Lecture Exam 4 Ch 17, 18, 22, 23, 24

When planning interventions for a community, what action by the nurse is best? a. Involve community leaders in planning. b. Create a plan of action addressing priorities. c. Determine what resources are available. d. Attempt to find funding for the plan.

ANS: A Stakeholders need to be involved in planning to ensure buy-in from the community. The stakeholders could be community or business leaders. The other actions are important, but if the community leaders are not committed to the plan, the plan is unlikely to work.

The student nurse learns that spirituality consists of practices that lead to connection to which items? (Select all that apply.) a. Other people b. Nature c. Religious institutions d. Oneself e. Higher power

ANS: A, D, E Spiritual practices generally promote three categories of activity: connection with oneself, with others, and with a higher power.

A nurse is planning a community event in which participants will be assessed for their risk of having a stroke. Which site does the nurse choose to access the highest risk population? a. Community elder center b. African American church c. Synagogue in a rural area d. Asian American grocery store

ANS: B African Americans have a higher rate of stroke death that do white Americans, even at younger ages. The nurse chooses the African American church for stroke screening. The other places will not have as large of a high-risk population.

The pediatric nurse is treating a patient who has questions about safer sexual practices. The patient states, "I think I should wait until marriage to be sexually active because I'm not sure sex is OK outside of marriage." The nurse understands the student is acting with which component of Freud's theory? a. Id b. Ego c. Superego d. Anal

ANS: C The superego is the structure that houses the moral branch of personality. The Id acts strictly on instinct without consideration of reality. The Ego is partly conscious but does not consider right from wrong. Freud's theory contains the "anal phase."

A school-aged child is scheduled for a minor procedure and is very nervous. What response by the nurse is best? a. Reassure the child the procedure is too minor to worry about. b. Read the child a pamphlet about what to expect during the procedure. c. Tell the child you will have the provider "put her to sleep" during the procedure. d. Explain the procedure and what to expect in simple terms.

ANS: D School-aged children benefit from simple explanations they can understand. Just telling the child not to worry is dismissive of the child's concerns. A school-aged child may not be able to read and/or understand a written pamphlet. Using phrases such as "put you to sleep" should be avoided since they can be misinterpreted.

The nurse working in a family practice clinic has very limited time to assess patients for health concerns. When working with middle-aged patients, which problems does the nurse assess for as the priorities? (Select all that apply.) a. Heart disease b. Cancer c. Sexually transmitted diseases d. Stroke e. Functional abilities

ANS: A, B, D Specific health concerns for this age-group include cardiovascular disease and cancer. The nurse should assess for heart disease, stroke, and cancer. Sexually transmitted diseases can occur in any group but is more a priority for the young adult. Functional abilities are more a priority for the older adult

The student using the FICA Spiritual Health Assessment will consider which factors? (Select all that apply.) a. Faith and belief b. Focused practices c. Importance of faith d. Faith community involvement e. Address spirituality in care

ANS: A, C, D, E FICA stands for faith and belief, importance of faith, faith community involvement, and address spirituality in care

The nurse working with an adult population knows that many age-related declines in function begin occurring at what age? a. 20 b. 30 c. 50 d. 70

ANS: B Many age-related functions peak before age 30 and begin to decline after that.

A nurse wants to volunteer for a community group providing secondary prevention. What activity would the nurse attend? a. Stroke rehabilitation support group b. Blood pressure screening at the mall c. Bicycle safety class at the elementary school d. Drop by nutrition station at the grocery store

ANS: B Secondary prevention activities are aimed at early diagnosis and prompt intervention. Blood pressure screening events are a good example. Stroke rehabilitation is tertiary prevention. Bicycle safety classes and nutrition education are examples of primary prevention.

A nurse working with a middle-aged adult is concerned that the adult is not meeting developmental tasks associated with Erikson's theory. What question by the nurse is most appropriate? a. Are there community organizations you would like to volunteer with? b. Do your children come to see you on a regular basis? c. Do you get at least 30 minutes of exercise most days of the week? d. How do you feel about reading for a leisure time activity?

ANS: A According to Erikson, this adult is in the Generativity versus Stagnation phase. Successful completion of the tasks associated with this stage includes reaching out to others beyond the nuclear family to community groups and society at large. Volunteering with an organization would be one way to meet the task. The other questions are related to individual-oriented behaviors

The public health nurse volunteers for a missionary group caring for Ebola patients in Africa. The nurse is reviewing the data using analytic epidemiology methods. What information does the nurse collect as the priority? a. Cultural norms in burial practices b. Genetic variables in disease acquisition c. Statistics related to incidence and prevalence d. Autopsy data on direct cause of death

ANS: A Analytic epidemiology hypothesizes why a disease is occurring in a community and looks at cultural practices, nutrition, and extrinsic factors such as the environment for links. Genetic variables and direct cause of death data are more related to epidemiology.

A home health care nurse has been working with a patient who has the Nursing diagnosis Spiritual Distress. After a few weeks of implementing the care plan, what method is best for the nurse to determine if goals have been met? a. Ask the patient to what extent he/she feels goals have been met. b. Ask the patient to rate the distress on a scale of 1 to 10. c. Assess for objective data to support goal attainment. d. Determine if the patient thinks the interventions are helpful.

ANS: A For a diagnosis with a large subjective component, getting the patient's feedback on goal attainment is best. There may be no objective data the nurse can use to rate goal attainment. Using a scale can be a part of the evaluation, but the patient's determination is best.

A nurse is providing anticipatory guidance to a new mother about the Erikson stage of trust versus mistrust. What education should the nurse provide to the mother to help her child successfully master this stage? a. Consistently provide your child with food and attention. b. Ensure someone is able to feed your child on a schedule. c. Allow unrestricted crawling and exploring as the child develops. d. Provide firm guidelines for behavior and activities.

ANS: A The most important item needed for a child to master this stage of development is a consistent caregiver who provides food and attention. If the caregiver is inconsistent or unable to meet these needs, the child will develop mistrust of those around him. Ensuring that someone feeds the child is not providing consistency. Allowing exploration within limits (setting boundaries) is important to master initiative versus shame and doubt.

. A nurse is planning primary prevention activities. Which activity would the nurse include in this plan? a. Safer sex education for teens b. Mammogram screening c. Medication compliance d. Annual physical exams

ANS: A Primary prevention includes activities designed to prevent a disease or condition from occurring in the first place. Examples of primary prevention activities include vaccinations, wellness programs, good nutrition for health, and safer sex programs. Mammograms and physical exams are secondary prevention measures. Medication compliance would be tertiary prevention

A nurse is concerned about not consistently meeting the spiritual needs of patients. What action by the nurse is best? a. Care for own spiritual needs. b. Begin a meditation practice. c. Consult the chaplain. d. Read books on the subject.

