HESI practice
Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? 1 Irish Americans 2 African Americans Correct3 Chinese Americans 4 Egyptian Americans
Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density. Irish Americans have taller and broader bones than other Euro-Americans. African Americans have a decreased incidence of osteoporosis. Egyptian Americans are shorter in stature than Euro-Americans and African Americans.
A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? 1 Easing pain 2 Minimizing scarring Correct3 Preventing infection 4 Preventing skin breakdown
Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.
What is the priority when the nurse is establishing a therapeutic environment for a client? Correct1 Ensuring the client's safety 2 Accepting the client's individuality 3 Promoting the client's independence 4 Explaining to the client what is being done
Safety is the priority before any other intervention is provided. Accepting the client's individuality, promoting the client's independence, and explaining to the client what is being done are all important, but less of a priority.
A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? 1 Airway obstruction 2 Inadequate nutrition 3 Prolonged gastric suction Correct4 Excessive mechanical ventilation
The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.
The nurse manager uses operant conditioning when managing the staff by providing positive reinforcement to motivate them to repeat constructive behavior. Which leadership theory is reflected in this practice? 1 Hierarchy of needs 2 Transformational theory 3 Situational contingency theory Correct4 Organizational behavior (OB) modification
OB modification theory is applied by providing positive reinforcement to the staff to motivate them to repeat constructive behaviors in the workplace. Awareness of the hierarchy of needs can be used to understand what motivates staff; for example, the need for security will override social needs. Transformational theory does not utilize operant conditioning for motivation. Situational contingency theory is applied to consider the challenge of a situation and encourages an adaptive leadership style to complement the issue being faced.
A client has a severe, unilateral throbbing headache that has lasted for 2 days. What should be the priority nursing care? 1 Administering gabapentin Correct2 Administering sumatriptan 3 Administering propranolol 4 Administering botulinum toxin A
A client with a unilateral throbbing headache which lasts from 4 to 72 hours is likely a migraine. The nurse should administer sumatriptan to reduce the symptoms of migraines, but it is most effective when taken at the onset of a migraine headache. Gabapentin is an antiseizure medication that is used in migraine prevention. Propranolol is an antihypertensive used as a prophylactic treatment. Botulinum toxin A is an effective prophylactic medication for treating chronic migraines and for migraines that do not respond to other medications.
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? Correct1 Coin in the umbilicus 2 Tight diaper over the umbilicus 3 Binder that encircles the umbilicus 4 Adhesive tape across the umbilicus
A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.
A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? Select all that apply. Correct1 Taking on parental roles 2 Adjusting to a reduction in family size 3 Development of intimate peer relationships Correct4 Adjusting the marital system to make space for children Incorrect5 Realigning relationships to in-laws and grandchildren
A family with more young children undergoes an emotional transition of accepting a new generation of members. These changes include taking on parental roles and adjusting the marital system to make space for children to proceed developmentally. Adjusting to a reduction in family size is required for the family life-cycle stage of children leaving the family home. The development of intimate peer relationships is required for an unattached young adult. Realigning relationships to in-laws and grandchildren is required for the family life-cycle stage of children leaving the home to start their own lives.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.
A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider? 1 A loud Korotkoff sound 2 An irregular pulse of 92 beats per minute Correct3 A diastolic blood pressure that remains greater than 90 mm Hg 4 A throbbing headache over the left eye when arising in the morning
A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and could indicate hypertension. A loud Korotkoff sound is unrelated to hypertension. An irregular pulse of 92 beats per minute reflects the heart rate and rhythm, not the pressure within the arteries. Initially hypertension usually is asymptomatic; although headaches can be associated with hypertension, there are other causes of headaches.
While performing the physical assessment of an infant, the nurse notices the infant has developed a color preference for red and yellow. What is most likely to be the age of the infant? 1 4 weeks 2 8 weeks 3 15 weeks Correct4 20 weeks
An infant develops a color preference for yellow and red between 20 to 28 weeks of age. At 4 weeks, the infant can follow a range of 90 degrees. Between 6 to 12 weeks of age, the infant develops peripheral vision to 180 degrees. Between 12 to 20 weeks of age, the infant is able to accommodate to near objects.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.
