which legal term best describes this situation?

False imprisonment The hospital is threatening to keep the infant; therefore false imprisonment is threatened. False imprisonment is restraining or confining a person without a clinical reason. False threat may be a term to describe false imprisonment; however it is inaccurate in this situation. Assault and battery legally means to threaten violence and the physical act of violence. Breach of confidentiality is a disclosure to a third party, without client consent or court order of private information.

Who should the nurse contact to receive training as a Community Emergency Response Team (CERT) member?

Federal Emergency Management Agency (FEMA) The Federal Emergency Management Agency (FEMA) provides Community Emergency Response Team (CERT) training. The National Disaster Life Support Foundation offers Core, Basic, and Advanced Disaster Life Support training courses. The Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) do not provide disaster preparedness training.

Which method of payment to Medicare-certified hospices is more economical for insurers and taxpayers?

Fee per diem Medicare-certified hospices receive fee per diem payments, which is more economical for insurers and taxpayers. Fees per visit are not economical for insurers and taxpayers. Prepaid and third-party payments are not appropriate payment methods to Medicare-certified hospices

A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first?

Female client on warfarin with an International Normalized Ratio (INR) of 7.5 The client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse, because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the primary healthcare provider and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a male is 14-18 g/dL; serum calcium is 9.0-10.5 mg/dL; BUN is 5-20 mg/dL and creatinine is 0.7-1.5 mg/dL.

Which type of documentation uses a modified list of nursing diagnoses as an index for nursing documentation instead of a problems list?

Focus charting format The focus charting format is a modified list of nursing diagnoses used as an index for nursing documentation instead of a problems list. An incident report is a form used to document any event that is not consistent with the routine care of the client. Charting by exception (CBE) is the method of documentation in which the nurse uses more detailed flow sheets that enhance the focus on existing concerns. The problem-oriented medical record is organized according to a scientific problem-solving system that includes a database, problems list, care plan, and progress notes. This helps to identify and prioritize the health problems on the master medical.

A client who was in a minor car accident is admitted to the hospital. The client refuses to receive the treatment because he believes medical treatment is against his god's wishes. To which type of health belief system does this client adhere?

Folk In a folk health belief system, treating illness involves performing rituals or repentance or giving into a supernatural force's wishes. In a holistic health belief system, treating illness involves restoring balance in the physical, social, and metaphysical worlds. In a biomedical health belief system, treatment focuses on the use of physical and chemical interventions. In an alternative or complementary health belief system, treatment may include one or more nonmedical forms such as acupuncture, aromatic therapy, meditation, and therapeutic touch.

A client is suffering from depression. The client's family member says that "it's better to leave the client to a supernatural force's wishes for treatment." To which type of belief system does the client's family member likely belong?

Folk health In a folk health belief system, treatment includes rituals or repentance or deferring to a supernatural force's wishes. A holistic health belief system designs treatment with the goal of restoring balance in the physical, social, and metaphysical worlds. An alternative or complementary belief system uses nonmedical alternative treatments. A biomedical health belief system believes in physical and chemical interventions for treatment.

Which palliative surgical procedure involves the insertion into the stomach of a catheter that is then sutured to the abdominal wall?

Gastrostomy Gastrostomy is a palliative surgical procedure that involves the insertion into the stomach of a catheter that is then sutured to the abdominal wall. Orchiectomy is the removal of the testes. Blalock-Taussig shunt is a palliative procedure that involves the creation of an artificial connection between the pulmonary artery and the aorta. Pulmonary artery banding impedes the flow of blood from the right ventricle to the pulmonary circulation.

Which organization provides health care to members for a fixed prepaid rate?

Health maintenance organizations (HMOs) provide health care to members for a fixed prepaid rate. These services include medical care, nursing care, diagnostic tests, hospitalization, and various inpatient and outpatient treatments. The American Hospital Association (AHA) is responsible for ensuring the client's fundamental rights to treatment with dignity and compassion. The National Federation of Licensed Practical Nurses (NFLPN) is responsible for addressing the needs of practical nursing education. The National Federation of Licensed Practical Nurses (NFLPN) changed its name to the National Association for Practical Nurse Education and Service (NAPNES) in 1959; this organization addresses the needs of practical nursing education.

The nurse is caring for a dying client. Which interventions should the nurse implement for the client and family? Select all that apply.

Help the family set up home care if required Know the client and family's strengths and weaknesses. Arrange for church or community support for the family. Because some dying clients prefer to be at home with the family during their last days, the nurse should help the family set up home care if required. The nurse should also know the client and family well to be able to provide client-centered care. The nurse should also arrange for church or community support to help the client and family during this difficult time. A dying client may be in pain and require hospice care, not restorative care. The nurse must maintain the trust in the nurse-client relationship and prepare the family for the client's death. The nurse should inform the family about the dying process.

Which statement correctly defines palliative care, according to the World Health Organization?

Helping patients and families deal with possibly fatal illnesses and quality-of-life issues According to the World Health Organization, palliative care is defined as helping patients and families deal with possibly fatal illnesses and quality-of-life issues. Postmortem care is the provision of care for a client's body after death. Physical care is the provision of adequate nutrition and maintenance of elimination patterns. Palliative care is the active, complete care of a client whose disease has not responded to curative therapy; it may be started earlier in the dying process, not only in the last 6 months of life

Which client conditions require the nurse to tag with red according to the disaster triage tag system? Select all that apply.