ANS: A To avoid burnout and a decreased ability to attend to the spiritual needs of patients, nurses must take care of their own spiritual needs first. This may include meditation, consultations, and reading, but other activities can guide the nurse into a reflective practice that will allow better spiritual care

A community nurse is working with a family that consists of a middle-aged adult, an older parent with dementia, and two school-aged children. Which assessment by the nurse is most important for this family? a. Stress-relieving methods b. Child care arrangements c. Functional ability of the older adult d. Knowledge of health screening needs

ANS: A Burnout can occur when caring for an older adult with dementia because their needs are great without lessening over time. Caring for both an older adult and school-aged children (often called the sandwich phenomenon or generation) adds even more stress. The priority assessment for this family is methods used to reduce stress

The nurse is asked by the parent of a pediatric patient to explain the difference between growth and development. Which response by the nurse is best? a. "Growth is physical while development relates to physical, emotional, and cognitive function." b. "There is no difference between the two since they occur simultaneously." c. "Development refers to musculoskeletal and nervous system abilities and growth is a change in height and weight." d. "Both refer to an increase in abilities and functions of the child that occur sequentially over time."

ANS: A Growth relates to physical changes in height and weight. Development refers to changes in ability across several dimensions such as physical, emotional, and cognitive. Stating that the two are not different does not show understanding of this difference. Development is not related strictly to changes in specific body systems. Although both refer to increases in abilities and functioning over time, this answer is too vague to give the parent useful information.

A young adult asks the nurse why she should participate in health screening and educational events. What response by the nurse is best? a. "Your choices now affect your future health." b. "It's free and full of good information." c. "Wouldn't you want to know if you had a problem?" d. "You can change bad habits now if you know about them

ANS: A Health behaviors entrenched in the young adult stage impact future health and well-being. While these events are free and full of information and bad habits can be changed if the person has knowledge and motivation, those responses do not give the person useful information. Asking if the person wants to know about health problems sounds accusatory

A nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best? a. Assess the patient's ability to read and understand. b. Determine if the patient wants to take written material home. c. Give the patient the same material as other patients get. d. Ask the patient if he/she has a need for written material.

ANS: A Health literacy in an important concept in health. If the patient cannot read or comprehend written material, it will be of limited use. The nurse first assesses the patient's ability to read and comprehend written material before choosing the material with which to send him/her home. Patients may or may not realize what they need for discharge, if anything. Giving the patient the same material other patients get does not acknowledge their need for holistic and individualized care.

A preschool-aged child got into the cookie jar and ate several cookies before dinner. When confronted by the parent, the child responds, "My pet horse ate them." What does the nurse teach the parents about this response? a. It is normal for children to have imaginary friends at this age. b. This vivid imagination will lead the child to misbehave later on. c. Lying is disobedient and should be punished consistently. d. The child is obviously afraid of the parents' response.

ANS: A It is common for toddlers to have imaginary friends. They are especially important in allowing the child to express something unpleasant. The other responses are not appropriate.

A patient who claims to be very involved in church is near death. What action by the nurse is best? a. Get permission to contact the religious leader. b. Allow the family to stay at the patient's bedside. c. Call the hospital chaplain to come to the bedside. d. Ask if the patient and family want to pray.

ANS: A Organized religions use rituals to mark important life events such as birth, marriage, and death. This patient would most likely want end-of-life rituals as practiced in his/her church. The nurse's best action is to contact the religious leader (with permission) of that church or institution. Allowing the family to remain at the bedside is important but not the best option to care for the patient's spirituality needs. The hospital chaplain is a valuable resource, but the patient's own religious leader would be better. Praying with the family is always acceptable, but it is best to let the family take the lead in prayer

A patient has the Nursing diagnosis Spiritual Distress. What assessment by the patient best indicates that an important goal has been met? a. Observed praying quietly. b. Indecisive about treatment. c. Asks nurse if God exists. d. Executes living will.

ANS: A Patients may have spiritual distress when facing situations that threaten their meaning and purpose in life, such as in the face of a terminal diagnosis. Patients often express anger, frustration, neediness, or crying. The patient who has worked through this situation and is able to pray has best shown goal attainment. Indecision and questioning do not indicate the resolution of this diagnosis. Executing a living will may be an indication of pragmatism

The parents of a 4 year old express concern that the child is wearing the same size clothing as she did last year. What action by the nurse is most appropriate? a. Weigh and measure the child and compare with last visit. b. Reassure parents that their child is growing normally. c. Assess the child's eating and activity patterns. d. Encourage the parents to provide the child a multivitamin.

ANS: A Physical growth slows during the preschool years, with most children only gaining about 5 lb and 2 1/2 to 3 inches a year. The nurse should weigh and measure the child and compare the readings to those taken at the last visit. Showing the parents these results and educating them on expected growth will reassure them. Simply telling the parents their child is normal does not provide objective information and is dismissive of their concern. The nurse should assess each child's eating and activity habits. The child may or may not need a vitamin. This can be discussed with the provider.

The nurse is caring for a patient that is actively trying to conceive a child but continues to drink alcohol. The patient states that she'll stop drinking once she is pregnant. What is the most appropriate response by the nurse? a. "Abstaining is best since most fetal development occurs before you realize you are pregnant." b. "Small amounts of alcohol are safe at any time during pregnancy." c. "Things will be okay if you quit drinking alcohol once you know you are pregnant." d. "Alcohol use should be avoided early in pregnancy but is acceptable past week 20."

ANS: A Rapid development occurs before many women know that they are pregnant, making alcohol consumption unsafe at any time during pregnancy.

The nurse plans to develop a comprehensive screening tool to use with young adults, assessing their lifestyles and healthy living habits. What barrier must the nurse plan to overcome to make this screening successful? a. Young adults may not see a health provider regularly. b. Young adults are so diversified that a screening tool may not be appropriate.

ANS: A Since young adults are at the peak of their physical development and abilities, they may not see a health care provider on a regular basis. Screening tools can be used with any population. When riskier behaviors are demonstrated, the more education is needed. Time constraints are generally not the main reason young adults do not have regular medical care.

A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting? a. Praying five times a day b. Having privacy c. Personal cleanliness d. Giving alms e. Maintaining modesty

ANS: A The five pillars of Islam are: believe in one God, pray five times a day facing Mecca, giving alms to the less fortunate, fasting during Ramadan, and making a pilgrimage to Mecca. The nurse is best able to help the patient maintain the practice of praying five times a day while hospitalized.