Which action demonstrates the "analyticity" concept of a critical thinker? Select all that apply. Incorrect1 The nurse is organized and focused. 2 The nurse trusts one's own reasoning process. Incorrect3 The nurse accepts multiple solutions to a problem. Correct4 The nurse uses evidence-based knowledge for clinical decision-making. Correct5 The nurse anticipates possible results or consequences in a given situation.
Analyticity is one of the concepts of a critical thinker and involves the use of evidence-based knowledge for clinical decision-making. This skill may also help in anticipating possible results or consequences of a procedure or a given situation. Being organized and focused reflects systematicity. Trusting one's own reasoning process reflects self-confidence. Accepting multiple solutions to a problem reflects maturity.
A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of what? 1 Providing individual and family therapy 2 Using positive reinforcement to reduce guilt 3 Uncovering unconscious conflicts and fantasies Correct4 Providing a supportive environment to benefit the client
Any aspect of the treatment environment can be used to benefit the client in milieu therapy. Individual and family therapy are separate treatment modalities, not part of milieu therapy. Using positive reinforcement to reduce guilt is part of behavioral modification, not milieu therapy. Uncovering unconscious conflicts and fantasies is part of psychoanalytical, not milieu, therapy.
A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list? 1 Orange juice, fried eggs, and sausage 2 Tomato juice, raisin bran cereal, and tea Correct3 Applesauce, cream of wheat, and apple juice 4 Sliced oranges, pancakes with syrup, and coffee
Applesauce, cream of wheat, and apple juice are bland foods that do not irritate the gastric mucosa. Orange juice, fried eggs, sausage, tomato juice, raisin bran cereal, tea, sliced oranges, and coffee are not bland; they may be irritating to the mucosal lining. Caffeine should be avoided.
The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? Correct1 Monitor for nonverbal cues of pain 2 Check the pressure dressing for bleeding 3 Assist the client to ambulate around his room 4 Irrigate the client's nasogastric tube with sterile water
Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.
Which clients should be considered for assessing the carotid pulse? Select all that apply. Correct1 Client with cardiac arrest 2 Client indicated for Allen test Correct3 Client under physiologic shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand
Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.
After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? 1 Increased cultural sensitivity 2 Decreased cultural imposition 3 Decreased cultural dissonance Correct4 Increased cultural competence
Cultural competence encompasses sensitivity as well as knowledge, desire, and skill in caring for those who are different from one's self. The nurses are already somewhat sensitive to those from different cultures and now must move forward in their ability to care for these clients. The nurses are not imposing their culture on the clients; they are avoiding them. There is no clashing of cultures in this situation.
During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia Correct2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios
During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia Correct2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios
Which statement describes the latency stage of Freud's psychoanalytic model of personality development? 1 During this stage, genital organs are the focus of pleasure. Correct2 During this stage, sexual urges are repressed and channeled into productive activities. 3 During this stage, an infant begins to think that his or her parent is separate from the self. 4 During this stage, sexual urges reawaken and are directed to an individual outside the family circle.
During the latency stage, Freud believed that sexual urges from the earlier Oedipal stage are repressed and channeled into productive activities that are socially acceptable. During the phallic stage, the genital organs are the focus of pleasure. During the oral stage, infants begin to think that the parent is something separate from the self. During the genital stage, sexual urges reawaken and are directed to an individual outside the family circle.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
The mother of a 6-year-old boy tells the nurse in the pediatric clinic that her son has become incontinent of stool. The nurse plans to assess the child to determine the cause of his encopresis. In what order should the nurse perform the assessments? Correct1.Bowel habits Correct2.Nutrition history Correct3.Psychosocial factors Correct4.Physical examination
First, a physical cause of the encopresis should be investigated. This includes the toilet training process and changes in bowel habits or routines. If there are no changes in bowel pattern, a nutrition history may reveal any changes in the child's eating habits that caused the encopresis. Next, the nurse should explore psychosocial factors that may have influenced the development of the encopresis. Finally, a physical examination should be performed.
A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? Correct1 Hand washing before and after providing client care 2 Cleaning all equipment with an approved disinfectant after use 3 Wearing personal protective equipment (PPE) when providing client care 4 Using medical and surgical aseptic techniques at all times
Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.
A registered nurse is educating a client with acquired immune deficiency syndrome about safe sexual practices. Which statement made by the client indicates a need for further education? 1 "I should use a dental dam during oral sex." Correct2 "I can participate in anal intercourse safely without using condoms." 3 "I should ask my partner to use a female condom while engaging in sexual activity." 4 "I should use condoms even while receiving highly active antiretroviral therapy (HAART)."
