Fundamentals NCLEX Review 2

the client is not motivated

then they may not participate in any activities.

the client is intrinsically motivated

they may approach health care professionals without external motivation.

Cerumen (ear wax) becomes drier and harder as a person ages. The epithelium of the lining of the ear becomes thinner and drier.

true

The hair in the auditory canal increases as in aging older adults

true

older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher pitched sounds.

true

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take?

Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?

"Have you ever had a transfusion before?" R: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. .

Place each step of the nursing process in the order that it should be used.

1. Obtain client's nursing history. 2. State client's nursing needs. Incorrect 3. Identify goals for care. 4. Develop a plan of care. 5. Implement nursing interventions.

There are guidelines that the nurse should use when delegating and planning assignments. These include the following:

1. ensure client safety; 2. be aware of individual variations in work abilities; 3. determine which tasks can be delegated and to whom; 4. match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; 5. provide directions that are clear, concise, accurate, and complete; 6. validate the delegatee's understanding of the directions; 7. communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and 8. maintain continuity of care as much as possible when assigning client care.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate.

3. "Can you share with me what you've been told about your surgery?"

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating *intracellular osmolarity* is what?

A decrease in serum *potassium* causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

The acuity level of the clients Client needs and workers' needs and abilities R: There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

Because the *plasma colloid oncotic pressure* is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in colloid oncotic pressure caused by

albuminuria results in edema.

The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?

chest xray

the client shows interest in learning new tasks that would benefit their health

extrinsically motivated with self-determination

If the client participates in activities because of the pressure of family members and does not know the importance of the activity, then the client is said to be

extrinsically motivated without self- determination.