back of the book question exam 2

The caregiver for a patient who is immobile and requires tube feedings asks the nurse to explain respite care. How does the nurse best explain this type of care? A. "It's a type of service that allows time away for caregivers." B. "It provides comfort and end-of-life services for the terminally ill and their families." C. "It is skilled care provided to older adults in a long-term care facility." D. "It provides living units available to people without regular shelter."

a. Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

During a meeting with nurses at all levels in an acute care hospital, the Director of Nursing discusses lost revenue due to Medicare penalties. The nurses plan improvements in practice designed to prevent penalties from which events? Select all that apply. A. Urinary catheter-related infections B. Blood infections from central venous catheters C. Excessive readmissions D. Pressure injuries E. High blood pressure

a, b, c, d. Medicare penalties are given to hospitals when patients are readmitted soon after discharge; this is designed to ensure patients receive needed coordinated care after discharge. In addition, Medicare no longer reimburses hospitals for conditions that result from preventable errors and lead to increased costs. These include pressure injuries, injuries caused by falls, infections associated with indwelling urinary catheters, vascular catheter-associated infections, infections of the mediastinum after coronary artery bypass graft, air embolisms, adverse reactions to incompatible blood infusions, and retained sponges or instruments during surgery.

A nurse is teaching parents about expected developmental aspects of sexuality in children. Which statements from parents indicate further teaching is needed? Select all that apply. A. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." B. "I should wean my infant by 4 months and encourage him to use a sippy cup." C. "I should explain sexuality to my 9-year-old in a factual manner when they ask questions about their body." D. "I should explain about body changes to my 11-year-old prior to them happening to alleviate their fears." E. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." F. "I should allow my teenager to establish their own beliefs and moral value system rather than sharing my own beliefs."

a, b, c, e, f. Self-manipulation of genitals is a normal behavior; parents should avoid telling a child this as "bad." Parents should avoid early weaning of infants to prevent oral deprivation. Parents should explain contraception and STIs to their adolescent children; it would be premature to do so for a 10-year-old. Parents should share their beliefs and moral system with their children. Parents should also give their children the desired information about sexuality in a clear, factual form and give them information about body changes before they experience them, to alleviate fears.

Nurses in the emergency department (ED) have received education on identification of victims of human trafficking. Which patients would the ED nurse identify may be at risk? Select all that apply. A. Those who work in hotels, nail salons, or home-cleaning services B. Those who perform agricultural or ranch work C. Those who show evidence of being controlled physically or psychologically D. Those accompanied by someone who encourages them to share their own information E. Those who produce identification documents (ID or passport) F. Those who show the loss of the sense of time or space or not do know what city or state they are in

a, b, c, e, f. Victims of human trafficking can be any age. The nurse observes for those engaging in sex work, agricultural, or ranch work; working in hotels, massage parlors, nail salons, or home-cleaning services; performing domestic labor (cleaning, childcare, eldercare, etc.); working in restaurants, bars, or cantinas; and begging, street peddling, or door-to-door sales. Victims of human trafficking may exhibit evidence of being controlled either physically or psychologically, an inability to leave home or their place of work, or an inability to speak for themselves or share their own information. Information is provided by someone accompanying the individual, and they do not have control of their own identification documents (ID or passport). They have few or no personal possessions, may owe a large debt that they are unable to pay off, and may demonstrate loss of sense of time or whereabouts.

A nurse is providing health care for patients in a clinic located in a predominately LGBTQIA+ community. Which health disparities should the nurse keep in mind when planning care for this population? Select all that apply. A. LGBTQIA+ youth are more likely to attempt suicide. B. LGBTQIA+ youth are more likely to be homeless. C. Lesbians are less likely to get preventive services for cancer. D. Lesbians and bisexual females are more likely to be underweight. E. Transgender people have a high prevalence of HIV and sexually transmitted infections. F. LGBTQIA+ populations have low rates of tobacco, alcohol, and other drug use.

a, b, c, e. LGBTQIA+ youth are two to three times more likely to attempt suicide and be homeless. Lesbians are less likely to get preventive services for cancer. Transgender people have a high prevalence of HIV and sexually transmitted infections. LGBTQIA+ youth are two to three times more likely to attempt suicide. Lesbians and bisexual females are more likely to be overweight or obese. LGBTQIA+ populations have the highest rates of tobacco, alcohol, and other drug use in the country. These health issues are partly thought to be the effects of chronic stress resulting from stigmatization

A nurse working in a gynecology practice screens patients for menstrual irregularities. Which patients would a nurse identify are at risk for menstrual cycle irregularities? Select all that apply. A. Breastfeeding mother B. Adolescent with anorexia C. Individual abstaining from sexual intercourse D. Patient diagnosed with pelvic inflammatory disease E. Patient obsessed with exercising F. Patient with a spinal cord injury

a, b, d, e. Causes of menstrual cycle irregularities include pregnancy or breastfeeding, eating disorders, extreme weight loss, excessive exercising, and pelvic inflammatory disease, as well as many other causes. Abstaining from sex and spinal cord injuries are not causes of menstrual irregularities.

