Fundamentals Final Part 2

A nurse is applying the nursing process in community-based care. Put these steps in the correct order.

- Complete a windshield survey. - Analyze the data. - Plan the care. - Implement the care. - Evaluate the care.

What are the components of a theory? Select all that apply.

- Concept - Definition - Phenomenon - Proposition

Which are considered characteristics of a hardy person? Select all that apply.

- Control - Commitment - Challenge

Which are functions of a client's medical record? Select all that apply.

- Legal record - Communication - Continuity of care - Quality improvement

Which are possible contributing factors to obesity in school-aged children? Select all that apply.

- Less time playing outside - More fast food consumption - Busy lifestyle

What type of advanced thinking develops during young adulthood?

Post-Formal Operations

Which is the most important factor a nurse should consider when planning a client's hygiene care?

Client's needs

Which describes the motivation to avoid illness?

Health protection

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair.

A nurse encourages a client who has suffered a left brain ischemic stroke to participate in rehabilitation. The nurse reminds the client of his or her family and grandchildren who are a large part of his or her life. The nurse is engaging in which component of caring?

Maintaining belief

Hand hygiene, environmental cleanliness, standard precautions, and protective isolations are components of which infection prevention strategy?

Medical asepsis

What is one online avenue for patients to gain support and learn more about their disease process?

Online forums

A client is admitted with flu and placed on droplet precautions. Which is a portal of exit for the virus that is the pathogen?

Sneeze

Which is considered a restraint?

Soft wrist holders

The nurse is preparing to discharge an Orthodox Jewish client who was diagnosed with end-stage renal disease. As the nurse is setting up outpatient hemodialysis three times a week and planning dietary instructions, what is the most important aspect for the nurse to remember?

The client would need dialysis Mondays, Wednesdays and Fridays.

Place the nurse's notes in order according to the SBAR documentation system.

- The client is lying in bed reading the newspaper. - The client underwent a colon resection due to colon cancer. - The abdominal wound staples are intact without drainage. - The nurse will continue to assess the wound every 4 hours.

The nurse is supervising a student nurse who is managing the care of a client who has lower extremity edema related to an arterial skin ulcer. Which action made by the nursing student requires correction?

Applying compression stockings

The nurse is teaching a client with newly diagnosed type 2 diabetes mellitus about self-management. What can the nurse do to focus on the family as the context for care?

Ask the client if the family will be helping with injections.

When washing a client's legs, which direction is correct?

Distal to proximal

To whom can a nurse delegate the administration of ophthalmic solutions?

LPN/LVN

Which client is most likely to have chronic health problems?

85-year-old African American male

Which part of the brain control circadian rhythms?

Hypothalamus

An elderly client has an appointment with his or her physician. The nurse is conducting an assessment. Which statement represents the greatest safety concern?

"I almost missed the office. I couldn't see the sign for the entrance."

At what age is HPV vaccine recommended for both boys and girls?

11 years of age

The pediatrician has ordered erythromycin 20 mg/kg of body weight for a 55-pound client. The medication on hand is 250 mg tablets. How many tablets will be administered to this client? Enter numeral only.

2 Rationale: Convert weight to kg: 55 lb/2.2 kg = 25 kg Determine amount needed: 20 mg x 25 = 500 mg Determine how many tablets needed to get 500 mg: 500/250 = 2

How much exercise per week is associated with the greatest health benefit?

2 hours 30 minutes

Which client is at highest risk for wound dehiscence?

A 55-year-old obese female who underwent an abdominal hysterectomy

Which of the following would meet the minimum guidelines for physical activity?

A brisk 15-minute walk, twice a day

There are various types of home care agencies that are funded by different sources. What is a proprietary home care agency?

A privately owned or corporate agency that provides home care services for a profit

Which is the single most important activity for preventing and controlling infection in a health-care setting?

Effective hand washing

Assessment of cranial nerve II is part of which assessment?

Eyes

Going beyond administering medication and direct care to treat the client as a whole is considered which type of theory-based intervention?

Holistic nursing care

When trying to identify a concept in research, which is considered an operational definition?

Lumbar pain is a verbal statement denoting a client's pain

How do computers increase the ability to have evidence-based practice for nurses in the health care setting?

Nurses can look up researched information

A client is being admitted to the emergency department. The nurse recognizes the following as an indicator of which of the following? Select all that apply. (bracelet)

The patient has an allergy

How can a patient's spiritual belief system benefit/inhibit her ability to deal with her stress?

The patient has the opportunity to develop a spiritual belief to help her cope with her stress through an effective nursing plan.

The nurse is documenting client care in a medical record. The facility uses a problem-oriented record system. In which area would the nurse document the medications he or she administers?

The progress notes

What is the purpose of the nursing process?

To guide the nurse in providing goal-directed, patient-centered care

An elderly client is ambulatory but requires assistance with bathing. The client has episodes of incontinence and his or her bed and gown is soiled. Which type of bath would be most appropriate?

Tub bath

A nurse is planning care for a client who requires airborne precautions. Which of the following should the nurse take?

Wear an N95 respirator mask

The nurse is learning about community health concepts. Which statement by the nurse correctly expresses the concept of an aggregate?

"An aggregate is a group of individuals with at least one shared characteristic, either personal or environmental."

Which statement reflects an example of nonassertive communication?

"Do you believe the client is breathing faster and using accessory muscles?"

The nurse is working with parents of a client recently diagnosed with cystic fibrosis, and they tell the nurse they fear the child will not have a normal life. Which statement made by the nurse indicates the use of restating?

"I understand your concern that your child may not live a normal life. More adults with cystic fibrosis have more normal lives as there are new treatments that prolong and improve quality of life."

Which statement may indicate an adult learner is likely to be resistant to learning?

"I've gotten by just fine all my life without taking any medicines. I don't need to know about them now."

The nurse is discussing the benefits of exercise with a client who has a history of hypertension and atherosclerosis. The client expresses hesitancy about beginning an exercise program while having heart disease. What is the nurse's best response?

"It is healthier for your heart to exercise than to be sedentary."

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide?

"It's my responsibility to remind you that we have to respect our clients' privacy."

A nurse is providing education to a client who is a heavy smoker. The client is not interested in quitting and states, "My grandmother smoked her whole life and she lived to be 94 years." How should the nurse respond?

"Not everyone who smokes gets lung cancer, emphysema, or heart disease, but your chances are far greater if you do."

Which statement made by the nurse indicates the use of a stereotype?

"People who are from China are good with computers."

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

"Rub all surfaces of your hands with an alcohol rub for 20-30 seconds."

Which statement is an example of elderspeak?

"Sweetie, when do we want to take our bath?"

The nurse is exploring personal issues with a client and wants to obtain more information. Which question asked by the nurse would obtain the most information?

"Tell me what happened to encourage you to seek counseling."

Which is the best feedback statement a nurse can provide to a client who is learning to self-administer injections?

"That last technique was really good. How do you think you could be more comfortable holding the syringe?"

Which statement best reflects a critical thinking philosophy being taught to a nursing student?

"Think about different interventions that can be used with this client."

The nurse is preparing to inject two types of insulin, Lente and Regular. Select the insulin vial that the nurse will draw up first.

"clear" Regular

A client presents to the emergency room after sustaining an injury where a nail entered the hand. Which questions should the nurse ask the client to determine if a tetanus shot is needed? Select all that apply.

- "Do you have any allergies to tetanus toxin?" - "Was the nail rusty or was it brand new out of the box?"

The nurse is discussing sleep patterns with a client who reports sleep disturbances. Which questions should the nurse ask the client to determine the cause of the sleep problem? Select all that apply.

- "Do you include exercise in your daily life?" - "What is a typical 24-hour food intake for you?" - "How many caffeinated beverages do you drink each day?"

The nurse is admitting a new client to an acute rehabilitation facility and is completing the paperwork. The client is getting frustrated with the amount of time it is taking. What information can the nurse provide about the admission assessment to help the client understand the process? Select all that apply.

- "We use this information to determine how you progress as you go through therapy." - "This information allows us to identify any needs you will have when you are discharged." - "It provides all health-care providers necessary information including allergies, needs, and abilities."

A nurse utilizing the HOPE approach to spiritual assessment would ask which questions when addressing the "H" part of the method? Select all that apply.

- "What are your sources of internal support?" - "What do you hold on to to get through your difficult times?"

A nurse utilizing the HOPE approach to spiritual assessment would ask which questions when addressing the "H" part of the method? Select all that apply.

- "What are your sources of internal support?" - What do you hold on to to get through difficult times?"

A client who speaks limited English comes to the emergency room with abdominal pain. Which questions would be most appropriate to ask the client first? Select all that apply.

- "What languages do you speak?" - "Are you comfortable speaking English?" - "Are you comfortable with using an interpreter?"

Which of the following is a safeguard in protecting patient confidentiality while using Electronic Medical Records?

- 1180 - Encryption - Privacy filters - Password and PIN numbers - Designated workstation

A nurse is performing an assessment on an 80-year-old female. Although the client is in overall good health, the nurse suspects she is depressed. Which are common contributing factors to depression in older adults? Select all that apply.

- A chronic medical condition - Certain medications - Loneliness and isolation

Which scenarios support the use of restraints in a hospital? Select all that apply.

- A confused client who continuously pulls out his or her IV line - An alert client who is ventilator dependent who is pulling at the endotracheal tube

Which are examples of client uniqueness that could cause challenges or differences in care and must be considered when creating a nursing plan? Select all that apply.

- A single mother recovering from a fall at work - An elderly Native-American admitted for malignant hypertension - A client living below the poverty line, admitted with pneumonia

Which are components of a person's health literacy? Select all that apply.

- Ability to find information and services to meet health needs for self and others - Ability to communicate health needs to others - Ability to read an informational brochure

The nurse is preparing to give a presentation to parents of adolescents about common risk-taking behaviors during the teenage years. What should the nurse include in the presentation? Select all that apply.

- Accepting dares - Using illicit drugs - Being sexually promiscuous

Healthy People 2020 provides 12 major health indicators to measure the health of a community. Select all that apply.

- Access to health services - Mental health - Tobacco use - Injury and violence

Which assessments are done as part of assessment of joint mobility and muscle function? Select all that apply.

- Active range of motion - Passive range of motion - Applying resistance

Which represent common developmental tasks of older adults? Select all that apply.

- Adjusting to retirement - Adjusting to death of a spouse - Adapting to flexible social roles

A postsurgical client has a new nursing diagnosis of "Constipation related to immobility and decreased gastrointestinal (GI) motility secondary to narcotic analgesics." Which are appropriate nursing interventions for this client?

- Administer laxative or stool softener as prescribed. - Encourage increased fluid intake, including warm liquids. - Educate the client about and encourage a high-fiber diet.

A new community nurse is learning about nursing roles. What are the roles of a community health nurse? Select all that apply.

