NURS1023-1 _ Unit 2 _ EAQ

C. Third level, which includes love and belonging needs

A client reports, "I feel frustrated because I do not spend enough time with my partner because of my job". In Maslow's hierarchy of needs, to which level of need does the given scenario correspond? A. First level, which includes physiological needs B. Second level, which includes safety and security needs C. Third level, which includes love and belonging needs D. Final level, which includes self-actualization needs

B. Changes in mental status and cognition

An older client who is usually cheerful and cooperative demonstrates irritability and restlessness during morning hygiene. Which assessments would the nurse perform first? A. Level of stress and ability to cope B. Changes in mental status and cognition C. Deviations from baseline mood and affect D. Feelings related to loss of independence

D. The newborn has no corneal reflect after a light touch

The nurse anticipates that a newborn has impaired vision. Which finding supports the nurse's conclusion? A. The newborn blinks in response to light B. The newborn has visual acuity of 20/100 C. The newborn does not produce tears while crying D. The newborn has no corneal reflex after a light touch

A. Oral temperature of 98.2F B. Apical pulse of 88 beats/min and regular D. Blood pressure of 116/78 mm Hg while in a sitting position

The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which finding is considered within normal range for this client? Select all that apply. One, some, or all responses may be correct. A. Oral temperature of 98.2F B. Apical pulse of 88 beats/min and regular C. Respiratory rate of 30 breaths/min D. Blood pressure of 116/78 mm Hg while in a sitting position E. Oxygen saturation of 92%

D. Preschooler D -- unable to imitate others

The nurse is documenting the assessment findings of four preschool children. Which child would the nurse suspect had delayed cognitive development? A. Preschooler A -- no proper understanding of left and right B. Preschooler B -- unable to understand the cause and effect of an injury C. Preschooler C -- unable to interpret time D. Preschooler D -- unable to imitate others

D. Implementation

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? A. Planning B. Evaluation C. Assessment D. Implementation

D. Implementation

The nurse is performing nursing care therapies and including the client has an active participant in the care. Which step of the nursing process is involved in this situation? A. Planning B. Evaluation C. Assessment D. Implementation

C. Ability to perform tasks without becoming frustrated

Which factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairement? A. Level of interest in unit activities B. Orientation to time, place, and person C. Ability to perform tasks without becoming frustrated D. Cognitive impairment, which will increase until adjustment to the home is accomplished

D. "Preschoolers are less likely to believe that inanimate objects have lifelike qualities"

Which parental statement would the nurse recognize as indicating the need for further education about cognitive changes in preschoolers? A. "Preschoolers are most fearful about physical harm" B. "Preschoolers are closely linked to concrete experiences" C. "Preschoolers are able to classify objects on the basis of color" D. "Preschoolers are less likely to believe that inanimate objects have lifelike qualities"

C. Stressors that appear to precipitate the client's disruptive behavior

Which priority parameter would the nurse assess when caring for an older adult client with a neurocognitive disorder who demonstrates disorientation and numerous unmanageable behaviors? A. Orientation to time, place, and person B. Ability to perform daily activities without assistance from others C. Stressors that appear to precipitate the client's disruptive behavior D. Cognitive impairments until complete adjustments are accomplished

B. 30 breaths/min

Which respiratory rate would the nurse expect for a 2-year-old child? A. 20 breaths/min B. 30 breaths/min C. 40 breaths/min D. 50 breaths/min

B. "My aim is to be a famous writer, and I will do anything to achieve my dream"

Which statement is last priority based on Maslow's hierarchy of needs? A. "I feel that I have failed to be a worthy child of my parents" B. "My aim is to be a famous writer, and I will do anything to achieve my dream" C. "I do not like to speak to the people in my neighborhood because they are all snobs" D. "My house is being reconstructed, and chunks of the ceiling are quite often falling off"

D. During the sensorimotor stage, infants develop an action pattern for dealing with their environment

Which statement is true about Piaget's theory of cognitive development? A. Piaget's theory includes five periods that are related to age B. In the late preoperational stage, the children experience animism C. In the preoperational stage, children are able to perform mental operations D. During the sensorimotor stage, infants develop an action pattern for dealing with their environment

