nurs 406 test 2

Client / age / heart beats per min 1 / 11 mo / 156 2 / 4 yrs / 105 3 / 2 yrs / 148 4 / 14 yrs / 87 A nurse is palpating the peripheral pulse of different clients. Which client has an unacceptable heart rate? Client 1 Client 2 Client 3 Client 4

client 3 The acceptable range of heartbeat for a toddler is between 90 and 140 beats per minute. Client 3, with a heartbeat of 148 beats per minute, has an abnormal heart rate. The normal range of heartbeat for an infant lies between 120 and 160 beats per minute. Preschoolers usually have a heartbeat ranging from 80 to 110 beats per minutes. A typical adolescent heart rate ranges from 60 to 90 beats per minute. Test-Taking Tip: Correlating the acceptable range of heartbeat with the age group will help in eliminating the wrong options.

chapter review questions

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EAQ questions

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fluid and electrolytes

Assess any patient with a problem of fluid and electrolyte balance for fall risk. QSEN: Safety • Supervise the oral fluid therapy and intake and output measurement aspects of care delegated to unlicensed assistive personnel. QSEN: Safety • Use a pump or controller to deliver IV fluids to patients with fluid overload. QSEN: Safety • Do not give IV potassium at a rate greater than 20 mEq/hr (mmol/hr). QSEN: Safety • Never give potassium supplements by the IM, subcutaneous, or IV push routes. QSEN: Safety • Use a pump or controller when giving IV potassium-containing solutions. QSEN: Safety • Assess the IV site hourly of an adult receiving IV solutions containing potassium and document its condition. QSEN: Safety • Use a gait belt when assisting a patient with muscle weakness to walk or transfer. QSEN: Safety • Use a lift sheet to move or reposition a patient with chronic hypocalcemia. QSEN: Safety Health Promotion and Maintenance • Encourage all patients to maintain an adequate fluid intake (minimum of 1.5 L per day) unless another condition requires fluid restriction. QSEN: Evidence-Based Practice • Teach all adults to increase fluid intake when exercising, when in hot or dry environments, or during conditions that increase metabolism (e.g., fever). QSEN: Patient-Centered Care • Instruct patients at risk for fluid imbalance to weigh themselves on the same scale daily, close to the same time each day, and with about the same amount of clothing on each time and to monitor these daily weights for changes or trends. QSEN: Patient-Centered Care • Ensure access to adequate fluids for patients who cannot talk or who have limited mobility. QSEN: Patient-Centered Care • Instruct caregivers of older adults who have cognitive impairments or mobility problems to schedule offerings of fluids at regular intervals throughout the day. QSEN: Evidence-Based Practice • Teach patients how to determine electrolyte content of processed foods by reading labels. QSEN: Patient-Centered Care Psychosocial Integrity • Explain the purpose of fluid restriction to the patient and the family to ensure cooperation and prevent any misunderstandings. QSEN: Patient-Centered Care • Assess patients who have a sudden change in cognition for a change in fluid and electrolyte balance. QSEN: Patient-Centered Care • Determine the patient's food preferences and dislikes when planning an electrolyte-restricted diet. QSEN: Patient-Centered Care Physiological Integrity • Assess skin turgor on the forehead or sternum of older patients. QSEN: Evidence-Based Practice • Use daily weights to determine fluid gains or losses. QSEN: Evidence-Based Practice • Ask patients about the use of drugs such as diuretics, laxatives, salt substitutes, and antihypertensives that may alter fluid and electrolyte balance. QSEN: Patient-Centered Care • Monitor the cardiac and pulmonary status at least every hour when patients with dehydration are receiving IV fluid replacement therapy. QSEN: Patient-Centered Care • Collaborate with the registered dietitian to teach patients about diets that are restricted in potassium, sodium, or calcium. QSEN: Teamwork and Collaboration • Immediately stop the infusion of potassium-containing solutions if infiltration is suspected. QSEN: Evidence-Based Practice • Assess all patients with hyperkalemia for cardiac dysrhythmias and ECG abnormalities, especially tall T waves, conduction delays, and heart block. QSEN: Evidence-Based Practice • Assess the respiratory status of all patients with hypokalemia. QSEN: Evidence-Based Practice • Assess the bowel sounds; heart rate, rhythm and quality; and muscle strength to evaluate the patient's responses to therapy for an electrolyte imbalance. QSEN: Evidence-Based Practice • Assess the cardiovascular system first in any patient at risk for acidosis because acidosis can lead to cardiac arrest from the accompanying hyperkalemia. QSEN: Safety • Assess the airway of any patient who has acute respiratory acidosis. QSEN: Safety • Assess heart rate and rhythm at least every 2 hours for any patient with an acid-base imbalance. QSEN: Safety • Monitor the neurologic status at least every 2 hours in patients being treated for a problem with ACID-BASE BALANCE. QSEN: Safety • Assess the ACID-BASE BALANCE of any patient with new-onset muscle weakness. QSEN: Safety • Use fall precautions for any patient with a problem in ACID-BASE BALANCE. QSEN: Safety Health Promotion and Maintenance • Teach patients to take drugs as prescribed, especially diuretics, antihypertensives, and cardiac drugs. QSEN: Patient-Centered Care • Instruct patients at continuing risk for respiratory acidosis to stop smoking. QSEN: Patient-Centered Care • Assess the gas exchange status of any patient with acute confusion. QSEN: Patient-Centered Care • Perform a mental status assessment in any patient with or at risk for problems of ACID-BASE BALANCE. QSEN: Patient-Centered Care • Assist patients who have anxiety-induced respiratory alkalosis to identify causes of anxiety. QSEN: Patient-Centered Care Physiological Integrity • Be aware of how the following principles, processes, and mechanisms influence the regulation of ACID-BASE BALANCE: • The normal pH of the body's extracellular fluids (including blood) is 7.35 to 7.45. • The more hydrogen ions present, the more acidic the fluid; the fewer hydrogen ions present, the more alkaline the fluid. • pH values below 7.35 indicate acidosis; pH values above 7.45 indicate alkalosis. • Anything that increases the CO2 level in the blood increases the hydrogen ion content and lowers the pH. • Acids are normally formed in the body as a result of metabolism. • Chemical blood buffers are the immediate way that acid-base imbalances are corrected. • The lungs control the amount of CO2 that is retained or exhaled. • The kidneys regulate the amount of hydrogen and bicarbonate ions that are retained or excreted by the body. • If a lung problem causes retention of carbon dioxide, the healthy kidney compensates by increasing the amount of bicarbonate that is produced and retained. • Acidosis reduces the excitability of cardiovascular muscle, neurons, skeletal muscle, and GI smooth muscle. • Alkalosis increases the sensitivity of excitable tissues, allowing them to over-respond to normal stimuli and respond even without stimulation. • Check the serum potassium level for any patient who has acidosis. QSEN: Evidence-Based Practice • Monitor arterial blood gas (ABG) values to evaluate the effectiveness of therapy for acid-base imbalances. QSEN: Patient-Centered Care

While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? Select all that apply. "I have difficulty judging things." "I forget to take medicines." "I am unable to do financial calculations." "I get confused about the proper date and time." "I am unable to recall words during conversations with my family."