- Advocate - Educator - Case manager - Counselor - Collaborator

A middle-aged patient is admitted with a diagnosis of cardiovascular disease. What two factors for this disease process are not in the patient's control? Select all that apply.

- Age - Family history

The nurse is caring for a 65-year-old female client recently diagnosed with breast cancer. According to Betty Neuman's health-illness continuum, which factors could have contributed to this illness?

- Age - Gender - Genetics

A client with restless leg syndrome reports difficulty sleeping. Which factors may be the cause? Select all that apply.

- Age - Low iron levels - Antidepressants

Which factors have led to a change in family living structures in the United States? Select all that apply.

- Aging population - Higher divorce rates - Socioeconomic factors - Older age at first marriage

Which of the following are benefits of electronic patient care records? Select all that apply.

- Allow for accurate billing - Provide reminders - Facilitate planning and documentation of care - Support efficient workflow

The nurse is educating a client with a new diagnosis of sleep apnea regarding consistent use of the continuous positive airway pressure (CPAP) machine. Which complications should the nurse instruct the client about that can occur with untreated sleep apnea? Select all that apply.

- Angina - Arrhythmias

Which of the following instructions should the nurse provide parents, when an antibiotic has been prescribed for their child? Select all that apply.

- Antibiotics should not be prescribed for a cold or the flu. - It is important for children to take the entire course of medication, even if the symptoms are gone.

The nurse is communicating with an elderly client, but it appears the client is not understanding what the nurse is explaining. What should the nurse assess for in the elderly client to determine communication barriers? Select all that apply.

- Assess for level of orientation - Assess for visual disturbances - Assess for hearing impairment

Which are nursing considerations when performing a physical assessment on an elderly client? Select all that apply.

- Assessment of support systems - Limiting position changes to make the exam less taxing - Stiff muscles and joints making positioning difficult - Adapting techniques to accommodate decreased vision and hearing abilities

What does the nurse know is true about conducting the nursing assessment?

- Assessments must be completed within 24 hours of inpatient admission. - Assessment cannot be delegated to others. - All clients are assessed for pain, nutritional status, and risk for falls.

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints. Select all that apply

- Assist the client with toileting at frequent intervals - Use an electronic position-sensitive device - Provide diversionary activities for the client - Involve the family in the client's care

Which of the following are ways to evaluate information on the Internet? Select all that apply.

- Authority or sponsor - Currency - Content quality - Purpose

The nurse is educating a group of nursing assistants regarding proper body mechanics. Which key concepts should the nurse include in the presentation? Select all that apply.

- Balance - Coordination - Joint mobility - Body alignment

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Select all that apply

- Bathe a client who had an amputation 2 days ago - Assist a client to ambulate using a gait belt - Feed a client who had a stroke 3 months ago

A mother has just learned her son has been involved in a fatal car accident. Match the actions to their chronological stage of crisis.

- Begins to call relatives, states she is okay - Can't decide if she should call work first or go to the hospital, or pack a bag. - Explains to visitors everything is okay, he really was fortunate it wasn't worse than it could have been, 'he will be fine', tells everyone to go home (doesn't want visitors now). - Begins to make plans for therapy, at home-care, work schedules. - Begins to overeat and indulge in excessive alcohol consumption.

A nurse is scheduled to administer the following drugs to the client: (1) insulin subcutaneously for diabetes, and (2) morphine intravenously to relieve pain. What factors should be considered that will affect the pharmacokinetics of the drugs when administering these medications? Select all that apply.

- Body mass - Gender - Pregnancy - Time of administration

Which of the following are risks faced by adolescent girls who are pregnant? Select all that apply.

- Bone density loss - Iron Deficiency Anemia - Loss of educational opportunities - Interruption of developmental tasks

What are examples of unknown factors that cause a disruption in health?

- Bringing a new baby home from the hospital - A physical defect found on ultrasound of a fetus - Injuries from a car accident

A nurse is conducting a family health assessment and wants to use a genogram. The genogram, constructed with a diagram that evaluates each family member's health risks, includes what information? Select all that apply.

- Causes of death - Important health problems - Infections - Occupations

A nurse is conducting a family health assessment and wants to use a genogram. The genogram, constructed with a diagram that evaluates each family member's health risks, includes what information? Select all that apply.

- Causes of death - Important health problems - Infections - Occupations

The nurse is interviewing a sexually active young adult who has multiple partners. Which of the following Sexually Transmitted Diseases would be a possible risk?

- Chlamydia - Genital Warts - Gonorrhea

A client has a medication, metoprolol (Lopressor), due at 0800, and the student nurse is not familiar with this medication. What information should be researched before giving this medication? Select all that apply.

- Classification of drug - The use of the medication - Body system affected

A posttraumatic sexual assault victim has a nursing diagnosis of Rape-Trauma Syndrome r/t sexual assault AEB guilt and embarrassment, physical trauma, fear, and self-blame. What nursing outcomes would be appropriate for this client? Select all that apply.

- Client will have a resolution of embarrassment, self-blame, guilt, and fear. - Client will state the results of the physical examination completed in the emergency department. - Client will discuss the need for follow-up crisis counseling and other supports.

Which are examples of protected health information? Select all that apply.

- Client's diagnosis - Treatment for depression - Account turned over to collections - Appointments

When educating a client, which are important factors to consider regarding the client's ability to learn and retain information? Select all that apply.

- Client's literacy level of client - Desire and motivation - Developmental and physical limitations - Barriers to communication - Culture and religious practices

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? Select all that apply

- Clients full name - Facility-assigned identification number

A client brought in from a sports injury to the right arm is being monitored for inflammation. What are the phases of the inflammation process the nurse should be watching for?

- Constriction of blood vessels to control bleeding - Phagocytes rush to the site and engulf bacteria and other foreign material - Exudate forms - Tissue is replaced through regeneration or repair

Which are the recommendations from the Centers for Disease Control for use of water in caring for contact lenses? Select all that apply.

- Contact lenses should be removed before showering or swimming. - Water can cause soft lenses to swell and stick to the eye. - If water touches the lens, the user should discard them.

Place in order the neuroendocrine responses that occur during the fight-or-flight response.

- Corticotropin-releasing hormone (CRH) is released from the hypothalamus. - Corticotropin-releasing hormone (CRH) stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH). - Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to release glucocorticoids (cortisol) and mineralocorticoids (aldosterone). - Antidiuretic hormone (ADH) stimulates the renal tubules to reabsorb water. - Endorphins are released by the hypothalamus and posterior pituitary, producing a sense of well-being and reducing pain. - Thyroid-stimulating hormone (TSH) is released by the pituitary gland to increase cellular metabolism efficiency and convert fat to energy.

Which factors can affect a person's hygiene practices? Select all that apply.

- Culture - Developmental level - Economic status

What should the nurse keep in mind when learning about cultures? Select all that apply.

- Culture is universal and dynamic - Cultural beliefs contribute to individuality - Culture is passed down throughout generations - Culture consists of common beliefs and practices - Culture assumptions and habits are unconscious

An elderly client is brought into the clinic by his or her adult children for a check-up. The nurse weighs the client and notices a weight loss of 10 lb since the last visit 6 months ago. For which factors should the nurse assess the client? Select all that apply.

- Current appetite level - Poorly fitting dentures - Available transportation

A registered nurse notices an increase in the unit of injuries related to anticoagulation therapy in elderly clients and wishes to conduct research. The nurse chooses a qualitative research design. What will be the characteristics of this design? Select all that apply.

- Data is derived from interviews and observations. - Data is objective and analyzed with statistical methods. - Data is gained from using small numbers of participants. - Data is obtained from the researcher's workplace or home setting. - Data is numerical and obtained through using questionnaires.

Which health challenges and functional difficulties are frequently experienced by the oldest-old age group, ages 85 and up? Select all that apply.

- Decreased vision - Difficulty hearing - Edentulism

The nurse is preparing a new skin care protocol for elderly residents in a nursing home. Which factors require specialized skin care for these clients? Select all that apply.

- Decreases in lean body mass - Thinning subcutaneous tissue layer - Diminishing sweat and sebaceous glands

A 78-year-old female was admitted overnight for confusion, delirium, and depression. She lives alone and has recently exhibited signs of memory loss and increased confusion, especially in the evening. She currently is on several medications for health-related issues, medication to help her sleep, and anti-anxiety medications. What should the nurse assess this client for?

- Dementia - Polypharmacy - Depression

Which factors increase the susceptibility of a host to infection? Select all that apply.

- Developmental stage - Illness or injury - Substance abuse

appropriate instructions to give to children if they encounter a firearm? Select all that apply.

- Do not touch it - Leave the area - Tell an adult

A client reports performing intense cardiovascular workouts every day for 45 minutes. Which information should the nurse include to prevent dehydration in the client? Select all that apply.

- Drink 8 ounces of fluid prior to exercise. - Continue to drink water throughout exercise.

Which factors lead to increased numbers of injuries in children and younger adults related to motor vehicle accidents?

- Driver distraction - Failure to use seat belts - Improperly placed car seats

Why is the role of teaching clients and families and ensuring their proper education important in health care? Select all that apply.

- Empowers autonomy - Allows client/family to perform self-care - Allows for informed decisions regarding health care

Which are advantages of online resources as sources of information? Select all that apply.

- Empowers clients to access information easily - Large amount of information easily available - Use of audiovisual materials engages clients - Private and can be used at any time

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? Select all that apply.

- Emptying urine from an indwelling urine collection bag - Providing oral care - Changing an ostomy pouch

When working with a postoperative bariatric client, how can the nurse promote client participation and adherence to the nursing plan?

- Ensure the client feels comfortable asking questions. - Keep the instructions simple, clear, and as specific as possible. - Determine if the client's goals for weight loss are the same as those in the nursing plan. - Help the client set realistic goals.

A nurse is caring for a 77-year-old client in the hospital. What are some methods the nurse can apply to promote independence and functional ability? Select all that apply.

- Ensure the client has access to a telephone at the bedside. - Ask the client if he or she would like to ambulate in the hall. - Offer the client meal choices.

Identify the five stages of illness behavior that individuals move through as they cope with disruptions in health.

- Experiencing symptoms - Sick role behavior - Seeking professional care - Dependence on others - Recovery

Which interventions should the nurse include when performing a procedure within the client's intimate space? Select all that apply.

- Explain to the client about the procedure. - Inform the client when the nurse will touch the client. - Acknowledge the client may be uncomfortable when the nurse is within the client's intimate space.

Which techniques are barriers to communication with clients? Select all that apply.

- Expressing approval - Providing false hope - Asking "why" questions

Which is a normal assessment finding for mental state and affect? Select all that apply.

- Eye contact - Awake, alert, and oriented - Mood appropriate for the situation

Which are parts of the assessment of the head? Select all that apply.