Hemorrhage Airway obstruction Clients with conditions such as airway obstruction need immediate emergency care. According to the disaster triage tag system, these clients are issued a red tag. A hemorrhage needs immediate care, as this is potentially life threatening, and these clients are also issued a red tag. Sprains and abrasions are minor injuries and do not require immediate care. Clients with such conditions are issued a green tag. Compound fractures are major injuries that require treatment and these clients will be issued a yellow tag.

Which statement is true about the nursing model "team nursing"?

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client's immediate nutritional needs?

High in protein and vitamin C Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

Which action of the nurse ensures safety during rectal temperature measurement?

Holding onto the thermometer throughout the procedure. Holding onto the thermometer throughout the procedure will ensure the client's safety. Assisting the client to get into a position of comfort will restore the client's sense of well-being. Holding the electronic probe until an audible signal occurs will ensure accurate measurement. Moving bed linens aside to expose only the rectal area will prevent the client from being unnecessarily exposed.

Which member of a primary hospice team is responsible for rendering personal care and assisting with the bathing of clients?

Hospice aide A hospice aide is responsible for providing personal care to the client and assisting with bathing. A primary nurse serves as a liaison among the client, health care provider, and interdisciplinary team; evaluates the client's response to treatment; and educates the client and family on disease process and care. A volunteer coordinator assesses the needs of the client and caregiver for volunteer services. A bereavement coordinator assesses and supports the bereaved survivor and facilitates support groups.

Which is the facility-level organizational model for disaster management?

Hospital Incident Command System (HICS) The facility-level organizational model for disaster management is the Hospital Incident Command System (HICS). The Medical Reserve Corps (MRC) is made up of a group of volunteer medical and public healthcare professionals who offer services to healthcare facilities or to the community during a disaster or pandemic disease outbreak. The Disaster Medical Assistance Team (DMAT) is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. The National Incident Management System (NIMS) was implemented by the Department of Homeland Security and FEMA to standardize disaster operations.

An institution-based health agency that receives fees from all sources is providing limited community health services. Who most likely governs this agency?

Hospital board of directors A hospital-based home health agency is an institution that provides limited community health services and receives fees from all sources. This agency is governed by a hospital board of directors. A board appointed by the owner governs a proprietary, or private, not-for-profit home health agency. A community board of directors governs a voluntary health agency. A volunteer board of representatives governs an official home health agency.

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which standard of the nursing practice as defined by the American Nurses Association does the nurse follow?

Implementation The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

Which statement is true regarding a folk health belief system?

It classifies illnesses or diseases as either natural or unnatural. A folk health belief system may commonly be referred to as having "third-world" beliefs and practices, and such systems classify illnesses or diseases as natural or unnatural. An alternative or complementary belief system addresses the whole client by viewing symptoms as the tip of the iceberg. In a biomedical health belief system, life is regulated by biomedical and physical processes, and humans can manipulate life processes with mechanical interventions. A holistic health belief system may include blessings from spiritual leaders, apparitions of dead relatives, and even miracle cures.

Which statement is true regarding rehabilitation services?

It focuses on restoring maximal possible function after illness or injury. Rehabilitation focuses on restoring maximal possible function after illness or injury. The long-term care facility is provided in a variety of settings, such as personal homes. The long-term care facility is required by the people of all ages who are permanently unable to function independently. The long-term care facility refers to a range of services that address the health, personal care, and social needs of all people.

Which statement about palliative care is correct, according to the World Health Organization (WHO)?

It helps clients and families deal with potentially fatal illnesses and quality-of-life issues. According to WHO, palliative care helps clients and families deal with possibly fatal illnesses and quality-of-life issues. WHO says that the goal of palliative care is improving and maintaining the client's quality of life as much as possible and that the focus of palliative care is preventing and relieving the suffering of clients by quickly identifying and treating pain. Palliative care is the relief of suffering through management of pain and symptoms in clients in any stage of a serious illness.

Which statement is true about home health care service?

It includes shoppers, respite care workers, and nursing care staff. Home health care service includes shoppers, respite care workers, and nursing care staff. A senior center is a community-funded facility that provides recreational activities, lunch, health screening, and exercise classes. Day care is the setting that provides structured age-appropriate activities for children during the day. Respite care involves providing caregivers with a break from the responsibility of providing care.

What is objective information in SOAPIER documentation?

It includes what the nurse can factually describe SOAPIER (Subjective, Objective, Assessment, Planning, Intervention, Evaluation, Revision) is an acronym for seven different aspects of charting in which "O" indicates objective information that includes what the nurse can measure or factually describe about the client. Subjective information is provided only by the client and includes the information about what the client states or feels. Evaluation is the response and effectiveness of the care plan implemented on the client. Planning includes a general statement of the plan of care that is to be given to the client.

Which statement is true regarding a biomedical health belief system?

