Module 3 PrepU Question Collection Assignment
A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she doesn't want to take the test and feels she should instead continue with the medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse? A) "Tell me more about how you are feeling." B) "Don't you want to improve your health?" C) "Most people tolerate the procedure quite well." D) "Emergency equipment is always kept ready."
"Tell me more about how you are feeling." Explanation: The client may have been anxious due to fear and anxiety related to the stress test. The nurse should try to explore the client's feelings by letting her express her concerns. Asking the client open-ended questions is best because it expresses concern for the client and encourages the client to verbalize her feelings. Stating that emergency equipment is always kept ready evokes more fear and interrupts communication. Questioning whether the client wants to get well or that others have tolerated this procedure quite well is inappropriate.
A 15-year-old with a urinary tract infection is admitted to the facility. She tells the nurse she hopes she's pregnant. How should the nurse respond? A) "Having a child can be a struggle when you are young." B) "What plans have you made to take care of a newborn?" C) "There are many resources available to assist young mothers." D) "Tell me what being pregnant would mean to you."
"Tell me what being pregnant would mean to you." Explanation: When talking with adolescents, it's best to get their viewpoints and thoughts before offering suggestions or giving advice. Doing so promotes therapeutic communication. It may be helpful to offer advice and ask directed questions after the inital assessment.
The nursing instructor is describing a professional nurse to the students. The nursing instructor identifies that the student understands s professional relationship if the student selects which nurse a sick patient would most likely place the most trust in as: A) A female nurse with mismatched scrub attire talking on her personal phone. B) A male nurse with visible tattoos, facial piercings, and a beard. C) A male nurse with a clean shaved face who is documenting at the nurses' station. D) A female nurse eating a salad in the hallway.
A male nurse with a clean shaved face who is documenting at the nurses' station. Explanation: It is of great importance to remember that helping relations are professional relationships. It can be helpful to identify nurse models who, through their appearance, demeanor, and behavior, communicate a clear sense of professionalism or confidence and expertise in their practice. Clients and the public are more likely to trust and value nurses who appear competent and confident and who are focused on the clients entrusted to their care. Rudeness, sloppiness, inattention to person, sexually inappropriate behavior, and other breaches of professionalism undermine nursing?s professional image and the effectiveness of individual nurses. Individual expression is important, but tattoos, facial piercings, and bearded faces may hinder a trusting relationship if the client translates the expression to be unprofessional. Mismatched scrub attire and use of a personal telephone may be perceived as unprofessional behavior. Eating in the hallway may be viewed as unprofessional, the nurse should move the food into a private break room.
A mother states that she is very angry with the health care provider who diagnosed her child with leukemia. Which statement helps the nurse understand this mother's reaction? A) Anger is rarely demonstrated by parents when coping with a sick child. B) Parents of sick children are usually unable to control their anger. C) The mother cannot overcome her anger in an acceptable manner. D) Anger is a natural result of a sense of loss and helplessness.
Anger is a natural result of a sense of loss and helplessness. Explanation: Anger is a natural result of feelings of loss and helplessness in normal, healthy people. It is a natural response to coping with a sick child. Nurses should recognize anger in clients and families. Parents are usually able to control their anger in a socially acceptable manner. Nurses can assist clients and families to overcome helplessness and anger in an acceptable manner.
The nurse is caring for a 5-year-old child in pain. Which of the following methods should the nurse use to most accurately assess the child's pain? A) Have the child make a mark on a continuum line that represents pain intensity. B) Go over a list of words that describe pain and have the child choose one. C) Ask the child to point to a face drawing that indicates pain intensity. D) Ask the child to rate the pain intensity on a scale of 1-10.
Ask the child to point to a face drawing that indicates pain intensity. Explanation: In this age group, it would be appropriate to use a nonverbal manner of pain assessment. The faces on the pain intensity rating scale consist of six faces with expressions ranging from happy and smiling to sad and tearful. The other options do not describe the best ways to assess pain in a 5-year-old child.