"I have difficulty judging things." "I am unable to do financial calculations." "I am unable to recall words during conversations with my family." Poor judgment, loss of the ability to calculate, and loss of language skills are related to cognitive impairment. These changes may develop due to an imbalance of neurotransmitters in brain. Forgetfulness and getting confused are symptoms that may be associated with normal aging changes. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? Sharing hope Correct2 Sharing humor 3 Sharing empathy 4 Sharing observations

Sharing humor Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.

key points from chapters

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Arrange the Erikson's theory of psychosocial development stages of life in the correct order.

1.Trust vs. Mistrust 2.Autonomy vs. Sense of Shame and Doubt 3.Initiative vs. Guilt 4.Industry vs. Inferiority 5.Identity vs. Role Confusion 6.Intimacy vs. Isolation According to Erikson's theory of psychosocial development, individuals need to accomplish a particular task successfully before progressing to the next one. Every task is framed with opposing conflicts. The first stage of this theory is trust vs. mistrust, which starts from birth and extends up to 1 year. The second stage, which ranges from 1 to 3 years, is autonomy vs. sense of shame and doubt. Initiative vs. guilt is the third stage, usually observed between 3 to 6 years. The fourth stage is industry vs. inferiority, which is observed between 6 to 11 years of age. Identity vs. role confusion is the fifth stage, which mainly signifies puberty. The young adult age signifies the sixth stage of intimacy vs. isolation.

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply. Assessing vital signs Administering injections Assessing wound drainage Bringing equipment to the client's room Transporting the client to a diagnostic test

Bringing equipment to the client's room Transporting the client to a diagnostic test The nursing assistive personnel can bring equipment to a client's room and transport the client from one place to another. Because the client is on isolation precautions, the registered nurse should assess vital signs, administer injections, and assess wound drainage.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? Data collection Data validation Data clustering Data interpretation

Data collection The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

Which figure depicts a nurse locating the fifth intercostal space (ICS)?

Figure 3 depicts the nurse using his or her fingertips to locate the fifth intercostal space. Figure 1 depicts the nurse locating the angle of Louis. Figure 2 depicts the nurse locating the second intercostal space. Figure 4 indicates the identification of the midclavicular line.

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 finds that the client's urine has presence of blood after the urinary catheter is removed." "The nurse checks if the client has a history of substance abuse before administering nasal medications." "The nurse finds that the client's skin color has changed to bluish purple after cold therapy is applied to reduce swelling." "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 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 data or information that comes from a client's assessment is known as the input component. When the nurse checks the client's health history for an allergy to iodine before inserting a urinary catheter, it is an example of 'input' component. When the nurse checks if the client has a history of substance abuse before administering nasal medication, it is an example of 'input' component. When the nurse checks the medical records of the client to see if he/she has had a rectal surgery in the past year before placing an internal fecal catheter, it is an example of 'input' component. When the nurse finds that the client's urine has blood in it after the urinary catheter is removed, it is an example of 'output' component. When the nurse finds that the client's skin color has changed to bluish purple after cold therapy is applied to reduce swelling, it is an example of 'output' component.

Which factor can elevate the oxygen saturation during an assessment? Nail polishes Carbon monoxide Intravascular dyes Skin pigmentation

Carbon monoxide Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

A nurse, the family, and an adolescent client with anorexia nervosa are planning appropriate outcomes for the client. What is an appropriate short-term goal for the client? Eat planned nutritious meals. Gain 10 lb (4.5 kg) within 1 month. Continue the same diet eaten at home. Add 100 calories of carbohydrates to each meal.

Eat planned nutritious meals. Ingesting planned nutritious meals is a realistic goal that is likely to evoke the least anxiety in the short term. A person with anorexia nervosa has great anxiety about weight gain and responds best to nutritious foods when he or she has input into planning. The thought of gaining 10 lb (4.5 kg) within 1 month will overwhelm the client and increase anxiety. The diet eaten at home was probably a very low-calorie diet that promoted weight loss. Adding 300 calories a day will increase the client's anxiety and probably result in nonadherence to the planned regimen.

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 Proceeding in an unhurried manner Speaking in a low and moderate voice Pantomiming words and simple actions while verbalizing them

Using medical terminology Nurses should follow certain guidelines when interpreter is not available while assessing a client who does not understand English. Rather than using medical terminology, the nursing student should use simple, more well-known words, like "pain" instead of "discomfort." The nursing student's other actions are appropriate. Proceeding in an unhurried manner; speaking in a low, moderate voice; and pantomiming words and simple actions while verbalizing them promote effective communication.

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client? Apnea Bradypnea Tachypnea Hyperpnea

bradypnea In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? Low fat Low carbohydrate Soft-textured and bland High protein and kilocalories

low fat The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

Which developmental changes should be evaluated in girls around 12 years of age? Motor skills Visual acuity Skeletal growth Hormonal changes

skeletal growth Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? The nurse notes nonverbal signs of discomfort. The nurse observes the client's position in bed. The nurse asks the client to explain the surgery. The nurse asks the client to rate the severity of pain.

The nurse asks the client to explain the surgery. The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? The student expects the interpreter to act as the client's advocate. The student expects the interpreter to have a health care background. The student maintains steady eye contact with the client. The student talks only to the interpreter about the client.

The student talks only to the interpreter about the client. A nurse should follow certain strategies while working with an interpreter for a client who does not understand English. The nurse should talk to the client about the client's condition and care and not to the interpreter. The interpreter may act as a client advocate and represent the client's needs to the nurse. The nurse should use a trained medical interpreter who has a health care background. The nurse should maintain eye contact with the client and obtain feedback to be certain that the client understands.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. Impaired vision Cognitive impairment Environmental hazards Inappropriate footwear Improper use of assistive devices

Environmental hazards Inappropriate footwear Improper use of assistive devices Environmental hazards, inappropriate foot wear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.