A nurse has assessed a community and has found many areas in which health can be improved. As a result, the nurse has multiple ideas for programming. What action by the nurse is best? a. Determine what the community thinks is most important. b. Use vital statistics to determine which is most important. c. See what other communities are focusing programming on. d. Choose the easiest problem to address first.

ANS: A The nurse's priorities may be very different from the community's. For programming to be successful, there must be buy-in from members of the community. Unless programming addresses a need the community thinks is important, it is unlikely to be successful.

. A nurse is wondering if home health care nursing is a good fit. What characteristic or ability does the experienced home health care nurse suggest is most important? a. Clinical reasoning b. Organization c. Assessment skills d. Time management

ANS: A The role of the registered nurse in home health care is essentially autonomous in that the nurse must be highly proficient in health assessment (physical and psychosocial), be well versed in complex technical and clinical skills, possess strong critical-thinking and clinical reasoning abilities, and demonstrate excellent organizational skills. All choices are important characteristics or abilities of home health care nurses. However, since the nurse working out in the community may not have the resources (personnel or materiel) available in an acute care facility and often must improvise, clinical reasoning would be the most important of the choices provided

The home health care nurse educates patients on which goals of hospice care? (Select all that apply.) a. Relieve suffering. b. Support the patient and family. c. Provide grief support. d. Keep patients out of the hospital. e. Lower medical expenses.

ANS: A, B, C The goals of hospice care include relief of suffering, supporting the family and patient, and providing grief support after the patient dies. Goals do not include keeping patients out of the hospital or lowering medical costs.

A high-school nurse is planning an educational presentation for juniors. What activities are most appropriate for the nurse's plan to include? (Select all that apply.) a. Video showing the aftermath of a drunk driving car crash b. Confidential depression and suicide risk assessment c. Same-age speaker sharing her story about the impact of HIV disease d. Charts and graphs showing the physical changes of puberty e. Bicycle helmet fitting station to see if child has outgrown the helmet

ANS: A, B, C, D Adolescents need education on drinking and driving, suicide and depression, safer sexual practices, and physical changes that occur during puberty. A bicycle helmet fitting station would not be a priority for this age-group.

The nurse explains to the patient that which services will be covered under Medicare? (Select all that apply.) a. Infusion therapy b. Ostomy management c. Renal dialysis d. Chemotherapy e. Grocery shopping

ANS: A, B, C, D Medicare will reimburse for professionally rendered services provided by a licensed health care provider. Grocery shopping would not be covered. If homemaker services are provided to a patient also receiving skilled care, then they too are reimbursed.

The nurse assessing a patient using the SPIRIT framework would ask which questions? (Select all that apply.) a. "Do you follow a particular religion?" b. "How involved in your church are you?" c. "Are there any practices I can help you with?" d. "How will your religion affect your care?" e. "What gives you hope in bad situations?"

ANS: A, B, C, D SPIRIT stands for Spiritual belief system, personal spirituality, integration and involvement in a spiritual community, ritualized practices and restrictions, implications for medical care, and terminal events planning. Hope is a good thing to assess but is more related to the HOPE framework.

When does the nurse assess patients' spirituality? (Select all that apply.) a. Upon admission b. New diagnosis c. Life-changing diagnosis d. When the chaplain makes rounds e. When facing treatment decisions

ANS: A, B, C, E There are many times at which a spiritual assessment is necessary. All patients should have their spirituality assessed upon admission at a minimum. Other assessments should be conducted at times when the patient is at risk for spiritual distress. Assessment should be done based on patient need, not when the chaplain is available

The nurse who incorporates the HOPE framework assesses a Native American patient for which of the following? (Select all that apply.) a. Desire for shaman to be present b. Personal use of herbs and prayers c. Desire to create a living will d. Power of storytelling for healing e. Involvement in church activities

ANS: A, B, D Native Americans often use shamans; prayers, songs, and dances; storytelling; and herbs in health care. The HOPE framework assesses sources of hope, meaning comfort, strength, peace, love, and connection; organized religion; personal spirituality and practice; and effects on medical care and end-of-life issues. The nurse who knows about both topics will assess this patient for the desire for a shaman to be present, the personal use of herbs and prayers, and storytelling. A living will is more accurately assessed with the SPIRIT framework. Involvement in church activities can be best assessed using either the SPIRIT or FICA framework.

The nurse tells the student that which disorders are related to the presence of free radicals? (Select all that apply.) a. Cancer b. Cataracts c. Glaucoma d. Arthritis e. Liver disease

ANS: A, B, D Free radicals are naturally occurring chemicals that can cause cellular damage. They are implicated in such diseases as cancer, cataracts, and arthritis. They are not implicated as a causative factor in glaucoma and liver disease.

A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.) a. Vaccination compliance b. Family structure c. Communication patterns d. Roles for women e. Education

ANS: A, B, D, E Income, education, health literacy, where people live or work, early childhood development, social exclusion, family structure, the status and role of women, and vaccination adherence are just some of the social determinants of health recognized worldwide. Communication patterns often are important to assess in culturally diverse individuals, families, and communities, but this is not considered a social determinant of health care.

The nurse is assessing hospitalized older adults for risk factors that could lead to delirium. For which patients does the nurse plan extra care to prevent delirium? (Select all that apply.) a. A 95 year old b. On multiple pain medications c. Is blind d. 2 days postoperative e. Intractable pain

ANS: A, B, D, E There are several risk factors for developing delirium, including advanced age, polypharmacy, pain, surgery, and hospitalization. Being blind is not a risk factor.

A nurse is planning a community education event for parents on the topic of school-aged children and the risks of too much social media time. What topics should the nurse plan to include? (Select all that apply.) a. Increased bullying b. Decreased physical activity c. Decreased understanding of spatial relationships d. Weight loss and malnutrition e. Increased aggressiveness

ANS: A, B, E Some of the risks associated with social media include bullying, decreased physical activity with resultant obesity, and aggressiveness.

. The nurse is teaching parents about actions to assist in developing a critical skill in the concrete operations phase of Piaget's developmental theory. What activities does the nurse suggest the parents participate with their child in? (Select all that apply.) a. Separating a collection of toy horses into functions each type performs. b. Exploring a space and astronomy museum and planetarium together. c. Making a scrapbook of leaves sorted by color or type of tree. d. Having the child explore how common objects can be used for different purposes. e. Asking the child to describe an event from several different points of view.

ANS: A, C In the concrete operational stage of Piaget's theory, seriation is an important task. This task includes separating or sorting objects using specific criteria. Separating toy horses by functions and arranging a leaf album by color or tree type are examples of seriation. Exploring museums does not contribute to seriation. Learning how objects can be used for unusual purposes and describing other points of view are part of the formal operations stage.