A nurse is assigned the care of a client who has been admitted to the health care facility with high fever. Which nursing skill should be put into practice at the first contact with the client? A) Counseling B) Comforting C) Caring D) Assessment
Assessment Explanation: On admission of the client to a health care facility, the nurse would be required to conduct an initial assessment of the client. Therefore, the nurse would implement his or her nursing skills in this case. This can be done by interviewing, observing, and examining the client. Caring skills are put into practice once the nursing needs are determined. Comforting and counseling skills may not have a major role in assessing client problems.
The nurse interviews a client during which step of the nursing process? A) Evaluation B) Planning C) Diagnosing D) Assessment
Assessment Explanation: The purpose of the client interview is to obtain accurate and thorough information. In nursing, the interview is a major tool for collecting data during the assessment step of the nursing process.
Which task may be delegated to a nursing assistant (unregulated care provider) in an acute care mental health setting? A) Administering medication B) Checking for sharp objects C) Discussing the treatment plan D) Assessing client's mental status on admission
Checking for sharp objects Explanation: A nursing assistant (unregulated care provider) may be assigned to search a client's luggage or room for potentially harmful objects, such as glass or sharp metal. A mental status assessment should be conducted by the nurse at the time of admission. Administering medication can't be delegated to an unlicensed (unregulated) person. A nurse or physician must discuss the treatment plan with the client.
A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first? A) Administer diazepam through the I.V. tubing. B) Ease the child to the floor and turn him on his side. C) Call the physician caring for the child. D) Notify the parents so they can be with their child.
Ease the child to the floor and turn him on his side. Explanation: Because the child is standing, he should first be eased to the floor and turned to the side to prevent aspiration. Notifying the physician wouldn't be the first action the nurse would take because the child's safety is of primary importance. Diazepam would be administered only if it had been ordered. Notifying the parents, although important, isn't the priority. They can be informed after the seizure is over.
The nurse is caring for two children in the same room. The parents of one child ask the nurse about the condition of the other child. What is the most appropriate response by the nurse? A) Give the parents information about the child that is inaccurate. B) Share the child's information if the parents promise not to tell. C) Explain that giving information would violate confidentiality. D) Provide a limited amount of information about the child.
Explain that giving information would violate confidentiality. Explanation: Evoke confidentiality and stress that you would also not share information about their child to anyone inquiring who was not directly responsible for the care of that particular child. None of the other answer options would be appropriate or professional.
A registered nurse is convicted of stealing narcotics from the medical surgical unit. Which of the following actions might be taken against the nursing license? A) Nursing license revoked B) Issued a limited nursing license C) No action taken on nursing license D) Denied initial licensure
Nursing license revoked Explanation: The nursing license and the right to practice nursing can be denied, revoked, or suspended for professional misconduct including chemical impairment, criminal actions, and incompetence. Denial of initial licensure would occur if the person was a student attempting to obtain the license versus a person who is already a registered nurse.
A 2-year-old tells his parent he is afraid to go to sleep because "the monsters will get him." What should the nurse tell the parent to do? A) Read a story to him before bedtime, and allow him to have a cuddly animal or a blanket. B) Allow him to stay up an hour later with the family until he falls asleep. C) Allow him to sleep with his parents in their bed whenever he is afraid. D) increase his activity before he goes to bed so he eventually falls asleep from being tired.
Read a story to him before bedtime, and allow him to have a cuddly animal or a blanket. Explanation: Behavior problems related to sleep and rest are common in young children. Consistent rituals around bedtime help to create an easier transition from waking to sleep. Allowing a child to sleep with his parents commonly creates more problems for the family and child and does not alleviate the problem or foster autonomy. Increasing activity before bedtime does not alleviate the separation anxiety in the toddler and causes further anxiety. Allowing him to stay up later than his normal time for bed will increase his anxiety, make it more difficult for him to fall asleep, and do nothing to lessen his fear.
A nurse working on the adolescent unit has a strained working relationship with a coworker and finds it difficult to work well with the coworker. What is the best way for the nurse to go about defusing this situation? A) Talk with the coworker and try to work out differences so they don't affect client care. B) Ask other nurses assigned to the unit to see what they think might improve the situation. C) Avoid the coworker by working different shifts. D) Complain to the nurse-manager about the coworker's attitude.
Talk with the coworker and try to work out differences so they don't affect client care. Explanation: When personal conflicts arise, it's always best to have the individuals involved try to work them out. If the differences are irreconcilable, other trained professionals may be needed to mediate the situation. Talking to other nurses, complaining to the nurse-manager, and avoiding the situation by working different shifts don't help resolve the problem.
