Nursing Fundamentals

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?

Client's wife

A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the MOST appropriate response by the nurse?

"Tell me more about how it feels to eat with your family."

A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she does not want to take the test and feels she should instead continue with the medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you are feeling."

A nurse visits a female victim of sexual assault for the fourth visit. The client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?

"Tell me more about the aspects that make you feel as if it happened yesterday."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply?

"The physician wants to monitor you and control your pain."

A nurse is examining a 3-year-old child with conjunctivitis. During the examination, the child starts crying and refuses to sit still. Which statement is appropriate for the nurse to tell the child?

"Would you like to see my flashlight?"

A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?

"You said that you do not smoke, but you have an open package of cigarettes in your pocket."

A nurse is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate to delegate to the LPN/LVN? (Select all that apply.)

1. Administer oral asprin and lisinopril to the client with hypertension 2. Insert a nasogastric tube in a client with absent bowel sounds 3. Reinforce a post-surgical abdominal dressing

A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions made by the nurse will promote the development of a therapeutic relationship? (Select all that apply.)

1. Asking the client when the client would like to have the bed linens changed 2. Encouraging the client to talk about the client's life

Nursing students are discussing the American Nursing Association (ANA) Nursing's Social Policy Statement. Which actions made by the nurse demonstrate proper understanding of the ANA Nursing's Social Policy Statement? (Select all that apply.)

1. Developing interventions based on client-desired outcomes 2. Caring for clients AND their families 3. Monitering client responses to interventions 4. Coordinating client care

A nurse needs to complete and assessment and vital signs on a client who has Alzheimer's disease. How should the nurse approach this client to gain cooperation? (Select all that apply)

1. Smile and maintain eye contact 2. Use the client's name 3. Approach the client from the front

The novice nurse demonstrates proper understanding of collaborative problems by making which statement?

A medical diagnosis of heart failure with the possible consequences of fluid in the lungs could lead to the collaborative problems of pulmonary edema

A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)?

Administering bedside blood glucose testing

A nurse is conducting an interview of a 40-year-old client who is admitted with chest pain. Which action by the nurse indicates active listening?

Asking for clarifications and repetitions

The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action?

Asking the client whether the client has cultural preferences

The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment?

Asking the client, "How are you today? I am really worried about you."

Which scenario represents a nurse demonstrating the critical thinking process?

Assessing whether physician help is needed

A client is brought to the emergency department with a head injury following an all-terrain vehicle (ATV) accident. The nurse asks the family members to describe how the accident occurred. The nurse is implementing which type of skill?

Assessment skills

A client reports to the emergency department with ankle pain due to a minor road accident. By asking the client to describe the accident, which type of nursing skill is the nurse using?

Assessment skills

In a nursing unit, the RN delegates nursing tasks to the LPN. Keeping in mind the delegation guidelines, which statement denotes the right task for the LPN?

Assist clients with nasogastric tube feeds

A nurse is asking a client health-related questions during a medical assessment. The client has developed lesions on the skin and warts around the mouth. Which factor affects oral communication?

Attention and concentration

A student wants to join a nursing program that provides flexibility in working at both staff and managerial positions. Which nursing program should the nurse suggest for this student?

Baccalaureate nursing programs

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know you're anxious, but removal will be painless and the IV location needs to be changed."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

Client himself

A male client who is recovering in the hospital from complications of total hip arthroplasty has orders for 5 to 10 mg of oxycodone as needed that can be administered q4h. In previous days, the client claimed relief with 5-mg doses but for the past 24 hours he has requested 10-mg doses. What is the most likely explanation for this phenomenon?

Client is developing a tolerance to the drug

What source of assessment data would the nurse expect to utilize when obtaining a review of systems (ROS)?

Client reports shooting pain up the left leg

One of the nursing achievements in the Crimean War was that the death rate of soldiers dropped from 60% to 1%. What is the MOST appropriate reason for the fall in the death rate?

decreased rate of infection and gangrene

A team of nurses who provide care in a community hospital have been encouraged to participate in continuing educational activities. Why is continuing education needed in nursing?