A nurse wants to create a community action plan for health problems related to air pollution from a nearby factory. Which stakeholders does the nurse consult as the priority? (Select all that apply.) a. Factory owners b. Stock shareholders c. Community residents d. Local health care providers e. Factory employees

ANS: A, C, D Stakeholders have a significant interest in a topic. The priority stakeholders the nurse would want to consult for this project include the factory owners, community residents, and health care providers. The stockholders would probably not be consulted. The employees could be a significant stakeholder if the action plan affected employment.

The nursing student learns which facts about religion and spirituality? (Select all that apply.) a. Spirituality focuses on the meaning of life to people. b. Religion and spirituality are mutually exclusive. c. Religion implies an organized way of worship. d. Religion provides the structure by which to understand spirituality. e. Spirituality is an individual practice that does not include others.

ANS: A, C, D Spirituality focuses on the meanings of life, death, and existence. Religion is an organized and structured method of practicing or expressing one's spirituality, so they are interconnected and not mutually exclusive. Religion provides the structure for expressing spirituality. Spirituality can be expressed through relationships with others.

The nurse is planning an educational workshop on health risks for the young adult. What topics does the nurse plan to include as priorities? (Select all that apply.) a. Sexually transmitted diseases b. Falling c. Responsible alcohol use d. Intimate partner and sexual violence e. Distracted driving

ANS: A, C, D, E Health risks for this population include sexually transmitted diseases, alcohol and illicit drug use, violence, and distracted driving. Fall prevention is more appropriately directed toward an older audience

The nurse is conducting a windshield survey. What items does the nurse assess? (Select all that apply.) a. Types of housing available b. Cars seen in parking lots c. Recreational facilities d. Health care facilities e. Places of worship

ANS: A, C, D, E A windshield survey is a type of community health assessment. The nurse walks or drives through a neighborhood and notes the type of housing available, the presence and condition of recreational facilities, the presence of health care facilities, and places of worship among other items. Types of cars noted in the neighborhood are not one of the assessments

Which actions by a nurse constitute spiritual care? (Select all that apply.) a. Baptizing a critically ill child per the parent's request b. Leaving the room, giving the patient and family privacy for prayer c. Considering developmental stage when planning care d. Notifying the hospital chaplain of a patient's request e. Praying with patients and families when requested

ANS: A, C, D, E Many activities fall into the realm of spiritual nursing care, including baptizing an infant in an emergency, notifying the chaplain or other religious leader of patient requests for service, and praying with the patient and family. The nurse always considers the patient's developmental level when planning or providing any type of care. The patient and/or family may or may not want privacy for prayer; the nurse should assess the situation and not just leave

. A nurse is assessing a 12 month old at a well-baby visit. For what developmental milestones does the nurse assess this child? (Select all that apply.) a. Attempting to walk with help b. Transferring objects from one hand to the other c. Ability to roll around on the floor d. Searching for objects that are out of sight e. Moving from lying on abdomen to sitting unassisted holding a bottle independently

ANS: A, D, E *?* A 12 month old should be attempting to walk with help, hold a bottle independently and move from lying on abdomen to sitting up unassisted. Transferring objects from one hand to the other and rolling from front to back are milestones seen around 7 months of age and holding a bottle independently occurs at 4 to 6 months

The nurse is performing wellness checks at a community center for older adults. Which person would the nurse evaluate as having the highest risk of stroke? a. Caucasian, 55 years of age, BP 148/92 mm Hg b. African American, 70 years of age, BP 150/100 mm Hg c. Asian American, 40 years of age, BP 146/78 mm Hg d. Caucasian, 74 years of age, BP 150/82 mm Hg

ANS: B African Americans have a higher rate of stroke than whites at any age. Hypertension is also a risk factor for stroke. Stroke risk also increases with age overall. Therefore, the person with the highest risk of stroke is the older hypertensive African American.

An adult caregiver for an older adult reports the adult is doing well other than sleeping more frequently and for longer periods. What response by the nurse is best? a. Assess the older adult for exercise habits. b. Perform a screening for depression. c. Reassure the caregiver that this is normal. d. Ask the older adult to provide a sleep diary.

ANS: B Depression is common in the older adult population and is frequently overlooked or misdiagnosed. People may think withdrawal and excessive sleeping are normal age-related changes, but they are not. The nurse should assess the older adult for depression. Other assessments can follow because they are not the priority for this patient.

A nurse is assessing an adolescent female who began menstruating 2 years ago. She has grown 1/2 inch in the last 2 years but has not gained any weight. What action by the nurse is most appropriate? a. Ask the teen to provide a 24-hour diet recall. b. Talk to the teen about healthy dietary practices. c. Reassure the teen she will have a growth spurt soon. d. Collaborate with the provider for endocrine testing.

ANS: B During the adolescent growth spurt, teens achieve approximately 20% to 25% of their final height. This occurs during the time span ending about 2 years after the onset of menses. Since this teen has already reached that mark with little growth, the nurse should assess the teen's knowledge and practice of healthy eating. Poor eating habits are common with this age-group. A 24-hour diet recall can be utilized but the nurse's assessment should encompass more than just the recall. The teen most likely will not have another growth spurt later. Endocrine testing is not warranted at this point

A nurse works in a pediatric oncology unit and is feeling depressed and discouraged. What initial action by the nurse is best? a. Apply for a job transfer to another unit. b. Consult with the hospital chaplain. c. Make an appointment with Employee Assistance. d. Ask other nurses how they deal with the stress

ANS: B Hospital chaplains are great resources for nurses experiencing burnout, moral distress, or spiritual distress. The nurse can take all options, but a consultation with the chaplain is the best place to start to see if the issue can be resolved. The chaplain has a wider range of perceptions and tools than do the other staff nurses

A nurse is a case manager for a home health care agency. The nurse often orders supplies for patients seen by the agency. What action by the nurse is best? a. Negotiate for cheaper prices from suppliers. b. Investigate what each patient's insurance will cover. c. Refer the patient to the closest supply source. d. Use the same supplier for all patients' needs.

ANS: B The case manager in home health care must be a well-versed financial steward and understand what each patient's insurance will cover to maximize the patient's benefit. The home health care nurse serves as a case manager (coordinator) of client care, needed services, and needed supplies in the home setting. The nurse must be well versed as a financial resource manager, who needs to be aware of what is or is not covered on the client's insurance plan.

The nurse is conducting a home visit on a newborn. What observation would require the nurse to provide further education? a. The caregiver warms the bottle and tests heat on the inside of the wrist. b. The parents state the infant is sleeping with them until they buy a crib. c. One parent states that when the child gets frustrating, the other parent takes over. d. Caregivers consistently wash their hands before holding the baby.

ANS: B Infants should not sleep in the same bed as their parents because of the risk of suffocation. The other actions are appropriate.