The nurse observes a surgeon explaining the procedure for an appendectomy to a client and asking the client to sign the consent for surgery. The nurse is aware that the client is Chinese and does not speak the native language fluently. Which of the following is the best action for the nurse to take to advocate for the client? A) Allow the client to sign the consent because delaying surgery might cause harm to the client. B) Suggest that a hospital interpreter explain the procedure to the client before the consent is signed. C) Draw a picture for the client to indicate the location of surgery and where the incision will be made. D) Ask the client's spouse to explain the procedure to the client in Chinese and to report the client's understanding of it.
Suggest that a hospital interpreter explain the procedure to the client before the consent is signed. Explanation: The nurse must intervene as an advocate on behalf of the client if he or she believes that the client does not understand the information provided because of a language barrier. The nurse should suggest the services of a hospital interpreter to ensure that the client is providing informed consent based on understanding the risks and benefits of the surgery. Drawing a picture would not allow the nurse to ensure that the client understands the full risks of the procedure. Having the client's spouse translate would not ensure that the information was being translated accurately. A hospital interpreter should be used in this situation.
A nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which behavior should be brought to the attention of the nurse-manager? A) The nurse keeps communication channels open among herself, the family, and other health care providers. B) The nurse works with the family members to find ways to accommodate their desire for prayer. C) The nurse has made accommodations for the family to stay in the room with the child. D) The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions.
The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions. Explanation: When a nurse attempts to influence a family's decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse's part, creating a nontherapeutic relationship. When a nurse keeps communication channels open, makes accommodations for prayer and staying with the child, the nurse is demonstrating an appropriate therapeutic relationship.
Which situation violates a hospitalized adolescent's right to confidentiality? A) A physician discusses treatment plans with the adolescent in the parent's presence. B) Two nurses talk about the adolescent on an elevator on their way to lunch. C) The adolescent talks about the disease to someone in the hallway. D) A physician discusses a new medication for the adolescent while on the phone with the pharmacist.
Two nurses talk about the adolescent on an elevator on their way to lunch. Explanation: The elevator isn't a secure area in which to talk about any client, including an adolescent; anyone could overhear the nurses' conversation. A client isn't breaching confidentiality by volunteering information about the client. When a client is present for the conversation, the client can object at any time to the content of the conversation. Physicians and other healthcare providers are expected to discuss clients and cases, as long as they do so within the context of a professional relationship and the discussion is necessary for the course of treatment.
The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should: assume the nursing assistant has completed the task to the nurse's satisfaction. A) document in the chart that the task has been completed. B) keep asking the nursing assistant if the task has been completed. C) allow adequate time for the nursing assistant to complete D) the task, then follow-up with the nursing assistant.
allow adequate time for the nursing assistant to complete the task, then follow-up with the nursing assistant. Explanation: The nurse remains accountable for all of the client's care, including tasks that have been delegated to the nursing assistant. The nurse should allow the nursing assistant ample time to complete the task, then follow up to make sure the nursing assistant has completed the task. Documentation occurs after the task has been completed satisfactorily. When a task is delegated, it's important to allow team members the authority to complete the assigned task. However, the nurse should follow up to make sure the nursing assistant has completed the task satisfactorily; the nurse can't assume that has been done.
A student nurse understands that the primary aim of the Healthy People 2020 initiatives is A) illness prevention. B) coping with disability. C) health restoration. D) health promotion.
health promotion. Explanation: Healthy People 2020 establishes health promotion guidelines for the nation as a whole. The guidelines contain 12 Leading Health Indicators, which are used to measure the health of the nation over a 10-year period. Illness prevention, health restoration, and coping with disability are components of the Healthy People 2020 guidelines, but are not considered as the primary goal of the initiative.
A charge nurse is at the front desk when a person demands information about a child who has been admitted on the unit. The nurse should: A) call security because of the person's angry demeanor. B) inform the person that confidentiality prevents the nurse from disclosing the information. C) direct the person to the child's room so as to prevent the behavior from escalating. D) refer to the child's chart and tell the person only the condition of the child, which is public knowledge.
inform the person that confidentiality prevents the nurse from disclosing the information. Explanation: The nurse has a legal responsibility to follow confidentiality guidelines regarding client information. She must never disclose information, such as a room number, about a client or the client's condition without the consent of the client or family members. The nurse doesn't need to call security at this point. The condition of the child is not public knowledge.