The registered nurse is teaching a nursing student how to communicate with a client with cognitive impairment. Which statements made by the nursing student indicate a need for further instruction? Select all that apply. "I should use visual cues." "I should ask one question at a time." "I should speak in a normal tone of voice." "I should give the client time to respond." "I should face the client to make my mouth visible."

"I should use visual cues." "I should speak in a normal tone of voice." "I should face the client to make my mouth visible." Communicating with a client who has special needs can be challenging, so the nurse should use techniques that improve communication that are relevant to the client's impairment. For example, when communicating with a cognitively impaired client, the nurse should ask one question at a time and give the client time to respond. When a client is unable to speak clearly or at all, the nurse should use visual cues. When a client has a visual impairment, the nurse should speak in a normal tone of voice. The nurse should face the client with a hearing impairment so that the nurse's lips are visible when speaking to the client. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Place the steps of the nursing process in its correct order. 1.Identify the client's health care needs by collecting subjective and objective data 2.Define the nursing diagnoses or collaborative problems clearly. 3.Plan the care by determining priorities, goals, and expected outcomes of care. 4.Perform the nursing interventions competently. 5.Evaluate the effects of the nursing interventions performed..

1 2 3 4 5 The nursing process consists of five steps. The first step is assessment, which involves identifying the client's need by collecting subjective and objective data. Based on this information, nursing diagnoses are made to define the client's problems. The care plan is created based on the nursing diagnoses, and includes determining priorities, goals, and expected outcomes of care. During the implementation phase, the planned care is delivered to the client. In the evaluation phase, the nurse evaluates the effectiveness of the nursing care provided by reassessing the client's condition.

What is the correct order of steps of the nursing diagnostic process?

1.Assess the client's health status. 2.Validate the data with other sources. 3.Interpret the meaning of the data. 4.Cluster data. 5.Look for defining characteristics. 6.Identify the client's needs. 7.Formulate nursing diagnoses. The diagnostic reasoning process involves the use of assessment data for the client. The assessment data is obtained from the client, family, and health care resources. The nurse validates and ensures the data is accurate and uses critical thinking to interpret and analyze the data before it is classified and organized into data clusters. This organization helps the nurse identify the client's health needs. The nurse then formulates the nursing diagnoses using standard formal nursing diagnostic statements.

According to Erikson's theory, at which age would a child develop self-control and independence? 18 months to 3 years old 3 to 6 years old 6 to 12 years old 12 to 19 years old

18 months to 3 years old According to Erikson's theory, between the ages of 18 months and 3 years, a child develops self-control and independence. At the age of 3 to 6 years old, a child is highly imaginative. At the age of 6 to 12 years old, a child is engaged in tasks and activities. Between the ages of 12 and 19 years of age, a child can differentiate between identity and role confusion.

A nursing student understands that a nursing theory is a conceptualization of some aspect of nursing that describes, explains, predicts, or prescribes nursing care. Which points about theories made by the nursing student are accurate? Select all that apply. A discipline constitutes a major portion of the knowledge of a theory. A nursing theory helps to identify the focus, means, and goals of practice. Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information. Theory and scientific inquiry do not go hand in hand because they fail to provide guidelines for decision making, problem solving, and nursing interventions. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions.

A nursing theory helps to identify the focus, means, and goals of practice. Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions. A nursing theory helps to identify the focus, means, and goals of practice. Theories give a perspective for assessing clients' situations and organizing data and methods for analyzing and interpreting information. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions. A theory constitutes much of the knowledge of a discipline. Theory and scientific inquiry are vital links to one another, providing guidelines for decision making, problem solving, and nursing interventions.

A registered nurse is teaching a nursing student about types of nursing theories. Which information provided by the registered nurse is accurate? Prescriptive theories do not provide guidance for specific nursing interventions. Descriptive theories describe, relate, and in some situations predict, nursing phenomena. Middle-range theories provide the structural framework for broad, abstract ideas about nursing. Grand theories are action-oriented and test the validity and predictability of a nursing intervention.

Descriptive theories describe, relate, and in some situations predict, nursing phenomena. Descriptive theories describe, relate, and in some situations predict, nursing phenomena. Descriptive theories describe, relate, and in some situations predict, nursing phenomena. Prescriptive theories are action-oriented and test the validity and predictability of a nursing intervention. Middle-range theories do not provide guidance for specific nursing interventions. Grand theories provide the structural framework for broad, abstract ideas about nursing.

A nurse is using evidence-based practice to formulate a treatment plan for a client. The nurse uses the PICOT format to ask a clinical question. What should be the next step in the decision-making process? Critically appraising all the evidence available Gathering the most relevant and best evidence Sharing the outcomes of the evidence-based practice changes with others Integrating all available evidence with clinical expertise and client preferences

Gathering the most relevant and best evidence After asking the clinical question, the nurse should gather the most relevant and best evidence. The nurse may perform a critical appraisal after gathering all the necessary evidence. Sharing the outcomes of the evidence-based practice changes with others is the last step of the decision-making process. After gathering relevant evidence and appraising the same, the nurse should integrate it with clinical expertise and client preferences. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

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 Assuming the client is being uncooperative Chewing gum while talking to the client Making sure that the client knows you are speaking Keeping the communication concise

Giving the client a chance to speak Making sure that the client knows you are speaking Keeping the communication concise When communicating with an older adult who has hearing disability, the nurse should give the client a chance to speak, make sure that the client knows the nurse is talking, and keep the communication concise. The nurse should not assume that the client is uncooperative if he or she does not reply or gives a delayed response. The nurse should also not chew gum while talking because this action may garble the nurse's language. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Arrange in order how the items of personal protection equipment (PPE) should be removed after exiting a medical or surgical isolation area. 1.Gloves 2.Gown 3.Face shield 4.Mask 5.Handwashing

Gloves Faceshield Gown Mask Handwashing OFF think GFGMH According to the Centers for Disease Control and Prevention, gloves should be removed first when exiting medical or surgical isolation in order to avoid those gloves touching and possibly contaminating other equipment outside of the isolation area. Next, the nurse removes the face shield, followed by the gown and then the mask. Handwashing is the next step that should occur after removing all personal protection equipment (PPE). Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

Which image shows the Trendelenburg position?