- Eyes - Ears - Throat

The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply.

- Fever - Urinary incontinence

Which behaviors should the nurse include when actively listening to a client? Select all that apply.

- Focus on nonverbal behaviors. - Face the client and lean in. - Sit at the eye level of the client.

Why might a client use folk healers instead of traditional medicine? Select all that apply.

- Folk healers share the client's values and beliefs. - Folk healers visit the sick in the home. - Folk healers speak the same language.

An older adult client's family members have reached out for help as they have seen a dramatic change in their father's "desire to live" and states he has disengaged from his family and friends, not attending functions he typically enjoys. What causes or situations should the nurse assess for when assessing this client?

- Forced retirement - Chronic illness - Death of relative/friend - Change in financial status

Which are examples of never events, or Serious Reportable Events? Select all that apply.

- Foreign object left in client after surgery - Catheter-associated urinary tract infection - Stage IV pressure ulcer that develops during hospitalization

Which type of data should be included in the discharge planning?

- Functional and self-care limitations - Emotional stability and ability to learn - Family or other caregivers available - Use of community services before admission

Place the action involved in the step of the nursing process in the order in which it occurs.

- Gather data. - Identify strengths and needs. - Developing outcomes and interventions. - Carry out interventions.

An older adult is being admitted after a fall in the assisted living facility in which she resides. The nurse recognizes that the client is somewhat disoriented and appears to be apprehensive. What can the nurse do to help ease the client and build trust?

- Gather information ahead of time and greet the client by name. - Introduce oneself to the client and family/caregiver if present. - Orient the client to the room and unit. - Establish a relationship with the client.

Place in order the steps for obtaining a sterile wound culture.

- Gather supplies and don nonsterile gloves. - Place an emesis basin under the base of the wound. - Irrigate the wound with a 35-mL syringe and 19-gauge angiocatheter. - Twist the top of the aerobic culturette tube to loosen the swab. - Press the swab against a beefy red portion of the wound bed. - Insert the swab into the aerobic culturette container. - Crush the bottom of the ampule to activate the culture medium. - Label the tube with the name, time, date, and source and send to the lab.

Which factors should the nurse take into account when interviewing clients? Select all that apply.

- Gender - Personal space - Developmental level - Sociocultural factors

Nursing theorist Jean Watson proposed that health consists of which elements? Select all that apply.

- General adaptive level of daily functioning - Absence of illness - High level of physical, mental, and social functioning

A client presents to the clinic requesting medication to help him or her sleep. The health-care provider diagnoses the client with insomnia. Which criteria would the nurse expect to be present related to this diagnosis? Select all that apply.

- Happens three days per week - Happens for at least three months

Which are examples of cue clusters for a nursing diagnosis?

- Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin - Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis - Urinary incontinence, lower abdominal pain, bladder spasm

Which concepts must be present in nursing theories? Select all that apply.

- Health - Person - Nursing - Environment

The Omaha interventions taxonomy provides four categories in community-oriented nursing practice. What are they? Select all that apply.

- Health teaching, guidance, and counseling - Treatments and procedures - Case management - Surveillance

Which chronic diseases are associated with increased risk due to smoking cigarettes? Select all that apply.

- Heart disease - Lung cancer - Emphysema

During a client's appointment at the women's clinic, she states her menstrual flow is very heavy, occurs about every 3 weeks, and is accompanied by severe abdominal cramping. The breast exam is normal, and the results of the Pap smear are normal. However, the client's hemoglobin level is low, and the nurse suspects the heavy menstrual bleeding may be causing anemia. Which information is considered primary data?

- Heavy menstrual flow every 3 weeks with severe abdominal cramping - Evidence of link between anemia and heavy menstruation

A home health nurse receives a referral to provide care to a client in his or her home. According to the Center for Medicare and Medicaid Services, what should the nurse document in the client's medical record? Select all that apply.

- Homebound status of the client - Ongoing need for skilled services

Clinical practice theories are instrumental in day-to-day nursing practice. Which are examples of theoretical practice? Select all that apply.

- Hospice nurse working with a newly widowed client - Basing the care plan for a 2-year-old client on the autonomy versus shame and doubt stage

The nurse is developing a plan of care for a client in the intensive care unit with fluid volume overload related to congestive heart failure who is receiving diuretics. Which factors can lead to altered sleep patterns for this client? Select all that apply.

- Hospitalization in an intensive care unit - Frequent urination related to diuretic use - Repeated interruptions throughout the day and night

Which might serve as settings for health promotion programs? Select all that apply.

- Hospitals - Schools - Workplaces

Which are measures that can support defenses to make a host less susceptible to infection? Select all that apply.

- Hygiene - Eating vegetables - Immunizations

Which scenarios are considered collaborative problems?

- Hyperglycemia with type 2 diabetes - Infection in a postsurgical client - Hemorrhage in a postpartum client

What are the components of a computerized literature search? Select all that apply.

- Identify the information - Formulate a clear definition - Use the search parameters

In which situation would hand hygiene with alcohol-based hand sanitizer not be appropriate? Select all that apply.

- If hands are visibly soiled - When there is a possibility of contact with bacterial spores.

How is critical thinking used in nursing other than in the nursing process? Select all that apply.

- In determining how many nurses to staff during a shift - When creating a list of inventory needed for the unit

The nurse is educating a group of high school students about the hazards of tobacco use. Which information about tobacco use can the nurse include during this session?

- Increases risk for cancer - Leads to low-birth-weight babies

The nurse is educating a group of teenagers regarding obtaining sufficient amounts of sleep. Which consequences of sleep deprivation should the nurse include in the presentation? Select all that apply.

- Increases sensitivity to pain - Intensifies insulin resistance - Increases the appetite and intake

Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority.

- Ineffective airway clearance - Ineffective breathing pattern - Deficient fluid volume - Risk for fall - Wandering - Impaired memory

Which are appropriate client teaching topics for nurses to provide to clients regarding nail care? Select all that apply.

- Inspect nails daily. - Clip toenails straight across. - Use moisturizing lotion to soften cuticles.

The nurse is educating a client with new onset type 1 diabetes mellitus regarding microvascular and macrovascular complications. Which interventions should the nurse instruct the client to include in daily care to prevent skin breakdown? Select all that apply.

- Inspect the feet daily. - Dry the feet thoroughly. - Wear well-fitting shoes.

The nurse is preparing to administer morning medications to a client. As the nurse reviews the electronic medication administration record, which medications require an assessment prior to administration? Select all that apply.

- Insulin - Digoxin - Antihypertensive - Chemotherapy drugs

Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply.

- Irregular wound edges - Wound bed beefy red - Periwound area reddened

When creating a nursing diagnosis for a client with renal failure, what questions should the nurse ask during the assessment process?

- Is the client still producing urine? - What is the client's oral intake? - Does the client exhibit signs of edema? - Can the client engage in activities of daily living?

When creating a nursing diagnosis for a client with renal failure, what questions should the nurse ask during the assessment process? Is the client still producing urine?

- Is the client still producing urine? - What is the client's oral intake? - Does the client exhibit signs of edema? - Can the client engage in activities of daily living?

Why is detailed client education important in today's health-care environment? Select all that apply.

- It helps reduce and manage health-care costs. - Hospital stays are shorter. - Clients can participate in health-care decisions.

Which activities would help a client reduce the risk for developing chronic disease?

- Jogging for 15 minutes most days - Walking on a daily basis - Gardening for 30 minutes a few days per week

How are medications eliminated from the body? Select all that apply.

- Kidneys - Blood plasma - Lungs - Intestinal mucosa

Which factors usually prevent nurses from providing spiritual care to clients? Select all that apply

- Lack of time - Lack of privacy - Lack of nursing expertise

Which factors usually prevent nurses from providing spiritual care to clients? Select all that apply.

- Lack of time - Lack of privacy - Lack of nursing expertise

Which are measures that should be taken by health-care workers to decrease radiation exposure for a client with a radioactive implant? Select all that apply.

- Limit the amount of time spent with the client. - Perform care near the client only when necessary. - Wear a lead apron.

There is a difference between a population and a vulnerable population. What are the characteristics of a vulnerable population? Select all that apply.

- Limited economic resources - Extremes in age - Chronic diseases

List the appropriate order of the chain of infection

- List the appropriate order of the chain of infection - Pathogen exists - Pathogens multiplies - Portal of exit and contact with another organism - Mode of transmission/contact with a susceptible person - Susceptible host/Pathogen is no longer contained

A client reports a pain rating of 9 on a scale of 1 to 10. The nurse administers an intravenous narcotic analgesic to the client. What will the nurse include when documenting this task? Select all that apply.

- Location and characteristics of the pain - Client's pain level 30 to 60 minutes after the medication is given - Administration of the intravenous narcotic analgesic medication

Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply.

- Location of the wound - Length, width, and depth - Presence of undermining or tunneling - Drainage amount, color, consistency, and odor

The nurse suspects that an older adult patient may have difficulty hearing. Which strategies will the nurse use to improve communication? Select all that apply.

- Look directly at the patient when speaking. - Speak more slowly than usual. - Speak loudly toward the patient's ears. - Allow some extra time for the patient to respond.

At which points of client care must the nurse complete a discharge summary? Select all that apply.

- Moved to an acute rehabilitation unit - Transferred to a long-term skilled facility - Allowed to leave the hospital and go home

Which changes can be noted during the deepest stage of non-REM sleep? Select all that apply.

- Muscles relax - Heart rate lowers - Respirations decrease

Which environmental factors should the nurse control when interviewing a client? Select all that apply.

- Noise - Odors - Comfortable temperature

Which are examples of primary defenses of the body against infection? Select all that apply.

- Normal flora - Skin - Saliva

A sixth-grade female is undergoing her physical examination. What should the nurse assess for during this visit?

- Nutrition and BMI - Scoliosis - Visual Acuity - Hepatitis B immunization

Which are common health problems of middle adulthood? Select all that apply.

- Obesity - Hypertension - Cancer

Which of the following are unique to the Scientific method of acquiring knowledge? Select all that apply.

- Objectivity - Use of Empirical data

A student nurse is bathing an obese client for the first time. What intervention could be suggested for bathing this client? Select all that apply.

- Offer a handheld shower with a long-handled brush. - Apply moisture barrier creams after bathing. - Separate skin folds with towels. - Rinse and dry the skin well.

Which sleep disorders are considered secondary and are caused by underlying health disorders? Select all that apply.

- Pain - Depression - Hyperthyroidism

A client with peripheral arterial disease presents to the clinic with an open wound to the left shin. Which clinical manifestations would the nurse expect to find during the assessment? Select all that apply.

- Pain - Loss of hair - Tissue necrosis

Which of the following are emphasized in Benner's expert nurse theory? Select all that apply.