A nurse is caring for patients in a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of these patients? Select all that apply. A. Asking a Buddhist if they have any diet restrictions related to the observance of holy days B. Asking a Christian Scientist who is in traction if they would like to try nonpharmacologic pain measures C. Administering medications to a Muslim patient and avoiding touching the patient's lips D. Asking a Roman Catholic patient if they would like to attend Mass in the common room on Sunday E. Avoiding scheduling treatment and procedures on Saturday for a Hindu patient F. Consulting with the medicine man of a Native American patient and incorporating their suggestions into the care plan

a, b, d, f. The nurse should ask a Buddhist if they have any diet restrictions related to the observance of holy days. Since Christian Scientists avoid the use of pain medications, the nurse should offer nonpharmacologic pain relief measures. A nurse administering medications to a Hindu patient avoids touching the patient's lips. A nurse should ask a Roman Catholic if they would like to attend Mass on Sunday. The nurse is careful not to schedule treatment and procedures on Saturday for a Jewish patient who observes the Sabbath. The nurse would appropriately consult with the medicine man of a Native American patient and incorporate their suggestions into the care plan.

A discharge nurse is evaluating patients and their families to determine the need referrals to other facilities after hospitalization. Which patients will the nurse recommend for these services? Select all that apply. A. Older adult diagnosed with dementia in the hospital B. Adult diagnosed with Parkinson disease C. Adult woman receiving chemotherapy for breast cancer D. Adolescent being discharged with a cast on his leg E. New mother who delivered a healthy infant via a cesarean birth F. Adult man diagnosed with end-stage cancer

a, b, f. The patients who are most likely to need a formal discharge plan or referral to another facility are those who are emotionally or mentally unstable (e.g., those with dementia), those who have recently diagnosed chronic disease (e.g., Parkinson disease), and those who have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources.

A nurse on a surgical unit is concerned about a colleague's possible substance use disorder. Which signs and symptoms could support the nurse's suspicion? Select all that apply. A. Exhibiting diminished alertness and somnolence while working B. Attending multiple continuing education conferences C. Offering to medicate coworkers' patients for pain D. Making incorrect narcotics counts and creating wastage E. Leaving the unit frequently

a, c, d, e. Signs of substance use in nurses may include diminished alertness or somnolence, leaving the unit frequently, incorrect narcotic counts, wastage, offers to medicate colleagues' patients, or changes in job performance, among others. Attending professional conferences is an example of a nurse who is fully engaged with their work.

A nurse is considering moving from the hospital setting to home health care. In speaking with other professionals, what qualities does the nurse find they should possess to be successful? Select all that apply. A. Making accurate assessments B. Researching new treatments for chronic diseases C. Communicating effectively D. Delegating tasks appropriately E. Performing clinical skills effectively F. Making independent decisions

a, c, e, f. Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing.

A nurse researcher follows current trends in health care delivery. Which present-day trends does the nurse observe? Select all that apply. A. Globalization of the economy and society B. Slowdown in technology development C. Decreasing diversity D. Increasing complexity of patient care E. Changing demographics F. Shortages of key health care professionals and educators

a, d, e, f. Trends to watch in health care delivery include globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educators, technology explosion, and increasing diversity.

A nurse in a urology practice performs sexual health assessments of male older adults. Which patients would the nurse identify as having an increased risk for erectile dysfunction? Select all that apply. A. Patient with a history of diabetes B. Patient with a new partner C. Patient with Parkinson disease D. Patient with alcoholism E. Patient taking antihypertensive medication F. Patient who is a tobacco smoker

a, d, e. Risk factors for erectile dysfunction include history of diabetes, spinal cord trauma, cardiovascular disease, surgical procedure, alcoholism, and use of antihypertensives, antidepressants, or illicit drugs. Having a new partner may be a risk factor for premature ejaculation, and a history of Parkinson disease may predispose the patient to delayed ejaculation. Smoking is not a risk factor for impotence.

Nursing students learn advance practice nurses can write medication prescriptions. Which roles may be performed by an advanced practice registered nurse? Select all that apply. A. Primary care provider B. Hospitalist C. Physical therapist D. Anesthetist E. Midwife F. Pharmacist

a, d, e. The Advanced Practice Registered Nurse (APRN) is a registered nurse educated at the master's or post-master's level in a specific role and for a specific population. Whether they are nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives, APRNs play a pivotal role in the future of health care. APRNs are often primary care providers and are at the forefront of providing preventive care to the public. Hospitalists are health care providers who provide care to patients when they visit the emergency department or are admitted to the hospital. A physical therapist completes a specific training program to learn to help patients restore function or to prevent further disability in a patient after an injury or illness. A pharmacist, prepared at the doctoral level, is licensed to formulate and dispense medications.