D. "I tend to get worried about every little thing because I cannot do anything successfully"

Which statement of the client would illustrate the self-esteem need based on Maslow's hierarchy of needs? A. "I fear that my partner will leave me because of my illness" B. "I want to stay fit because my aim is to be a successful entrepreneur" C. "I do not have anyone in my life, as my family has disowned me" D. "I tend to get worried about every little thing because I cannot do anything successfully"

A. Be alert about common sources of client injuries B. Gain knowledge regarding current nursing practices D. Communicate with the client regarding tests and treatment plans

Which steps would the nurse take when caring for a client to prevent nursing malpractice? Select all that apply. One, some, or all responses may be correct. A. Be alert about common sources of client injuries B. Gain knowledge regarding current nursing practices C. Refrain from speaking falsely about a clients medical condition D. Communicate with the client regarding tests and treatment plans E. Refrain from divulging medical information to unauthorized persons

C. Normal acid-base balance

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89mm Hg, PCO2 35mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? A. Respiratory alkalosis B. Poor oxygen perfusion C. Normal acid-base balance D. Compensated metabolic acidosis

C. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia and lives alone, with adult children living nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. Which nursing intervention is correct to assist the client with taking the medication? A. Contact the client's children and ask them to hire a private-duty aide who will provide round-the-clock care B. Develop a chart for the client, listing the times the medication should be taken C. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen D. Instruct the client and client's children to put medications in a weekly pill organizer

B. Education about adequate housing and recreation C. Education about attention to personality development D. Instructions about good standard of nutrition adjusted to developmental phases of life

Which activities would the nurse participate in while providing a primary level of preventive care? Select all that apply. One, some, or all responses may be correct. A. Individual and mass screening activities B. Education about adequate housing and recreation C. Education about attention to personality development D. Instructions about good standard of nutrition adjusted to developmental phases of life E. Providing hospital and community facilities for retraining and education to maximize use of remaining capacities

A. Toileting the client every 2 hours

Which approach would the nurse take for an older adult client who is confused, does not recognize family members, and often soils clothing with feces and urine? A. Toileting the client every 2 hours B. Placing the client in orientation therapy C. Supervising the client's bathroom activities closely D. Explaining to the client how offensive the behavior is to others

D. Increased carbon dioxide level

Which arterial blood gas finding would be expected in a child with an acute asthma exacerbation? A. High oxygen level B. Increased alkalinity C. Decreased bicarbonate D. Increased carbon dioxide level

C. Current behavior, appearance, cognitive function, affect, and orientaion

Which assessments are priority for a disturbed client who is brought to the emergency department by the police? A. Recollection of past events and events preceding police involvement B. Previous history of incarceration or hospitalization for psychiatric disorders C. Current behavior, appearance, cognitive function, affect, and orientation D. Cultural background, family history, developmental level, and verbal skills

A. The child is unable to feed themself B. The child is unable to climb the stairs

Which behavior of a 3-year-old child indicates delayed development? Select all that apply. One, some, or all responses may be correct. A. The child is unable to feed themself B. The child is unable to climb the stairs C. The child is unable to name the colors D. The child is unable to count when asked E. The child is unable to tie their shoes

B. Has multiple fainting episodes due to lack of proper nutrition

Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs? A. Feels like is leading a worthless life B. Has multiple fainting episodes due to lack of proper nutrition C. Shows signs of lack of interest in carrying out social interaction D. Conveys to the nurse that is estranged from all family members

B. Client B

Which client would the nurse care for first based on vital signs? A. Patient A -- respirations: 16 breaths per minute blood pressure: 128/62 mm Hg B. Patient B -- respirations: 28 breaths per minute spO2: 70% C. Patient C -- respirations: 14 breaths per minute blood pressure: 140/86 mm Hg D. Patient D -- 20 breaths per minute spO2: 90%

A. Restlessness C. Short attention span D. Disordered reasoning E. Impaired motor activities

Which clinical manifestation is expected for a client with moderate dementia? Select all that apply. One, some, or all responses may be correct. A. Restlessness B. Pessimism C. Short attention span D. Disordered reasoning E. Impaired motor activities