- Patient - Environment - Health

A nurse is assisting a morbidly obese client with bathing. Which specific considerations should be taken? Select all that apply.

- Pay special attention to drying skin folds. - Provide a trapeze to assist with movement. - Provide a long-handled shower head or brush.

Health-care economists predict several changes in the home care industry over the next few decades. What are the driving factors? Select all that apply.

- People are living longer - Research is needed to improve effectiveness of care in the community. - There is an increased demand for hospice and palliative care.

What factors influence the health-illness continuum?

- Personal perceptions - Genetic makeup - Gender - Age

Which are secondary defenses of the body? Select all that apply.

- Phagocytosis - Inflammation - Fever

Which nursing interventions are considered direct-care interventions?

- Physical care - Emotional support - Client education

A nurse is assisting a client who has had a stroke that caused the loss of use of the left side with activities of daily living. What actions can the nurse take to encourage self-care and as much independence as possible?

- Place all hygiene items on the client's right side and assist with what the client cannot reach.

A client who has a strong spiritual belief in healing is in the adaptation stage of stress. What practices might this client engage in to reduce stress?

- Practice meditation - Pray - Meet with clergy

There are four essential phases of a therapeutic relationship. Place these statements in order from first phase to last phase.

- Pre-interaction phase - Orientation phase - Working phase - Termination phase

Place the stages of change in the appropriate order according to the transtheoretical model of change.

- Precontemplation - Contemplation - Preparation - Action - Maintenance

Match the stages of the transtheoretical model of change to the behavior.

- Precontemplation - Contemplation - Preparation - Action - Maintenance - Termination

A client is scheduled for an annual PPD for work. What considerations should the nurse be aware of before administering this test? Select all that apply.

- Pregnancy - Previous skin reaction - Use of topical anesthetic

Which are care and hygiene challenges nurses must consider when providing care for morbidly obese clients? Select all that apply.

- Pressure - Friction and sheer - Moisture

The nurse is working with an older client who wants to begin an exercise regimen. The client asks the nurse about the benefits of moderate walking 30 minutes per day. What would be the nurse's best response? Select all that apply.

- Prevents falls - Improves memory - Reduces depression - Lowers risk of Alzheimer's

What are the functions of the stratum corneum layer of the skin?

- Prevents water loss - Functions as a protective barrier - Stops chemicals from entering the body

The nurse contacts the primary health-care provider about a change in a client's status. The primary health-care provider in turn gives the nurse orders over the telephone. What are the nurse's responsibilities related to accepting these orders? Select all that apply.

- Pronouncing numerical digits separately - Spelling out any unfamiliar names or words - Repeating what was stated before hanging up - Having a second nurse listen to verify the orders

What are the goals of infection prevention and control in health care? Select all that apply.

- Protect clients from contagions. - Lower the cost of health care services. - Meet professional standards and guidelines. - Protect employees from contracting infections.

The postsurgical client on the medical-surgical unit has suffered a stroke and is now being transferred to the ICU. How can the nurse assigned to this client help make this transition as easy as possible with less stress on the family?

- Provide for teaching needs. - Ensure safety and comfort. - Communicate with the new unit.

Which falls prevention measures can a nurse delegate to nursing assistive personnel?

- Provide nonskid slippers. - Lock beds and wheelchairs. - Keep room free of clutter.

Which of the following would be important components of an adolescent health history?

- Psychosocial profile - Nutrition and body image - Tattoos and piercings - Sleep patterns

Which would be considered critical thinking skills when assessing a newly admitted client who has Alzheimer's disease and pneumonia? Select all that apply.

- Questioning the client's family or caregivers as well as the client for clarification of information - Separating random information from pertinent information - Carefully reading the physician's notes and orders and prioritizing how to proceed with the nursing plan

What conditions are contraindicated in rectal suppository administration? Select all that apply.

- Recent rectal surgery - Rectal bleeding - Cardiac disease

What should the nurse include when trying to motivate a group of adolescents to include exercise in their daily regimen? Select all that apply.

- Recognize barriers to exercise. - Reward yourself when goals are met. - Tailor the exercise regimen to meet needs.

How is a telephone application improving the at-home care delivered by home health aides? Select all that apply.

- Records the time they arrive. - Records the location of the patient care. - Increases time spent with patient because of less recording by the home health aide.

Which interventions should the nurse include in the plan of care for a postmenopausal client with osteoporosis? Select all that apply.

- Refrain from cigarette smoking - Perform weight-bearing exercises - Include Vitamin D and phosphorus in daily intake.

A nurse is about to plug in an IV pump and notices that the electrical cord is frayed. What action should the nurse take?

- Remove the pump from service and submit a work order for repair.

Which nursing interventions are important for the home health nurse to perform to promote safety when caring for elderly clients?

- Removing throw rugs - Moving electrical cords - Changing positions slowly - Using visual and hearing aids

What should the nurse include to promote effective communication with the health-care team? Select all that apply.

- Report any concerns to the proper person. - Discuss any clinical errors with coworkers. - Question the health-care provider regarding unclear orders.

Which are examples of nursing diagnoses?

- Risk for impaired skin/tissue integrity - Ineffective impulse control - Insufficient breast milk

When educating an older adult on maintaining functional ability and promoting independence, what information should be included?

- Safety issues such as changes in stamina and reflexes - Illness prevention and immunizations - Encourage physical exercise - Facilitate empowerment

Which neurotransmitters are related to excitatory and inhibitory sleep mechanisms? Select all that apply.

- Serotonin - Histamine - Prostaglandins - Acetylcholine

A 22-year-old female has been brought into the emergency department by EMS after she was found nonresponsive on the sidewalk outside a liquor store. She appears to be disheveled with a foul body odor, has an extremely low body weight, and is indicating that she is in pain. The triage nurse assumes she is homeless and a drug user and quickly takes her vital signs without speaking to her, and gives only short answers to her questions. What aspect of communication has this nurse not engaged in?

- Settling in - Acceptance - Attuning - Enjoying

An adolescent reports constant fatigue and an inability to stay awake in school. Which factors should the nurse assess for that could be interfering with sleep? Select all that apply.

- Smart phone use - Drug and alcohol use - Caffeine consumption - School work and studying

Which are common causes of fire in a health-care setting?

- Smoking - Anesthesia - Malfunctioning electrical equipment

Which lifestyle choices can lead to alterations in skin integrity? Select all that apply.

- Smoking - Tanning

The occupational health nurse is educating a group of workers who do heavy lifting. Which safety aspects should be included in the session? Select all that apply.

- Squat to lift objects. - Spread legs apart when lifting. - Use thigh muscles when lifting.

Place the markers of developmental stages of children in the appropriate order.

- Stepping reflex - Throwing tantrums - Imaginative play - Peer relationships become important

What are considered components of a community? Select all that apply.

- Structure - Status - Process

Which type of exercises should the nurse recommend to an obese client to reduce pain and increase compliance? Select all that apply.

- Swimming - Using a rowing machine - Riding a recumbent bike

In which ways can anxiety interfere with a client having a restful night's sleep? Select all that apply.

- Tachycardia - Increased respirations - Increased gastric secretions

Which factors can affect geriatric clients' ability to obtain adequate sleep at night? Select all that apply.

- Taking longer to fall asleep - Awakening for longer periods during the night - Nocturia interfering with sleep

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? Select all that apply.

- Teach the client to use the call light - Keep the client's bed in the lowest position - Place a fall-risk identification band on the client's wrist

There are differences between how nursing care is delivered in the hospital and in the home setting. What is unique to providing care in the home? Select all that apply.

- The client is in control if care will be delivered. - The nurse is responsible for making assessments and deciding when to advise the primary care provider of client changes. - The nurse must have all supplies available ahead of time. - The nurse must be able to distinguish between skilled and homemaker services.

Which precautions and considerations should a nurse take when bathing a client with dementia? Select all that apply.

- The client may experience fear and loss of control. - Clients who are agitated during a bath my stay agitated for hours. - Prepackaged bathing products can help complete the bath faster and more comfortably.

What requirements must be met in order for home health services to be reimbursed by Medicare? Select all that apply.

- The client needs a skilled service. - The agency needs to be approved by Medicare - The client is homebound. - The client requires intermittent nursing care. - The care must be authorized by a physician.

What is the fundamental concept of Neuman's health continuum?

- The more energy generated than expended, the healthier an individual will be. - When energy output exceeds input, illness occurs.

The diabetic nurse educator is meeting a new client recently diagnosed with type 2 diabetes mellitus. Which statements are accurate about what this nurse will accomplish during the orientation phase? Select all that apply.

- The nurse explains that information will be shared with the primary health-care provider. - The nurse establishes a level of trust with the client by providing the client with accurate information.

When arriving to take a client's blood pressure, a nurse witnesses an argument between the client and spouse. Recognizing that stress can alter blood pressure, the nurse encourages the spouse to step out and get something to drink, giving the client an opportunity to calm down. The nurse returns later to take the client's blood pressure after the client has had time to settle down. What is true about this situation? Select all that apply.

- The nurse used theoretical knowledge by recognizing the argument would raise blood pressure. - The nurse used ethical knowledge by returning to get an accurate reading instead of just assuming the client's blood pressure would return to normal. - The nurse used practical knowledge by communicating with the spouse and suggesting a break in order to get an accurate reading.

Which of the following are part of informed consent? Select all that apply.

- The right to know what is expected - The right to be provided written information - The right to provide written consent

Which statements describe theories? Select all that apply.

- Theories help find meaning in our experiences. - A theory organizes thinking around an idea. - Theories assist in the development of ideas or insight into work performed.

Which of the following are true about Conceptual Frameworks? Select all that apply.

- They have not been tested in Practice - They are broader than a theory - They contain a set of concepts

Which are benefits of large systems using electronic health records (EHRs)? Select all that apply.

- To develop better disease treatment methods - To understand disease causes and progression - To determine outcomes for various populations

Which are examples of health behaviors that affect overall status of health? Select all that apply.

- Tobacco use - Sedentary lifestyle - Use of recreational drugs

Which are components of an effective culture of safety on a nursing unit? Select all that apply.

- Transparency - Accountability - Team empowerment

According to the Health Information Portability and Accountability Act Privacy Rule, protected health information can be shared for only which purposes? Select all that apply.

- Treatment - To ensure everyone on a nursing unit is aware of the client - Reassurance to family - Payment - Operations - Understanding past treatments

A nurse is visiting a new home health client who was discharged after partial amputation with a Foley catheter and a history of diabetes. What should the nurse assess for increased risk of infection for this client? Select all that apply.

- Uncontrolled home environment - Increased use of indwelling devices - Complexity of illness and care outside of the hospital - Ineffective reporting and monitoring

Which are contributing factors for escalation of violent behavior? Select all that apply.

- Under the influence of drugs or alcohol - Chaotic environment - History of violent behavior

Which are classification systems for drugs? Select all that apply.