It states that life processes can be manipulated by humans with mechanical interventions. As per the biomedical health belief system, life is regulated by biomedical and physical processes. Therefore life processes can be manipulated by humans with mechanical interventions, like medicine and surgery. Folk health belief systems are commonly considered as having "third-world" beliefs and practices. Alternative or complementary belief systems may include acupuncture, aromatic therapy, meditation, therapeutic touch, and a variety of other nonmedical techniques. A holistic health belief system may include such things as blessings from spiritual leaders, apparitions of dead relatives, and miracle cures.

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this?

It would be helpful to understand; let's talk. "It would be helpful to understand; let's talk" attempts to open the communication process. Reflecting the words, not the feelings, serves to entrench the communicant's position and does little to open the flow of communication. Saying "I was a teenager once too" shifts the focus away from the client. Telling the client to try to understand others is authoritative and closes the flow of communication.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied?

Malpractice Malpractice is the unskilled or faulty treatment by a professional that causes injury or harm to a client. It can result from a lack of professional knowledge or skill that can be expected in others in the profession, or from a failure to exercise reasonable care or judgment in the applying of professional knowledge, experience, or skill. Malice is the desire or intent to inflict injury, harm, or suffering. A tort is a wrongful act, not including a breach of contract or trust, that results in injury to another person and for which the injured person is entitled to compensation. Case law is law established by judicial decisions in particular cases instead of by legislation action.

What responsibilities belong to the nurse coordinator on an interdisciplinary hospice team? Select all that apply.

Manages the care of clients Assigns the primary hospice team Admits clients into the hospice program On an interdisciplinary hospice team, the nurse coordinator manages the care of clients, assigns the primary hospice team, and admits clients into the hospice program. The medical coordinator provides consultation relative to the medical aspects of care and mediates between the hospice team and attending medical provider.

Which health insurance program is a state-operated of medical assistance to people with low incomes?

Medicaid is a health insurance program which is a state-operated for medical assistance to people with low incomes. Medicare is a federally funded national health insurance program for people older than age 65. Health Care Financing Administration makes available the information it obtains about quality of long-term care facilities to beneficiaries, provides, researches, and state surveyors. Occupational Safety and Health Administration guidelines ensure a safe environment for the personnel.

Which treatments are associated with an alternative or complementary belief system? Select all that apply.

Meditation Acupuncture Aromatic therapy An alternative or complementary belief system believes in nonmedical treatment like meditation, acupuncture, and aromatic therapy. The biomedical health belief system uses physical and chemical interventions like surgery and drug therapy.

A nurse cares for an older adult client whose culture of origin prohibits touch between unmarried individuals. To which culture does this client most likely belong?

Middle Eastern Touch outside marriage is sometimes forbidden in older adults from the Middle East. Although individuals belonging to the German culture are unlikely to touch each other in public or accept casual touching by strangers, touching outside marriage is not prohibited. South American culture allows for touching between unmarried individuals. People of Native American descent may find casual touching by strangers, such as a firm handshake, a sign of aggression.

Which statement regarding death rites in Observant Judaism is true?

Mirrors should be covered in the room where a death has occurred In Observant Judaism, the family of the deceased often requests that mirrors be covered to symbolize that a death has occurred. Although Orthodox Jews and some Conservative Jews do not approve of autopsies, an autopsy may be performed if absolutely necessary, as long as all body parts remain with the body. After death, the body should not be left alone until burial, which is usually performed within 24 hours of the death. When death occurs, the body should remain untouched for 8 to 30 minutes. In addition, medical personnel are not to touch or wash the body; this may be done only by an Orthodox person or a member of the Jewish Burial Society.

Individuals belonging to which religion do not drink caffeinated beverages such as cola, coffee, and tea?

Mormons abstain from beverages with caffeine such as colas, coffees, and teas. They also abstain from tobacco, alcohol, and other substances that are considered injurious. Baptists are expected to abstain from alcohol but have no restrictions on caffeinated beverages. Individuals belonging to the Assemblies of God Church abstain from alcohol, tobacco, and all illegal drugs, but not caffeinated beverages. The use of alcohol and tobacco is forbidden among individuals belonging to the Church of the Nazarene.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what?

Moves the walker no more than 12 inches ahead during use. Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

A caregiver fails to give medications on time to an older adult. Which type of abuse is this?

Neglect Neglect occurs when a caregiver intentionally or unintentionally causes harm by failing to provide appropriate care. Physical abuse is causing someone harm with physical force. Sexual abuse is nonconsensual sexual contact of any kind, including with someone who is incapable of giving consent. Psychological or emotional abuse involves the infliction of agony, emotional pain, or distress through verbal or nonverbal acts.

Which home care services provided to older adults may charge an extra fee? Select all that apply.

Nutritional programs Transportation services Nutritional programs and transportation services may charge a fee to elderly individuals receiving home care services. Day care, senior centers, and home care services may not involve an extra fee.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern?

Offer a cup of prune juice. Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol, which increases water retention in feces. Administration of mineral enema requires an order from a health care provider. Encouraging the client's fluid intake by offering one cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as a prune juice. Removing impactions does not establish regular bowel patterns.

Which perspective defines home health care as a component of comprehensive health care in which individuals and their families receive services in their places of residence?