Image 1 shows the Trendelenburg position, in which the client is supine with the legs below the level of the heart. Image 2 shows the supine position, in which the client is on his or her back. Image 3 shows lateral position, in which the client is on his or her side. Image 4 shows prone position, in which the client is on his or her stomach.

An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? Interview the client without the presence of family members. Report the abuse to the appropriate state agency for investigation. Accept the adult child's explanation until more data can be collected. Refer the client's clinical record to the hospital ethics committee for review.

Interview the client without the presence of family members. Privacy may provide an environment that is conducive to the client sharing information about the situation. The client needs to be kept safe; this action ensures additional time for assessment to rule out the possibility of abuse. Reporting the abuse to the appropriate state agency for investigation is premature; further assessment is needed to determine if it is necessary to notify the appropriate agency. Accepting the adult child's explanation until more data can be collected will form a separate relationship with the adult child, which is not in the client's best interest. Referring the client's clinical record to the hospital ethics committee for review is inappropriate; this situation presents a legal, not ethical, issue. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? Hypoventilation Biot's respiration Kussmaul's respiration Cheyne-Stokes respiration

Kussmaul's respiration Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

According to Sigmund Freud's developmental theory, which developmental age is called the latent stage? Toddler Preschool Middle childhood Adolescence

Middle childhood According to Sigmund Freud's developmental theory, middle childhood age is the latent stage. Early childhood and toddlers are in the anal stage. Preschool is the phallic stage. Adolescence is the genital stage.

Which action is the least likely to prevent sleep disturbances? Avoiding reading, writing, and eating in bed Getting out of bed if unable to fall sleep after 20 minutes Performing strenuous exercise within an hour before going to bed Lowering the temperature of the bedroom and keeping it dark and quiet

Performing strenuous exercise within an hour before going to bed To prevent sleep disturbances, a client should not perform strenuous exercise within six hours before bedtime. A client should avoid reading, writing, and eating in bed. To prevent sleep disturbances, a client should get out of bed if he or she is not able to fall sleep after 20 minutes. The client should also lower the temperature of the bedroom and keep it dark and quiet.

A nurse, providing care in a hospital skilled nursing unit, witnesses a client's spouse shaking the elderly client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with managers and report the abuse to which party? the client The client's spouse The client's primary healthcare provider adult protective services

adult protective services The nurse has a legal responsibility to report suspicions of abuse to the appropriate agency, which in this instance is Adult Protective Services. The client will not be able to understand the discussion. It is not the nurse's responsibility to directly challenge the spouse's behavior in this situation; the nurse may act as a client advocate by interrupting the spouse's behavior and providing immediate physical and emotional care. The nurse should then report suspicions of abuse to Adult Protective Services. Although the nurse may report suspicions about the spouse's behavior to the healthcare provider, the law requires that Adult Protective Services be notified. The term Adult Protective Services refers to the range of laws and regulations enacted to deal with abusive situations. The laws and regulations are typically administered by an agency within the state, for example, the Department of Social Services, which receives and investigates complaints. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? Analysis Evaluation Explanation Interpretation

explanation The critical-thinking skill of explanation involves using knowledge and experience to provide client care. The nursing practice of assessing whether the obtained data is true is called analysis. Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions is an evaluation skill. The nursing practice of being orderly in data collection and looking for patterns to categorize data refers to interpretation.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? Right task Right person Right supervision Right communication

right communication Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations while delegating a task. Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person is delegating a task to the correct person who has the ability to perform said task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.

A nursing student is learning about Erikson's theory of psychosocial development. Which statement made by the client indicates 'Initiative versus Guilt' stage? "See, I have got highest marks among all my friends in the class." "My child likes to fantasize and tries out new characters every day."' "I give healthy finger foods to my baby so that he or she can pick it up and eat it by himself or herself." "Look, I have learnt the numbers between 1 to 1000 and my teacher says that I am the best student."

"My child likes to fantasize and tries out new characters every day." According to Erikson's theory of psychosocial development, in the Initiative versus Guilt stage, children like to pretend and try out new roles. An example of this stage is a kid who likes to fantasize and tries out new characters every day. A child who talks about receiving the highest test scores among his or her friends in class is in the Industry versus Inferiority stage. A baby who can pick up and independently eat healthy foods is in the Autonomy versus Sense of Shame and Doubt stage. A child who has learned the numbers between 1 and 1000 and is proud of being congratulated by the teacher is in the Industry versus Inferiority stage.

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. "While assessing a client, the nurse finds a history of mental illness." "While assessing an obese client, the nurse finds a history of asthma." "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."

"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." The output component determines whether the client's health status has improved, declined, or is stable as a result of nursing care. Noticing that the client's wounds have healed after performing regular wound debridement is an example of output. Noticing the development of an infection at a client's surgical site after the dressing has been changed and noticing that the blood pressure level of a client has increased even after medication is administered on a timely basis are also examples of output. When the nurse discovers that a client has a history of mental illness, this finding an example of input. When the nurse discovers that an obese client has a history of asthma, this finding is an example of 'input' component.

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as content components? Select all that apply. "A nurse assessing a client's medical records before surgery finds that the client is allergic to latex." "The nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli." "The nurse checks the client's medical records for any blood transfusion reactions before administering a blood transfusion." "The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy." "The nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent the spread of pathogens."

"The nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli." "The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy." "The nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent the spread of pathogens." The content component involves information about the nursing interventions for clients with specific health care problems. When the nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli, this action is an example of the content component. When the nurse understands that many clients practice polypharmacy by purchasing prescribed medications from multiple stores, this understanding is an example of the content component. When the nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent spread of pathogens, this knowledge is an example of the content component. When the nurse assessing a client's medical records before surgery finds that the client is allergic to latex, this discovery is an example of the input component. When the nurse checks the medical records of the client for blood transfusion reaction before administering a blood transfusion, this action is an example of the input component.

Which client's need should be considered high priority? A client with dysphagia who is choking while eating A client who needs discharge teaching about medications A client who needs a dressing change of the surgical wound A client who has a knowledge deficit regarding the use of an insulin pen

A client with dysphagia who is choking while eating Client needs should be met based on priority. A high-priority need is a life-threatening condition. The client with dysphagia who choked while eating needs intervention to establish a patent airway. Therefore, this client should be attended to first. The need for discharge teaching does not pose a threat to life and is considered low priority. The need for dressing change to prevent infection is considered an intermediate priority. The need for teaching regarding the use of insulin pens is a low-priority need.

