Module 1 Exam

Name the ABCs of nursing prioritization

Airway, Breathing, Circulation

When receiving chemotherapy for non-Hodgkin lymphoma, a client states, "I get so sick to my stomach. The medication is useless." What is the best response by the nurse that uses the technique of paraphrasing?

"You don't think the medication is helping you."

What happens of you deflate BP cuff to quickly?

Gives you a false low systolic and a false high diastolic

Which feature is characteristic of a risk nursing diagnosis?

The DX does NOT have related factors

The registered nurse is teaching a nursing student about caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client?

"I will involve the client's family members as interpreters."

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as the 'input' component? Select all that apply.

"The nurse checks the client's health history for allergy to iodine before inserting a urinary catheter." "The nurse checks if the client has a history of substance abuse before administering nasal medications." "The nurse checks the medical records of the client to know if he/she has had a rectal surgery in the past year before placing an internal fecal catheter."

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?

AD-PIE! Assessment, Diagnosis, Planning, Implementation, Evaluation

What is the difference between risk nursing diagnoses and actual nursing diagnoses?

Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors.

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake?

Assessment

Which client is likely to have a health promotion nursing diagnosis?

Client willing to take a 30 min walk

During the termination phase of a therapeutic relationship a client misses a series of appointments without any explanation. What should the nurse do?

Contact the client to encourage another session.

Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations?

Demonstrating a nonjudgmental attitude

What nursing actions best promote communication when obtaining a nursing history? Select all that apply.

Establishing eye contact Paraphrasing the client's message Using broad, open-ended statement

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

Planning

A nurse is caring for a client who belongs to a different cultural community. The client is not very fluent in the language that the nurse is communicating. What would the nurse say to the client to initiate appropriate communication? Select all that apply.

Please tell me about the healthcare practices and beliefs of your community." "Let me bring in an interpreter to help you understand the medical procedures better." "I would like to know your personal beliefs regarding healthcare traditions and practices."

A nurse is working in the orientation phase of a therapeutic relationship with a client who has borderline personality disorder. What will be most difficult for the client at this stage of the relationship?

Setting mutual goals for the relationship

The nurse assesses for what client symptoms that indicate hyperthermia? Select all that apply.

Vasodilation Dry and flushed skin Decreased urinary output

After assessing a dark-skinned client, the nurse concludes that the client has cyanosis. Which assessment color variation helped the nurse reach this conclusion?

gray

A nurse sits with a depressed client twice a day, but there is little verbal communication. One afternoon the client asks, "Do you think they'll ever let me out of here?" What is the best reply by the nurse?

"How do you feel about leaving here?"

Which clients are ideal candidates for interpreter service in order to prevent contributing health disparities? Select all that apply.

A non-English-speaking client in the emergency department A Spanish-speaking client ready to be discharged from the facility An Indian American who does not speak the language used at the facility

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?

Assessment

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation?

Assessment

The nurse, as a leader, is planning to provide information about personal hygiene to a group of clients. Which communication methods should the nurse use to talk to the clients? Select all that apply.

Being sensitive to nonverbal communication Providing the opportunity for dialogue and feedback Presenting information that addresses the listener's self-interest

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?

Contact an interpreter provided by the hospital.

While entering data for a client in the electronic health record (EHR), the nurse uses North American Nursing Diagnosis Association (NANDA) International terminology to document which part of the nursing process?

Diagnosis

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied?

Evaluation

The nurse is assessing a client with impaired hearing. Which action of the nurse is most important for establishing a good communication with the client?

Getting the client's attention before speaking

The nurse is communicating with an older adult who has a hearing disability. Which intervention by the nurse is beneficial to promote communication? Select all that apply.

Giving the client a chance to speak Making sure that the client knows you are speaking Keeping the communication concise

Which step in the research process is similar to the assessment step of the nursing process?

Identifying the problem

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next?

Implementation

Which nursing process involves delegation and verbal discussion with the healthcare team?

Implementation

Which step in the nursing process would involve promoting a safe environment for the client?

Implementation

Which of these is a one-on-one communication between a nurse and another person?

Interpersonal communication

The nurse leader mentors the staff on types of conflict. Which statement of the leader describes intrapersonal conflict?

It arises due to imbalances between the nurse's personal and professional priorities.

The nurse is using non-verbal active listening skills during a clinical therapeutic encounter with a client. Which non-verbal action best conveys engagement in this client interaction?

Leaning toward the client

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format?

NANDA-I label, related factor, and defining characteristics

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.

Nursing diagnoses involve the client when possible. Nursing diagnoses involve the sorting of health problems within the nursing domain. Nursing diagnoses involve clinical judgment about the client's response to health problems

A nursing student is learning about the nursing process, which consists of four components. Which scenarios would be considered output components? Select all that apply.

Output = Visual assessment, what you can see & measure. "The nurse notices that the client's wounds have healed after performing regular wound debridement." "The nurse notices that the client has developed an infection at the surgical site after the dressing has been changed." "The nurse finds that the client's blood pressure has increased even though medication is administered on a timely basis."

name maslow's hierarchy of needs from bottom to top

Physiological needs, Safety needs, Love and Belonging needs, Esteem needs, Self-Actualization needs,

In the orientation phase, a nurse and a client meet and get to know each other. Which actions should the nurse follow in this phase? Select all that apply.

Prioritizing the client's problems Clarifying the client's and nurse's roles

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do?

Provide a means for the client to write

A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication?

Providing relevant information to the client

The nurse asks questions to an older client about past experiences and listens attentively. Which therapeutic communication strategy is involved when the older client is recalling the past?

Reminiscing

In order to provide ideal therapeutic communication to clients, a health care facility provides interpreter services. Which statement regarding an interpreter is correct?

The interpreter should be able to interpret not only the language but also the culture.

What does a nurse do during the orientation phase of a helping relationship?

The nurse develops a healthy relationship with the client.

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities?

The student talks only to the interpreter about the client.

The nurse is overseeing a nursing student who is conducting an assessment of a client who does not speak English. No interpreter is available. Which action requires further teaching?

Using medical terminology

Which action of the leader signifies the implementation phase of the nursing process to teaching?

sequences different tasks