- Usage - Body system - Chemical or pharmacological class

Which of the following safety interventions should the nurse review with the school-age child and his or her parents?

- Use a helmet while bicycling - Use safety equipment while playing sports - Wear a seatbelt in the car

What should the nurse educator include when giving a presentation to a group of nurses about ways to prevent nurse back injuries while transferring a patient? Select all that apply.

- Use of electric or mechanical lift for transfers - Obtain assistance from other staff members - Lock wheels and furniture and equipment before moving clients.

Due to social media, adolescents are more likely to contract an STD. Which of the following is contributing to this growing trend? Select all that apply.

- Use of social media for "hooking up" - Concurrent sexual partners and multiple sexual partners - The belief that condoms protect from all STIs - Oral sex has increased in prevalence among adolescents

Which of the following techniques would the nurse use when communicating with someone who has cognitive deficits? Select all that apply.

- Use simple short sentences. - Repeat your words exactly.

Based on what has been learned about personal relationships and health status, which families would experience higher levels of wellness?

- Views the family as capable and successful - Teaches good negotiation skills, builds a network of family support, while encouraging the development of independence - Encourages open communication and works through disagreements

Which represent the main groups of pathogenic microorganisms seen in a health-care setting? Select all that apply.

- Viruses - Bacteria - Fungi

A nurse is preparing to teach an older adult client about his or her new blood pressure medication and diet modification. Which barriers should the nurse assess for prior to teaching? Select all that apply.

- Vision impairment - Reduced mobility - Medication effects

Verbal communication is a key process for caring for clients. Verbal communication consists of which factors? Select all that apply.

- Vocabulary - Pacing and rhythm - Timing and relevance

Place the procedural steps in order for administering otic solutions.

- Warm the otic solution bottle in hand. - Assisting the client, have him or her lie on the side with ear facing up. - Clean the external ear with cotton tip swab. - Fill the dropper with the appropriate amount of solution. - Straighten the ear canal as appropriate for age. - Instill the designated number of drops. - Gently tug on the ear. - Instruct the client to remain on the side for approximately 5-10 minutes. - Place a cotton ball, or a piece of cotton, in the opening for approximately 15 minutes.

Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply.

- Weather - Pollutants - Financial strains

The nurse is caring for a client who fell while trying to get out of bed without assistance. As the nurse is completing the incident report, what should the nurse include in the documentation? Select all that apply.

- What happened in an objective manner - Actual statements from the client - The date, time, and location of the incident

Which are issues a nurse should be aware of when assessing anxiety and ego defense mechanisms?

- When used sparingly, defense mechanisms can be helpful. - When overused, defense mechanisms become habits that appear as if we are coping. - If defense mechanisms are inadequate to diminish perceived threats and restore equilibrium, anxiety disorders may develop.

Which are examples of secondary prevention activities? Select all that apply

- Yearly mammogram - Lipid screening - Scoliosis screening

A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? Select all that apply.

- bid - 30 mL

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. Prior to the scan, the client consumes 12 oz sodium diatrizoate and megluminet diatrizoate. The client has an IV of D5 1/2 NS running at 75 mL/hr from 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500. At 1500, the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?

1005 mL Sodium diatrizoate and meglumine: 12 oz 1 oz = 30 mL 12 oz X 30 = 360 mL D5 1/2 NS IV: 75 mL/hr from 0700 until 1200: 75mL/hr X 5 hr = 375 mL 30 mL/hr from 1200 until 1500: 30 mL/hr X 3 hr = 90 mL Total IV intake = 90 mL + 375 mL = 465 mL Juice: 6 oz 1 oz = 30 mL 6 oz X 30 = 180 mL Total the amounts: 360 mL + 465 mL + 180 mL = 1,005 mL

The nurse is assessing a client's risk for skin breakdown using the Braden scale. The nurse notes: The client is alert and oriented to person and is able to answer commands. The client has skin that is occasionally moist due to urinary incontinence. The client stays in the chair most of the day, needs assistance to get up. The client is unable to reposition on his or her own and frequently needs to be pulled up in bed. The client eats about 50% of breakfast and dinner but frequently skips lunch. What would the nurse rate as the client's Braden score? Enter numeral only.

14

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?

1800

A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose?

3 capsules Have/Quantity = Desired/X 300 mg/1 capsule = 900 mg/X capsule X = 3

A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr?

35 mL/hr

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following results should the nurse expect?

4.0

Which description best explains learning?

A change in behavior, knowledge, skills, or attitudes to reach common goals

A community health nurse wants to conduct a community assessment with a population of 50,000 people. What assessment method is the most cost-effective?

A windshield survey

Which type of immunity is present when the body makes its own antibodies or T cells to protect the body against a pathogen?

Active

The nurse has been alerted that a special needs client is about to be admitted from the residential facility. What would be an appropriate way to alleviate anxiety and ease the transition?

Allow more time for the admissions process if preadmission cannot be arranged.

What is the benefit of using an automated dispensing system?

Allows for immediate availability and administration of newly prescribed and prn medications

The nurse is reviewing electroencephalograph results for a client who reports sleep difficulty. Which waves would the nurse expect to disappear when the client is asleep?

Alpha

What is the best explanation of teaching?

An interactive process involving planning and implementing instructional activities that meet intended outcomes as well as activities that allow the learner to learn

A nurse is learning about various communication concepts and techniques. Which statement by the nurse is correct about intrapersonal communication?

An internal dialogue is known as self-talk.

A client presents with sweating, trembling, and is tearful stating they are nauseated and feel restless. What should the nurse assess this client for?

Anxiety

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

The nurse is providing frequent dressing changes to an abdominal wound due to large amounts of drainage. The repeated use of tape is irritating the skin. Which intervention would be the best option for the nurse to use to alleviate the problem?

Apply Montgomery straps

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time

Which would be an appropriate intervention for the nursing diagnosis of Self-care deficits related to fatigue and mental status changes?

Arrange for care as needed, and teach caregivers how and when to seek professional help.

The nurse enters the room of a client who is unresponsive. Which intervention best helps the nurse establish communication during the orientation phase?

Ask family members how the client would prefer to be addressed.

The nurse enters the room of a client who is tearful and holding a rosary. The client states he or she has been given a terminal diagnosis. In addition to sitting down with the client to talk, what is the best intervention for the nurse to implement first?

Ask the client if he or she would like the chaplain to visit.

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Assess the client

Which describes the use of the Morse scale?

Assesses a client's likelihood of falling

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment

The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursing plan?

Basic three-part statement

Which term describes a type of bath in which a client is in bed but able to bathe himself or herself?

Bed bath

A client has a high risk of gum bleeding due to painful mouth lesions. What might the nurse consider as a precaution?

Brush teeth with a foam or cotton mouth swab

A client is brought by ambulance to a hospital after being found in a closed garage with the car running. The physician orders 100% humidified oxygen. Which type of poisoning does this client have?

Carbon monoxide inhalation

Which is a leading cause of death in the middle adult years?

Cardiovascular disease

A nurse becomes irritated with a client who is requesting more ice chips and refers to the client as "the ice man in 201" to other nursing staff. In which important component of nursing has the nurse failed to engage?

Caring

A client reports to the nurse that there is drainage leaking around the Jackson-Pratt (JP) drain. The nurse notices the JP drain bulb is empty and the dressing is saturated with serosanguineous drainage. What should the nurse do first?

Check the JP drain tubing for kinks

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

Using structural-functional theory, the nurse is working with a family going through a divorce. As the nurse plans the sessions, what will be the focus?

Children developing healthy coping patterns

Which fire extinguisher classification is approved for use with combustible metals?

Class D

While conducting research on weight management among Native Americans, what information would be integral in developing a theory?

Client preferences regarding weight management (timing, location, and costs) and how meeting these preferences will influence success

Which communication technique allows the nurse to provide input while discussing goals at the client's bedside?

Client rounding

Which is an appropriate goal statement for a postpartum female client with a nursing diagnosis of "lower abdominal pain r/t uterine contractions and hyperextension of cervix"?

Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period.

When assessing a young adult, what characteristics might alert the nurse to potential diabetes or heart disease?

Clients who are overweight

Which intervention can the nurse include in the plan of care for a client in the hospital to promote sleep and rest?

Clustering activities

Which domain of learning skills describes the mental activities for processing incoming information?

Cognitive

A community health nurse is concerned about poor compliance with recommended immunization schedules for infants (birth to 2 years). After surveying some of the parents, it is determined there are many variables inhibiting compliance, such as limited clinic hours, difficulty making appointments through an automatic system, and no reminder call/email or follow-up intervention. When meeting with staff, managers, and physicians to resolve the issues, it is revealed there are many underlying issues that must be addressed, such as an insufficient number of providers available to treat this demographic. This nurse is acting in what capacity?

Collaborator

According to general systems theory, which element is part of the suprasystem?

Community

A nurse provides a bath in which the nurse washes the client's entire body. The client is unable to assist. Which type of bath is this?

Complete bath

Which describes the entry of orders directly into an electronic health record by a provider?

Computerized physician order entry

Which information is needed to record an evaluative statement?

Conclusion and supportive data

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

Which is the appropriate initial action if a client has a possible poisoning?

Contact the nearest poison control center

A recently widowed 72-year-old client expresses concern about living alone and is fearful of falling and safety issues. Other than typical age-related issues, she is healthy and social. What type of living environment could the nurse recommend for her?

Continuing care retirement community

A 76-year-old female client has recently been moved to an assisted living facility by her family due to declining health and inability to care for herself. The nursing staff notices she is having a hard time adjusting and appears to be confused and depressed. What can be suggested to help her feel more at home and improve her health and well-being?

Create an area in her room with pictures and other items from home to brighten her environment, making it feel more like her space.

Which are discrete entities that are described objectively without interpretation?

Data

A home care nurse is developing nursing diagnoses for a 78-year-old client with congestive heart failure who has been admitted to the hospital three times in 4 months. What nursing diagnosis is the highest priority for this client?

Deficient knowledge

Which would be the most appropriate teaching strategy for a 9-year-old who is learning to clean his or her new stoma following a colectomy?

Demonstrate on a model how to clean the stoma, and then allow the child to try the same technique.

A client has had COPD and emphysema for 11 years and has continued to work and support his or her family. When approached by the nurse, the client states, "I would be better off dead." Because of oxygen dependency, the client must quit work, and the spouse will have to begin a new job and support the family. Which action should the nurse take?

Develop a care plan for the family.

Which of the following is an example of the intimacy vs isolation phase of social development for young adults?

Developing lasting friendships and associations

There are various types of disasters that an emergency response nurse may be involved in. What is a biological disaster?

Disasters that involve exposure to pathogenic microorganisms, toxins, or other bioactive substances

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Discard the tablet and obtain another dose of medication

A client with rheumatoid arthritis (RA) informs the nurse he or she wants to begin an exercise program to prevent the disease from getting worse. What should the nurse instruct the client?