The nurse is assessing a client's pulse strength and records it as a 3+. Which description best describes this client's pulse strength? Bounding Absent Expected Diminished

Bounding A pulse strength of 3+ is considered full or bounding. A pulse strength is considered normal, expected, and easily palpable when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+. An absent pulse is a grade 0 pulse.

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply. Check tubing for kinks Run wires under carpeting Post "no smoking" signs in the clients' rooms Place oxygen tanks flat in the carts when not in use Make sure that the client is familiar with the phrase "Stop, drop, and roll"

Check tubing for kinks Post "no smoking" signs in the clients' rooms Oxygen tubing should be checked for kinks during oxygen use. "No smoking" signs should be posted in the clients' rooms. Wires should not be kept under carpeting because heat buildup or friction can cause a fire. Oxygen tanks should be placed in an upright position in their carts or flat on floors. Being familiar with the phrase "Stop, drop, and roll" helps to describe when clothing or skin is burning.

Which statement is true about the nursing model "team nursing"? The registered nurse is responsible for all aspects of client care. Client care can be delegated to other healthcare team members. The registered nurse works directly with the client, family members, and healthcare team members. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

What is an example of the critical thinking attitude of independent thinking in nursing practice? To refer to a policy and procedure manual to review steps of a skill To talk with other nurses to share ideas about nursing interventions To recognize when one requires more information for making a decision To explore and learn more about the client for making appropriate clinical judgments

To talk with other nurses to share ideas about nursing interventions Nurses talking to each other and sharing ideas about nursing interventions reflects independent thinking. Responsibility and authority require referring to a policy and procedure manual for reviewing steps of a skill. Humility involves recognizing the need for more information for making a decision. Curiosity is exploring and learning about clients to help make appropriate clinical judgment.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. Heart Vagina Rectum Female genitalia Musculoskeletal system

Vagina Rectum Sims' position is indicated to examine vagina and rectum. Lithotomy to check female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system.

abuse

• Sexual assault is a common and often underreported crime of violence. • Females are far more likely to be victims of sexual assault and tend to know their perpetrators. Sexual assault of males tends to be underreported due to the humiliation and stigma attached to such victimization. • Psychoactive substances play a major role in sexual assault, and alcohol is the most commonly used date-rape drug. Other disinhibiting and amnestic substances play a role in forcible sex acts. • A rape survivor experiences a wide range of feelings, which may or may not be exhibited to others. • Sexual assault is often followed by feelings of fear, degradation, anger, and rage. Helplessness, anxiety, sleep disturbances, disturbed relationships, flashbacks, depression, and somatic complaints are also common. • The initial medical evaluation may be frightening and stressful. A police interview, repeated questioning by health professionals, and the physical examination itself all have the potential to add to the trauma and revictimization of the sexual assault. • Nurses can minimize repetition of questions and support the patient as she goes through the medical and legal evaluation. • Survivors require long-term healthcare that can include counseling to minimize long-term effects of the rape and assisting in an early return to a normal living pattern. • Telephone and online resources are available to assist sexual assault and rape survivors.

A nurse is educating a client about Maslow's hierarchy of needs by citing examples. Which examples mentioned by the nurse belong to the third level of needs? Select all that apply. Correct1 "A client is depressed because his/her spouse has passed away." 2 "A client is constipated due to excess loss of fluids from the body." Correct3 "A client wants to reconnect with old friends after being diagnosed with cancer." 4 "A client has to live in a rat-infested apartment due to lack of financial resources." Correct5 "A client never goes to family gatherings because he/she is not accepted by family members."

"A client is depressed because his/her spouse has passed away." "A client wants to reconnect with old friends after being diagnosed with cancer." "A client never goes to family gatherings because he/she is not accepted by family members." According to Maslow's hierarchy of needs, the third level of needs is love and belonging. This includes friendship, social relationships, sexual love, etc. If the client is depressed due to the death of the spouse, this is an example of the third level of needs not being met. If the client feels the urge to reconnect with old friends after being diagnosed with a terminal illness, the client is in need of emotional support and love. If the client refuses to retain social relationships with family members, this is an example of a failure to meet love and belonging needs. If the client is losing body fluids leading to constipation, this indicates a deficit in the first level of needs, which are physiological. If the client lives in a rat-infested apartment, there is an increased the risk of infections and disease, which indicates a lack of physical safety, and this is an example of the second level of needs not being met.

disorders : personality

• All personality disorders share characteristics of inflexibility and difficulties in interpersonal relationships that impair social or occupational functioning. • Personality disorders are most likely caused by a combination of biological and psychosocial factors. • Patients with personality disorders often enter psychiatric treatment because of distress from a comorbid mental illness. • Nurses may experience intense emotional reactions to patients with personality disorders and need to make use of clinical supervision to maintain objectivity. • Despite the relatively fixed patterns of maladaptive behavior, some patients with personality disorders are able to change their behavior over time as a result of treatment.

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

1.Assessment 2.Diagnosis 3.Planning 4.Implementation 5.Evaluation The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client's health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client's response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client's care. The nurse selects interventions (nursing and collaborative) individualized to each of the client's nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client's response and whether the interventions were effective. The nursing process is dynamic and continuous.

eating disorders

A number of theoretical models help explain the origins of eating disorders. • Neurobiological theories focus on neurotransmitters in the brain that regulate mood and hunger. • Psychological theories explore issues of control in anorexia and affective instability and poor impulse control in bulimia. • Genetic theories postulate the existence of vulnerabilities that may predispose people toward eating disorders. • Sociocultural models look at our present societal ideal of being thin. • Anorexia nervosa is a potentially life-threatening eating disorder that includes severe underweight; low blood pressure, pulse, and temperature; dehydration; and dysrhythmias. • Anorexia may be treated in an inpatient treatment setting in which milieu therapy, psychotherapy (cognitive), development of self-care skills, and psychobiological interventions can be implemented. • Long-term treatment is provided on an outpatient basis and aims to help patients maintain healthy weight. It includes treatment modalities such as individual therapy, family therapy, group therapy, psychopharmacology, and nutrition counseling. • Patients with bulimia nervosa are typically within the normal weight range, but some may be slightly below or above ideal body weight. • Assessment of the patient with bulimia nervosa may show enlargement of the parotid glands, dental erosion, and caries if the patient has induced vomiting. • Acute care may be necessary when life-threatening complications such as gastric rupture (rare), electrolyte imbalance, and cardiac dysrhythmias are present. • The goal of interventions is to interrupt the binge-purge cycle. Psychotherapy and self-care skill training are included in the treatment plan. • Therapy is the long-term treatment focus to address coexisting depression, substance abuse, and/or personality disorders that are causing the patient distress and interfering with the quality of life. Self-worth and interpersonal functioning eventually become issues that are useful for the patient to target. • Effective treatment for obese patients with binge-eating disorder includes binge abstinence, improvement of depressive symptoms, and achievement of an appropriate weight for the individual. • Patients with binge-eating disorder often have upper and lower GI problems that bring them to medical professionals for management. • Feeding disorders have multiple etiologies and are often associated with developmental delays of childhood. • Feeding disorders may result in significant nutritional deficiencies and can be fatal. Behavioral interventions to increase appropriate food consumption are the primary treatments.