At the last staff meeting, the nurse manager discussed the organizational initiative to improve provision of culturally competent care. During rounds, which behaviors inconsistent with this goal require the manager to intervene? Select all that apply. A. A staff nurse tells the AP that patients should not be given a choice, but should shower or bathe daily. B. A nurse asks the family of a patient who has died if they would like to wash their loved one's body. C. A nurse tells another nurse that Jewish dietary restrictions are just a way for them to get special foods. D. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E. A nurse obtains a translator to speak to the patient in their native language. F. A nurse refuses to care for a married gay patient who is HIV positive because the nurse is against same-sex marriage.

a, d. Cultural imposition occurs when someone believes others should conform to their beliefs, such as whether or not to shower or bathe daily, when a Catholic nurse insists that a terminally ill patient see a chaplain. Cultural blindness occurs when a nurse treats all patients the same regardless of culture. Culture conflict occurs when a nurse judges a patient's dietary restrictions as a way to get their favorite foods. When a nurse refuses to respect an older adult's ability to speak for themselves, or refuses to treat a patient based on their sexual orientation, stereotyping has occurred.

A nursing student is assisting with nursing care for patients in a primary care center. Based on the setting, what activities will the student expect to perform? A. Assisting with major surgery B. Performing health assessments C. Maintaining patients' function and independence D. Maintaining immunization records

b. Performing health assessments is a common role of the nurse in a primary care center. Assisting with major surgery is a role of the nurse in the hospital setting. Maintaining patients' function and independence is a role of the nurse in a rehabilitation or extended-care facility, and keeping student immunization records up to date is a role of the school nurse.

Nursing students approaching graduation and licensure are required to read the state nurse practice act. Which topics in the law will they identity as guides to professional practice? Select all that apply. A. Actions resulting in discipline B. Clinical procedures C. Medication administration D. Scope of practice E. Delegation policies F. Medicare reimbursement

a, d. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through federal legislation.

A nursing student is on clinical rotation in a long-term care facility. Which action best reflects the student acting as advocate? A. Telling the health care team that a patient clearly stated they do not want to be transported to the hospital B. Avoiding input in care conferences, as patient advocacy is primarily performed by the health care provider C. Assisting the primary nurse in making good health care decisions for patients and residents D. Deferring to whatever decisions patients and residents want

a. Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the very old, those who are seriously ill, and those with disabilities. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents; rather, they facilitate patient decision making. Advocacy does not entail supporting patients in all their preferences.

The nurse reports to their manager that informed consent was not obtained from a patient for whom HIV testing was already performed. The nurse suggests which intentional tort may have been committed? A. Assault B. Battery C. Invasion of privacy D. False imprisonment

a. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.

A nurse tells a patient, "tonight's menu selection is pork. I understand many people in your culture do not eat pork; may I order something else for you?" When the patient states they no longer observe this dietary practice, the nurse understands that the patient has experienced what transition? A. Cultural assimilation B. Cultural imposition C. Culture shock D. Ethnocentrism

a. Assimilation occurs when minority groups living within a dominant group lose the cultural characteristics that make them different. Cultural imposition occurs when one person believes that everyone should conform to their own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.

A nurse working in a primary care facility prepares insurance forms in which the provider is given a fixed monetary amount per enrollee in the health plan. What term do the nurses apply to this type of reimbursement? A. Capitation B. Prospective payment system C. Bundled payment D. Rate setting

a. Capitation plans give providers a fixed amount per enrollee in the health plan to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services.

Which elements are necessary to prove liability in a malpractice lawsuit? A. Client is injured B. Failure to conform to standards of care C. Injury caused by breach of duty D. Injuries must be visible and verified E. Nurse intended to cause harm F. Recognized relationship between client and nurse

a. Client is injured b. Failure to conform to standards of care c. Injury caused by breach of duty f. Recognized relationship between client and nurse

Which elements are essential in a clinician's duty to warn? A. Client makes threatening statements B. History of violence C. Potential victim(s) are identifiable D. Potential victim is easy to locate E. Threat is not a delusion F. Threat of harm is serious

a. Client makes threatening statements c. Potential victim(s) are identifiable f. Threat of harm is serious

A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? A. "HPV causes genital warts and cervical and other cancers." B. "HPV causes a single painless genital lesion and can lead to sterility." C. "Fifty percent of females between ages 14 and 19 years are infected with HPV." D. "The HPV vaccination is only recommended for the female population."

a. HPV causes genital warts and cervical and other cancers. It manifests as pale, soft, papillary lesions found around the internal and external genitalia, perianal and rectal areas of the body. One in four young females between ages 14 and 19 years is infected with at least one of the most common STIs, which include the human papillomavirus (HPV). The HPV vaccination is recommended for males and females.

A nurse on a medical-surgical unit is teaching a patient's family about hospice care. How does the nurse best explain the focus of this care? A. Hospice care focuses on symptom and pain relief. B. Nutrition is provided orally or by tube to maintain intake. C. Surgical procedures are performed when medically necessary. D. Services are provided until the patient's death.

a. Hospice services include pain management, physician and nurse practitioner services, spiritual support, respite services, and bereavement counseling.

A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services provided. What best describes managed care? A. System designed to control cost of care while maintaining quality B. Care coordination to maximize positive outcomes to contain costs C. Delivery of services from initial contact through ongoing care D. Based on a philosophy of ensuring death in comfort and dignity

a. Managed care is a way of providing care designed to control costs while maintaining the quality of care.