Having anal intercourse indicates the client needs more teaching because this statement is incorrect. The client should wear a condom or use other genital barriers to prevent the transmission of human immunodeficiency virus (HIV). Anal intercourse is a risky sexual practice that allows contact between the seminal fluid and the rectal mucous membranes. Anal intercourse also tears the mucous membranes, making an infection more likely. All the other statements are correct and do not indicate further education is needed. Barriers such as female condoms and dental dams are recommended while participating in sexual activity. Though the viral load may decrease with the use of HAART, the risk for transmission still exists. Therefore the client should use condoms during sexual contact
The primary health care provider prescribes contact precautions for a client with hepatitis A. What nursing interventions are required for contact precautions? 1 Private room with the door closed Incorrect2 Gown, mask, and gloves for all persons entering the room Correct3 Gown and gloves when handling articles contaminated by urine or feces 4 Gowns and gloves only when handling the client's soiled linen, dishes, or utensils
Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.
A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement? 1 Report these findings to the healthcare provider. Correct2 Encourage the family to bring in special foods preferred in their culture. 3 Order a high-protein milkshake to supplement between meals. 4 Call the dietitian to work with client to plan high calorie meals for the client to eat
In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression Correct4 Acceptance
In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.
Which internal variable influences health beliefs and practices? 1 Family practices Incorrect2 Cultural background 3 Socioeconomic factors Correct4 Intellectual background
Intellectual background is an internal factor that affects the client's health beliefs and practices. A client's knowledge, educational background, and past experiences influence how a client thinks about health. Family practices, cultural background, and socioeconomic factors are among the external factors that influence health beliefs and practices.
A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? Correct1 Contact an interpreter provided by the hospital. 2 Contact the client's family member to translate for the client. 3 Communicate with the client using Spanish phrases the nurse learned in a college course. 4 Communicate with the client with the use of a hospital-approved Spanish dictionary.
Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.
What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? 1 Knowledge reduces general anxiety. 2 Capacity to learn decreases with age. Correct3 Continued reinforcement is advantageous. Incorrect4 Readiness of the learner precedes instruction.
Neurologic aging causes forgetfulness and a slower response time; repetition increases learning. Continued reinforcement is an example of repetition. The facts that knowledge reduces general anxiety and that the readiness of the learner precedes instruction reflect principles that are applicable to learning regardless of the client's age. Capacity to learn decreases with age.
What is a primary component of the nursing plan of care for a client with the diagnosis of anorexia nervosa? Correct1 Observing the client after meals Incorrect2 Weighing the client before meals 3 Measuring the client's fluid balance 4 Limiting the client's interaction with peers
Observing the client after meals is the only way the nurse can be certain that the client does not engage in purging. Weighing will not help the nurse assess the client's electrolyte or nutritional status. An accurate intake and output record is difficult to obtain unless the individual is closely observed throughout the day. There is no need to isolate the client from peers.
A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients? 1 Reviewing the past is depressing. 2 Stimulating new situations are ideal. 3 Dependency increases as age progresses. Correct4 Staying healthy promotes a quality retirement.
Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. The person may be in despair when reviewing the past is depressing. Most older adults prefer familiar routines and environments and desire independence even when coping with the effects of aging and chronic illness.Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.
A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube? 1 Return of usual tidal volume 2 Decreased adventitious sounds Incorrect3 Absence of additional drainage Correct4 Comparison of chest radiographs
Serial chest x-rays help determine treatment effectiveness. Chest x-ray films or radiographs reveal the degree to which the lung fills the pleural cavity and also the presence or absence of mediastinal shift. Return of usual tidal volume is not specific to expansion of the affected lung. Decreased adventitious sounds are abnormal chest sounds and do not indicate the degree of lung expansion. The chest tube may have minimal drainage and the lung may still not be expanded.
What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1 Wear support hose continuously. 2 Lie down for 30 minutes after taking medication. 3 Avoid tasks that require high-energy expenditure. Correct4 Sit on the edge of the bed for 5 minutes before standing
Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.