Which scenario is most likely to contribute to health disparities? An English-speaking critical care nurse assesses a Hispanic client in a coma. An English-speaking nurse plans the nursing procedures for a black Latino client. An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing. An English-speaking nurse single-handedly conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

An English-speaking nurse single-handedly conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English. As per the U.S. Department of Health and Human Services Office of Minority Health, health care organizations should offer and provide language assistance services, including an interpreter, to each client with limited English proficiency at all points of contact during all hours of operation and service. Therefore, presence of an interpreter is essential for the admission interview of a Puerto Rican immigrant with limited knowledge of English. A Hispanic client in a coma is not able to speak, so an interpreter is not necessary. Interpreter service is not required while the nurse plans nursing procedures because the nurse does not interact with the client directly during this phase. Although the nurse must ensure that the hard-of-hearing client can hear discharge instructions, there is lower risk for health disparities since the nurse and the client speak the same language.

Client / Action: A / brings objects from hand to mouth B / holds a baby bottle C / sits alone without support D / picks up small objects The nurse is assessing four clients. Which infant has exhibited a gross-motor skill?

Client C Client C, who sits alone without support, indicates large muscle movement of the arms, feet, and body; this is known as a gross-motor skill. Infants who bring objects from their hands to their mouths, hold baby bottles, and pick up small objects are exhibiting fine-motor skills. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

In the clinical setting, which clients exhibit affiliative motivation? Select all that apply. A client who follows a low-fat diet due to the fear of having a heart attack An obese teenager who follows dietary restrictions to fit in with a peer group A client who becomes a vegetarian, loses weight, and continues with the change A client who complies with taking their medication to please the client's spouse A young person who performs aerobic exercise and also teaches others to exercise

An obese teenager who follows dietary restrictions to fit in with a peer group A client who complies with taking their medication to please the client's spouse Affiliative motivation is usually seen in people who are nonassertive and dependent on others. Their health-seeking actions are usually directed towards establishing, maintaining, and restoring close personal relationships with others. The client who complies with taking medication to please his or her spouse is exhibiting affiliative motivation, because self-care behavior is not intended for restoring health, but to please someone else. The teenager who follows dietary restrictions to lose weight to fit into a peer group exhibits affiliative motivation. The teenager follows the dietary restrictions not to become healthy, but to get peer approval. A client who follows a low-fat diet for fear of having a heart attack exhibits avoidance motivation. A young person who does aerobic exercise and teaches others exhibits power motivation. A client who becomes a vegetarian, loses weight, and continues with the change exhibits achievement motivation.

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? Confirm the client's relationship first. Ask the client's primary healthcare provider. Inform the nurse manager and show the records. Explain that medical health records are confidential.

Explain that medical health records are confidential. The Health Insurance Portability and Accountability Act (HIPAA) sets the standards for the protection of the client's health information. The nurse must explain that medical health records are confidential. The healthcare team must be aware of the organization's policies for reviewing a client's medical record for assessment. The nurse need not confirm the client's relationship because the client's medical records are confidential and cannot be shared with anyone unless authorized by the client. The primary healthcare provider cannot authorize the nurse to show the medical records. The nurse cannot inform the nurse manager and show the medical record to persons not involved in direct client care. Healthcare providers share information with reasonable safeguards within the healthcare team for the purpose of providing client care. Test-Taking Tip: The nurse must follow the standards set by The Health Insurance Portability and Accountability Act.

Which therapeutic communication technique is most useful for the nurse to use when the client begins to repeat previously mentioned issues in the same therapeutic conversation? Focusing Clarifying Paraphrasing Summarizing

Focusing Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

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? Sitting with a relaxed posture Leaning toward the client Making eye contact Facing the client

Leaning toward the client Leaning toward the client during a therapeutic communication encounter is the best way to convey engagement in a client interaction. Sitting with a relaxed posture conveys that the nurse may be comfortable but not necessarily engaged in the encounter. Facing the client can convey that the nurse is interested in what the client is saying, but the nurse may not yet be engaged in this encounter. Making eye contact can convey the nurse's willingness to listen to the client, but it does not demonstrate engagement in this interaction as well as leaning toward the client does.

Which is an indirect nursing care intervention? Administering medications Managing the client's environment Counseling the family during a time of grief Inserting intravenous infusion

Managing the client's environment Indirect nursing care interventions are treatment actions not performed directly to the client but are done to aid the client. Indirect care intervention includes managing the client's environment. Direct care interventions include administration of medications, counseling the family during a time of grief, and insertion of an intravenous infusion.

A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain? Domain Paradigm Phenomenon Environment or situation

Phenomenon A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon. The domain is the perspective of a profession. A paradigm is a pattern of thought that is useful in describing the domain of a discipline. Environment or situation includes all possible conditions affecting clients and the settings in which their health care needs occur.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% Temporal temperature of 37.4 °C Radial pulse rate of 72 and irregular

Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? There is absence of a pulse. The pulse strength is normal. The pulse strength is bounding. The pulse strength is barely palpable.

The pulse strength is barely palpable. A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is bounding, then it is documented as 4+.

Which related factor is appropriate for a nursing diagnosis? Prostectomy Trauma of incision Acute renal failure Knee replacement surgery

Trauma of incision The related factor or etiology of a nursing diagnosis is always within the nursing domain. The nurse must ensure that the related factor is a condition that responds to nursing interventions. Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostectomy is a medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also a medical condition. Nursing interventions should be directed towards behaviors or conditions that can be managed or treated by the nurse. Knee replacement surgery is a medical condition that cannot be managed by nursing interventions.

