lippin cott final 4

A nurse is conducting a health history interview for a client at an assisted living facility. The client says, "I have been so constipated lately." How should the nurse respond?

"Do you take anything to help your constipation?"

Which question or statement would be appropriate for eliciting further information when conducting a health history interview?

"Do you take anything to help your constipation?"

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement?

"Highly reliable organizations think about the possibility of failure and what to do to avoid it."

The nurse is caring for Jerry, a 3 year old boy, who is admitted with a respiratory infection. His mother, Mrs. Baker, is a single parent and works. She can only be with Jerry during the late afternoon and evening. Today she tells the nurse that Jerry has been toilet trained for a year and she is very surprised and disappointed that he is wetting and soiling his bed now. What is the nurse's best response?

"His regression is normal and is related to stress."

Which statement indicates that a plan to assist a client in developing and following an exercise program has been effective?

"I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day."

A nurse is caring for a client who is in acute respiratory distress from pneumonia but refuses to stay for treatment. It is the nurse's responsibility to:

notify the physician, discuss the outcomes of the client's decision, and have the client sign a release form.

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?

nursing care rounds

A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which type of data?

objective

When providing end of life care for clients, what will the nurse most often need to prioritize?

pain control and emotional support

A nurse is caring for a 17 year old pregnant client who is unable to afford health care. Which resource should the nurse suggest to the client to obtain support?

A social services office to inquire about Medicaid benefits

Which may be classified as a nursing diagnosis?

Grieving

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data?

Subjective

Kübler Ross defines five stages of psychosocial responses to dying and death. Which statement is characteristic of the bargaining stage?

"Just let me live to see my grandson born."

Which six trends in health care reflect the Institute of Medicine's (IOM) focus?

"The system should be safe, effective, efficient, patient centered, timely, and equitable."

A nurse has been asked to speak to a high school health class about expected trends in health care. Which statement should the nurse include when speaking to this class?

"We can expect that technology is going to continue to change health care delivery."

A nurse is admitting an older client named Grace Staples to a long term care facility. How should the nurse address the client?

"What name do you want us to use for you?"

A client is scheduled for hospital outpatient surgery. The client tells the nurse, "I don't know what that word, outpatient, means." How would the nurse respond?

"You will have surgery and go home that same day."

Which client is the most appropriate candidate for receiving outpatient care?

A client whose complaints of irregular bowel movements have necessitated a colonoscopy

Which nurse is most likely to care for clients who are trying to resolve identity versus role confusion?

A nurse who provides care in a large junior high school

The primary nurse shares with the health care team the need for a client, diagnosed with cancer, to go out on a pass to attend a daughter's wedding. What role is this nurse serving in?

Advocate

Which authoritative statements guide current professional nursing practice?

American Nurses Association Standards of Nursing Practice

The nurse is justified in assessing for sexual dysfunction among male clients who are receiving which of the following?

Antihypertensive medication

What is the nurse's priority action when a client expresses the intention to leave the hospital against medical advice?

Ask the client to sign a form releasing the hospital from legal responsibility

A nurse takes the vital signs of a new hospital client admitted for severe abdominal pain. Which step of the nursing process is this nurse performing?

Assessment

An older adult client is being admitted to the hospital for treatment of a fractured hip. Which part of the nursing process would the nurse carry out first ?

Assessment

Which statement regarding perceptions of death by children is accurate?

At about age 9, the child perceives death as irreversible.

A nurse is taking care of a 15 year old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart.

Which of the following health care practices may be influenced by a young woman's religion?

Birth-control measures

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

Which is most recommended to ensure safety for the home health care nurse?

Carrying a cell phone

Which of the following actions should a nurse take in order to apply theories of development into nursing care?

Choose outcomes that are reflective of clients' developmental stages

Which statements most accurately describe clients as health care consumers today

Clients often obtain health information from the internet., Clients prefer to control decisions about their own health care., Clients express concern regarding access to care and the quality of service., Clients have helped develop clients' rights and cost containment measures

A nurse is working in a public school as the school nurse. This nurse is considered to be working in which role?

Community-based care

A nurse is helping clients access the health insurance marketplace. What is the goal of this health insurance coverage concept?

Comparison of available health care plans

A registered nurse is making a visit to a client in the home. What actions should the home health care nurse expect to accomplish?

Complete an assessment on each visit.,Provide support to the client and family.,Administer treatments and medications.,Document actions regarding client, activities, and progress.

What is one responsibility of nurses who work in physicians' offices?

Conducting health assessments

Which are components of the nursing case management process

Coordinating,Making referrals,Monitoring medical progress, Filing and completing paperwork

What term is used to describe various disorders that progressively affect cognitive function?

Dementia

How should the nurse ensure that care is not legally negligent?

Documenting the nursing actions in the client's record

A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long term plan can be formed

Enroll the client in Meals on Wheels.

A home health care nurse has observed that a client 80 years of age, who has multiple chronic health problems, takes a total of 19 medications on either a scheduled or PRN (as needed) basis. How should the nurse address this client's risk of harm from polypharmacy?

Ensure that the client's care is coordinated and encourage the primary care provider to review the medication regimen.

A man 50 years of age has a long history of diabetes, which is poorly controlled. What does diabetes greatly increase the man's risk of experiencing?

Erectile dysfunction

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for intravenous pain medication every 4 hours as needed. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect.