A. A trended urinary output of at least 30mL/h

Which clinical manifestation would the nurse associate with successful fluid replacement therapy? A. A trended urinary output of at least 30mL/h B. Central venous pressure reading of 1.5 mm Hg C. Baseline pulse rate of 120 beats per minute decreasing to 110 beats per minute within a 15-minute period D. Baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period

D. Exploring a newfound ability for limited abstract thoughts

Which cognitive development is seen in early adolescence? A. Having established abstract thoughts B. Developing capacity for abstract thinking C. Exploring the ability to attract opposite sex D. Exploring a newfound ability for limited abstract thoughts

B. Sequence of steps used to meet the client's needs

Which definition is correct to explain the nursing process? A. Procedures used to implement client care B. Sequence of steps used to meet the client's needs C. Activities employed to identify a client's problem D. Mechanisms applied to determine nursing goals for the client

D. Delegation refers to process for the nurse to direct another person to perform nursing tasks and activities

Which definition of delegation given by the nurse is correct? A. Delegation refers to activities undertaken by a group of people who have common interests B. Delegation refers to transfer of both accountability and task responsibility from one person to another C. Delegation refers to an organized and innovative plan that helps an organization achieve its objectives D. Delegation refers to process for the nurse to direct another person to perform nursing tasks and activities

B. Uses six- and eight- word sentences E. Has a vocabulary of 1000 words

Which developmental language milestone would the nurse expect in a 4-year-old child? Select all that apply. One, some, or all responses may be correct. A. Uses appropriate grammar B. Uses six- and eight- word sentences C. Pronounces the sounds "ch" and "th" D. Asks about the meanings of new words E. Has a vocabulary of 1000 words

D. The nurse identifies the client is not aware of perineal care and has impaired skin integrity

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

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

Which feature distinguishes nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct. A. Nursing diagnoses involve the client when possible B. Nursing diagnoses are based on results of diagnostic tests and procedures C. Nursing diagnoses are the identification of a disease condition in the client D. Nursing diagnoses involve clinical judgment about the client's response to health problems

D. Personal motivation E. Previous health care experience

Which health care factor creates barriers that prevents older adults from participating in health care promotion and disease prevention? Select all that apply. One, some, or all responses may be correct. A. Finance B. Activity level C. Transportation D. Personal motivation E. Previous health care experience

A. Assess the client for pain before teaching C. Ensure that the client is not preoccupied or anxious D. Explain one concept at a time based on the client's interest

Which intervention would the nurse implement when providing health education to an elderly client? Select all that apply. One, some, or all responses may be correct. A. Assess the client for pain before teaching B. Take notes while taking to the client C. Ensure that the client is not preoccupied or anxious D. Explain one concept at a time based on the client's interest E. Teach a family caregiver if the client does not respond quickly

A. Peer pressure

Which is a primary contributing factor for the risk-taking behavior for school-aged children? A. Peer pressure B. Cognitive ability C. Chronological age D. Developmental stage

A. Sundowning D. Exaggeration of premorbid traits

Which manifestations are associated with moderate dementia? Select all that apply. One, some, or all responses may be correct. A. Sundowning B. Hypervigilance C. Increased inhibition D. Exaggeration of premorbid traits E. Inability to recognize family members

B. "The ambulance brought me to the emergency department"

Which response would best reflect that the anxious client's cognitive abilities have been affected by anxiety when asked, "What brought you to the emergency department tonight"? A. "It's obvious why I came to the emergency department" B. "The ambulance brought me to the emergency department" C. "Why do you want to know why I came to the emergency department?" D. "What do you mean by 'What brought you to the emergency department'?"

C. "I hardly speak to my children because they live in different countries"

Which statement made by the client illustrates the love and belonging need based on Maslow's hierarchy of needs? A. "I do not like the way I look, speak, or act" B. "I dream of becoming the richest person in the world" C. "I hardly speak to my children because they live in different countries" D. "I want to go back home because I am afraid of the tests you are performing"

A. Planning

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? A. Planning B. Evaluation C. Assessment D. Implementation