What instructions should a nurse provide to adolescent boys regarding the usual procedure to be followed and normal findings observed during testicular self-examination. Select all that apply. Correct1 A firm, smooth, egg-shaped organ can be palpated. Correct2 Each testicle is examined individually after relaxing the scrotal skin. 3 A hard mass that can be palpated on anterior or lateral aspect of testicle. Correct4 The thumb and fingers of both hands can be used to apply firm and gentle pressure. Correct5 A raised swelling that can be palpated on the superior aspect of the testicle is the epididymis.
Testicular self-examination is usually performed after a warm bath when the scrotal skin is relaxed. A firm organ with smooth and egg shaped contours that can be palpated is the testicle. Each testicle is examined individually using thumb and fingers of both hands applying firm and gentle pressure. A raised swelling that can be palpated on the superior aspect of testicle is the epididymis. Testicular cancer can be suspected if a hard mass can be palpated on the anterior or lateral aspect of testicle.
What statement by the nursing student indicates understanding of the precautions needed in the provision of care to a 7-year-old child who is HIV positive? 1 "I'll put on a mask." 2 "I'll put on an N-95 mask." 3 "I'll put on a gown and gloves." Correct4 "I'll put on gloves if I'm going to be in contact with body fluids."
The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) recommends standard precautions for the care of individuals with HIV infection or AIDS without opportunistic infections. Droplet precautions are not necessary because HIV is not transmitted in large-particle respiratory droplets. Contact precautions are not necessary unless the HIV infection or AIDS is complicated by the presence of disease or infection, necessitating the addition of these precautions to standard precautions. Airborne precautions are unnecessary because HIV is not spread in airborne droplet nuclei; these precautions are used in addition to standard precautions if an opportunistic infection such as Mycobacterium tuberculosis is present.
A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history? 1 Evaluating the client's adjustment to the unit Correct2 Providing the client with a sense of security and safety 3 Exploring the client's memory loss and fear of going out 4 Assessing the client's perception of reasons for the hospitalization
The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. Unless the client is provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.
A toddler in the pediatric intensive care unit is on a ventilator. One of the nurses asks what should be done when condensation collects in the ventilator tubing. How should the nurse manager respond? 1 Notify the physician assistant. 2 Decrease the amount of humidity. Correct3 Empty the fluid and reconnect the tubing to the ventilator. 4 Measure the fluid and mark it on the intake and output record
The correct course of action is to empty the fluid from the tubing and reconnect it because accumulated fluid may flood the trachea. Removing condensation from the tubing does not require help from a physician assistant; the nurse or respiratory therapist, depending on hospital protocol, is responsible for this remedial action. Humidity is necessary to preserve moisture in the respiratory tract. The amount of condensation is irrelevant in terms of recording intake and output.
While caring for a female client, the nursing student feels tenderness and a lump in the client's breast. The nursing student tells the registered nurse, "I think this client has breast cancer." Which statements of the registered nurse would be appropriate in accordance with the knowing element of Swanson's theory? Select all that apply. 1 "Try to comfort the client." Correct2 "Avoid making assumptions." Correct3 "Assess the client thoroughly." Correct4 "Check for other signs of breast cancer." 5 "Try to provide support and care to the client."
The knowing element of the caring process involves understanding an event. Avoiding assumptions, performing a thorough assessment of the client, and checking for other signs of breast cancer and are related to the knowing element of Swanson's theory of caring. The doing for element includes comforting the client. The caring process of being with involves the nurse providing emotional support.
The mother of a 5-month-old boy calls the nurse in the pediatric clinic to ask why her son no longer turns his head toward her breast when she touches his cheek. How should the nurse respond? 1 "Is he able to sit unsupported?" Correct2 "Usually this reflex disappears around 4 months." 3 "Do his toes still flare out when you stroke the sole of his foot?" 4 "Please bring him to the clinic—he may have a feeding problem."
The mother is describing the rooting reflex; when touched on the cheek, the infant reflexively turns the head to that side. The rooting reflex is expected to disappear by 4 months of age. An infant can sit without support at 8 months; this is not expected of a 5-month-old infant. Stroking the sole of the foot elicits the Babinski reflex, which disappears between 8 and 12 months of age. The disappearance of the rooting reflex at 5 months of age does not require further intervention.