Do your exercise in the afternoon or evening

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD), becomes fatigued easily, and is unable to perform all activities of daily living (ADLs). The work of which nursing theorist would best help the nurse plan care for this client?

Dorothea Orem

A nurse has just completed inventory on the controlled substances on the unit, has completed necessary documentation, and locked the cabinet. He or she walks away, leaving the locked cabinet on the counter in an open workstation. What step has the nurse not completed?

Double-locking the controlled substances

The student nurse is about to administer a rectal suppository to an older adult. What advice should the preceptor offer this student in regard to older clients and rectal suppositories?

Due to poor sphincter control, a bed pan should be used during the procedure.

The nurse is obtaining a health history from a 22-year-old female client. Which of the following would be an appropriate recommendation from the nurse regarding exercise?

Exercise at a moderate intensity for 2.5 hours a week

The nurse is working with a client who is having difficulty understanding how to self-administer insulin. The client apologizes and the nurse says it is okay, but the nurse then turns around and rolls his or her eyes. Which type of nonverbal communication demonstrates the nurse's true feelings?

Facial expression

A client is processing information regarding a new diagnosis and the treatment the physician has recommended. The client's family has provided excessive input and are attempting to have the nurse "convince" the client to see things their way. Which Critical thinking attitude should the nurse present?

Fair-mindedness

Which theory used by the nurse caring for a family would focus on the roles of each family member?

Family interactional theory

A nurse has been taught how to set up a sterile field and sets one up with supervision from the preceptor. When the nurse has finished, the preceptor says, "You did a good job with the sterile field, but you need to work on adding items to the field. You almost contaminated it at one point." Which is this an example of?

Feedback

Which type of exercise program does a nurse recommend to an older adult to prevent injury and muscle strain?

Flexibility

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

Which statement best describes how Florence Nightingale's theory benefits nursing today?

Hand hygiene greatly decreases nosocomial infections.

Which describes the universal symbol for choking?

Hands clutching the neck

A client presents to her physician's office. She reports that her husband left her and their two children about 6 months ago. She said she was depressed for a time, but she is now taking classes to earn a degree and has a weekly support group. Which characteristic is she exhibiting in response to stress?

Hardiness

Finding ways to help individuals develop a state of physical, spiritual, and mental well-being refers to which health concept?

Health promotion

The family asks the student nurse if the client can have a piece of cake. The student nurse states, "No, unfortunately the client is NPO." Which type of communication is the student nurse using?

Health-care jargon

Which of the following known prevention measures can help older adults avoid many illnesses and disabilities associated with chronic diseases?

Healthy lifestyle and immunizations

Which of the following examples of age and demographics would likely have the longest lifespan at birth according to data from National Center for Health Statistics (2017)?

Hispanic female

Which is the leading cause of complications of hospital care?

Hospital-acquired infections

A co-worker makes a sarcastic remark when the nurse is late for their shift and "throws" a stack of paperwork and a list of clients who need assessing to them before they can settle in. Why is this co-worker possibly behaving this way?

Hostility and resentment of the late nurse

The nurse begins a shift, performs a client assessment, and then proceeds to prepare to administer medications. At what point should the nurse document the assessment?

Immediately after the assessment

A client has been prescribed an antibiotic that has side effects including nausea, vomiting, abdominal pain, and diarrhea. What nursing intervention would be appropriate for this client?

Instruct the client on side effects, what to report, and when.

Asking questions that begin with "What if ...?" or "How can we ...?" are characteristic of a nurse who has which critical thinking quality?

Intellectual curiosity

The nurse is caring for a client admitted with abdominal pain, nausea, and a bowel obstruction. The client states, "I feel nauseous, and I am going to vomit." The nurse administers an antiemetic after the client vomits 200 mL of greenish-brown fluid. In the SOAPIE documentation system, under which aspect would the administration of the antiemetic be documented?

Interventions provided

Which is the correct meaning of the abbreviation IVPB?

Intravenous piggyback

A client is brought into the emergency department in shock due to a trauma. What method would be the most effective route for administering emergency medications?

Intravenously

Which is the best action of the nurse to build trust in an elderly client who has been admitted to an emergency facility?

Introduce oneself to the client and explain his or her role.

What should the nurse monitor in a client who is taking blood pressure medication?

Ischemia

A client who is bedridden asks the nurse what exercises can be included to prevent muscle atrophy. What is the nurse's best response?

Isometric

How can telehealth be beneficial to healthcare?

It allows the client to be empowered for self-management.

Why is the diagnosis step critical to the nursing process?

It connects the assessment with planning, interventions, and follow-up evaluation.

The nurse is caring for a client who is deficient in protein and has poor skin turgor. Which skin cells would be causing this to happen?

Keratinocytes

Which type of joint is a synovial joint?

Knee joints

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A client presents to the clinic after falling in a parking lot and sustaining an injury. There is a break in the skin with jagged edges. There is no evidence of foreign debris in the wound. As the nurse documents the wound care, which term would the nurse use in the health record?

Laceration

Tuberculosis that is acquired by an individual who has no symptoms for several years is an example of which type of infection?

Latent infection

The nurse is preparing to administer an insulin injection to a client with an elevated blood glucose level. What should the nurse check in the electronic medication administration record prior to giving the dose?

Location of last injection

Mrs. Williams is a 67-year-old woman who was admitted yesterday after suffering a stroke that paralyzed her right side. She has a history of diabetes and high blood pressure for many years, but has been able to manage her health care up to this point. Since the stroke, she has been unable to speak clearly and becomes frustrated as she attempts to communicate her needs. Her daughter states her mother is a proud, independent, and tidy woman who has been living alone since her husband's death 8-months ago. Until her stroke, she had been driving her car, cleaning her house, doing her grocery shopping, and maintaining the yard and garden. What could be the most likely new stressor for Mrs. Williams as she enters the hospital?

Loss of privacy and control

A nurse is attempting healthy lifestyle teaching for a client who has new onset hypertension. She begins to provide information about lifestyle changes. The client responds, "What's the point of this? If I get sick, I get sick. It's just meant to be." What does this reflect in regard to this client's locus of control?

Low sense of control

According to Maslow's hierarchy of needs theory, which basic level of physiologic need must be met before higher level needs can be addressed?

Making sure the client has food

The 48-year-old male client is about to be discharged in tomorrow after having total hip arthroplasty of his right hip. He has been following the nursing care plan and has made tremendous progress towards recovery and the physician feels he is ready to be released with continued physical therapy and the use of an ambulatory aid (walker). After a visit with his spouse and children he begins to exhibit signs of regression and begins to complain of excessive pain and extreme fatigue and states he doesn't think he's ready to go home. What should the nurse assess for in this client?

Malingering

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

Malpractice

There are various insurance companies that pay for health-care services. What is unique about Medicaid?

Medicaid is insurance that is jointly sponsored by the federal and state governments.

What is a CAM (complementary and alternative medicine) therapy a nurse can teach the client that involves a heightened awareness of the mind, body, and spirit?

Meditation

Which is the largest medical database online?

Medline

Which communication element is being used by the nurse when he or she informs the charge nurse of an inability to handle a new admission?

Message

The nurse is working with a client newly diagnosed with narcolepsy. Which treatment regimen would the nurse expect to be prescribed for this client?

Methylphenidate (Ritalin)

What intervention should be implemented for an aging adult with a nursing diagnosis of Readiness for increased activity level r/t frailty prevention?

Moderate-intensity group exercise three times a week for 30 minutes.

Which would be considered a bloodborne pathogen exposure?

Needle stick injury

Which sleep disorder involves a person suddenly waking up thrashing about and hallucinating?

Night terrors

The nurse documents, "Anxiety related to change in health status and situational crisis." This is an example of which step in the nursing process?

Nursing diagnosis

A new antibiotic is prescribed to treat the client's pneumonia. The student nurse feels more information is needed to plan nursing interventions based on side effects of the drug. What resource would be best suited to obtain this information?

Nursing drug handbook

The nurse uses the SOAP format for documentation and types in a client's medical record, "The left coccyx wound is reddened and measures 1 cm x 2 cm x 0.2 cm and is without drainage." Which aspect of the SOAP format is this considered?

Objective

The nurse recognizes his coworker has been working 12 hour shifts and picking up extra shifts in between on different units. Lately, she has experienced several clients who have expired or have been diagnosed with late stage cancers. He notices the coworker has made several mistakes when conducting inventory on the meds cabinet and has been extremely fatigued, forgetful, and has been preoccupied. What should the nurse do to help prevent burnout in the coworker?

Offer support to help with tasks or with their feelings and suggest speaking with a supervisor

A client admitted 2 days ago has not slept well due to pain from injuries. The nurse recognizes this and adjusts the client's nursing diagnosis to reflect the change in status. The nurse then creates a new plan to address the change. What type of planning is this considered?

Ongoing planning

Which type of communication would the nurse be using when giving a bedside change of shift report to another nurse?

Oral communication

In which position should the nurse place the client with chronic obstructive pulmonary disease (COPD) who is short of breath?

Orthopneic

Evelyn is a 47-year-old who recently lost her husband suddenly in a tragic accident. In addition, she is responsible for the daily care of her elderly mother who is suffering with Alzheimer's and failing health. Evelyn is in the office complaining of chest pain, extreme fatigue, and shortness of breath. Upon assessment, it is discovered she has gained about 10 pounds in a short period of time and has started smoking again after being a non-smoker for 25 years. What should the nurse investigate further in Evelyn?

Other issues or stressors suggesting maladaptive coping issues.

Which is the fastest-growing segment of the older adult population?

Over 85

Which is a normal finding when percussing the abdominal area?

Overall tympany, with dullness over organs or structures

The nurse is assessing the cardiovascular status of a client including pulses. Which action made by the nurse can place the client at risk for a stroke?

Palpate the carotid arteries simultaneously.

A client complains of sore throat, fever, and cough. Which focused assessment should be performed?

Palpation of lymph nodes

Which has been shown to be the most effective method of teaching adults?

Performing an action

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Performing hand hygiene before, during, and after direct contact with the client

A new school nurse is going through orientation and learning about her responsibilities in the health office. Which activity is secondary prevention?

Performing vision and hearing screenings

The parents of a toddler report difficulty getting their child to sleep at night. The child wants to play and not go to sleep. Which intervention suggested by the nurse would be most effective?

Plan sedentary activities the last hour before bed.

In a client's health record, the nurse documents, "Nutritional status will improve as evidenced by a weight gain of 3 lb (1.4 kg) by July 1." This statement is an example of which step of the nursing process?

Planning

The nurse is planning a teaching workshop about maintaining an active lifestyle at the local community center for a group of older adults. What information is most important to discuss at the workshop?