Official Officially, home health care is defined as a component of comprehensive health care in which individuals and their families receive services in their places of residence. Viewed from the client's perspective, home health care is skilled and compassionate care provided on a one-to-one basis in the comforting and familiar surroundings of the home. Viewed from a family's perspective, home health care is a means of keeping the family together as a functioning, integrated unit. Viewed from the provider's perspective, home health care challenges all disciplines involved to provide excellent care in often less-than-excellent conditions and surroundings.

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest?

Older adults Chronic illness increases in older adults because of the multiple stresses of aging. Younger individuals have greater physiological reserves, and chronic illnesses are not common.

Which act instituted significant Medicare and Medicaid requirements for documentation?

Omnibus Budget Reconciliation Act The Omnibus Budget Reconciliation Act (OBRA) instituted significant Medicare and Medicaid requirements for documentation. The joint commission outlined the legal guidelines to be followed while documenting. Department of Health and Human Services is responsible for making access to medical records easier for the clients. The Health Insurance Portability and Accountability Act (HIPAA) is an act that affords certain protections to persons covered by health care plans.

An interdisciplinary team of health care professionals is caring for a client with hemiplegia. Which statement about the care provided to the client is correct?

On an interdisciplinary team of health care providers, the speech therapist has the role of promoting the speech and communication skills of the client, who may have had a speech impairment caused by hemiplegia. The dietitian is responsible for determining the client's nutritional requirements. The clinical nurse specialist provides medication instructions to the client. The social worker conducts counseling sessions.

Which treatment measure may be used as a palliative therapy for a client with metastatic prostate cancer?

Orchiectomy Orchiectomy may be used as a palliative therapy for a client with metastatic prostate cancer. Gastrostomy is a surgical procedure that may be performed as a palliative treatment measure in a client with esophageal cancer. Blalock-Taussig shunt is a palliative procedure that is used to manage tetralogy of Fallot in infants. Pulmonary artery banding is a palliative procedure performed in infants with symptomatic ventricular septal defect.

Which type of surgery is performed for relief or reduction of intensity of disease symptoms?

Palliative Palliative surgery is performed for relief or reduction of intensity of disease symptoms. Ablative surgery is the excision or removal of a diseased body part. Constructive surgery is performed to restore body functions that are lost or reduced as a result of congenital anomalies. Reconstructive surgery is performed to restore function or appearance to traumatized or malfunctioning tissue.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures to:

Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

Two nurses are planning to help a client with one-sided weakness to move up in bed. What should the nurses do to conform to proper body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.

Several emergency preparedness agencies are developing emergency response plans in case of an earthquake alert. In which phase of the disaster management continuum would the nurse state this activity is included?

Preparedness The first phase of the disaster management continuum is preparedness. This is a protective plan designed before the event to structure the response, assess the risk, and evaluate the response. The response phase of the disaster continuum includes the actual implementation of the disaster plan. The recovery phase is related to actions focusing on stabilization of the community and returning it to the previous state. The mitigation phase includes attempts to limit a disaster's impact on human health and community function.

What is the purpose of critical incident stress debriefing (CISD) after a disaster?

Prevent post-traumatic stress disorder (PTSD Critical incident stress debriefing (CISD) addresses precrisis through postcrisis interventions. After working through the turmoil and the emotional impact of the incident as well as the aftermath, the staff may find it difficult to "get back to normal." Without intervention during and after the emergency, they may develop post-traumatic stress disorder (PTSD). CISD is not conducted to evaluate outcomes of care, ensure documentation is completed, or analyze role performance during the disaster.

A client with a terminal disease is admitted to hospice care. The nurse coordinator assigns a primary team. Which member of the hospice team evaluates the client's response to treatment and provides emotional support to the client and his caregiver?

Primary nurse The primary nurse, a licensed nurse, would evaluate the client's response to treatment and provide emotional support to the client and his caregiver. The hospice aide, certified as a home health aide, is tasked with administering personal care and providing assistance with bathing. The hospice pharmacist, a licensed registered pharmacist, would provide drug consultation. The bereavement coordinator, a professional with grief experience, provides emotional support but does so for the bereaved survivor while facilitating support groups.

A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect?

Primary prevention Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what?

Promote cell growth and bone union There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. High protein intake during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain.

Which actions could be performed by a rehabilitation registered nurse (RN)?

Promotes independence A rehabilitation registered nurse (RN) promotes independence of the client. The other responsibilities belong to other rehabilitation team members. A physical therapist provides physiotherapy to promote client mobility. An occupational therapist suggests equipment modifications. A rehabilitation licensed practical nurse (LPN) assists in treatment, planning, and implementation.

A freestanding home health agency receives support from some sources that participate in Medicare-Medicaid and some that do not. Which type of agency is this?

Proprietary A proprietary home health agency is freestanding and receives support from sources that may or may not participate in Medicare-Medicaid. An official home health agency receives support from local government, grants, fees from limited sources, and charitable contributions. A voluntary home health-care agency receives support from tax-deductible contributions, grants, and fees. A combination home health care agency receives support from local government revenues, grants, fees from limited sources, and charitable contributions.

Which type of home health care agency is most likely to be owned by corporate chains and be profit oriented?

Proprietary agency Proprietary agencies are a part of home health care agency; they are associated with corporate chains and are profit driven. Official agencies are part of home care agency; they are authorized by law to deliver services to a defined area or community. Voluntary agencies deliver nursing care in the home. The hospital-based agency is a type of home care agency that gets most of its referrals from the hospital itself.

