PrepU - Foundations - all chapters

A nurse observes another nurse place an unused dose of narcotics in their pocket. If caught, the nurse could be charged with which type of crime?

Felony

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met?

Grab bars are installed in a client bathroom to facilitate safe showering.

A client who was admitted to a drug treatment centre 3 days ago is boasting to the other residents that he used drugs for 2 years, and that his former employer never suspected that he was using drugs. Which action, if taken by the nurse, would be most appropriate for this client?

Have the client assume responsibility for the cleanliness of the dayroom.

The nurse is assessing a family parented by a 60-year-old grandmother and her three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families?

Increased financial concerns

A young couple who have been married less than a year are having difficulty with adjusting to parenting. What is a contributing factor to this level of maladjustment?

Limited time in learning to be a marital partner

A home healthcare nurse is performing a home visit to a 58-year-old man and his 56-year-old wife who receives home chemotherapy as part of her treatment regimen for breast cancer. The nurse will recognize that this family is likely to be engaged in which of the following development tasks?

Maintaining ties with older and younger generations

A nurse is caring for a 78-year-old male patient who has been hospitalized following a stroke. Which nursing action has the highest priority for this patient?

Measuring the patient's I&O during recovery

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher.

The home health nurse is making an initial assessment visit to a family that consists of two parents and twin 3-year-old boys. During the interview, the nurse is most concerned if the client makes which statement?

The father states, "I don't discuss money matters with my wife because I don't want her to worry."

The health care facility is involved in litigation by four clients. When reviewing the cases, which legal case would the nurse attorney identify to best describe malpractice?

The nurse administers amoxicillin (Amicar) to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.

Which action by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs?

The nurse arranges for the client's clergy to visit after visiting hours.

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse ensures that the client's family signs the consent form.

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What are examples of legal safeguards for the nurse? Select all that apply.

The nurse obtains informed consent from a client to perform a procedure. The nurse educates the client about The Patient Care Partnership. The nurse documents all client care in a timely manner.

The nurse is implementing care for several clients. Which of the following clients is the nurse helping to reach the highest level of Maslow's hierarchy of basic human needs?

The nurse provides privacy for the client and family during times of prayer.

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action?

Wash her hands before and after the dressing change.

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave her current position on a medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which of the following processes of credentialing?

certification

A nurse fails to administer a medication that prevents seizures, and the client has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of?

civil

The nurse receives a client assignment. Which client should the nurse see first?

client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

A community is defined as a social group that may or may not share common geographic boundaries yet interact because of

common interests

The home health nurse is making an initial visit to a client's home. During the visit she observes the mother cooking dinner, the father watching television with a child on his lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following?

extended family

The nurse is assessing the family structure of the client. The family household is comprised of two parents, three children, and one grandparent. The nurse recognizes that this is a(n):

extended family

In caring for a patient, the nurse recognizes which of the following as the primary educational and support structure for an individual?

family members

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies?

healthcare institution

A nurse has the Petty Family as a client, who consists of a wife, husband, and their 4-year-old daughter. The husband has been unemployed for 8 months, and they lost their apartment. The family has been staying in neighborhood shelters and, on occasion, with the husband's father for a night or two. When evaluating this family, the nurse identifies this family as which type?

homeless family

An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed?

invasion of privacy

The student nurse tells her family about a client with AIDS that she cared for in clinical yesterday. Which tort has the student committed?

invasion of privacy

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:

invasion of privacy

Patient care dealing with nutrition and metabolism should include which factors? Select all that apply.

knowledge about the value of the food pyramid understanding food preferences of clients from the Jewish community information on the client's financial status related to meal provisions ability of the client to prepare food at home

The client being admitted to the oncology unit conveys his wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in his best interest to obtain which document?

living will

While caring for an infant, the nurse hears another child screaming in the next room. She rushes to the other room to check on the screaming child, forgetting to put the side rails up on the infant's crib. She returns to the room to find the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for?

malpractice

A family that consists of two homosexual parents and three children living in the same house is an example of which type of family?

nuclear

There are four common concepts in nursing theory. While all concepts are important, the focus of nursing is always on which of the following?

person

The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which of the following is an individual need?

safety

The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs?

safety; security

A nurse is overheard in the hospital cafeteria making false comments about a client. The nurse is guilty of:

slander

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged?

slander

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?

socialization

The community environment affects the well-being of the individual and the family. Which of the following is the health responsibility of the family?

to maintain a healthy lifestyle

The nurse educator is presenting an in-service on nursing and malpractice. Which statements, made by the nursing staff, would indicate to the educator that further teaching is required? Select all that apply.

• "If I make a mistake, I will not tell anyone" • "I will have the supervisor fill out the incident report when I make an error."