Family members and friends stage an intervention for an alcoholic adolescent. The intervention is successful when the adolescent: A) says, "I'm sorry. I'll never drink again." B) is motivated to enter an alcohol rehabilitation program. C) breaks down and cries. D) is willing to talk with the friends.
is motivated to enter an alcohol rehabilitation program. Explanation: Willingness to enter a rehabilitation program indicates that the adolescent is motivated to change. An intervention is an emotionally charged meeting; crying may be an indication of manipulation, rather than a sign that the intervention has succeeded. Relapses are common among alcoholics who simply stop drinking; success in overcoming alcoholism is more likely when a structured program is part of the rehabilitation process. Talking with friends doesn't indicate a successful intervention.
An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include: A) slapping, kicking, and punching others. B) pulling hair and hitting. C) loud crying and screaming. D) poor hygiene and weight loss.
poor hygiene and weight loss. Explanation: Signs of neglect include poor hygiene and weight loss because neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, pulling hair, hitting, and punching are examples of forms of physical abuse, not neglect. Loud crying and screaming are normal findings in a 3-year-old boy.
A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a client's room to empty his or her urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should: A) ignore the statement and empty the urinary catheter. B) sit at the bedside and allow the patient to explain the statement. C) smile at the patient and apologize. D) inform the patient that the unit was very busy that day.
sit at the bedside and allow the patient to explain the statement. Explanation: Clients might or might not feel able to speak freely to the nurse. Often, the signals indicating their readiness to talk are subtle. Don?t miss valuable opportunities for important communication by approaching clients with a closed mind or focusing on your own needs rather than on the client?s needs. Nurses who lack confidence in their own ability to meet the challenges a client presents might become defensive in response to a client?s comments. Nurse defensiveness is a huge barrier to open and trusting communication. Smiling and apologizing and ignoring the client close lines of communication. Although the unit may have been busy, it is best to listen to the client express themselves.
In comparison with licensure, which measures entry-level competence, what does certification validate? A) innocence of any disciplinary violation B) ability to practice in more than one area C) specialty knowledge and clinical judgment D) more than 10 years of nursing practice
specialty knowledge and clinical judgment Explanation: Whereas licensure measures entry-level competence, certification validates specialty knowledge, experience, and clinical judgment. Certification does not validate innocence, years of practice, or ability in multiple practice areas.
An overweight adolescent client has lost 12 lb (5.4 kg) in 8 weeks using diet strategies. The client reaches a weight loss plateau and is discouraged. The nurse instructs the client to keep a food diary for what purpose? A) to help the client stay busy and more focused on losing weight B) to help the nurse determine whether the diet is being followed C) to provide a written record of caloric intake for the nurse D) to help the client analyze how much food is consumed and when
to help the client analyze how much food is consumed and when Explanation: Keeping a food diary allows the adolescent client to use the cognitive level of formal operations to help identify and evaluate eating behaviors of which he may not be aware. It is primarily a tool to assist in self-correction and behavior modification. The client does not need to be preoccupied with weight loss. The nurse can provide insights based on the diary entries, but this device is not for the nurse.
A potentially pregnant 16-year-old client says that she has been "hooking up" with a boy she considers to be her boyfriend. Which response should the nurse make first? A) "Describe what you mean by 'hooking up.'" B) "I think we need to talk about what is involved in sexual intercourse." C) "You mean you have had sexual intercourse?" D) "All you have been doing with your boyfriend is hooking up?"
"Describe what you mean by 'hooking up.'" Explanation: Because of the client's potential pregnancy, the nurse needs to determine exactly what the client means by the term "hooking up" by asking the client to describe what she has been doing in sexual encounters with her boyfriend. Asking the client if she means sexual intercourse or telling the client that they need to talk about sexual intercourse makes an assumption that may or may not be appropriate. The nurse needs to determine exactly what the client means by the terms used. Repeating the client's statement does not elicit the necessary information to interpret the client's statement. Additionally, this type of response assumes an understanding of what the client has said.