Which system did Congress enact as a part of the Tax Equity and Fiscal Responsibility Act?

Prospective Payment System (PPS The Prospective Payment System (PPS) was enacted by the Congress as a part of the Tax Equity and Fiscal Responsibility Act. This system pays a set rate based on major diagnostic categories and diagnosis-related groups (DRGs). New limits on home health payments were imposed through a provision of the Balanced Budget Act, called the Interim Payment System (IPS). The Social Security Administration directly impacted home health care. Health maintenance organizations (HMO) offer prepaid health plans; they operate independently or through employer groups.

Which system has majorly influenced home health care costs?

Prospective payment system The prospective payment system has had a major influence on health care cost. The prospective payment system groups payments into diagnosis-related groups for Medicare and Medicaid clients. The United States Congress imposed new limits on home health payments through a provision of the Balanced Budget Act called the interim payment system (IPS). The Omnibus Budget Reconciliation Act involved the formulation of new standards for training and competency evaluation that are now in effect under Medicare training aides. The Health Care Financing Administration (HCFA) implemented a payment system for home health agencies to increase payment to clients.

What is the role of a hospice volunteer on a primary hospice team?

Providing companionship to clients and caregivers A hospice volunteer provides companionship to clients and caregivers. A hospice aide helps with personal care and assists the client with bathing. A bereavement coordinator assesses bereaved survivors.

An individual is verbally inflicting anguish, emotional pain, and distress on an older adult. Which type of abuse is this?

Psychological Psychological or emotional abuse involves the infliction of anguish, emotional pain, or distress through verbal or nonverbal acts. Sexual abuse is nonconsensual sexual contact including with someone who is incapable of giving consent. Physical abuse involves the use of physical force that may cause bodily injury, physical pain, or impairment. Material abuse is defined as illegal or improper exploitation of an older adult's funds, property, or other assets.

A group of individuals is working as a team in a rehabilitation program. Which nursing team member has the responsibility of acting as the team leader?

RN The registered nurse has responsibility for a group of individuals that work on a team. The unit secretary is an individual with no medical training and cannot accept any responsibilities of the team. The licensed practical nurse and unlicensed nursing personnel are individuals who work under the directions of a registered nurse.

Which therapy may help ease the pain caused by local recurrence and metastasis associated with breast cancer?

Radiation therapy Radiation therapy may help ease the pain caused by local recurrence and metastasis associated with breast cancer. However, clients who have lymph node involvement or metastasis to distant organs may require chemotherapy. Hormonal therapy may be useful in clients with breast cancer cells that are estrogen receptor positive. Monoclonal antibody therapy may be used to treat metastatic breast cancer in women who overexpress a breast cancer cell antigen called HER2.

Which therapy may be used as primary or palliative treatment in advanced stages of prostate cancer?

Radiation therapy may be used as primary or palliative treatment in the advanced stages of prostate cancer. Antibiotic therapy is the mainstay of tuberculosis treatment. Oxygen therapy is not as likely to provide relief for symptoms of prostate cancer. Photochemotherapy is used in the management of psoriasis.

Which healthcare system is required after a physical or mental illness, injury, or chemical addiction?

Rehabilitation Clients require rehabilitation after a physical illness, mental illness, injury, or chemical addiction. An intensive care unit is required when a client needs close monitoring in addition to medical care. Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities.

The rehabilitation team is caring for an older adult client, who is completely immobile, with a history of knee replacement. Which member of the team reinforces education about the processes of rehabilitation provided to the client and family members?

Rehabilitation licensed practical nurse/licensed registered nurse An elderly bedridden client with a history of knee replacement may experience joint stiffness. It is a duty of a rehabilitation licensed practical nurse/licensed registered nurse to reinforce education about the processes of rehabilitation provided to the client and family members. The physical therapist provides therapy and training and assesses the client's needs. The rehabilitation registered nurse provides the education itself as well as support and also promotes independence. The vocational rehabilitation counselor helps the client find training for new or continued employment.

Which nursing action is confidential and protected from legal action?

Reporting incidents of suspected child abuse to the appropriate authorities The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.

After delegating the task of ambulating a client to a certified nursing assistant (CNA), a nurse intervenes, evaluates the situation, and provides feedback to the CNA. Which right of delegation is the nurse fulfilling?

Right supervision involves conducting the appropriate monitoring, evaluation, intervention, and feedback. The nurse's evaluation, intervention, and giving of feedback to the certified nursing assistant (CNA) fulfills this right. Right task involves delegating care for a specific client and ensuring that the delegated task is within the delegatee's scope of practice. Right direction involves giving a clear, concise description of the task. Right circumstances involves considering the setting, available resources, and other relevant factors.

Which is the briefer adaptation of the charting format for the POMR (Problem-Oriented Medical Record)?

SOAPE SOAPE (Subjective, Objective, Assessment, Plan, and Evaluation) is the briefer adaptation of the charting format for the POMR (Problem-Oriented Medical Record). SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation. DARE (Data, Action, Response and evaluation, Education and patient teaching) is the acronym for the four different aspects of charting using focus format. SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision) is an acronym for seven different aspects of charting.

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of Needs does this nursing action address?