According to Swanson's caring process, the nurse must know the client. Which factors enable the nurse to know the client better? Select all that apply. 1 Economic constraints Correct2 Continuity of care by the nursing staff 3 Fewer nurses in the healthcare facility Correct4 Collection of data about the client's clinical condition Correct5 Engagement in a caring relationship without assumptions
The nurse gets to know the client over time with continuity in care. The nurse enters into a caring process by collecting data about the client's clinical condition. The data enables the nurse to use critical thinking and clinical judgments during client care. The nurse should engage in a caring relationship with the client without any assumptions and use knowledge and experience to detect changes in the client's health condition. Economic constraints may lead to the client spending less time in the healthcare facility. This acts as a barrier in providing client-centered care. Changes in the organizational structure may result in fewer nurses caring for more clients. This results in fewer interactions with the client.
An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. Correct1 Minimizing medications Correct2 Modifying the home environment 3 Teaching clients about the safe use of the Internet Correct4 Manage foot and footwear problems 5 Providing information about the effects of using alcohol
The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment and managing foot and footwear problems. Teaching clients about the safe use of Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.
When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? Correct1 Third 2 Fourth 3 Second 4 Seventh
The third cranial nerve (oculomotor) contains autonomic fibers that innervate the smooth muscle responsible for constriction of pupils. The trochlear nerve is concerned with eye movements; lesions result in diplopia, strabismus, and head tilt to the affected side. The optic nerve is concerned with vision; lesions result in visual field defects and loss of visual acuity. The facial nerve is concerned with facial expressions; lesions result in loss of taste and paralysis of the facial muscles and the eyelids (lids remain open).
A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective? 1 Easing the client's feelings of guilt Correct2 Maintaining a supportive, structured environment 3 Pointing out reality through continued communication 4 Broadening the client's contacts with other people on the unit
These clients are acutely aware of and sensitive to the environment; they need a structured environment in which stimuli are minimized and a feeling of acceptance and support is present. Lessening the client's feelings of guilt is a vague objective; it is not measurable. Pointing out reality through continued communication is not the priority. Reality orientation is not needed as much as maintaining a safe structured environment is. The client needs minimal, not increased, stimuli.
The nurse is assessing the clinical data of four clients. Which client is characterized with mixed conductive-sensorineural type of hearing loss? 1 Client A Correct2 Client B 3 Client C 4 Client D
There are four types of hearing loss: Conductive Hearing LossHearing loss caused by something that stops sounds from getting through the outer or middle ear. This type of hearing loss can often be treated with medicine or surgery. Sensorineural Hearing LossHearing loss that occurs when there is a problem in the way the inner ear or hearing nerve works. Mixed Hearing LossHearing loss that includes both a conductive and a sensorineural hearing loss. Auditory Neuropathy Spectrum DisorderHearing loss that occurs when sound enters the ear normally, but because of damage to the inner ear or the hearing nerve, sound isn't organized in a way that the brain can understand. Client B is diagnosed with a retraction in the tympanic membrane, causing obstruction to sound wave transmission. Damaged cochlear hair results in decreased sensory perception. Therefore, this client is characterized by a mixed conductive-sensorineural type of hearing loss. Client A is diagnosed with inflammation in the tympanic membrane resulting in retraction or bulging of the tympanic membrane, leading to obstruction of sound wave transmission thereby causing conductive hearing loss. The type of hearing loss diagnosed in client C is characterized as sensorineural hearing loss, as there is damage to the vestibulocochlear cranial nerve. Client D is diagnosed with fused bony ossicles, which obstructs sound wave transmission thereby causing conductive hearing loss.Test-Taking Tip: Chart/exhibit items present a situation and a variety of objective and subjective information about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, and health history), physical assessment data, and notes about client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Correct1 Become aware of their personal values 2 Gain information related to their needs 3 Make correct decisions related to their health 4 Alter their value systems to make them more socially acceptable
Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.
A nurse is planning play activities for a 6-year-old child whose energy level has improved after an acute episode of gastroenteritis. What activity should the nurse encourage? 1 Using a set of building blocks 2 Finger-painting on a large paper surface Correct3 Drawing and writing with a pencil or marker
Writing and drawing pictures provides a 6-year-old, who is of school age, with an appropriate way to express feelings. Playing with blocks is appropriate for preschoolers, who have active imaginations. Finger-painting is appropriate for preschoolers, who enjoy experimenting with different textures. Manipulating pieces of a toy is appropriate for preschoolers, who like repetition.