A client has been recently diagnosed with type 1 diabetes mellitus. He is seen in the emergency room every day with high blood sugar. The client apologizes to the nurse for bothering them every day, but he cannot give himself insulin injections. What should the nurse's response be? A) "You should learn to take injections yourself." B) "Has someone taught you how to take them?" C) "Ask the doctor to change the medications." D) "I myself cannot take insulin injections."
"Has someone taught you how to take them?" Explanation: The nurse should assess whether the client has a knowledge deficit regarding self-injection. If there is a knowledge deficit, the nurse should teach the client the correct method to take insulin injections. The first response is a negative reinforcement and is therefore inappropriate. Demanding that the client learn injection administration is also inappropriate. The fourth response, too, is inappropriate, because the nurse cannot offer a change that cannot be carried out.
A nurse manager notices that a new nurse is violating the dress code by wearing hoop earrings while working. Which of the following statements by the nurse manager is most appropriate to address this situation? A) "Hoop earrings are not allowed because I do not believe they are appropriate." B) "If I allow you to wear hoop earrings, the next thing will be an eyebrow ring." C) "Hoop earrings present a safety risk for you and your clients." D) "Hoop earrings worn with a nursing uniform make you look cheap."
"Hoop earrings present a safety risk for you and your clients." Explanation: The correct answer is objective and based on fact and policy. By stating the facts, the nurse manager is addressing the behavior, not the individual. The other options are incorrect because they include the manager's personal likes, dislikes, or biases, not objective rationale for not wearing hoop earrings.
A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. The mother says that her infant can't sit alone. A) "This is very abnormal. Your child must be sick." B) "Let's see about further developmental testing." C) "Maybe you just haven't seen her do it." D) "Don't worry, this is normal for her age."
"Let's see about further developmental testing." Explanation: Stating that further developmental testing is necessary is appropriate because at age 12 months a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Saying the infant's behavior is abnormal or suggesting that the mother hasn't seen her infant do these milestones isn't therapeutic and can cut off communication with the mother. Telling the mother that the infant's behavior is normal misleads the mother with false reassurance.
A nurse is calling a physician to communicate a change in the client's condition. According to the I-SBAR-R format for hand-off communication among healthcare personnel, which is the most appropriate way to begin the conversation? A) "My name is Sue Smith, RN and I am calling regarding Mrs. Jones in room 356 at Jefferson hospital." B) "My name is Sue and I am calling about Mrs. Jones, a client of yours at Jefferson hospital." C) "Good morning, I am calling about Mrs. Jones who is a client of yours." D) "I have a client of yours at Jefferson hospital experiencing a change in her condition and needs seen immediately!"
"My name is Sue Smith, RN and I am calling regarding Mrs. Jones in room 356 at Jefferson hospital." Explanation: I-SBAR-R was recently revised by the QSEN institute to include initial identification of yourself and your client. The nurse should identify herself and her role during the initial conversation with the physician. This allows the physician to understand the role of the healthcare provider they are speaking with regarding the client should the physician need to provide orders or instructions regarding the client. The other responses fail to have the nurse identify herself in the beginning of the conversation or fail to recognize identification of the client.
A child, age 3, is admitted to the pediatric unit with dehydration after 2 days of nausea and vomiting. The parent tells the nurse that the child's illness "is all my fault." How should the nurse respond? A) "Maybe next time you'll bring the child in sooner." B) "Tell me why you think this is your fault." C) "Don't be so upset. Your child will be fine." D) "Try not to cry in front of the child. It'll only upset the child."
"Tell me why you think this is your fault." Explanation: Having the parent explain why they feel the illness is their fault is appropriate because many parents feel responsible for their child's illness and may need instruction about the actual cause of the illness. Pointing out that the parent could have brought the child in sooner could increase the parent's feelings of guilt. Telling the parent not to cry or be upset ignores the parent's feelings.
A patient scheduled to have hip replacement surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response by the nurse? A) "What questions do you have about the surgery?" B) "What will happen if you don't have surgery?" C) "Your wife will be in the surgery waiting room the entire time." D) "You really don't have anything to worry about."