A nurse reads on a patient's chart that she has sarcopenia. What assessment does the nurse perform to confirm this? a. Mini-mental state exam b. Tests of muscle strength c. Gait and balance d. Vision and hearing

ANS: B "Sarcopenia" means loss of tissue. Muscle tissue and muscle mass both tend to decrease starting in the 30s. The nurse assesses muscle strength to get information about possible sarcopenia in this patient. Tests of cognition, gait and balance, and sensory perception are not related.

A home health care nurse is working with the family of a patient who has Alzheimer disease and requires 24-hour care. What assessment by the nurse indicates the family is meeting an important goal for caregiver role stress? a. Family eats dinner together every night. b. Family uses respite care one night a week. c. Family investigates research trials for patient. d. Family verbalizes exhaustion from caregiving

ANS: B Caregiver role stress can occur when the caregiver(s) is unable to meet obligations or unable to take care of personal needs. Using a respite caregiver once a week gives the family a little time off to accomplish needed tasks. The other observations are not tied to this diagnosis

A father expresses frustration that his school-aged child is suddenly "sick all the time." What action by the nurse is best? a. Encourage the father to give the child a multivitamin each day. b. Explain that illness is frequent in this age-group because of exposure to others. c. Encourage the father to discuss testing the child's immunity with the provider. d. Make sure the parents are washing their hands frequently in the home.

ANS: B Children in this age-group tend to have a higher incidence of minor illnesses because of exposure to others. The nurse can reassure the father by explaining this. No other action is needed at this point.

A nurse is assessing a middle-aged adult for cognitive skills. The patient has difficulty with seriation tests. What action by the nurse is most appropriate? a. Document the findings and continue the assessment. b. Perform another test for fluid intelligence. c. Consult with the provider about dementia screening. d. Ask the patient about family medical history.

ANS: B Middle-aged adults (especially younger ones) often have trouble with math processing (fluid intelligence) because of the prevalence of calculators and computers and dependence upon them to do work formerly done by the individual. The nurse should conduct other tests for fluid intelligence. The findings should be documented, but this is not the only action needed. Dementia screening is not indicated with one test result. Family medical history should be part of all screenings but is not directly related to this issue.

A nurse is completing an OASIS assessment on a patient. What data would be most important for the nurse to assess? a. Presence of grocery stores nearby b. Safety concerns within the home c. Number and kind of pets d. Proximity to a health care facility

ANS: B OASIS (Outcomes and Assessment Information Set) is a data set of outcome measures for adult home health care clients that is used to track outcome-based quality improvement. Factors that could potentially affect patient safety in the home are particularly important. The other options are not included in this assessment.

A home health care nurse is making a well-baby visit to the home of a new mother who has an infant. What assessment finding leads the nurse to provide further anticipatory guidance and teaching to the mother? a. Mother states she does not breastfeed but uses a recommended formula. b. Crib has colorful blankets and pillows for the baby to cuddle. c. A mobile is hanging well above the crib playing soft music. d. Several rattles and plush toys are available in different textures.

ANS: B Objects such as pillows and blankets pose a suffocation hazard to infants and should be kept out of cribs. The other items are appropriate for a newborn.

.A nurse has referred a patient to a community agency. When talking to the patient later, he states that he did not find the agency helpful. What action by the nurse is best? a. Determine what the patient would find helpful. b. Review the agency's mission and scope. c. Make another appointment with the agency. d. Warn the patient that nonadherence affects payment.

ANS: B One of the most important aspects of a community health nurse's role is to be familiar with referral agencies. Awareness of the scope of an agency's influence and services helps the community nurse to pinpoint which agencies are best able to address specific needs. The nurse may have sent this patient to an agency that did not meet his needs. The nurse should ask the patient's opinion about what services are needed. Making another appointment without ensuring that this is the right agency for the patient will not solve the problem. Telling the patient that payment might not be ensured for nonadherence is not therapeutic communication.

A patient died suddenly in the emergency department. Which action by the nurse best provides the family connection with others? a. Offering the family written information on grief support groups . b. Asking the family if there is someone the nurse can call for them. c. Having the hospital social worker or chaplain sit with the family. d. Offering to stay with the family during this difficult time.

ANS: B Promoting connectedness means recognizing that family and friends are providing at least some of the patient's spiritual care. The nurse best assists when offering to call someone for the patient or family. The other options may be appropriate but are not directly related to connectedness

The student nurse asks why spirituality is important in health care. What response by the registered nurse is best? a. "All people have a spiritual aspect to their beings." b. "Spirituality affects behavior, which also affects health." c. "Knowledge of it is needed to understand a patient holistically." d. "People who are less spiritual have worse outcomes."

ANS: B Spirituality affects behavior, which has a direct impact on health. Spirituality is a universal concept, but all people may not recognize it in themselves. Holistic knowledge is indeed based in part on spirituality, but that does not give the student information on a concrete link. Less spiritual people may or may not have worse outcomes.

A nurse is interested in epidemiology. What work activity would best fit this role? a. Studying census data to determine common causes of death b. Researching population variables that contribute to disease c. Developing sanitary measures to prevent foodborne illness d. Designing research to determine the connection between pollution and cancer

ANS: B The epidemiologist works to develop programs to prevent the development and spread of disease. Studying census data, researching population variables, and designing studies do not fall in this field

A young adult tells the nurse he has quit smoking cigarettes and now "vapes" (uses electronic cigarettes [e-cigarettes]). What response by the nurse is best? a. "Excellent! That is so much better for you than tobacco." b. "The health consequences of e-cigarettes are not known." c. "Using e-cigarettes actually is much worse for your health." d. "Tobacco or e-cigarettes ... doesn't matter. You need to quit.

ANS: B The health consequences of using e-cigarettes are not yet known because they are new products. The nurse educates the young adult to this fact.

The perinatal clinic nurse is going to teach a woman from a culture unfamiliar to the nurse about child-rearing practices. What action by the nurse is best before planning the education? a. Ensure the availability of written material to give the woman. b. Assess what practices are important to her cultural group. c. Determine if the woman is the primary family decision maker. d. Refer the woman to a prenatal educational class.

ANS: B The nurse must ensure he/she has a solid understanding of important child-rearing concepts in the woman's culture or risk that any teaching done will be irrelevant and perhaps in opposition to important beliefs. Since the nurse is unfamiliar with this culture, the first step is to assess. Written material is helpful if the patient can read and comprehend it. It would be important to determine if the woman is the decision maker, but this is not as much of a priority as learning about the culture. Referring the woman to an educational group may or may not be helpful

The nurse is collecting a history from the parents of a 4-year-old female at a well-child visit. The parents express concern that they often find their daughter performing what appears to be masturbation. The nurse offers reassurance by explaining which stage of development according to Freud? a. Oral b. Phalli c. Anal d. Latency

ANS: B The phallic stage occurs between the ages of 3 and 6 years, and pleasure centers on the child's discovery that self-stimulation is enjoyable. The oral stage is seen in infants where pleasure centers around the mouth and putting things in the mouth. The Anal stage occurs between 18 months and 3 years of age and is when tension and release of tension occur through anal elimination. The latency stage occurs between the ages of 6 years and puberty during which interest in sexuality is repressed.