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply. Use of hard soap Frequent bathing Use of tanning pills Presence of an allergy Use of petroleum products

Use of hard soap Frequent bathing The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply. Using pincer grasp well Correct2 Picking up small objects Correct3 Showing hand preference 4 Crawling on hands and knees 5 Pulling oneself to standing or sitting

Using pincer grasp well Picking up small objects Showing hand preference The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

personality disorder cluster pneumonic

cluster A: *eccentric* people still suck (paranoid schizoid schizotypal) cluster B: *erratic* boy needs his apple (borderline narcissistic histrionic antisocial) cluster C: *anxious* amy depends on company (anxious dependent obsessive-compulsive)

A nursing student is learning about theoretical foundations of nursing practice. Which statement by the nursing student matches with Leininger's theory? "Incorporate the client's cultural traditions, values, and beliefs into the plan of care." "Determine why a client is unable to meet biological, psychological, developmental, or social needs." "Determine which demands are causing problems for a client and assess how well he/she is adapting to them. " "Establish effective nurse-client communication when obtaining nursing histories, providing education, or counseling clients and their families."

"Incorporate the client's cultural traditions, values, and beliefs into the plan of care." The main idea of Leininger's theory is cultural diversity, and the goal of nursing care is to provide the client with culturally specific nursing care. Therefore, the nurse needs to incorporate the client's cultural traditions, values, and beliefs into the plan of care according to Leininger's Theory. When following Dorothea Orem's self-care deficit theory, the nurse needs to determine why a client is unable to meet biological, psychological, developmental, or social needs to help him/her to perform self-care. When following the Roy adaptation model, the nurse needs to determine which demands are causing problems for a client and assesses how well he/she is adapting to them. When following Hildegard Peplau's theory, the nurse needs to establish effective nurse-client communication while obtaining nursing histories, providing education, or counseling clients and their families. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nursing student is learning about Erikson's theory of psychosocial development. Which statement made by the client indicates the Autonomy versus Sense of Shame and Doubt stage? "My kid has started to walk on his or her toes, with the legs wide apart." "I do not want to consume meat even though my family owns a slaughterhouse." "I want to go to the club with my friends but my dad will not allow it." "I have been in a relationship for three years and now my partner does not want to be with me."

"My kid has started to walk on his or her toes, with the legs wide apart." According to Erikson's theory of psychosocial development, in the Autonomy versus Sense of Shame and Doubt stage, the child develops basic self-care activities and develops his or her autonomy by making choices. A kid who has started walking on his or her toes with the legs wide apart is in the Autonomy versus Sense of Shame and Doubt stage. An example of the Identity versus Role Confusion stage is a client who says that he or she does not want to consume meat even though his or her family owns a slaughterhouse. Another example of the Identity versus Role Confusion stage is a client who says that he or she wants to go to the club with friends although his or her dad is against it. An example of the Intimacy versus Isolation stage is a client who says he or she has been in a relationship for three years and now his or her partner does not want to be with him or her.

After abdominal surgery a client reports pain. What action should the nurse take first? Reposition the client. Obtain the client's vital signs. Administer the prescribed analgesic. Determine the characteristics of the pain.

Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Intake and output results Client's report about fluid intake Blood lab results

Blood lab results Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

Which nursing interventions can help a terminally ill client cope with feelings related to death? Select all that apply. Providing medications and therapies for pain management Teaching the client about importance of complementary medicine Helping the client to find meaning and purpose in life by listening to his or her concerns Allowing time for religious readings, spiritual visitations, or attendance at religious services Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment

Helping the client to find meaning and purpose in life by listening to his or her concerns Allowing time for religious readings, spiritual visitations, or attendance at religious services Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment Feelings of connectedness are important for the client who is terminally ill; therefore, the nurse should promote connectedness by helping the client find meaning and purpose in life by listening to his or her concerns. Prayer and devotion can help the client cope with feelings related to death, so the nurse should allow time for religious readings, spiritual visitations, or attendance at religious services. The nurse can also encourage the client to pray if he or she wishes by facilitating privacy and a proper environment. To help the client to cope with the pain, the nurse should provide medications and therapies for pain management. To help the client manage other aspects of the illness, the nurse can educate the client about complementary medicine.

A registered nurse is teaching a nursing student about various developmental theories. What points mentioned by the registered nurse are accurate? Select all that apply. Moral development theory attempts to define how moral reasoning matures in an individual. Developmental theory provides a basis for nurses to assess and understand a client's responses. Biophysical development theory describes human development from the perspectives of personality, thinking, and behavior. Psychosocial theories explore theories of why individuals age from a biological standpoint and why development follows a predictable sequence. Cognitive development focuses on rational thinking processes that include changes in children, adolescents, and adults to perform intellectual operations.

Moral development theory attempts to define how moral reasoning matures in an individual. Developmental theory provides a basis for nurses to assess and understand a client's responses. Cognitive development focuses on rational thinking processes that include changes in children, adolescents, and adults to perform intellectual operations. Moral development theory attempts to define how moral reasoning matures in an individual. Developmental theory provides a basis for nurses to assess and understand a client's responses. Cognitive development focuses on rational thinking processes that include the changes in children, adolescents, and adults to perform intellectual operations. Biophysical development explores theories of why individuals age from a biological standpoint as well as why development follows a predictable sequence. Psychosocial theories describe human development from the perspectives of personality, thinking, and behavior.

Which points about nursing care and nursing practice have been accurately stated? Select all that apply. Nursing theories help to describe, explain, predict, and/or prescribe nursing care measures. Expertise in nursing is a result of clinical experience and substantial knowledge is not required. The scientific work used in developing theories expands the scientific knowledge of the profession. Nursing theories offer inadequate rationales for how and why nurses perform specific interventions and for predicting client behaviors and outcomes. The expertise required to interpret clinical situations and make clinical judgments is the essence of nursing care and the basis for advancing nursing practice and nursing science.