"What questions do you have about the surgery?" Explanation: The nurse should allow the client time to express his fears about the anesthesia and the surgery. Telling the client that his wife will be waiting or not to worry, and asking what will happen if he doesn't have the surgery do not address the patient's concerns.
A worried mother confides in the nurse that she wants to change health care providers (HCPs) because her infant is not getting better. What is the nurse's best response? A) "I know you are worried, but the primary care provider has an excellent reputation." B) "This primary care provider has been on our staff for 20 years." C) "Your infant's condition takes time to heal." D) "You always have an option to change. Tell me about your concerns."
"You always have an option to change. Tell me about your concerns." Explanation: Asking the mother to talk about her concerns acknowledges the mother's rights and encourages open discussion. The other responses negate the parent's concerns.
A 16-year-old client who has been confined to a wheelchair since early childhood has lately been acting rebellious and rude. Her parents ask the nurse, "Are all adolescents like this?" The nurse should respond with which statement? A) "Your daughter's behavior results from feelings about her disability: ignore them." B) "Yes, although your daughter's behaviors are more like those of an adolescent boy." C) "Your daughter's behavior seems to be typical adolescent behavior. Let us talk more about it." D) "No. Your daughter must need some help in dealing with her feelings."
"Your daughter's behavior seems to be typical adolescent behavior. Let us talk more about it." Explanation: It is normal behavior for adolescents to assert independence and begin to separate from their parents; the behavior is not changed by their daughter's disability, nor is it unique to a girl. The nurse offers reassurance to the parents and then opens the conversation for additional discussion.
A patient admitted to the telemetry floor informs the nurse that he has an advance directive and does not wish to be resuscitated if his heart stops beating. The patient takes a copy of the advance directive from his wallet and hands it to the nurse. The nurse documents on the electronic chart that the patient has an advance directive, makes a copy of the advance directive, and immediately informs the patient's physician. In this situation, what is the nursing role demonstrated by the nurse? A) Advocate B) Counselor C) Leader D) Researcher
Advocate Explanation: The nursing role that focuses on advocacy involves the protection of human or legal rights and the securing of care for all patients based on the belief that patients have the right to make informed decisions about their own health and lives. In this situation, the nurse recognizes the patient's right to make end-of-life decisions and advocates for the patient by documenting that the patient has an advance directive and also by communicating this information to the patient's physician.
After a car accident, a child, age 10, is treated in the emergency department for a fractured clavicle and evaluated for a possible head injury. Alert and oriented, she keeps asking what will happen to her. Which nursing diagnosis is most appropriate? A) Anxiety related to separation from parents and an unfamiliar environment B) Interrupted family processes related to maturational crisis C) Risk for infection related to sepsis D) Hypothermia related to head injury
Anxiety related to separation from parents and an unfamiliar environment Explanation: The nature of the accident, the child's pain, and the unfamiliar facility environment support a nursing diagnosis of Anxiety related to separation from parents and an unfamiliar environment. A diagnosis of Hypothermia related to head injury isn't appropriate because the child is alert and oriented, indicating that a head injury, if present, isn't severe and is unlikely to cause hypothermia. Unlike the homecoming of a new baby or riding a bicycle for the first time, a car accident isn't a maturational crisis. Risk for infection related to sepsis isn't a plausible nursing diagnosis at this time.
A nurse receives an x-ray report on a newly admitted patient suspected of having a fractured tibia. The nurse contacts the physician to report the findings. What role is the nurse engaged in? A) Caregiver B) Communicator C) Advocate D) Researcher
Communicator Explanation: Nurses are communicators when they report findings to the healthcare team. Advocacy involves actions such as protecting the patient's safety or rights. Administering care measures directly to the patient demonstrates the caregiver role. Research involves collecting and analyzing data.
An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care? A) Determine whether the adolescent has had intermittent episodes of euphoria. B) Determine whether the adolescent's mood is related to a lack of sun exposure. C) Determine whether the adolescent has had trouble adjusting to a stressful event. D) Determine whether the adolescent has developed a plan for committing suicide.