Which of the following nursing activities is the most significant in assisting with transitioning from the adolescent to the young adult age group?

Facilitating healthy family relationships

Which phrase best describes continuity of care?

Facilitating transition between settings

Which factors have led to shorter hospital stays

Federal regulations for health care reimbursement policies,Increased emphasis on preventive care, Improvement in treatment of illness

A nurse is caring for an older adult client who has been confined to bed for several weeks following a fall. The client has been exhibiting symptoms of sundowner's syndrome. Which of the following are characteristics of sundowner's syndrome?

Feeling agitated and wakeful at night

A man runs into the emergency room with an 18 month old boy in his arms. The man screams, "Help, my son is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?

High priority

A client has had a total knee replacement and will need to walk with crutches for six weeks. The client is being discharged home with a referral for home health care. What will the home care nurse need to assess during the initial assessment?

Home environment

The nurse is planning the discharge of a client who had surgery for a left hip replacement. The client is being discharged from the hospital to the home and requires a walker and high rise toilet seat. Which type of home health care service does the client require?

Home medical services

Nurses who assist clients to deal holistically with their health care needs at the end of their lives work primarily in which health care delivery system?

Hospice

Giving medication occurs in which step of the nursing process?

Implementation

Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?

Implementing

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done.

Which is the primary criterion for admission to a long term care facility?

Inability to provide self-care

When assessing a client during the middle adult years, the nurse recognizes which of the following as a normal physical change?

Increased loss of calcium from the bones

Which nursing diagnosis is the priority?

Ineffective breathing patterns

What spiritual need is believed to underlie all religious traditions and is common to all people?

Love and relatedness

A nurse is assisting during a medical emergency on the medical unit. Which action by the nurse when documenting entries in a client's healthcare record would be the most accurate?

Making entries in chronological order

Which health care insurance program is most suitable for a client 68 years of age?

Medicare

Which is the largest single source of reimbursement for home health care services?

Medicare

The implementation of diagnosis related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

An adolescent with diabetes has a nursing diagnosis of noncompliance related to activities that interfere with the treatment plan as evidenced by elevated blood glucose levels. The outcome for this client is to maintain blood glucose levels between 70 and 110 mg/dL (3.89 and 6.11 mmol/L). The main intervention is to educate the client about the effects of abnormal blood glucose level on the body and ensure that the client has the resources to be compliant. Evaluation reveals that the client's blood glucose level remains elevated and that the outcome has not been met. What is the most appropriate action by the nurse?

Modify the plan of care to find alternative ways to meet client needs.

Which client care concern is clearly a nursing responsibility?

Monitoring health status changes

A nurse works with clients in a crisis intervention center. What ability would be most important for this nurse to develop?

Strong communication and counseling skills

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

Nurses

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12 hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.

Which measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

Medicare uses a prospective payment plan based on diagnosis related groups (DRGs). What are DRGs?

Predetermined payment for services based on medical diagnoses

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated?

Provide the teaching.

Which qualities are essential for a community based nurse

Strong knowledge foundation,Effective communication skills,Keen physical assessment skills

While providing hygiene care to a confused older adult client diagnosed with Alzheimer's disease, the nurse is called to the nursing station. To ensure patient safety the nurse must do what?

Put side rails up before leaving the client.

According to established standards, which health care provider should conduct a holistic assessment for all clients admitted to the hospital?

RN

A nurse caring for a client with a terminal illness understands which statement to be true?

Recovery is not expected.

During a home care visit to a home bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain?

Respite care

A school nurse is providing a class on sexually transmitted infections (STIs). Which statement is correct regarding STIs?

STIs are most prevalent among teenagers and young adults.

A nurse is collecting data from a home care client. In addition to information about the client's health status, which is another critical observation the nurse should make?

Safety of the immediate environment

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The Nurse

The nurse is about to record the fluid intake for a client with congestive heart failure. Which documentation is most appropriate?

The client consumed 780 mL of fluid for the 8-hour shift.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding.

The nurse is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to an unlicensed assistive person (UAP) while the nurse collects data. After completing the admission process, the client reports a severe headache, so the nurse reassesses the vital signs and find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

The nurse

The nurse is met in the staff lounge by the nurse who has been caring for the client team on this shift. The off going nurse says, "Sorry, but I have to get out of here." The nurse then gives a quick overview of each client on the team and says, "All the rest is in the chart if you need anything." Which essential part of the handoff is missing?

The opportunity for the oncoming nurse to ask questions

Why are quality assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

According to Erikson, normal adolescent behavior includes trying on new roles and possibly even rebelling. What is the purpose of this behavior in adolescents?

To establish a sense of identity

A pediatric nurse recognizes that preschoolers think of death as:

a long sleep

Some religious beliefs may conflict with prevalent health care practices. For example, which type of treatment is prohibited by the doctrine of Jehovah's Witnesses?

administering blood transfusions

A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing?

anticipatory loss

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?

assessing

The correct progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation.

The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is:

condoms

A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an):

durable power of attorney.

A nurse is performing a home assessment for a 90 year old widower who lives in a third story apartment. As the nurse considers his home environment, the nurse knows that the greatest risk of injury related death or disability for the client comes from:

falls

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

A nurse is evaluating the outcome of the plan of care after teaching a client how to prepare and administer an insulin pen. Which type of outcome is the nurse addressing?

psychomotor

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

revise or modify the client care plan.