Safety A call bell system enables the client to communicate with the staff and supports safety and security, which is a second-level need. Self-esteem involves intrapersonal needs, the fourth level of basic needs. Physiological needs include air, food, and water and represent the first level of needs. Interpersonal needs involve love and belonging, which are third-level needs.

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply.

Self-worth Achievement Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

Which statement regarding abuse is true?

Sexual abuse is nonconsensual sexual contact with another individual. Sexual abuse is nonconsensual sexual contact with another individual, including one who is incapable of providing consent. Emotional, not physical, abuse involves inflicting anguish, emotional pain, or distress through verbal or nonverbal acts. Material abuse, not neglect, is the improper exploitation of the victim's funds, property, or assets. Not feeding an individual is an example of neglect, not emotional abuse.

Which statement regarding Orthodox Judaism religion is true?

Shaving with a razor is prohibited. For Orthodox Jewish clients, shaving should not be done with a razor, but rather with scissors or an electric razor, because no blade is to contact the skin. A mohel, not a priest, performs the circumcision on Jewish infants. Artificial methods of birth control are not encouraged in Judaism. Jewish female babies, not male babies, are usually named during the reading of the Torah; male babies are named eight days after birth when they are circumcised.

The nurse leader teaches student nurses about ways of making care visible. During a follow up visit, the leader observes the nurse holding the client's hand after finding him or her anxious before radiation therapy. Which communication skill applied by the student nurse shows effective learning?

Showing nonverbal care The use of a facial expression, intonation, posture, eye contact, and other body language to mirror the client's feelings signify nonverbal care. Expressing appreciation may involve giving a personal gift of positive regard. A blameless apology is used to express the genuine regret for a negative experience. Positive intent is made clear by explaining the work being done to suit the client's best interest.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do?

Sit on the edge of the bed while they hold the client upright. Sitting allows the nurses to support the client until orthostatic hypotension subsides. The client's stable pulse and color indicate that the situation does not warrant placing the client in the supine position. Sliding slowly to the floor to prevent a fall and injury, bending forward, or rapid movement will permit flexion of the vertebrae, which may traumatize the spinal cord. A light-headed feeling usually is transient until the body adapts to the upright position, so leg elevation is unnecessary.

Which statement is most appropriate regarding situational leadership?

Situational leadership is based on the flexibility of the manager in adapting to the needs of the individual." Situational leadership is a comprehensive approach to the issue of management that takes into account the style of the leader, the group being managed, and the situation at hand. This style is based on the flexibility of the manager in adapting to the needs of the individual. In autocratic leadership, the leader retains all authority and responsibility, assigns clearly defined tasks, and establishes one-way communication with the group. In laissez-faire leadership, the leader avoids responsibility by delegating all decision making to the group. Democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members.

It is appropriate for the nurse to pull up on the client's skin, release it, and determine if the skin returns immediately to its original position to assess for what?

Skin turgor Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

Which is the definition of health equity?

Something that is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged Health equity is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged. Determinants of health are factors that help explain why some people experience poorer health than others. Health status is the health of a person or community along with the many measures that contribute to this health. Health disparities are defined as the differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations.

Which rehabilitation team member plays a role in designing a rehabilitation communication program?

Speech-language pathologist A speech-language pathologist plays a role in designing a rehabilitation communication program. A physical therapist designs an exercise program. A clinical psychologist acts as an emotional evaluator. A rehabilitation registered nurse acts as a coordinator and educator.

Which of these is the source of support for visiting nurse associations that provide community health services?

Tax-deductible contributions A visiting nurse association that provides community health services is a voluntary health agency. Tax-deductible contributions support such organizations. State revenues, charitable contributions, and fees from limited sources support state health departments, county health departments, and city health departments. These are all considered official health agencies.

Which action is appropriate while assessing the body temperature in a client who is suspected of having hypothermia?

Temperature assessed via the rectal route provides an accurate core temperature reading. The use of an electronic thermometer is safer and more accurate when compared to glass thermometer. Assessing oral temperature with a glass thermometer is no longer recommended. The axillary route provides the least accurate temperature readings. The rectal route is preferred than the tympanic route.

While caring for a client with schizophrenia, a nurse understands that psychotherapy is against the client's religious beliefs. To which religious community does the client likely belong?

The Christian Science community is against certain therapies including psychotherapy. The Mormon, Disciples of Christ, and Assemblies of God communities do not prohibit psychotherapy.

Which act creates incentives for Medicare and Medicaid providers to improve staffing in long-term care facilities?

The Patient Protection and Affordable Care Act (PPACA) The Patient Protection and Affordable Care Act (PPACA) expands information about the quality of individual nursing homes on the Medicare website and creates incentives for Medicare and Medicaid providers to improve staffing. The Omnibus Budget Reconciliation Act (OBRA) defines requirements for the quality of care given to residents and covers many aspects of institutional life. The Health Care Financing Administration (HCFA) makes available information about the quality of long-term care facilities to beneficiaries, providers, researchers, and state surveyors. The Occupational Safety and Health Administration (OSHA) involves the use of long-term health care facilities and the establishment of guidelines that increase the cost of health care.

What should a nurse understand regarding the Uniform Anatomical Gift Act?