Determine whether the adolescent has developed a plan for committing suicide. Explanation: The adolescent is experiencing a major depression, which is a type of mood disturbance that lasts over 2 weeks. Symptoms may include overwhelming feelings of sadness and grief, loss of interest or pleasure in activities that are usually enjoyed, and feelings of worthlessness or guilt. It may result in poor sleep, a change in appetite, severe fatigue, and difficulty concentrating. It increases the risk of suicide. The nurse needs to determine whether the adolescent has a plan for suicide, which would increase the likelihood that a suicide would occur.
The physician orders a nasogastric (NG) tube for a young adult diagnosed with end-stage ovarian cancer suspected of having a bowel obstruction. The newly hired nurse explains the procedure and rational for NG tube placement. The patient refuses to consent to NG tube placement stating "I would rather keep vomiting than to have the tube in my nose." Following the American Nurses Association Code of Ethics for Nurses what should the nurse do next? A) Delegate the NG tube placement to a more experienced nurse B) Make a referral to Social Services related to body-image disturbance C) Call the patient's husband so he can consent to the procedure D) Document the patient's wishes and notify the physician
Document the patient's wishes and notify the physician Explanation: The American Nurses Association Code of Ethics for Nurses directs the nurse to advocates for, and strives to, protect rights of the patient. There is no indication that this patient is not able to make informed decisions related to her care. Referral to the social worker is not an appropriate nursing intervention for this patient. The patient has the right to refuse the procedure. Experience of the nurse does not make a difference in this situation. The nurse needs to be an advocate for the patient. The patient's husband cannot make this decision for his wife while she is competent to make decisions for herself.
Parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they're concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to? A) Certified nurse-midwife B) Social worker C) Clergy D) Genetic counselor
Genetic counselor Explanation: A genetic counselor can educate the couple about an inherited disorder, as well as screening tests and treatments that can be done; the counselor can also provide emotional support. Clergy are available to provide spiritual support. A social worker can provide emotional support and help with referrals for financial problems. A nurse-midwife cares for women during pregnancy and birth.
The nurse recognizes that immunizations are an example of: A) Facilitating coping with disability and death B) Illness prevention C) Health promotion D) Health restoration
Illness prevention Explanation: The aim of illness prevention activities is to reduce the risk for illness, to promote good health habits, and to maintain optimal functioning. Immunization administration is an example of illness prevention. Assisting with crutch-walking and teaching medication administration are examples of health restoration activities, which encompasses early detection of a disease to rehabilitation. Hospice care is an example of facilitating coping with disability and death.
A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role? A) The essential components of professional nursing care are strength, endurance, and cure. B) It is the role of the physician, not the nurse, to assist patients in understanding their health problems. C) It is the role of nursing to provide a caring relationship that facilitates health and healing. D) Nursing is a profession dependent upon the medical community as a whole.
It is the role of nursing to provide a caring relationship that facilitates health and healing. Explanation: The American Nurses Association (ANA) defines nursing as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" (ANA, 2010). The ANA does not see nursing as dependent upon medicine. The ANA sees one of the roles of the nurse as assisting clients in understanding their health problems. The ANA does not address essential components of professional nursing care with terms such as strength, endurance, and cure.
The nurse has entered a patient's room to find the patient diaphoretic (sweat-covered) and shivering, inferring that the patient has a fever. How should the nurse best follow up this cue and inference? A) Ask a colleague for assistance. B) Give the patient a clean gown and warm blankets. C) Obtain an order for blood cultures. D) Measure the patient's oral temperature.
Measure the patient's oral temperature. Explanation: An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the patient's temperature. This should precede interventions such as blood work or even providing a warm blanket.
A nurse identifies a patient's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case? A) Nursing standards B) Nursing process C) Nursing orders D) Nurse practice acts
Nursing process Explanation: Devising a plan of care is based on the nursing process. This process, identifies the client's healthcare needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes. Nursing standards allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where healthcare is given. Nurse practice acts are laws established in each state in the United States to regulate the practice of nursing. Nursing orders prescribe the nursing care to be given to assist the client to meet health goals.
Then nurse is providing flu shots to the elderly at a nurse managed wellness center. This is an example of which following aims of nursing? A) Promoting health literacy B) Resotoring health C) Preventing illness D) Coping with disability
Preventing illness Explanation: The objectives of illness prevention activities are to reduce the risk for illness, promote good health habits, and to maintain optimal functioning.