Continuing education has the potential to partially alleviate the nursing shortage

Beginning with Florence Nightingale, many definitions of nursing have been put forth by individual nurses and by nursing organizations. Which statement best describes an aspect of the changes in these definitions over time?

Definition of an independent health care practice that is not solely dependent on physicians

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action should the nurse perform before revising a plan of care?

Discuss any lack of progress with the client

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?

Disturbed body image related to the incision scar

A client is admitted to a psychiatric treatment unit with psychosis. What is the highest priority diagnosis for this client?

Disturbed thought process in client

A nurse at a health care facility provides information, assistance, and encouragement to clients during the various phases of nursing care. In which activity does the nurse use counseling skills?

Educating a group of young girls about AIDS

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy

A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?

Encourage family discussions of feelings

The nurse is studying nursing models for a Baccalaureate course. Which action made by the nurse exemplifies proper application of the Adaptation model?

Helping the client adjust to blood sugar testing every morning

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch her breath. What appropriate nursing diagnosis should the nurse document?

Impaired Verbal Communication related to the breathing problem

A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which nursing diagnosis is the highest priority for this client?

Impaired comfort

A group of students are studying modern day nursing practices. What is the theme that enhanced the practice of nursing in the 21st century?

Improved treatment of women

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?

Nausea

A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse has liaised with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?

Nurse as collaborator

A nurse who has been practicing for three decades has seen significant changes in the roles that clients are expected to perform in the course of their care. What is a role that clients are normally expected to perform while they are receiving care?

Participate actively in the planning and execution of their care

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment?

Perform an initial history specific to substance use

A nurse has completed a hospital-based educational program that has allowed the nurse to become cross-trained. A nurse who is cross-trained is able to:

Perform certain non-nursing duties in addition to traditional nursing duties.

A nurse is caring for a client with Parkinson's disease. Which nursing diagnosis identified by the nurse should be of the highest priority?

Potential for injury

The scope and character of nursing practice underwent significant changes in the years following the Civil War. Which activity exemplifies nursing practice in the early years of the 20th century?

Providing basic health care to recent immigrants to the United States

A nursing student has begun a clinical placement at a large hospital that serves a diverse population. The student has consequently acquired a new appreciation for the fact that nursing combines art with science. What is the clearest manifestation of the scientific basis for nursing?

Providing evidence-based nursing care

A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming words and his tone is nasal. Which communication strategy is an effective one for this client?

Repeat what the client has said to verify the meaning

When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which action is a priority role of the nurse when caring for a client with collaborative problems?

Reporting trends that suggest development of complications

The registered nurse (RN) is delegating the task of assisting a post-operative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions, and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed, and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline was omitted by the nurse?

Right circumstance

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be of the highest priority, keeping in mind the client's condition?

Risk for infection

A medical-surgical unit manager intends Licensed Practical Nurses (LPNs) in the unit to administer intravenous push (IVP) medications. What source would the manager contact to include this procedure in the LPNs' practice?

State Nurse Practice Act (NPA)

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

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

A nurse and an older adult client with chronic back pain are in the working phase of the nurse-client relationship. Which activity occurs in the working phase?

The nurse tries to avoid hampering the client's independence

A nursing student is conducting a client interview in order to determine the client's health history. The student's instructor observes that the student frequently twists her hair with her fingers while asking the client questions. What is the most plausible meaning of the student's nonverbal communication?

The student feels insecure during the interview

A nurse is working with an adult client who has been admitted with hyperglycemia following a period of poor glycemic control. The nurse has many similarities to the client with regard to age, gender, and socioeconomic status but is careful to utilize therapeutic communication techniques rather than social communication. How does therapeutic communication differ from social communication?

Therapeutic communication is focused on a particular goal while social communication is more superficial in content

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

To ambulate the client to a bedside chair

Training schools for nurses were established in the United States after the Civil War. The standards of U.S. schools deviated from those of the Nightingale paradigm. Which statement is true about U.S. training schools?

Training schools eliminated the need to pay employees