Planning and participating in leisure activities and exercise

When performing auscultation of heart sounds, which describes the small vibration at the 5th intercostal space at the midclavicular line, where is the strongest impact of the systolic heart beat located?

Point of maximum impact

Which describes the attachment of a muscle to a more stable bone?

Point of origin

Which is the leading cause of unintentional deaths in the United States?

Poisoning

Which is the term for a person taking multiple medications who may need support and teaching about health management?

Polypharmacy

Which diagnostic test involves measuring brain wave activity, oxygen and carbon dioxide levels, and vital signs?

Polysomnography

When checking the medication administration record, the nurse notices it is time to prepare the next dose of antibiotics for IV administration. The nurse also notices the client received morphine for pain 1 hour ago. When entering the room, the nurse finds the client sleeping and is unable to waken him or her to verify the need to proceed. What can be inferred from what is observed?

Possible adverse reaction

A 16-year-old female presents to a public health clinic 20 weeks pregnant. In performing the assessment of health behaviors, which other threat to health is the client at high risk of?

Poverty

A nurse is caring for a client with a history of diabetes and feels as if something is "not right." The nurse takes the client's blood glucose level. The nurse is acting on which type of knowledge?

Practical

Which characteristic of the electronic health record (EHR) helps prevent medication errors?

Preventing medications from being administered to clients with allergies

Which type of prevention includes activities designed to prevent or slow the onset of disease?

Primary prevention

The nurse is teaching a group of middle-age adults. What is the focus of the nurse when educating this group?

Promotion of a healthy lifestyle

An individual who is ill, whose needs are met by a health-care facility, and who has access to appropriate medications, diet, and health-care instruction falls into what area of Dunn's Wellness Grid?

Protected poor health in a favorable environment

How does informatics fit into the full spectrum nursing process?

Provides a framework of data, information, and knowledge with which the nurse works

A nurse is performing an assessment and asks a client how he or she has been feeling lately. The client responds, "Yellow." What should the nurse assess further after hearing this answer?

Psychiatric disorders

A nurse has demonstrated the proper cleaning and dressing change techniques for a client's postoperative wound. The nurse has the client then demonstrate the proper technique and repeat the instructions on when to change the dressing and why. By allowing the client to demonstrate learning, which type of educational learning has been practiced?

Psychomotor

A client is brought in to the emergency room from a motor vehicle accident. The client reports a headache and some dizziness, but no mental status deficits. The client is admitted for observation and four hours later, the nurse notes the client is lethargic and restless. Based on these findings, what should the nurse assess next?

Pupillary response

Which is a barrier to adoption of an electron health record?

Purchase and installation cost

Which type of research strives to look at the lived experience of the patient?

Qualitative

A nurse is in charge of a client with multiple challenges who is not responding to care as predicted. Upon evaluating the care plan and outcomes the nurse realizes the interventions should be altered. What is the next step in the nursing process?

Reassess the client, create a new nursing diagnosis if needed, and plan for new outcomes with new interventions.

While helping a postsurgical client ambulate, the nurse notices the client becomes short of breath with little exertion. Which is the next step in the nursing process for this client?

Reevaluating and creating a new nursing diagnosis and outcome

The scientific basis for client care is ever-changing. What can a nurse do to stay current with this multifaceted information?

Refine critical thinking skills as well as update knowledge and skills frequently.

The nurse is assessing a 13-year-old client brought in from a sports injury to the right arm. The client immediately retracts her arm when it is touched. What type of local adaptive response it this?

Reflex pain response

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the client's family.

Which stage of General Adaptive Syndrome (GAS) would a client be in if he or she was failing to adapt to the point that exhaustion will occur if left unresolved?

Resistance

Which type of isolation is indicated for a client who is immunosuppressed?

Reverse isolation

A nurse is enrolling a client into a research study and is going over the paperwork. Which rights should the nurse review with the client before obtaining informed consent? Select all that apply.

Right to full disclosure Right to confidentiality Right to self-determination Right to not be harmed Right to knowledge of placebo administration

A nurse uses a child's doll to teach. The nurse allows the child to "be the nurse and give the doll a shot." The child has the doll say "Ouch," then the shot is over. Which teaching strategy is this an example of?

Role modeling

Which describes the process in which a safety event is analyzed to determine the underlying cause and to prevent the event from occurring again?

Root cause analysis

The Joint Commission has safety goals for home care services. What is the most important goal?

Safe medication administration

A homeless client comes to the emergency room via ambulance after being found unresponsive on a park bench. The client is diagnosed with diabetes mellitus and needs his or her blood glucose levels monitored twice a day. The client is not interested in self-monitoring. According to Maslow, which type of needs must be met prior to being successful with client education about glucose regulation?

Safety and security needs.

The nurse is caring for a client with an elevated bilirubin level. Select where a nurse should assess for jaundice?

Sclera

A community health nurse is coordinating a blood pressure clinic at the local mall. What level of prevention is the nurse conducting?

Secondary

An elderly female client is admitted with pneumonia. During the course of hospitalization, she develops shingles, caused by herpes zoster virus, related to a history of varicella. Which type of infection is the shingles?

Secondary infection

The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring?

Secondary intention

A woman performing a monthly breast self-exam is an example of which level of prevention?

Secondary prevention

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record?

Serosanguineous

A nurse is documenting information in a computerized health record. Which of the following nursing action jeopardizes client confidentiality?

Sharing computer passwords with coworkers

Which is the most preferred method of bathing for ambulatory clients?

Shower

What is important to obtain before giving out any information about patient care?

Signed consent

The nurse enters the room to discuss ostomy care with the client, who is lying in bed. Which form of nonverbal language is most appropriate when speaking with the client?

Sit down to speak at eye level with the client.

Which nursing intervention reflects Jean Watson's caring theory, including personal presence?

Sitting down for several minutes with a client who is preparing to undergo a permanent colostomy formation.

What is the reason for a slight loss of height during the middle years?

Slight loss of bone density

Which strategy might help facilitate trust when a nurse is performing an examination of an adolescent?

Speak directly to the client and ask if he or she wants the parent present for the examination.

Offering to call a client's clergy member during illness is an example of which type of theory-based implementation?

Spiritual care

Which aspect of the exercise regimen should the nurse refrain from including when developing an exercise program for an older client with arthritis?

Standing on one foot, then the other, to improve balance

While setting up a sterile field, a nurse opens a package of 4 X 4 gauze and drops it onto the sterile field. One corner of the gauze is outside of the sterile field. What action should the nurse take?

Start over with setting up the sterile field

Which is a method of asepsis that involves the removal of all pathogens from an area when providing care?

Sterile technique

What can the nurse include in the day at work to minimize stress and maintain health?

Take a 20-minute walk on a break

Which scenario would likely require the greatest amount of time for client teaching?

Teaching parents of an infant with meningitis appropriate isolation precautions

Drawings, models, teach-back techniques, and preprinted materials are examples of which aspect of learning?

Teaching strategies

There are three levels of nursing interventions in a community health model. What level is most appropriate for the role of collaborator?

Tertiary

Which level of health prevention is represented by a client receiving physical therapy following a hip fracture?

Tertiary prevention

Home health nurses utilize various methods to collect clinical and demographic information on their clients. Which system is required for all Medicare clients?

The OASIS form

Which of the following best defines intimate partner violence?

The abuse of power and control within an intimate relationship.

Which must a nurse remember when accessing articles on the internet related to nursing practice?

The article may not be reliable

The nurse examines a wound on a client's hip and notes purulent drainage. The wound culture report states it has developed critical colonization. How should the nurse interpret these findings?

The bacteria have overwhelmed body defenses.

When planning nursing care for an older adult, which consideration should have the highest priority?

The care plan should be individualized, not based on age.

Which is an indication that teaching has been effective?

The client can name three medications he or she is taking.

The nurse is interviewing a client who has moved from Russia to the United States and has assimilated into American culture. Which statement is the best example of this process?

The client consumes a typical American diet

Which is an appropriate statement for the nurse to use when documenting a client's ethnicity?

The client is Bosnian

How can a nurse determine that teaching has been effective?

The client is able to repeat back the instructions given.

What role does stress play in overall health?

The more stress a person has in his or her life, the more likely the person is to experience a disruption in health.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

The nurse should inhale slowly and evenly through her nose until chest expansion is maximized

According to validation theory, what is the nurse's best response when caring for an elderly client with dementia who asks when his or her mother is coming to visit?

The nurse should tell the client he or she would like to hear more information about the mother.

Which is an example of interpersonal communication? The nurse stating to himself or herself, "I can't do this!" Rationale: This is an example of negative self-talk and is not interpersonal communication. It is a form of intrapersonal communication. Three nurses discussing the client's plan of care Rationale: Interpersonal communication occurs between two or more people. The nurse talking to himself or herself about a situation Rationale: When the nurse is talking to himself or herself, this is an example of intrapersonal communication. Multiple health-care professionals meeting to discuss a problem on the unit Rationale: A group of health-care professionals who meet to discuss a problem on the unit are participating in group communication. Test Taking Tips: Nurses use interpersonal communication to gather information during assessment, to teach about health issues, to explain care, and to provide comfort and support. In addition, professional nurses communicate with other nurses and healthcare team members to provide comprehensive care for clients.

Three nurses discussing the client's plan of care

A nurse is learning about the differences between home health care and hospice care. What is the primary purpose of hospice?

To promote comfort and quality of life

Which statement describes the purpose of utilization review as related to documentation in the medical record?

To verify medical treatments are necessary

The nurse is gathering supplies for the administration of enteral medications. Select the equipment that the nurse needs for the procedure.

Toomey (piston) syringe

Which of the following is one use of a GPS in providing healthcare?

Tracking of Alzheimer's patients

What should the nurse use prior to moving a client who needs an assist device to help move from the bed to a chair?

Transfer belt

A nurse is providing oral care for a client who is immobile. Which of the following should the nurse take?

Turn the client on his side before starting oral care.

Which is an appropriate nursing order for a client with a nursing diagnosis of "ineffective airway clearance"?

Turn, cough, and deep breathe every 2 hours.

A nurse is performing oral care on an unconscious client. How should the nurse hold the mouth open?

Use a padded tongue blade.

A client is providing A.M. care to a client who is on anticoagulation therapy. When assisting the client with shaving, which consideration should be taken?

Use an electric razor

Which is an effective nursing intervention for preventing falls?

Use of bed alarms

Which describes an organism that carries a pathogen to a susceptible host?

Vector

Which indicates a positive Weber test?

Vibration from a tuning fork louder in one ear than the other

Which describes the power and ability of an organism to cause disease?

Virulence

Which is a description of the frail elderly?

Vulnerability to a downward spiral in response to any health problem

Which is the safest way to warm infant formula prior to feeding an infant?