A nurse is caring for a client in a semi-private room. The nurse is preparing to discuss the medical treatment plan with the client. To best ensure privacy the nurse should do what? A) Direct the client in the other bed to walk in the hallway. B) Bring the client into the hallway to discuss the treatment plan. C) Pull the curtain dividing the two beds, maintain eye contact, and speak in a low, audible voice. D) Ask all visitors to leave the room.
Pull the curtain dividing the two beds, maintain eye contact, and speak in a low, audible voice. Explanation: It might not always be possible to carry on conversations alone with the client in a room, but every effort should be made to provide privacy and to prevent conversations from being overheard by others. Sometimes merely drawing the curtains around the bed in a hospital or long-term care facility or sitting in a corner of the waiting room or lounge can provide the sense of privacy that is so important in most interactions. It is not appropriate to ask the client in the other bed to leave their room. Personal information should not be discussed in public thoroughfares.
A nurse is sitting near a patient while conducting a health history. The patient keeps edging away from the nurse. What might this mean in terms of personal space? A) The nurse is too far away from the patient. B) The patient does not like the nurse. C) The patient has concerns about the questions. D) The nurse is in the patient's personal space.
The nurse is in the patient's personal space. Explanation: Each person has a sense of how much personal or private space is needed and what distance between individuals is optimum. It is best to take cues from the patient; a patient moving backward indicates discomfort with invasion of his or her personal space.
Assessment of suicidal risk in children and adolescents requires the nurse to know what information? A) The risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord being most at risk. B) Children rarely commit suicide unless one of their parents has already committed suicide, especially in the past year. C) Children do have a suicidal risk that coincides with some significant event such as a recent gun purchase in the family. D) Adolescents typically do not choose suicide unless they live in certain geographical regions of the United States or Canada.
The risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord being most at risk. Explanation: Adolescents are more likely than children to attempt or commit suicide. Loss, abuse, and family discord remain significant risk factors. There is no evidence to support that children rarely commit suicide. Additionally, evidence fails to support the belief that children who have lost a parent to suicide will attempt it themselves. Significant events, such as a recent firearm purchase, have not been linked to suicide attempts in children. No geographical region in the United States or Canada is free from adolescent suicide.
The nurse is caring for a client after a stroke that left the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals? A) To prevent illness B) To restore health C) To promote health D) To faciliate coping
To restore health Explanation: The four broad aims of nursing practice are to promote health, prevent illness, restore health, and facilitate coping with death and/or disability. In the example, the nurse is coordinating care with the other disciplines in an attempt regain some of the strength in the client's right side. This is an example of restoring a client's health. The nurse is not preventing the stroke or promoting health prior to the stroke or facilitating coping with the stroke.
An experienced nurse is orienting a new nurse to the unit. The experienced nurse tells the new nurse that to be an effective caregiver, the new nurse needs to: A) read client medical records thoroughly. B) attempt to obtain a specialty certification. C) develop good communication skills. D) spend as much time as possible with clients.
develop good communication skills. Explanation: Any nurse who wishes to be an effective caregiver must first learn how to be an effective communicator. Good communication skills enable nurses to get to know their clients and, ultimately, to diagnose and to meet their needs for nursing care. Obtaining a specialty certificate should be encouraged but is not as important as effective communication. Reading a client's chart thoroughly does not necessarily contribute to being an effective caregiver. Nurses should use their judgment in determining how much time to spend with each client.
The nurse plans discharge care with the parents of a 16-year-old boy who recently attempted suicide. The nurse should advise the parents to notify a heath care provider immediately for which client finding? A) desiring to spend more time with friends. B) expressing a desire to date. C) deciding to try out for an extracurricular activity. D) giving away valued personal items.
giving away valued personal items. Explanation: Giving away personal items has consistently been shown to be an indicator of suicidal plans in the depressed and suicidal individual. The other behaviors indicate a return of interest in normal adolescent activities.
A nurse says she's forgotten her computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage? A) writing down the password so the nurse won't forget it B) telling the nurse that she may not use the password C) telling the nurse that she may use the password D) telling the nurse to ask someone else for their password
telling the nurse that she may not use the password Explanation: Computer passwords should never be shared. If a coworker uses a nurse's password, the nurse may be held liable for anything the coworker does.