A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? A. "We're at the age when we should consider stopping sexual activity." B. "We need more time for sexual stimulation than we used to." C. "If we are unable to have sex, we can still have an intimate relationship." D. "If we change our position, we can still have sex and be more comfortable."

a. Sexual activity need not be hindered by age, and couples who have been consistently sexually active throughout their lives may continue their intimate relationship for as long as they desire. Nurses should teach couples that adaptation to bodily changes is possible with use of comfortable positions for intercourse and increased time for stimulation as well as teach alternatives to coitus, such as caressing, hugging, and stroking, when coitus is impossible because of illness or disability.

A patient who developed a pulmonary embolism (blood clot in the lung) after using oral contraceptives asks the nurse what she should do if she can no longer use "the pill." The nurse suggests which mechanical barrier for birth control? A. Diaphragm B. Transdermal contraceptive patch C. Depo-Provera D. Evra patch

a. The diaphragm is the only barrier method of contraception listed; all the other methods are hormonal.

As part of a clinical paper, a nursing student interviews a hospice nurse about their role. How will the student describe the type of care the nurse provides? A. Physical, psychological, social, and spiritual care for dying patients, their families, and loved ones B. Preventive, primary care, focusing on diabetes education, immunizations, and prenatal care C. Care focusing on rare diseases and specialty care D. Care to meet the patient's health care needs while giving a break to the patient's caregiver

a. The hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care caregivers of homebound ill, disabled, or older adults. Palliative care, which can be used in conjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted-living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages.

A nurse tells a new mother from Africa that she should not carry her infant in a sling because bassinets are safer. The charge nurse suggests the nurse is displaying which behavior? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

a. The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.

An attorney representing a patient's family who is suing for wrongful death calls the nurse to obtain a better understanding of the nurse's actions. How will the nurse respond? A. "I can't talk with you; you will have to contact my attorney." B. "I will answer your questions, so you'll understand how the situation occurred. C. "I hope I won't be blamed for the death because it was so busy that day." D. "First tell me why you are doing this to me. This could ruin my career!"

a. The nurse should not discuss the case with anyone at the facility (except the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for nurse defendants.

After terminating a pregnancy, a patient tells the nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." They then talk with their priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? A. Patient stated, "I wish I had talked with the priest sooner. I now know God has forgiven me, and my mother is beginning to understand." B. Patient has slept from 10 pm to 6 am for 3 consecutive nights without medication. C. Patient has developed mutually caring relationships with others. D. Patient has identified several spiritual beliefs that give purpose to their life.

a. The patient's statements indicate feelings of guilt, which has caused spiritual distress. Only option a clearly evaluates whether the patient's feelings of guilt have resolved after speaking to the priest.

A patient is being transferred from the intensive care unit (ICU) to a medical-surgical unit. What is the responsibility of the ICU nurse during the transfer of care? A. Providing a verbal report to the nurse on the new unit B. Giving a detailed written report to the unit secretary C. Delegating the responsibility for providing information D. Making a copy of the patient's medical record

a. The transferring (ICU) nurse gives a verbal report on the patient's condition and nursing care needs to the receiving nurse. This information should not be given to a unit secretary, nor can this be delegated to others. The medical record is transferred with the patient; a copy is not made for transfers within the agency.

A 17-year-old college student calls the emergency department (ED) and tells the nurse they were raped by a professor. They want to come to the ED, but only if the nurse promises their parents will not be contacted. What should be the nurse's first priority? A. Getting the patient into a safe environment and mobilizing support for them B. Encouraging the student to disclose the name of the professor C. Ensuring the student is assessed for pregnancy, STIs, and other complications D. Convincing the student to tell their parents to receive their support

a. While the remaining options may be indicated, the priority is to ensure the safety of the woman and to get her the support she needs at this moment.

A client has a prescription for haloperidol, 5 mg orally two times a day, as ordered by the physician. The client is suspicious and refuses to take the medication. The nurse says, "If you don't take this pill, I'll get an order to give you an injection." The nurse's statement is an example of A. assault. B. battery. C. malpractice. D. unintentional tort.

a. assault

The client who is involuntarily committed to an inpatient psychiatric unit loses which right? A. Right to freedom B. Right to refuse treatment C. Right to sign legal documents D. The client loses no rights

a. right to freedom

Which intervention is an example of primary prevention implemented by a public health nurse? A. Reporting suspected child abuse B. Monitoring compliance with medications for a client with schizophrenia C. Teaching effective problem-solving skills to high school students D. Helping a client apply for disability benefits

c. teaching effective problem-solving skills to high school students

When transferring a patient from the operating room to the medical-surgical unit, a nurse uses the SBAR format for handoff communication. Place the components of the SBAR communication (Situation, Background, Assessment, and Recommendations) in their proper order. A. This 20-year-old patient presented to the ER with right lower quadrant pain, fever, and an elevated WBC count. B. The patient is postlaparoscopic appendectomy. C. The patient may need pain medication in 30 minutes. D. The patient is sleepy, but responsive; five small bandages on the abdomen are clean and dry.

b, a, c, d. The SBAR communication for this patient should be: The patient is post laparoscopic appendectomy. This 20-year-old patient presented to the ER with right lower quadrant pain, fever, and an elevated WBC count. The patient may need pain medication in 30 minutes. The patient is sleepy, but responsive; there are five small bandages on the abdomen that are clean and dry.