The nurse working in long-term care knows that there are multiple theories regarding aging. The one the nurse most identifies with proposes that the body's cells are leading to damaged organs and organ systems. This description is congruent with which theory? a. Cross-linking theory of aging b. Wear-and-tear theory c. Gould's theory on adult development d. Senescence theory of aging

ANS: B The wear-and-tear theory states that body cells are damaged from years of hard use. The cross-linking theory relates changes of aging to cross-linked and connected cells and systems become hardened over time, decreasing function. Gould's theory is a psychosocial one looking at tasks the adult completes, not physical changes. "Senescence" means biologic aging; there is no senescence theory of aging

The nurse is caring for four patients. Which one should the nurse assess for spirituality needs as a priority? a. New mother, older child at home. b. Faces terminal diagnosis. c. Needs to change medications. d. Pleasant but quiet

ANS: B There are many cues to alert the nurse that a patient might have unmet spiritual needs, including facing a terminal illness. The nurse should conduct spiritual assessments on all patients, but this one is the priority.

A home health care nurse notes a parent becoming irritated when his toddler repeatedly throws his rattle from the high chair to the floor. What action by the nurse is most appropriate? a. Teach the parent about age-appropriate discipline. b. Educate the parent on age-appropriate behaviors. c. Tell the parent to stop giving the rattle back to the child. d. Assess the child for signs of abuse or neglect.

ANS: B Throwing an object down to watch someone else pick it up is a typical behavior for this age-group. The nurse should teach the parent about how this behavior relates to toddler growth and development. The other actions are not appropriate in this situation.

The student studying community health nursing learns that vulnerable populations can be best assisted by which activity? a. Researching their genetic risk for health problems b. Working with the community to decrease health risks c. Studying vital statistics to determine their causes of death d. Making sure the population maintains immunizations

ANS: B Vulnerable populations have some characteristic that puts them at higher risk for identified health problems. The nurse can best assist vulnerable populations by identifying and working with them to decrease their risks. Researching genetic risks, studying vital statistics, and improving immunizations are all part of the solution, but the overarching priority action is to help the community decrease its risks.

The student of adult development learns that cognitive abilities improve during the young adult stage because of the influence of which experiences? (Select all that apply.) a. Physical growth of the brain b. Formal education c. Occupational training d. Overall life experiences e. Specific profession chosen

ANS: B, C, D Formal education, occupational training, and overall life experiences contribute to refining cognitive skills such as rational thinking and problem solving. Physical growth of the brain and specific profession chosen are not as directly related.

The nurse who is aware of spirituality practices of major religions knows that which religions view health and illness as a process of balance or imbalance? (Select all that apply.) a. Catholicism b. Native American c. Hinduism d. Greek Orthodox e. Buddhism

ANS: B, C, E Native American, Hindu, and Buddhist practitioners believe that health and illness are a matter of balance or imbalance in the body.

A pregnant woman in her second trimester is scheduled for quad testing. What conditions does the nurse explain are screened for in this assessment? (Select all that apply.) a. Blood clotting abnormalities b. Neural tube defects c. Heart abnormalities d. Trisomy 18 e. Trisomy 21

ANS: B, D, E Quad testing includes assessing for neural tube defects, trisomy 18, and trisomy 21 (Down syndrome). It does not screen for heart or blood-clotting problems.

A nurse is studying intrinsic factors that influence the development of asthma in a community. What factors does the nurse assess? (Select all that apply.) a. Socioeconomic status b. Genetics c. Pollution in the area d. Water cleanliness e. Immunization status

ANS: B, E Host, or intrinsic factors are individual variables such as genetics, age, gender, ethnic group, immunization status, and human behavior that impact a person's health. The other options are all extrinsic factors, which pertain to environmental characteristics.

The nurse knows that which attributes are characteristics of the young adult age-group? (Select all that apply.) a. The number of high school graduates going to college is decreasing. b. More than 88% of people aged 25 to 34 have completed high school. c. More males aged 20 to 24 were married than females in the same age-group. d. A significant percentage of those aged 25 to 34 has advanced degrees. e. Adult roles for the young adult are more diverse than for other age-groups.

ANS: B, E More than 88% of people aged 25 to 34 have completed high school. Adult roles, which are influenced by many factors, are diverse and are not normed for this age-group. The number of high school graduates going to college is increasing. More females than males aged 20 to 24 are married. Only about 9% of those 25 to 34 have advanced degrees.

A nurse assesses a 4-month-old infant and notes the baby does not follow a moving object with her eyes. What action by the nurse is best? a. Document the findings and continue the assessment. b. Refer the child and parent to a pediatric neurologist. c. Assess the child for other age-appropriate behaviors. d. Assess the child for signs of child abuse or neglect.

ANS: C A 3-month-old child should be able to follow a moving object with his or her eyes. However, one single abnormal assessment finding does not necessarily mean that the child has a growth and developmental delay. The nurse should assess for other age-appropriate behaviors. Documentation should occur but is not the priority action at this point. A referral is not warranted nor is assessing for child abuse based on the data.

A nurse who uses Havighurst's theory of development is assessing a young adult. What question does the nurse ask to provide the most relevant information about this person's successful negotiation of this developmental stage? a. "Do you find yourself doing familiar tasks in new ways to accomplish them?" b. "Please count backwards from 100 by 7s, such as 100, 93, and so on." c. "What occupation have you chosen for your life's work?" d. "Do you still have a good relationship with your parents and siblings?"

ANS: C According to Havighurst, one of the tasks of the young adult is to select an occupation. Changing the approach one performs familiar tasks is seen in the middle adult stage. Seriation activities test fluid intelligence and are often used in middle adulthood. Although for Havighurst, achieving emotional independence from parents is important, that does not preclude having a good relationship with them

The student nurse asks why he needs to assess a patient's spirituality when he can call the chaplain. What response by the nurse is best? a. "This way you learn what is involved in a spiritual assessment." b. "Students need to perform all aspects of patient care." c. "Regulatory organizations list this as a required BSN competence." d. "All patients should have a spirituality assessment."