The nurse recognizes that many factors place the family at increased risk for altered health. Which items represent lifestyle risk factors for altered family health? Select all that apply.

• Ingestion of high fat foods • Smoking by parents • Inadequate dental hygiene

A nurse is planning education on self-administration of insulin to the client and his family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be?

"Family members are equally involved in planning and implementation of care."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" What is the most appropriate response made by the nurse?

"Take it with you. It is recognized universally in the United States."

The nurse is admitting a 38-year-old male client to the oncology unit whose religious background is different from her own. The nurse is assessing how the client's religion may affect his health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care?

"What can we do to help you meet any religious needs you may have?"

While teaching about advance care planning, which fact is important for the nurse to share with a client who has been diagnosed with a terminal illness?

A durable power of attorney for health care appoints an agent the person trusts to make decisions.

Once physiologic needs are met, nurses can concentrate on meeting self-actualization needs of patients. What are examples of self- actualization needs according to Maslow's hierarchy of needs? (Select all that apply.)

A nurse attains a master's degree in nursing by going to school in the evening. A student nurse takes a course in communication to improve her ability to relate to patients. A nurse subscribes to several nursing journals to stay abreast of developments in the

A home health nurse is visiting the Goldstein family after the recent death of their matriarch. She observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. She asks Mr. Goldstein's cousin what is happening, and he says, "We are Jewish, and the family is 'Sitting Shiva' for my aunt." This family is fulfilling which family function?

Affective and coping functions

The nurse is reviewing the health care records of several families from the Health care clinic. Which family does the nurse identify as being at risk for factors affecting their health? Select all that apply.

Family is vegan Family uses herbal medicine Family fasts for religious purposes Family receives public assistance Family is headed by a single mother

The nurse in the adolescent in-patient psychiatric unit is interviewing the family of a 16-year-old client admitted for depression and threatened suicide. What assessment information is most essential for the nurse in determining the affective and coping function of the family?

Family patterns of communication

The nursing faculty is lecturing on unintentional and intentional torts. The faculty asks a nursing student to provide an example of an unintentional tort. Which example, if provided by the student, would indicate the student has a clear understanding of torts?

A nurse gives a medication and client has an adverse reaction.

Which of the following is an example of certification?

A nurse who demonstrates advanced expertise in a content area of nursing through special testing.

An adolescent confides in the school nurse that she is arguing daily with her mother, and she often wonders if her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health?

A psychosocial risk factor

Which process evaluates and recognizes educational programs as having met certain standards?

Accreditation

Nursing, as a profession, has long held the belief that providing nursing care to an individual patient means providing nursing care to the entire family. What does this mean when put into a holistic framework of patient care?

Active participation by individuals and families in health promotion is integral to this framework of patient care.

A nurse is caring for a client diagnosed with pancreatitis. Which of the following is a priority need for nursing management?

Acute pain in the abdomen

You are the nurse caring for a patient newly diagnosed with diabetes and you are developing a holistic plan of care. You know that for this plan of care to be successful it must what?

Address the disease but also incorporate the mind, body, and spirit.

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include?

Adjustment to retirement

In conjunction with the client, the nurse has set the following client outcomes. Which client outcome reflects Maslow's level of self-esteem needs?

The client will verbalize feelings of increased confidence in performing a finger-stick blood sugar.

A client informs the nurse that he is leaving the health care facility because he is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval.

A client admitted to a mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which of the following?

Battery

A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. When discussing the nurse's action, the charge nurse appropriately identifies which wrongdoing the nurse has violated?

Battery

A nursing student's parents are both physicians. The nursing instructor may feel the student has

Been socialized in healthcare

A home health care nurse who works in a low- income community assesses the risk factors for patients being serviced. What is an example of a community risk factor?

Children are kept inside the home on a sunny summer day because of lack of recreational opportunities.

The parents of a blended family have a baby boy age six months who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which of the following factors is the primary influence on this aspect of the family's health?

Community health care structure

You are the community-based nurse who acts as case-manager for a small town about 60 miles from a major health care centre. What is the most important factor of community-based nursing for you be knowledgeable about?

Community resources available to patients.

The charge nurse is assigning client care for the upcoming shift. Which is the priority evaluation when performing this task?

Determine the level and intensity of client care needed according to physical and psychosocial factors.

The nurse has developed a strong therapeutic partnership with a 44-year-old electrician who suffered severe burns while working on an industrial site. Which of the nurse's following actions most directly addresses the patient's self-actualization needs?

Discussing the patient's strengths and dialoguing with him about his body image

A client states that his recent fall was caused by the fact that his scheduled antihypertensive medications were mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident.