Nursing students are discussing the care-based approach to ethical practice. What actions will the students ensure are included in the discussion? Select all that apply. A. Understanding that the needs of the many prevail versus the needs of the few B. Promoting the dignity and respect of patients as people C. Attending to the individual attributes of each patient D. Cultivating responsiveness to others and professional responsibility E. Understanding that moral skills include kindness, attentiveness, compassion, and reliability

b, c, d, e. A care-based approach, essential to thoughtful, person-centered care, directs attention to the specific patient situation, viewed within the context of their life narrative. The care-based approach includes the following characteristics: centrality of the caring relationship; promotion of patient dignity and respect; attention to patient particulars; cultivation of responsiveness to others; professional responsibility; and redefinition of fundamental moral skills like kindness, attentiveness, empathy, compassion, and reliability. An action is right or wrong based on a rule, independent of its consequences, such as "the needs of the many outweigh the needs of the few.

An 18-year-old presents at a women's health care clinic seeking oral contraceptives before having heterosexual intercourse for the first time. She tells the nurse she doesn't know what to expect. What accurate statements by the nurse would be helpful? Select all that apply. A. "During the excitement phase, your breasts swell and the nipples invert." B. "Lubrication of the vagina seeps outside of the body making stimulation more pleasurable by decreasing friction." C. "Your clitoris enlarges and emerges slightly from the clitoral hood." D. "The first obvious sign of arousal in your partner is an erection of the penis caused by increased blood flow." E. "The man's scrotum noticeably elevates, thickens, and enlarges." F. "The skin of the penis and scrotum become pale in color."

b, c, d, e. It is appropriate to provide education about sexuality and sexual responses. The nurse could teach that during the excitement phase, the female breasts swell and the nipples become erect and hard to the touch. Lubrication of the vagina seeps along the vulvar creases decreasing friction and making stimulation of the genitals more pleasurable. The upper two thirds of the vagina enlarge and expand. The clitoris enlarges and emerges slightly from the clitoral hood. The labia also enlarge and separate and turn a deep rosy-red with arousal. The first obvious sign of arousal in the male is an erection of the penis caused by increased pelvic congestion of blood. The scrotum noticeably elevates, thickens, and enlarges. The skin of the penis and scrotum turns a deep reddish purple in response to congestion and arousal. Male nipples may also harden and become erect. The nurse should also discuss contraception, preventing STIs, and the patient's right to say no if she chooses.

A nurse caring for patients in the intensive care unit develops values from their experiences when forming a personal code of ethics. Which statements correctly guide this process? Select all that apply. A. People are born with values. B. Values act as standards to guide behavior. C. Values are ranked on a continuum of importance. D. Values influence beliefs about health and illness. E. Value systems are not related to personal codes of conduct. F. Nurses should not let their values influence patient care.

b, c, d. A value is a belief about the worth of something, about what matters, that acts as a standard to guide our behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture.

An ambulatory care nurse serving a large, culturally diverse population is planning a free blood pressure screening clinic. Based on the nurse's understanding of racial differences in health and illness, which groups will the nurse target for screening? Select all that apply. A. Native American people B. African American people C. Alaska Native people D. Asian people E. White people F. Hispanic people

b, c, e. African American people, Asian people, and White people are more prone to developing hypertension. Alaska Native individuals and Native American individuals are prone to heart disease, diabetes, cirrhosis, and fetal alcohol syndrome.

A nurse answers a call light and finds the patient on the floor. After the health care provider examines the patient and finds no injury, the nurse returns the patient to bed and fills out an incident report. What statements are true about incident reports? Select all that apply. A. They can be used as disciplinary action against staff members. B. They can be used as a means of identifying risks. C. They can be used for quality control. D. They must be completed by the facility manager. E. They make facts available in litigation cases. F. They should be documented in the patient record.

b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

Nurses provide care to patients in secondary health care facilities. Which patients do the nurses anticipate will receive this type of care? Select all that apply. A. Patient seeking treatment at a community clinic for possible strep throat B. Patient treated in the hospital following a myocardial infarction C. Child brought to the emergency department following a seizure D. Individual with osteogenesis imperfecta being treated in a medical center E. Child visiting a specialist to correct a congenital heart defect F. Patient who has a hernia repair in an ambulatory care center

b, c, f. Secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care. Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations.

A patient with an advanced directive and do-not-resuscitate order is sobbing and reporting severe pain. The nurse contacts the provider, who refuses to increase the medication dose due to the patient's hypotension. What actions would the nurse take next? Select all that apply. A. Lodge a complaint with the state board of nursing B. Consult with the ethics committee C. Contact a different health care provider D. Speak with the nurse manager E. Request a palliative care consultation

b, d, e. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute due to institutional or other constraints (in this case, the nurse fears inability to collaborate with the provider). The nurse uses available resources such as seeking guidance from the nurse manager, attempting to secure a palliative care consult, and consulting the ethics committee. The state board of nursing does not regulate medical practice. The nurse does not circumvent the patient's health care provider.