ANS: C Although there is some truth to all options, several regulatory groups list conducting a spiritual assessment as a vital skill for nurses, including the American Association of Colleges of Nursing, The Joint Commission, and the American Nurses Association

A nurse is orienting to a new job in a home health care agency and is told that most of her patients need tertiary prevention. What activity does the nurse plan to include in the daily routine? a. Household safety checks b. Well-baby checkups c. Antibiotic administration d. Monthly blood pressure assessments

ANS: C Tertiary care is aimed at people who are already experiencing a health alteration, such as those with an infection who need antibiotics. The other options are secondary prevention.

Ch. 23 The student learns that which is the best definition of a public health nurse? a. Works with the public. b. Works in public areas. c. Works with the greater community. d. Works with public funding

ANS: C A public health nurse works with communities as a larger whole and is concerned with specific target or vulnerable groups within that community. The other options are inaccurate

A patient asks the nurse to pray with him. The nurse is an atheist and uncomfortable with this request. What action by the nurse is best? a. Deny the request because of atheistic beliefs. b. Offer to call the chaplain instead. c. Agree to sit with the patient while he prays. d. Ask the patient if he will meditate instead.

ANS: C Although the nurse is uncomfortable with the request, the patient's needs (not the nurse's) come first. The nurse should attempt to honor the request while not imposing his/her ideas of religion and spirituality on the patient. The best option is to agree to sit with the patient while he prays himself. This is consistent with caring behaviors and fulfilling the patient's needs. Denying the request does nothing to address the patient's needs. The nurse can offer to call the chaplain in addition to sitting with the patient. Asking the patient to change his practices is unethical.

To help a hospitalized infant master the tasks in Erikson's stage of Trust versus Mistrust, which action by the nurse is best? a. Provide calming music during quiet time so the infant can sleep. b. Give the family food vouchers for the hospital cafeteria. c. Arrange to have a cot or small bed placed in the infant's room. d. Do not allow unlicensed assistive personnel to care for the infant.

ANS: C Caregiver consistency is vital to accomplishing this task. The nurse should provide the parent(s) a comfortable place to stay in the infant's room. Giving food vouchers is also a good intervention, but not as important as ensuring the parent(s) can stay with the child. Calming music is appropriate for a child this age but does not help the child master tasks in this phase. Sleep is important for any hospitalized patient but is unrelated to mastering the tasks in this phase.

A patient is hesitating to accept a blood transfusion as a course of treatment. What Nursing diagnosis is most appropriate for this patient? a. Spiritual distress b. Anxiety c. Moral distress d. Decisional conflict

ANS: C Moral distress is cultural conflict between medical treatment and religious beliefs, expressions of concern about rejection by religious community, hesitation in accepting blood transfusion. The other diagnoses are not related.

The nurse concerned about a patient's spiritual needs can best address this by which action? a. Leaving a note on the chart for other professionals b. Calling the chaplain to come see the patient c. Collaborating during interdisciplinary rounds d. Informing the provider of the patient's needs

ANS: C Spiritual care must be multidisciplinary to be most effective. The nurse best addresses patients' spiritual needs by discussing them during interdisciplinary rounds.

A parent is concerned that her 16 year old is spending most of his time away from the family in his room and does not want to be involved in family activities he used to enjoy. What action by the nurse is best? a. Reassure the parent the teen is exerting independence. b. Ask the parent about the teen's friends and activities. c. Assess the teen for depression and possible suicide risk. d. Refer the family to the community depression support group.

ANS: C Teens typically begin to withdraw from the family to maintain privacy and exert independence, so this alone is not concerning. However, since the teen is not participating in activities he once enjoyed, the nurse should conduct a depression assessment. If the teen is depressed, the nurse should assess his suicide risk. If these screenings are normal, the nurse can reassure the parent. The teen himself is the best source of information about friends and activities, although the parent can be a good secondary source. A referral is not warranted without further assessment.

. A community was devastated by a tornado several months ago. What nursing diagnosis would be most appropriate for the nurse to consider? a. Social isolation b. Deficient community resources c. Ineffective community coping d. Deficient community health

ANS: C This diagnosis considers those in a community who may be feeling helpless, hopeless, or frustrated because of an extraordinary event. Financial and physical resources may not be available for rebuilding. Social isolation refers to unacceptable social behavior. Deficient community resources is not an approved diagnosis. Deficient community health may become a problem if sanitary conditions lead to an outbreak of disease

A patient, who is an adherent Muslim, is in a burn unit with severe burns. The patient has high caloric requirements but is refusing to eat during Ramadan. What action by the nurse is best? a. Insert a feeding tube and provide enteral feedings. b. Ask the provider about Total Peripheral Nutrition. c. Call the patient's religious leader for advice. d. Tell the patient he has to eat to get better.

ANS: C With permission, the nurse should consult with the patient's religious leader on this situation. There may be exceptions to the rule to fast during Ramadan for medical conditions. The other options ignore the patient's religious preferences, and both the tube feeding and parenteral nutrition have potential serious side effects

The student nurse learns the ANA's Scope and Standards of Practice for public health nursing include components? (Select all that apply.) a. Team membership b. Developing research c. Ethical behavior d. Responsible resource use e. Advocacy

ANS: C, D, E The ANA's Scope and Standards of Practice for public health nursing requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy like the standards of practice for all nurses. Team membership and developing one's own research are not included

. The community health nurse knows that which are standards of professional performance for home care nurses according to the ANA? (Select all that apply.) a. Collegiality b. Performance appraisal c. Ethical behavior d. Outcome identification e. Resource utilization

ANS: C, E The ANA's Public Health Nursing: Scope and Standards of Practice (2013) requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy similar to the standards of practice for all nurses.

A nurse is conducting a preschool screening in the community. Which child would the nurse refer for further assessment? a. A 4 year old who throws a ball over-handed but better under-handed. b. A 4 year old who can skip across the room after being shown how. c. A 5 year old who is able to ride a bicycle with training wheels. d. A 5 year old who is unable to ride a tricycle without falling.

ANS: D A 3 year old should be able to ride a tricycle, so a 5 year old unable to perform this task needs further assessment. The other activities are appropriate for each child's age.

A nurse in the family practice clinic is assessing an older adult who has dementia. The adult daughter/caregiver expresses concern that the parent should no longer be left alone while the daughter is at work. What response by the nurse is best? a. Refer the family to a social worker. b. Encourage the daughter to look into nursing homes. c. Tell the daughter there are medications for dementia. d. Help the daughter explore adult day care options.

ANS: D Adult day care facilities offer care of the older person during the working hours. This might be a good option for the family. A social worker can help, but the nurse should be active in problem solving with the daughter. Medications are available for dementia, but dementia remains a progressive disorder, so this does not help solve the problem. A nursing home may not yet be needed.