The nurse is concerned about a potential malpractice or negligence lawsuit regarding a client that was cared for on the unit. What specific elements must be established to prove that malpractice or negligence has occurred in this client? (Select all that apply.)

Duty Breach of duty Causation Damages

Which of the following theorists supports the developmental framework of family assessment?

Duvall

According to Archer, what are the three general types of communities?

Emotional, structural, and functional

A client newly diagnosed with congestive heart failure has a prescription for digoxin (Lanoxin). The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care?

Nurse withheld the medication and notified the health care practitioner

Injuries related to lifting or transferring patients occur in the health care setting and may be considered a work-related injury. Which law was intended to reduce work-related injuries and illnesses?

Occupational Safety and Health Act of 1970

The nurse is caring for an 85-year-old, female client hospitalized for dehydration. The nurse notices that the patient is shivering and takes the client's temperature. She notes an oral temperature of 97.8°:F (36.6°:C). The client also says that she is "chilly." What action, if taken by the nurse, is most appropriate?

Offer the client an extra blanket.

Which intervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow's Hierarchy of Needs?

Providing the mother the phone number for the Poison Control Center

The nurse is taking care of a female client who is scheduled for a mastectomy. The client tells the nurse that she is apprehensive about the operation and asks the nurse to read a passage from the Koran to help her prepare herself for surgery. Which action by the nurse is the most appropriate?

Read the Koran passage to the client.

During the admission assessment of a female client age 40 years with a suspected mandibular fracture, the client discloses to the nurse that her injury came as a result of her husband hitting her. Which action should the nurse prioritize when responding to this disclosure?

Reporting the abuse to the appropriate authorities

The nurse is assigned to take care of a client with rheumatoid arthritis. She notices that the client is wearing a copper bracelet. When she asks him about the bracelet, he says, "I believe that the bracelet will relieve the arthritis pain in my hands." Which action by the nurse is the most appropriate?

Respect the client's beliefs associated with the copper bracelet and allow him to wear it.

When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery?

The elderly client refuses the intramuscular injection, but the staff nurse administered it.

A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?

Self-esteem needs

The community health nurse working at the local church is developing a program to address the issue of diabetic management. The nurse recognizes what church activity could adversely affect the health of the diabetic parishioners?

Serving doughnuts, fruit juice, and coffee after church services on Sunday

A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for patients in this developmental stage?

Setting up parenting classes

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?

Sociocultural dimension

A couple with adolescent children is most likely to focus on which of the following developmental tasks?

Strengthening marital relationships

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the atenolol to 12.5 mg. However, since the physician is late for another visit, she requests that the nurse write down the order for her. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

Place the following nursing interventions in order of priority according to Maslow's hierarchy of basic needs.

The nurse teaches the client about foods high in fiber. The nurse teaches the daughter how to administer the client's insulin. The nurse assists the client in making a phone call to the client's daughter. The nurse positions the bed of the Muslim client who is bedfast toward Mecca.

After reporting to work for a night shift, the nurse learns that the unit will be understaffed because two RNs called out sick. As a result, each nurse on the unit will need to provide care for an additional four acute clients, in addition to her regular client assignment. Which statement is true for this nurse when working in understaffed circumstances?

The nurse will be legally held to the same standards of care as when staffing levels are normal.

Two nurses meet at their home, where one of the nurses discusses a client who had been physically abused. The next day, the client is shifted to another nursing unit after a surgical procedure and becomes the care of the second nurse who had been part of the original discussion. Nurse No. 2 asks the client about the physical abuse. The client discovers that his original nurse revealed the information and is hurt. What would be the charges if the client files a suit?

The nurses could be charged for slander.

A family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which of the following aspects of the family's structure and function would be considered a psychosocial risk factor?

The parents have a tumultuous relationship with frequent separations in the past.

Which of the following statements is true regarding Friedman's theory of family-centered nursing care?

The role of the family is essential in every level of nursing care.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure activity. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

To evaluate quality care and potential risks for injury to the client

A 44-year-old female client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which of the following values?

Urine output of 1500 ml in 24 hours

Which are stressors that affect the health of the family?

Well-funded school systems and inadequate childcare services

Nurses are occasionally asked to witness a testator's (person who makes the will) signing of his or her will. Which of the following guidelines is true regarding a nurse's role is witnessing a testator's signature?

Witnesses to a signature do not need to read the will.

Which client requires priority intervention when providing care on a medical-surgical unit?

a postsurgical client who is feeling dizzy with a heart rate of 45/bpm

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's daughter to direct his care, is a(an):

advance directive

An RN is working on a medical surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action?

asking the LPN/LVN to teach a new diabetic client how to administer insulin

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

battery

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?

breach of duty