On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? Correct1 Assess her breastfeeding techniques to identify possible causes. 2 Provide a nipple shield to keep the infant's mouth off the nipples. 3 Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. 4 Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.
The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.
A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1 Assign articles about various cultures so that they can become more knowledgeable. 2 Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3 Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. Correct4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.
A workshop provides an opportunity to discuss cultural diversity; this should include identification of one's own feelings. Also, it provides an opportunity for participants to ask questions. Although articles provide information, they do not promote a discussion about the topic. Relocation is not feasible or desirable; clients from other cultures are found in all settings. Rotating the nurses' assignments probably will increase tension on the unit.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
What role is the nurse expected to have in a community-based nursing practice if there is a sudden spread of malaria? 1 Educator 2 Collaborator Correct3 Epidemiologist 4 Client advocate
As an epidemiologist, the nurse is responsible for community surveillance for risk factors such as the sudden spread of malaria. An epidemiologist nurse protects the health level of the community, develops sensitivity to changes in the health status of the community, and helps identify the cause of these changes. As an educator in a community-based setting, the nurse provides knowledge to clients and families so they can learn how to care for themselves. As a collaborator in a community-based nursing practice, the nurse collaborates with hospice staff, social workers, and pastoral care to initiate a plan to support end-of-life care for the client and support the family. As a client advocate in a community-based setting, the nurse provides necessary information for clients to make informed decisions in choosing and using services.
A physically ill client is being verbally aggressive to the nursing staff who is performing intravenous therapy on the client. What is the most appropriate initial nursing response? Correct1 Tell me why you are upset. Incorrect2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions
At this time the client is using this behavior as a defense mechanism. Using an open-ended question regarding the client's verbal aggression can be an effective interpersonal technique because it is nonjudgmental and allows the client to elaborate on feelings at the time. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies nonacceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.
A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? 1 Sweating Correct2 Hyperpnea 3 Bradycardia 4 Hypertension
Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.
Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. Correct1 Encouraging regular dental checkups Incorrect2 Facilitating smoking cessation programs Incorrect3 Administering influenza vaccines to older adults Correct4 Teaching the procedure for breast self-examination 5 Referring clients with a chronic illness to a support group
Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.
A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? 1 "It will keep your baby from going blind." 2 "This ointment will protect your baby from bright lights." 3 "There is a law that newborns must be given this medicine." Correct4 "This antibiotic helps keep babies from contracting eye infections."
Erythromycin ophthalmic ointment is used to treat gonorrhea and Chlamydia infections, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered.
Which nursing intervention is most appropriate for a client in skeletal traction? 1 Add and remove weights as the client desires. Correct2 Assess the pin sites at least every shift and as needed. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day.
Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.
Four clients with osteomyelitis are prescribed antibiotics. Which client is at risk for Achilles tendon rupture? 1 Client A Correct2 Client B 3 Client C 4 Client D
Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Tendon rupture can occur with use of the fluoroquinolones. Therefore client B, prescribed ciprofloxacin, is at risk for Achilles tendon rupture. Client A, prescribed gentamicin, is at risk for visual and hearing problems. Client C, prescribed cefazolin, is at risk for severe watery diarrhea and mouth sores. Client D, prescribed tobramycin, is at risk for nephrotoxicity.Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.In a clinical exam, you may be expected to select instruments, arrange instruments, and/or perform some other task. Acquaint yourself with the physical facility. If the required procedures are not clear to you, ask for clarification.
Which reactions does a nurse expect of a 4-year-old child in response to illness and hospitalization? 1 Anger, resentment over depersonalization, and loss of peer support 2 Boredom, depression over separation from family, and fear of death Correct3 Out-of-control behavior, regression to overdependency, and fear of bodily mutilation 4 Intense panic, loss of security over separation from parents, and low frustration tolerance
Preschoolers experience loss of control caused by physical restriction, loss of routines, and enforced dependency, which may make them feel out of control. Preschoolers are also likely to experience feelings of regression or overdependency and fear of bodily mutilation. Anger, resentment over depersonalization, and loss of peer support are typical feelings expressed in adolescence. Boredom, depression over separation from family, and fear of death are typical feelings expressed by school-age children. Intense panic, loss of security over separation from parents, and low frustration tolerance are feelings usually experienced by toddlers.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.