A nurse notes an older adult puts excessive amounts of salt on her food. What intervention by the nurse is best? a. Teach the adult how salt intake relates to hypertension. b. Ask the older adult why she puts so much salt on food. c. Encourage the older adult to use less salt on her food. d. Explore other herbs and flavor enhancers with the adult.

ANS: D Older adults tend to lose their sense of taste and smell. Food becomes less attractive to them and they may respond by adding salt. The nurse who understands this concept will help the older adult explore other flavor enhancers for food. Teaching about the relationship of sodium to hypertension is important but does not address the problem. Encouraging the adult to use less salt does not give her a strategy to do so. Asking "why" questions is a communication barrier that often causes people to become defensive

A young nursing student is assessing an older patient. The student nurse questions if a sexual history needs to be taken. What response by the faculty is best? a. Since procreation is not an issue, you do not need to discuss this. b. Only discuss this topic if you are comfortable in doing so. c. Ask the patient if he/she wants to talk about sexuality. d. Sexuality is a basic human need and needs to be assessed.

ANS: D Sexuality is a basic human need. The faculty should tell the student to complete the assessment. Procreation is not an issue currently; however, this does not eliminate the need to discuss sexual issues. Asking permission may be an important part of taking a sexual history, but that response is implying the student can "get out of" the assessment if the patient is agreeable. The student needs practice to improve his/her comfort with this assessment

The nurse working with older adults encourages them to stay healthy. What instruction by the nurse takes priority? a. Eat at least seven servings of produce a day. b. Get at least 8 hours of sleep a night. c. Get some exercise at least most days of the week. d. Stay away from people who are ill.

ANS: D One normal age-related change seen in the older adult is decreased immune function. The older adult should place high priority on avoiding illness by staying away from people who are sick and avoiding large crowds during peak communicable illness periods. The other instructions are also relevant but do not address this age-related change

A patient is scheduled to have an MRI and has a metal religious icon pinned to his gown, which can't go in the scanner. What action by the nurse is best? a. Take the icon off the patient's gown until she returns. b. Give the icon to the patient's family for safekeeping. c. Pin the icon to the patient's pillow so it can go to radiology. d. Explain the restriction and ask the patient's preference.

ANS: D The religious icon has profound significance for the patient and should not be removed by the nurse. Since the icon cannot go into the MRI scanner itself, the nurse should explain the situation to the patient and get the patient's opinion of various options. All other options are possibilities, but it should be the patient's determination.

An adult child brings his father to the emergency department and describes the sudden onset of a panic attack and aggressiveness. After ruling out an infectious process, what action by the nurse is best? a. Assess the patient for mental illness. b. Perform a mini-mental state exam on the patient. c. Ask about risk factors for delirium. d. Assess the patient for illicit drug use

ANS: D Abuse of illicit drugs can cause many symptoms, including panic attacks and aggressive behavior. After assessing for an infectious process, the nurse should determine if the patient has used any recreational drugs. The other assessments are not as important and can be completed later

A nurse is obtaining a history from a 37-year-old patient. What statement by the patient indicates that he has met the age-appropriate developmental task according to Gould? a. Patient describes moving out of his parents' house into an apartment. b. Patient reminisces about past life events and accomplishments. c. Patient questions his life choices such as profession and decision not to marry. d. Patient expresses satisfaction in having his own family and successful career.

ANS: D According to Gould, this patient is in the midlife decade, which occurs after the upheaval of entering the adult world and questioning one's decisions, but prior to reconciling one's life and becoming stabilized. The patient who has moved out of his parents' house is demonstrating activities seen in the early adulthood stage in which leaving the parents' world is paramount. Reminiscing about the past life occurs as part of the reconciliation stage, seen in an older person. Questioning and reexamining are typically seen in the stage for 28- to 34-year olds.

The home health care nurse is visiting a family with a 3 year old to observe a meal. The parent gives the child a plate with 1/2 cup of pureed meat. What action by the nurse is best? a. Document how well the child eats the serving of meat. b. Inquire if the child still drinks from a bottle between meals. c. Ask the parents what they serve the child for snacks. d. Provide teaching on the appropriate serving size for this child.

ANS: D An appropriate serving size is 1 tablespoon per year of age, so an appropriate amount of meat for this child is 3 tablespoons, not 1/2 cup (which is 8 tablespoons). The nurse should provide more education to the family. The other options are appropriate but are not directly related to the serving size of meat.

A patient is finding conflict when trying to maintain personal beliefs while making health care decisions. What Nursing diagnosis is a priority as the nurse plans care? a. Spiritual distress b. Impaired religiosity c. Moral distress d. Decisional conflict

ANS: D Decisional conflict is unclear personal beliefs, questioning of personal beliefs while making decisions, delayed decision making. The other diagnoses may exist as well, but they are not manifested by this conflict.

The nurse has implemented a community-wide immunization program for seasonal influenza. Once the program has ended, what action by the nurse is best? a. Begin planning for next year's program. b. Send mail surveys to participants. c. Determine financial gains or losses. d. Evaluate the program and outcomes

ANS: D The last step of the nursing process is evaluation. The nurse should evaluate the program to see if interventions had the desired effect. Evaluation could include surveys or looking at financial outcomes, but those are only limited aspects of the process. Planning for next year's event should not occur until after evaluation has been completed.

The charge nurse overhears a new nurse telling a patient that he should no longer follow his vegetarian diet because his protein needs are so high and because "God made animals for us to eat." What action by the charge nurse is best? a. No action is necessary for the charge nurse to take. b. Reinforce the nurse's teaching on proper diet. c. Offer to call the dietitian to work with the patient. d. Privately speak to the nurse about this conversation.

ANS: D The nurse should not share opinions or religious edicts with patients when those beliefs contradict the patient's. The charge nurse should counsel the new nurse about this practice. The patient may hold deep convictions about being a vegetarian and may feel disapproval from the nurse, which will impact the nurse-patient relationship. The other options are not appropriate, although the charge nurse could suggest the new nurse collaborate with the dietitian and patient to determine high-protein foods the patient finds acceptable

A toddler has been hospitalized. The parents become upset when the toddler starts wetting his bed, saying that he has been potty trained for some time now. What response by the nurse is best? a. "Don't worry, this behavior will stop when he gets home." b. "Maybe he has a urinary tract infection; I'll get a urine sample." c. "I can call the Child Life Specialist for diversionary activities." d. "It is common for kids in the hospital to regress to earlier behaviors."

ANS: D The stress of hospitalization often causes toddlers to regress in their behaviors, and the nurse should provide this information to the parents. Stating that the behavior will stop, although accurate, does not provide an explanation. There is no need for a urine sample. Using Child Life is always a good idea for hospitalized children but is not related to the question.