Fundamentals Adaptive Quizzing Assignment
Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. 1 Interventions to restore tissue integrity 2 Interventions to optimize neurologic functions 3 Interventions to manage restricted body movements 4 Interventions to promote comfort using psychosocial techniques 5 Interventions to provide care before, during, and immediately after surgery
1 Interventions to restore tissue integrity 2 Interventions to optimize neurologic functions 5 Interventions to provide care before, during, and immediately after surgery
Place the steps of the nursing process in its correct order. 1. Perform the nursing interventions competently. 2. Evaluate the effects of the nursing interventions performed. 3. Define the nursing diagnoses or collaborative problems clearly. 4. Identify the client's health care needs by collecting subjective and objective data. 5. Plan the care by determining priorities, goals, and expected outcomes of care.
1. Identify the client's health care needs by collecting subjective and objective data. 2.Define the nursing diagnoses or collaborative problems clearly. 3.Plan the care by determining priorities, goals, and expected outcomes of care. 4.Perform the nursing interventions competently. 5.Evaluate the effects of the nursing interventions performed.
During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia 2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios
Anorexia nervosa Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image.
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? Red blood cell count Sputum culture Arterial blood gas Total hemoglobin
Arterial blood gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.
The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Diagnosis
Assessment Assessment involves taking the history of and verbally interviewing a client. Planning is the phase of the nursing process that includes the development of a written document of expected outcomes. Evaluation is the phase of the process when the care plan is modified and updated. Diagnosis involves the documentation and validation of healthcare needs and priorities via verbal discussion with the client.
A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1 Attempt to identify the client's concerns. 2 Reassure the client that the surgery is routine. 3 Report the client's anxiety to the healthcare provider. 4 Provide privacy by pulling the curtain around the client.
Attempt to identify the client's concerns. The nurse should assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the healthcare provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety. Topics
After reviewing a client's reports, the primary healthcare provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. 1 Peptic ulcer 2 Chronic renal failure 3 Cognitive impairment 4 Congestive heart failure 5 Chronic obstructive lung disease
Chronic renal failure Congestive heart failure Chronic obstructive lung disease Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore, these clients do not require palliative care.
How can a nurse best evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiologic responses
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.
What principal components are associated with a nurse's time management skill? Select all that apply. 1 Autonomy 2 Goal setting 3 Priority setting 4 Interruption control 5 Right communication
Goal setting 3 Priority setting 4 Interruption control Goal setting, priority setting, and interruption control forms the principal components of time management. Autonomy is an important component in the decision-making process. Right communication is considered one of the rights of delegation.
Which intrinsic factor is associated with the fall of an older adult? 1 Wet floors 2 Poor lighting 3 Deconditioning 4 Inappropriate footwear
Deconditioning Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.
Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? 1 Evaluation 2 Explanation 3 Interpretation 4 Self-regulation
Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.
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? 1 Exploring 2 Reflecting 3 Refocusing 4 Acknowledging
Exploring 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 statement defines the term family resiliency? 1 Family resiliency is the uniqueness of each family. 2 Family resiliency is the ability of the family to cope with stressors. 3 Family resiliency is the intrafamilial system of support and structure. 4 Family resiliency is the ability of the family to transcend.
Family resiliency is the ability of the family to cope with stressors. Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.
Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1 Activity theory 2 Continuity theory 3 Disengagement theory 4 Gerotranscendence theory
Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.
Which nursing process involves delegation and verbal discussion with the healthcare team? 1 Planning 2 Evaluation 3 Assessment 4 Implementation
Implementation The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.
Which action correlates with the relevance strategy of the motivational learning model proposed by John Keller? 1 Extrinsic and intrinsic reinforcements for any learning effort 2 Linking the person's needs, interests, and motives for learning 3 Arousing and sustaining a person's curiosity and interest in learning 4 Having positive hope for successful achievements as a result of learning
Linking the person's needs, interests, and motives for learning John Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.
he nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? Provide perineal care. Turn and position the client. Give a complete bed bath. Document the bowel movement.
Provide perineal care. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.
A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? 1 Restore the client's health. 2 Promote the client's recovery. 3 Relieve the client's discomfort. 4 Support the client's significant others.
Relieve the client's discomfort. 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.
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? 1 Sodium 2 Potassium 3 Chloride 4 Calcium
Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.
A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? 1 Potassium 2 Sodium bicarbonate 3 Carbon dioxide 4 Sodium chloride
Sodium bicarbonate Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H2CO3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.
How should the nurse prevent footdrop in a client with a leg cast? 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.
Support the foot with 90 degrees of flexion. To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.
The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? 1 The baby has a head lag when pulled to sit. 2 The baby can turn from the side to the back. 3 The baby can turn from the abdomen to the back. 4 The baby supports much of his own weight when he or she is pulled to stand.
The baby has a head lag when pulled to sit. A normal five-month-old infant should be able to sit up without a head lag. This finding should cause the nurse to conduct a further assessment. A baby should be able to turn from the side to the back by four months of age. At five months of age, the baby should be able to turn from the abdomen to the back. The baby should be able to support much of his own weight when pulled to stand by the age of five to six months.
The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1 All nursing functions will be completed by discharge. 2 All invasive intravenous lines will remain patent. 3 The client will remain awake, alert, and oriented at all times. 4 The client will be free of signs and symptoms of infection by discharge.
The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse? 1 The client's gag reflex has returned. 2 The client is confused due to anesthesia. 3 The client is nauseated and wants to vomit. 4 The client's airway is becoming obstructed.
The client's gag reflex has returned. The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not obstruct the airway.
Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter? Tubing luer-lok port Distal end of the tubing Urinary drainage bag Catheter insertion site
Tubing luer-lok port The tubing luer-lok port is the best site for obtaining a urine specimen for a critical care client with an indwelling urine catheter. The nurse applies a clamp to the drainage tubing distal to the luer-lok port, cleans the port with antiseptic, attaches a sterile 5-mL or 10-mL syringe onto the port, and aspirates the urine quantity desired. The tubing luer-lok sampling port should not be confused with the balloon inflation port, which is the access port for inflating the retaining balloon in the bladder and does not provide access to urine in the catheter. A critical care client typically has an indwelling catheter for several days, so taking a urine sample from the distal end of the tubing or the bedside drainage bag is not suitable because the longer the urine has been in the bag the more time there has been for bacterial growth which taints laboratory results. The client's urine should be contained within the catheter tubing and bag and not at the catheter insertion site unless the catheter is leaking.
A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? 1 Increase fluids. 2 Increase fiber in the diet. 3 Wash hands with soap and water. 4 Wash hands with an alcohol-based hand sanitizer.
Wash hands with soap and water. Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.