A hospice nurse who provides pastoral care is teaching nursing students about the three spiritual needs believed to be common to all people. Which of these will the nurse include in the discussion? Select all that apply. A. Food, clothing, and shelter B. Meaning and purpose C. Family D. Love and relatedness E. Forgiveness F. Rules to live by

b, d, e. Meaning and purpose, love and relatedness, and forgiveness are the three spiritual needs believed to be common to all people. Option a is a human need as described by Maslow, as is family (love and belonging). Many people live by a set of rules, but this is not a common spiritual need.

A discharge nurse manager is preparing the plan for a patient returning home after receiving a kidney transplant. What actions will the nurse perform to ensure continuity of care? Select all that apply. A. Conduct an admission health assessment B. Evaluate the effectiveness of the current nursing care plan C. Participate in transferring the patient to the postoperative care unit D. Make referrals to appropriate facilities E. Maintain records of patient satisfaction with services received F. Assess the strengths and limitations of the patient and family

b, d, f. The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. The staff typically performs an admission health assessment and assists with patient transfers from the OR. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager.

A nurse who is working in a hospital setting uses value clarification to help patients understand the values that motivate patient behavior. What patient actions help the nurse determine if they demonstrate "prizing" during this process? Select all that apply. A. They stop smoking after a diagnosis of lung cancer. B. They show off a new outfit that after losing 20 lb. C. They choose to work fewer hours following a myocardial infarction. D. They adopt a low-cholesterol diet. E. They join a gym and schedule classes throughout the year. F. They proudly display a certificate for completing a marathon.

b, f. Prizing something you value involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, you choose freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joining a gym for the year and following a low-cholesterol diet faithfully.

A nurse who is comfortable with spirituality is caring for a patient who needs spiritual counseling. What action will the nurse take first? A. Calling the patient's own spiritual advisor B. Asking if the patient has a spiritual advisor they wish to consult C. Counseling the patient and, if unsuccessful, making a referral to a spiritual advisor D. Explaining the best health options for the patient to the spiritual advisor

b. Even when a nurse feels comfortable discussing spiritual concerns, they should always determine whether the patient has a spiritual advisor they would like to consult. Calling the patient's spiritual advisor may be premature if it is a matter the nurse can handle. The other two options deny the patient's right to speak privately with their spiritual advisor from the outset, if that is their preference.

During a checkup in a pediatric office, the mother of a school-aged boy tells the nurse that she is worried because she has occasionally found him masturbating. She asks the nurse how she should handle this "problem." How would the nurse best respond to this mother's concern? A. "Children should be taught not to masturbate because most people believe self-stimulation is wrong." B. "Masturbation is a means of learning what a person prefers sexually; overreacting can lead the child to believe sex is bad or dirty." C. "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." D. "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

b. Masturbation is a technique of sexual expression in which a person practices self-stimulation. It is a way for people to learn what they prefer during stimulation and what feels good. People masturbate regardless of sex, age, or marital status. Negative reaction or overreaction by parents to a child's masturbating can lead to a belief that the genitals and sex are bad or dirty, causing guilt or a feeling they are wrong. People may not masturbate due to guilt about it or believe self-stimulation is wrong. It is important to let patients know masturbation is not "dirty" and will not lead to blindness or insanity.

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish, and the nurse speaks only English. Which action should the nurse take next? A. Use short words and speak loudly B. Obtain a medical interpreter C. Explain why care cannot be provided D. Provide instructions in writing

b. Requesting an interpreter reflects best practice. Qualified interpreters, available in many facilities or via video or phone, have knowledge of health care and can provide assistance. Using short words, talking loudly, and providing instructions in writing will not aid communication. Explaining why care cannot be provided will not meet the patient's health needs; the nurse is required to provide care. Since the patient doesn't speak English, this will not be understood.

All are characteristics of ACT except which? A. Services are provided in the home or community. B. Services are provided by the client's case manager. C. There are no time limitations on ACT services. D. All necessary support systems are involved in ACT.

b. Services are provided by the client's case manager

A nursing student is preparing to administer medications and asks the clinical instructor about legal liability in clinical practice. What is the most appropriate response? A. "Students are not responsible for their acts of negligence resulting in patient injury." B. "Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse." C. "Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor." D. "Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary."

b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.

A nurse caring for patients in the city-run health clinic expresses a commitment to social justice. Working toward which action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honestly

b. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy.

A nurse is using the Explanatory Model of Health and Illness (ESFT) model to assess how a patient from another culture views their diagnosis of chronic obstructive pulmonary disease (COPD). What interview question is most appropriate to assess the E aspect of this model? A. How do you get your medications? B. How does having COPD affect your lifestyle? C. Are you concerned about the side effects of your medications? D. Can you describe how you will take your medications?

b. The ESFT model, a cross-cultural communication tool, guides providers in understanding a patient's explanatory model (a patient's conception of their illness), social and environmental factors, and fears and concerns and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.