Warming infant formula in a pan of warm water

Infection control in the home is just as important an aspect of care as it is in the hospital setting. What is the best method for minimizing cross-contamination between the nurse and client?

Wash hands with soap and water at the beginning and end of each visit.

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Wear clean gloves

A statement such as "readiness for enhanced self-care" is an example of which type of nursing diagnosis?

Wellness diagnosis

A graduate nurse is considering taking employment as a community health nurse and is concerned that there may not be adequate resources available to the client population. Which observatory assessment would most help to analyze the community?

Windshield survey

The home health nurse visits a client who is bedridden after a stroke and notices the client is quiet and withdrawn when the caregiver enters the room. What would the nurse assess for in the caregiver to support a nursing diagnosis of caregiver role strain? Select all that apply.

- Apathy - Aggression - Depression

A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform. Select all that apply

- Apply ice to the affected area - Apply a compression bandage - Elevate the foot

What can a nurse do during the assessment process to help a client who is experiencing post-traumatic syndrome focus?

- Ask short, direct questions. - Ask open-ended questions as client begins to give more detail. - Demonstrate empathy and develop a rapport - Recognize and relieve immediate stressor

The nurse educator is preparing a class for new graduate nurses about barriers to therapeutic communication. What do the barriers include? Select all that apply.

- Asking too many questions - Asking "why" - Changing the subject inappropriately - Offering advice - Providing false reassurance

Identify the examples of acute illness.

- Cholecystitis - Pyelonephritis - Appendicitis

Which health factors affect a person's self-care ability? Select all that apply.

- Pain - Limited mobility - Cognitive impairment

Which are client privacy and security safeguards in an electronic medical record system? Select all that apply

- Passwords and PIN numbers - Encrypting - Workstation privacy filters

Which factors present in clients make the most positive impact on learning motivation? Select all that apply.

- Recognizing the need to learn - Believing it is possible to improve their health - Having an interest in the information provided

When preparing to administer an otic solution to a client, what should the nurse assess the client for? Select all that apply.

- Redness - Cerumen - Drainage - Ear pain

While reflecting and determining what should be done, which questions might help focus thinking? Select all that apply.

- What else might work in this situation? - What was done? Why was it done? - What rationale do I have for my decisions?

In which scenario would an appropriate nursing intervention be using brief, frequent learning sessions and repetition in instruction?

The client has a brain injury that affects cognitive abilities.

Which of the following would be the best definition of the "spiral of vulnerability"?

The client has a decrease in mobility, which leads to a fall, which leads to hospitalization

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client's family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information?

The client has most likely not had a recent physical examination.

The nursing diagnosis risk for Caregiver Role Strain is assigned to the client the nurse will be taking over care for during her shift. What is a complication with this particular diagnosis?

The diagnosis is incomplete, not allowing for proper planning and outcomes.

Which statement best describes parasomnia?

Parasomnia is a pattern of waking behavior that involves sleepwalking.

Nursing students depend on computers in what ways? Select all that apply.

- Communicating - Searching online databases - Performing and documenting course assignments - Using clinical simulation mannequins

Which examples would be considered health disruptions?

- Competing demands of life - Loss of a spouse - Bipolar disorder - Fibromyalgia

Which are causes of obstructive sleep apnea? Select all that apply.

- Being overweight - Enlarged tonsils - Deviated nasal septum

Which are forms of electronic communication? Select all that apply.

- Email - Text message - Telehealth

Which is an effect of vascular response in inflammation?

- Hyperemia - Edema - Leukocytes move to the area

Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis?

A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently.

In the communication process, what does the nurse understand the channel to be?

A method to send the message

A client was brought into the emergency department and was the victim of a robbery. Upon assessment, his heart rate is 112 bpm, respirations 34 and deep, and he is complaining of nausea and lower abdominal pain. Which stage of general adaptive syndrome (GAS) is this client in?

Alarm

Which describes the type of bath in which a client does as much as possible, but the nurse assists with hard-to-reach areas, such as the back, feet, and legs?

Assist bath

How could a nurse reduce a confused client's risk of falls?

Assist with toileting frequently

Which stage of the transtheoretical model is demonstrated by a client stating she is sick and tired of being overweight and is thinking about doing something about it?

Contemplation

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1 C (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP

Correct body mechanics should be utilized by nurses to prevent which type of injury?

Back injury

Which is the cause of body odor?

Bacteria

Which process assists nurses with selecting correct medication and dosing?

Bar coding

A client is brought to the emergency room via ambulance after sustaining injuries in a motor vehicle accident and is critically ill. The nurse learns the client is a Jehovah's Witness. Which procedure would the nurse know the health-care team cannot perform?

Blood transfusion

Advil is an example of which type of drug name?

Brand name

Which describes breath sounds auscultated over the trachea?

Bronchial

Which phase of wound healing describes collagen fibers breaking down and remodeling?

Epithelialization

Which is part of the assessment of the musculoskeletal system?

Gait

The nurse is caring for a client following a surgical procedure. The health-care provider's orders include vital signs every 15 minutes for one hour, every 30 minutes for two hours, then every hour for four hours. Which type of document would best serve this nurse?

Graphic chart

How can nurses use computers to ensure they are following best practices?

Perform a literature search

How can the nurse be supportive to the caregiver of a client suffering from dementia?

Provide rapid support during times of crisis.

Which statement best describes "lived experience" in healthcare?

The uniqueness of how a client experiences disruptions in health

According to the Institute of Medicine, which competency best promotes nursing research?

Evidence-based practice

Cardiovascular fitness, muscular fitness, and flexibility are elements of which type of assessment?

Physical fitness

Which is a factor that contributes to the overall increased life expectancy in older adults?

Advances in medicine and medical technology

A nurse is assisting a 10-year-old client with diabetes on the use of insulin through role playing and storytelling. Which domain of learning is being utilized?

Affective

Which describes the intentional release, or threat of release, of disease-producing organisms with the intent of causing illness, fear, or death?

Bioterrorism

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

Gloves

Which hormone is released during sleep?

Growth hormone

When is a back massage typically offered as part of scheduled care?

H.S. care

Which of the nurse's questions demonstrates critical thinking?

"Have I gathered enough data to make a decision?"

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

"I will wear gloves and a gown when bathing a client who has open skin lesions."

The nurse is working with a 57-year-old client who is worried about exercising too hard. What would be this client's maximum heart rate for high-intensity exercise? Insert numeral only.

138

Older adults (those over 65) make up approximately what percentage of the total population in the United States?

15%

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to radiology department for a chest x-ray?

Have the client wear a mask

A person who joins a gym, shops for healthy food, and avoids snacking during the day is likely in which stage of change?

Action

The nurse is working with an adolescent around issues that affect health. Which of the following should the nurse stress about the adolescent's diet?

Adolescents should intake 1300 mg of calcium and 400 IU of vitamin D daily

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne

A nurse works night shift in an intensive care unit. After a night of multiple clients developing abnormal heart rhythms, and alarms going off continuously, the nurse does not notice that a client has developed a potentially lethal rhythm and the alarm is sounding. What does this describe?

Alarm fatigue

Which is the appropriate procedure for disposal of used isolation supplies?

All supplies are bagged inside the room by a health-care worker wearing appropriate PPE, and a second health-care worker outside the room contains the waste in a separate bag.

The nursing supervisor has developed a new protocol for implementing family support through family-centered care. The majority of the staff is apprehensive about trying the new procedure. If the supervisor continues with implementing the plan, which critical thinking attitude is he or she displaying?

Courage

The nurse is reviewing laboratory results for a 55-year-old client with a venous stasis ulcer. Which result reflects the presence of chronic wound inflammation?

Erythrocyte sedimentation rate (ESR) 40 mm/hour

The care plan for a client includes ambulating for 10 minutes every hour, but the client has been unable to achieve the full amount of time. What is the next step in the nursing process?

Evaluation

How often must a long-term care facility complete the Minimum Data Set for Resident Assessment and Care Screening (MDS) after initial admission?

Every 3 months

A research-based method for judging and choosing nursing interventions is referred to as what?

Evidence-based practice

What should the nurse do for a client with orthostatic hypotension who is preparing to get out of bed to walk for the first time in several days?

Dangle the client's legs off the side of the bed

What can cause a client to abandon normal coping skills during illness?

Dealing with the cumulative effect of illness and other life disruptions

How are critical thinking skills used when following hydration recommendations for two different clients with dehydration issues, one due to a gastrointestinal virus and one with kidney dysfunction?

Decisions are geared toward individual differences.

What is a contributing factor to foot problems in elderly clients?

Decreased circulation to lower extremities

A recently admitted 32-year-old female client has just been told she has Stage IV breast cancer. She immediately tells her family members to leave the room and not to come back and becomes agitated with the nursing staff when trying to implement the nursing plan. Which best describes this type of behavior?

Defense mechanism

Which is the best method of preventing needlestick injuries and exposure to bloodborne pathogens while providing client care?

Dispose of the needles in a sharps container

A graduate nurse from an Associate's degree in nursing (ADN) program asks the nurse manager what the expectations are for ADN nurses in research. What responsibility should the nurse manager include in the explanation?

Identify problems in practice

A nurse is caring for a client who has been newly diagnosed with diabetes. The client is very tearful and feeling overwhelmed about his or her diet and medication teaching. Which would be the most appropriate nursing diagnosis for this client?

Impaired ability to learn related to anxiety

Which is a major disadvantage of the electronic health record (EHR)?

Incapability to integrate records from multiple locations

The nurse is caring for a client admitted with uncontrolled type 2 diabetes mellitus. Which instruction should the nurse provide to the client to move him or her to the health aspect of the health-illness continuum?

Include fresh fruits and vegetables in the diet.

The nurse is working with a client with low total protein and serum albumin levels. The client presents with bilateral pitting lower extremity edema. Which education should the nurse provide to decrease and prevent edema formation?

Increase protein foods in the diet.

Which nursing diagnosis related to stress references the behavioral domain?

Ineffective coping r/t stress AEB disinterest in present and distancing from support.

Which of the following vaccines should middle adults be encouraged to have?

Influenza

Which is the most common cause of tooth loss in adults over 35?

Periodontal disease

Which is referred to as the assessment of arousal and orientation?

Level of consciousness

Which type of bath is most likely to be a medical order?

Therapeutic bath

Which high-amplitude brain waves found during deep sleep are common in children but rare in adults?

Theta

Why are lipid-soluble drugs used for sedation?

They can pass through the blood-brain barrier.

Which is an important consideration when palpating carotid arteries?

They should be palpated one at a time.

Which is an example of interpersonal communication?

Three nurses discussing the client's plan of care

What is the role of the nurse in health promotion?

To motivate and support change

The nurse is caring for a 7-year-old client admitted for pneumonia. Which action made by the nurse would facilitate communication with the child?

Using words and phrases the child understands