The Uniform Anatomical Gift Act gives individuals who have reached 18 years of age the right to make an organ donation. According to the Uniform Anatomical Gift Act, individuals who are at least 18 years of age have the right to make organ donations. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. The Americans with Disabilities Act (1990) protects the rights of people with physical or mental disabilities. The National Organ Transplant Act of 1984 provides civil and criminal immunity to hospitals and healthcare providers.

A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness?

The children do not have a physical shelter and may sleep outdoors or in vehicles. Public health organizations use the term absolute homelessness to describe people who have no physical shelter. These children sleep outdoors, in vehicles, abandoned buildings, or other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety. Children from both sections of the community tend to be under-immunized and are at risk for childhood illnesses. Both types of homeless children are unable to meet residency requirements for public schools and are more likely to drop out of school and be rendered unemployable. A lack of finances leads both types of homeless children to seek healthcare only in emergency conditions.

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting of impending death?

The client is revising the client's will and planning a visit to a friend. Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time. Crying and talking openly about death are signs of depression. Going from health care provider to health care provider demonstrates disbelief, denial, or desperation. Refusing to follow treatments and stating that the client is going to die anyway indicates anger and hopelessness, not acceptance.

A licensed practical nurse cares for a client of Italian descent after the client has given birth. The nurse is aware of the significance of touch in the client's culture. What does the nurse anticipate to be true of the client's preferences regarding touch?

The client would be comforted if the nurse pats her shoulder during their conversation. Some cultural groups are more comfortable than others with touching or maintaining eye contact. People of Italian descent are likely to be comfortable with touching other people during conversation and with being touched. Patting the client's shoulder while talking with her might be comforting for a client of this cultural group. In Observant Judaism, a woman is considered to be in a ritual state of impurity whenever blood is coming from her uterus, such as after the birth of a child. During this time, her husband would not make physical contact with her and would not be able to assist her in moving in the bed. Many Native Americans would see a firm handshake as a sign of aggression. Because people of Italian descent are comfortable touching one other, the nurse may touch the client's hand.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. What factor of special concern will the nurse identify when caring for this client?

The client's inability to maintain an optimal level of functioning The onset of disabling illness will divert an older person's energies, making it difficult to maintain an optimum level of functioning. Irritability in response to deprivation is an expected response. Decreased ability to recall recent facts can result from the aging process and the change in environment; it is not as important as the loss of function. A gradual memory loss and some confusion are expected; a sudden memory loss is cause for alarm.

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools. Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and also produce stools that are manageable, depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Food high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.

The nurse observes that an older client rarely eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." The nurse determines that the client needs to be taught about what?

The foods that meet basic nutritional needs The nurse determines that the client needs to be taught about the foods that meet basic nutritional needs because it is incorrect to state that older people do not need protein every day. The need for home-delivered meals, the effect of aging on the need for some foods, and the need for meat at least once per day throughout life are incorrect answers.

Which statement is true regarding focus charting format of documentation?

The format uses a modified list of nursing diagnosis The focus charting format uses a modified list of nursing diagnoses that involve a positive concept of client's needs rather than using a problems list. The focus charting format uses DARE (Data, Action, Response and evaluation, Education and patient teaching) form of documentation and not SOAPE (Subjective, Objective, Assessment, Plan, Evaluation). The focus charting format uses a positive concept of the client's needs, not concepts of medical diagnoses and problems of a client. The nurse must use all the steps of SOAPE each time when documenting.

How does the nurse identify an illness as chronic? Select all that apply.

The illness persists for longer than 6 months. The client may develop a life-threatening relapse. The illness affects the functioning of one or more systems. A chronic illness usually lasts longer than 6 months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

What is the most fundamental ethical principle in the health care setting?

The most fundamental ethical principle in the health care setting is respect for people. Justice is the concept of fairness. Truthfulness is telling the client the truth. Freedom of personal choice or autonomy is the right to be independent and make decisions freely. These are all important but not as fundamental.

A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when use of the heating pad was initiated. Which principle would legally apply?

The nurse could be held liable for the injury that occurred. A nurse can be held responsible for any action performed that causes a client to be harmed. Legally, someone will assume liability for the action. If sued in this case, the nurse would have to prove that her actions were reasonable and prudent under the circumstances. The manufacturer may also be liable depending on whether the equipment was used correctly, but initially the actions of the nurse will be reviewed.

A client is receiving heparin sodium intravenously at 1500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number.

The ordered rate is 1500 u/hr. The available concentration is 25,000 u in 500 mL. Make the necessary conversions and use dimensional analysis to determine the appropriate rate in mL/h. The ratio and proportion method is not appropriate for this situation. 30 mL x 8 hours = 240 mL

Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____

The prescribed dose is 1200 mcg. The available medication is a tablet with 0.6 mg. First, convert the prescribed medication to units of the available medication. Then, use the dimensional analysis and/or ratio and proportion methods to determine the appropriate number of tablets to be administered. 1 mg = 1000 mcg 0.6 mg x 1000 =600 1200/600= 2 tabs

The health care professional is recording the client's initial admission nursing history. Which member of the health care team is held responsible for this documentation?