At an interprofessional meeting, nurses discuss appropriate uses for an organizational ethics committee. Which referral do the nurses identify as appropriate? A. Giving input into policies affecting work life balance B. Providing interprofessional input on clinical care C. Determining if the patient's cultural beliefs are valid D. Advising the board of nursing on policy for licensure

b. The Joint Commission mandates that accredited facilities have a mechanism for addressing ethical problems. Health care institutions often have multidisciplinary ethics committees who provide case review and consultation and participate in education, policy making, quality, and (in some cases) research. Nurses contribute unique knowledge about the patient and family, interpret technical facts, identify appropriate decision makers, represent the patient's best interests, and help ensure the course of action is justified by sound ethical principles. Nurses play an important role in policy making, identifying needed policies to address ethical concerns or suggest needed modifications of existing policies. The human resource department focuses on employee policy; the health care team cannot judge or force a patient to reevaluate their cultural beliefs and observances.

A nurse working in a pediatric clinic provides codes for a patient's services to a third-party payer who pays all or most of the care. How does the nurse refer to this method of payment? A. Out-of-pocket payment B. Individual private insurance C. Employer-based group private insurance D. Government financing

b. The four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. The International Classification of Diseases, 10th Edition and procedure codes, or ICD-10, includes codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes. With individual private insurance, members pay monthly premiums either by themselves or in combination with employer payments. These plans are called third-party payers because the insurance company pays all or most of the cost of care. Out-of-pocket payment is paying for health care with cash payments. Employer-based private insurance is employer-sponsored coverage and government financing is provided through Medicare and Medicaid, and other federally funded programs.

A visiting nurse is performing the initial assessment and plan for a patient who receives Medicare and was recently discharged from the acute care hospital. Before implementing the plan of care, what follow-up is required by the nurse? A. Validating the patient's consent for care B. Obtaining the health care provider's signature and approval C. Determining how the patient will pay for services D. Ensuring that a family member or friend can assist with implementation

b. The nurse assesses the patient eligible for home services and presents the plan to the health care provider for approval. This approval the plan allows for provision of care and reimbursement of services.

A nurse is reviewing the discharge plan with a patient who had major abdominal surgery. Which statement by the nurse is most appropriate? A. "I'll bet you will be so glad to be home and sleep in your own bed." B. "Tell me about your understanding of your recovery needs after discharge." C. "Be sure to take your pain medications and change your dressing." D. "You will just be fine! Please stop worrying."

b. The purpose of discharge planning is to ensure for continuity of care for the patient and family needs. The nurse uses open-ended assessment questions to begin a planning session. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are examples of communication or interventions, which may be included after an assessment. The statement "You will just be fine! Please stop worrying." is a cliché and is avoided.

A hospitalized client is delusional, yelling, "The world is coming to an end. We must all run to safety!" When other clients complain that this client is loud and annoying, the nurse decides to put the client in seclusion. The client has made no threatening gestures or statements to anyone. The nurse's action is an example of A. assault. B. false imprisonment. C. malpractice. D. negligence.

b. false imprisonment

A home health nurse is scheduled to visit a patient recently discharged from the hospital with a new colostomy. During the entry phase of the home visit, what actions will the nurse perform? Select all that apply. A. Collect information about the patient's diagnosis, surgery, and treatments B. Call the patient to make initial contact and schedule a visit C. Develop rapport with the patient and their family D. Assess the patient to identify their needs E. Assess the physical environment of the home F. Evaluate safety issues including the neighborhood in which the patient lives

c, d, e. In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange for a visit, and assesses the patient's neighborhood for safety issues.

Nursing students are reviewing information about health care delivery systems in post conference. Which statements describing current U.S. health care delivery practices should be included in the discussion? Select all that apply. A. Access to care depends only on the ability to pay, not the availability of services. B. The Patient Protection and Affordable Care Act provides private health care insurance to underserved populations. C. Every health insurance plan in the Health Insurance Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. D. The uninsured pay for more than one third of their care out of pocket and are usually charged lower amounts for their care than the insured pay. E. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do. F. Quality of care can be defined as the right care for the right person at the right time.

c, e, f. The Health Insurance Marketplace is designed to help people more easily find health insurance that fits their budget. All plans in the Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. There are many less primary care providers in the United States than there were 50 years ago. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The Patient Protection and Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty. The uninsured pay for more than one third of their care out of pocket and are often charged higher amounts for their care than the insured pay.

A patient admitted through the emergency department for a severe infection is receiving intravenous (IV) antibiotics. The patient, who has been oriented, demands the nurse remove the IV because the patient is leaving now. What action will the nurse take? A. Apply soft wrist restraints B. Perform a neurologic assessment C. Explain that after signing an "against medical order form," the patient may leave D. Call the patient's family to encourage the patient to stay

c. A person cannot be legally forced to remain in a health facility, such as a hospital, if that person is of sound mind. The patient signs an "against medical orders" form when insisting on being discharged, to indicate not holding the facility responsible for harm from leaving. Applying soft wrist restraints when the patient has expressed wanting to leave constitutes battery, which includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to or held by that other person. The patient has been oriented, so another assessment is not indicated. The patient, not the family, has autonomy.