Nursing theories help to describe, explain, predict, and/or prescribe nursing care measures. The scientific work used in developing theories expands the scientific knowledge of the profession. The expertise required to interpret clinical situations and make clinical judgments is the essence of nursing care and the basis for advancing nursing practice and nursing science. Nursing theories help to describe, explain, predict, and/or prescribe nursing care measures. The scientific work used in developing theories expands the scientific knowledge of the profession. The expertise required to interpret clinical situations and make clinical judgments is the essence of nursing care and the basis for advancing nursing practice and nursing science. Expertise in nursing is a result of clinical experience as well as knowledge. Nursing theories offer well-grounded rationales for how and why nurses perform specific interventions and for predicting client behaviors and outcomes. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

sexual disorders

Sexual dysfunction is an extremely common problem that involves a disturbance in the desire, excitement, or orgasm phases of the sexual response cycle or pain during sexual intercourse. • There are seven different disorders of sexual dysfunction. • Sexual problems have the potential to disrupt meaningful relationships. • Healthcare workers are often uncomfortable asking questions related to sexuality. Providing professional and holistic care requires that nurses include this vital area of assessment. • Certain medical and surgical conditions and some drugs result in a variety of sexual dysfunctions, including low libido, impotence, erectile dysfunction, anorgasmia, and priapism. • There are distinctions between biological sex and gender identity. Gender dysphoria is a strong and persistent cross-gender identification accompanied by anxiety, discomfort, and unhappiness. • Paraphilia is a term used to identify repetitive or preferred sexual fantasies or behaviors that involve preference for use of a nonhuman object, repetitive sexual activity with humans involving real or simulated suffering or humiliation, and repetitive sexual activity with nonconsenting partners. • Paraphilic disorders include exhibitionistic disorder, fetishistic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder, voyeuristic disorder, and paraphilic disorders not otherwise specified. • In addition to conducting a sexual assessment, nurses are involved in milieu and behavioral therapy, counseling, education, and medication management. • Nursing interventions for paraphilic disorders involve administration of medications (e.g., medroxyprogesterone [Depo-Provera] and SSRIs) and therapy. • Advanced practice nurses may specialize in the area of sexual counseling, treatment, and therapy.

A nurse is recollecting Sigmund Freud's psychoanalytical model of personality development. What are the characteristics of the genital stage according to this model? Select all that apply. The focus of pleasure changes to the anal zone. Sexual urges are directed outside the family circle. Unresolved sexual conflicts resurface during this stage. An individual may resolve the sexual conflicts at this stage. Sexual urges from the oedipal stage are repressed and channeled productively.

Sexual urges are directed outside the family circle. Unresolved sexual conflicts resurface during this stage. An individual may resolve the sexual conflicts at this stage. According to Sigmund Freud's psychoanalytical model of personality development, an individual passes through five stages of psychosexual development. The last stage is the genital stage, which lasts from puberty to adulthood. At this stage, sexual urges are reawakened and directed towards people outside the family circle. In the adolescent period, unresolved previous sexual conflicts resurface. An individual may resolve these conflicts at this stage. Upon reaching the anal stage, the focus of a child's pleasure shifts to the anal area. When an individual reaches the anal stage, sexual urges from the oedipal stage are repressed and channeled into productive activities that are socially acceptable.

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client's nutritional needs? Stay with the client during meals. Take the client to the dining room. Bring the client a tray of finger foods. Talk with the client about the importance of nutrition.

Stay with the client during meals. Active support is demonstrated when the nurse sits with the client during meals. Even if taken to the dining room, a depressed client may lack the physical or emotional energy to eat. Finger foods are more effectively given to clients experiencing mania. Discussing the importance of nutrition is too passive an intervention for a depressed client and usually will not stimulate the client to take action or change eating behaviors. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which warning signals should the nurse observe in a child suspected to be a victim of abuse? Select all that apply. The child doesn't want to be touched by anyone. The child sleeps for an average of 15 hours a day. The child frequently visits the emergency department. The child suffers from fever and tenderness in the abdomen. The child looks at the caregiver before answering any question.

The child doesn't want to be touched by anyone. The child frequently visits the emergency department. The child looks at the caregiver before answering any question. The child may become scared if touched. The physical abuse may cause injuries and the child may visit the emergency department frequently. An abused child may look at the caregiver before answering any question due to fear. The child sleeping for an average of 15 hours a day does not indicate abuse. Fever and tenderness in the abdomen are not signs of abuse; it could indicate an organic cause.

Which client is likely to have a health promotion nursing diagnosis? The client with acute pain due to appendicitis. The client who is willing to take a 30-minute walk daily. The elderly client with dementia admitted to the healthcare facility. The client with reduced cognitive ability while recovering from surgery.The client who is willing to take a 30-minute walk daily.

The client who is willing to take a 30-minute walk daily. A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client's response to a particular health condition. A risk nursing diagnosis describes an individual's response to health conditions that may develop in a vulnerable individual. The elderly client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls

How does the nurse identify an illness as chronic? Select all that apply. The illness is reversible and often severe. The illness persists for longer than six months. The client may develop life threatening relapse. The symptoms are intense and appear abruptly. The illness affects the functioning of one or more systems.

The illness persists for longer than six months. The client may develop life threatening relapse. The illness affects the functioning of one or more systems. A chronic illness usually lasts longer than six months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

Why does the nurse establish "moderately hard" client-centered goals? Select all that apply. To decrease the cost of treatment during therapy To decrease the number of follow-up visits by the client To achieve the goal in a shorter period of time with less effort To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal

To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal Healthcare providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? The nurse understands that the client has pain due to a tracheostomy. The nurse identifies that the client is anxious about the cardiac catheterization. The nurse realizes that the client has diarrhea and needs the bedpan frequently. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

The nurse identifies that the client is not aware of perineal care and has impaired skin integrity. The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan. Test-Taking Tip: The nursing diagnosis should lead to etiology-specific interventions and enhanced client outcomes.

What is the goal of Healthy People 2020? To ensure the well-being of clients cared for in a hospital setting To encourage the nurse to do good for the client To have the nurse act as an advocate for clients who are not capable of self-determination To eliminate health disparities related to race, ethnicity, and socioeconomic status

To eliminate health disparities related to race, ethnicity, and socioeconomic status The primary goal of Healthy People 2020 is to eliminate health disparities related to race, ethnicity, and socioeconomic status. This helps to increase the quality of health care and help people live longer. Nonmaleficence is the ethical concept that emphasizes the importance of preventing harm and ensuring the client's well-being. Beneficence is the ethical concept that encourages the nurse to do good for the client. According to the American Nurses Association (ANA) Code of Ethics for Nurses (2010), if the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate within the professional scope of nursing practice.

Which nursing process involves delegation and verbal discussion with the healthcare team? Planning Evaluation Assessment Implementation

implementation The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.