The registered nurse has the primary responsibility to record the client's initial admission nursing history. The physical therapist helps the client with rehabilitation and performing exercises. The licensed practical nurse (LPN) and unlicensed assistive personnel (UNP) may document the details in later sessions, once they are assigned to provide care to a client.

Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care?

The registered nurse is accountable for the initial assessment and ongoing evaluation of the client. A licensed practical nurse is not accountable for initial assessment and ongoing evaluation of the client. The primary health care provider is accountable for diagnosing the problem and reviewing the client responses. An unlicensed nursing personnel performs the tasks delegated by the registered nurse or other delegators.

A 3-year-old child has eczema of the face and arms. The nurse finds the toddler scratching so intensely that the child's arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted?

These actions can be construed as assault and battery. Assault is a threat or an attempt to do violence to another, and battery means touching an individual in an offensive manner or actually injuring another person. The nurse's behavior demonstrates anger and does not take into account the growth and developmental needs of children in this age group. Although the behavior (scratching) needs to be decreased, this can be done with mittens, not immobilization. A 3-year-old child does not have the capacity to understand cause (scratching) and effect (bleeding).

What is the time period required to recertify a home care treatment plan in order for the client to continue to receive services?

To receive home care benefits beyond the original 60-day period, a recertification must be completed for each subsequent 60-day period.

What would the nurse describe as the uses of automated tracking systems with infrared and radiofrequency technology (RFT) in emergency departments? Select all that apply.

To track client's triage priority upon arrival To track interaction of clients with caregivers To portray the overall census and acuity of clients Emergency departments use automated tracking systems with infrared and RFT for disaster treatment. These systems track client's triage priority upon arrival, track interaction of clients with caregivers, and portray the overall census and acuity of clients. Identification of clients is done using a special bracelet with a disaster number. Categorizing triage priority is done using a disaster triage tag system.

What items should the nurse instruct community members to include in a personal preparedness bag? Select all that apply.

Toiletries Cell phone and charger Three-day supply of clothing Three-day supply of nonperishable food items Items that should be included in a personal preparedness go bag include toiletries, cell phone and charger, and a 3-day supply of clothing and nonperishable food items. Although a laptop computer may be desired, it is unlikely that this item can be stored for potential use. Also, the chances that this device would be helpful during a disaster will depend upon a power source and access to the Internet.

Which statement is true about values?

Values held by an individual can be clarified by expressing feelings and thoughts. Value clarification is the process of self-evaluation that helps gain insight into personal values. Nurses are in the unique position of having the ability to help clients clarify their values by encouraging them to express feelings and thoughts related to a situation without contributing the nurse's personal opinions. All values are not always equal for each individual. Some values are more important than others, and the choices between competing or conflicting values are based on the priority placed on each particular value. Some values are consciously chosen; others are adopted unconsciously. Values influence everyday decisions, and not just major life decisions.

A nurse is caring for a hospitalized older adult. On assessment, the nurse suspects that the client is experiencing abuse. Which behavioral findings might have led the nurse to this suspicion?

Verbal aggression Of the listed behavioral findings, an abused older adult is most likely to exhibit verbal aggression. Profound and rapid personality changes and regressed behavior are more likely to be findings in abused children, and low self-esteem is more likely to be a finding in a victim of intimate partner violence.

What is an example of a voluntary home health agency?

Visiting nurse association A visiting nurse association is an example of a voluntary home health agency. City health departments and county health departments are examples of official home health agencies. A nursing home-based health agency is an example of a private for-profit or nonprofit institution-based home health agency.

Which type of home health agency has a community-based board of directors?

Voluntary A voluntary home health agency has a community-based board of directors. Official home care agencies are governed by a state, county, city, or other local unit of government and volunteer board representatives from the area. A hospital-based home health agency is governed by a hospital board of directors. A combination home care agency is jointly governed by a community-based board of directors and volunteer board representatives from the area.

Which type of home care agency includes Visiting Nurses Association?

Voluntary agency Voluntary agencies were the first to deliver nursing care in the home. Visiting Nurses Associations are the most common examples of voluntary agencies. Official agencies are those supported by tax dollars and are authorized by law to deliver services to a defined area or community. Proprietary agencies are organized to make a profit on their operation. The hospital-based agency usually gets most of its referrals from the hospital itself.

Who governs an official home health agency?

Volunteer board representatives from the area Volunteer board representatives from the area govern an official home health agency along with a local unit of government. Paid boards of directors govern proprietary home health agencies. A hospital board of directors governs a hospital-based home health agency. A community-based board of directors governs a voluntary home health agency.

Which member of the hospice care team is responsible for providing respite care to the client's caregiver?

Volunteer coordinator A volunteer coordinator of a hospice care team is responsible for providing respite care to the caregiver of the client. A nurse coordinator manages the client's care, explains the services, and assigns a primary team. A spiritual coordinator serves as a liaison between the client and the spiritual community and coordinates spiritual support. A bereavement coordinator assesses and supports the bereaved survivor and facilitates support groups.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt, which contains calcium, is digested more easily because it contains the enzyme lactase, which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an 8-oz container, depending on how it is prepared. Eggs contain approximately 22 mg of calcium. One potato contains approximately 7 to 20 mg of calcium, depending on how it is prepared. Eight ounces of applesauce contain approximately 3 mg of calcium.