A nurse is interviewing a newly admitted patient from another culture. What question best displays cultural sensitivity? A. "Do you think you'll be able to eat the food we have here?" B. "You do understand that we can't prepare special meals?" C. "What types of food do you typically prepare for meals?" D. "Could you make an exception on what food you eat while you are here?"

c. Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

A new graduate nurse tells the preceptor they want to obtain recognition in wound care, a specialty area of nursing. What credential will this nurse need to seek? A. Accreditation B. Licensure C. Certification D. Board approval

c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

A nurse who is caring for patients on a pediatric unit is assessing children's spiritual needs. Which is the most important source of learning for a child's own spirituality? A. Child's church or religious organization B. What their parents say about God and religion C. Their parents' behavior in relationship to the family, others, and to God D. Family's spiritual advisor

c. Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God (or a higher being). What parents say about God and religion, the family's spiritual advisor, and the child's church or religious organization are less important sources of learning.

A parish nurse is speaking to a congregant whose adolescent child was arrested for shoplifting. The congregant is very angry, stating they cannot face the child, let alone discuss the situation: "I just will not tolerate a thief." What nursing action will best assist the congregant at this time? A. Assuring the congregant that many parents feel the same way B. Reassuring the congregant that many teenagers act rebelliously and that it will pass C. Assisting the congregant to identify how withholding forgiveness hurts them D. Asking the congregant if they have spent sufficient time with their child

c. Helping the congregant identify how their unforgiving feelings may be harmful to themselves is the only intervention that directly addresses forgiveness, a universal spiritual need. Assuring the congregant that many parents would feel the same way or that many teenagers shoplift out of rebelliousness may make them feel better initially, but this does not address the benefits of forgiveness. Suggesting the congregant may not have spent enough time with their child may be untrue and could promote guilty feelings, when they may be unwarranted.

A community organization includes provision of culturally competent care in their mission. Which action has the organization set as a priority? A. Learning the predominant language of the community B. Obtaining significant information about the community C. Treating each patient at the clinic as an individual D. Recognizing the importance of the patient's family

c. In all aspects of nursing, patients should be treated as individuals; this remains true when providing culturally competent care. Additional ways to provide culturally competent care include learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.

The nurses at a large community hospital with several campuses are members of a committee working toward obtaining Magnet status. What activity will best meet their goal? A. Recruiting excellent surgeons and medical doctors B. Offering health prevention activities in the community C. Providing high-quality patient care, using innovative practices D. Seeking culturally diverse clergy to meet patient's spiritual concerns

c. Magnet hospitals meet strict requirements and standards representing the highest quality of professional nursing practice and patient care, nursing excellence, and innovations in practice. Physicians are recruited by the medical department, health prevention activities in the community could be conducted by nursing staff but are not required activities; chaplains, nurses, and others may provide spiritual care, but it is not the focus of a Magnet designation.

A nursing professor pulls a student aside to discuss documenting a patient's blood pressure of 202/122 but not reporting this to the primary nurse. When discovered, the patient was transferred to the intensive care unit for treatment and monitoring. How does the faculty best explain to the student that their inaction reflects negligence? A. "You did not re-assess your patient." B. "There was poor interprofessional communication with the health care team." C. "You failed to act as a reasonably prudent nurse would under similar circumstances." D. "This action is consistent with a felony criminal action."

c. Negligence is defined as performing an action that the reasonably prudent nurse would not perform or failing to act as a reasonably prudent nurse would in similar circumstances. Negligence may be an act of omission or commission. Criminal law concerning state and federal criminal statutes includes murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

A surgeon tells a patient who is a Jehovah's Witness that they need emergency surgery to repair an aortic aneurysm, which will require blood transfusions. The patient states, "If I receive blood, I will not go to paradise. It is against my religion." What nursing response to the patient is appropriate? A. "I understand you will not receive blood products, even if it means you will die." B. "Please listen to the surgeon; I've seen many aneurysms successfully repaired" C. "Have you discussed your decision to refuse surgery with your family?" D. "What can I say to help you through this difficult decision?"

c. Patients who practice the Jehovah's Witness faith believe blood transfusions violate God's laws and do not allow them. The nurse supports the patient's beliefs. It is disrespectful of the nurse to attempt to coerce a decision or impose their beliefs on the patient.

A nurse in a long-term care facility is performing spirituality assessments of residents on their unit. What is the best question the nurse could use to assess for spiritual needs? A. "Can you describe your usual spiritual practices and how you maintain them daily?" B. "Are your spiritual beliefs causing you any concern?" C. "How can I and the other nurses help you maintain your spiritual practices?" D. "How do your religious beliefs help you to feel at peace?"

c. Questioning how the staff can meet patients' spiritual practices assesses spiritual needs. Asking the patient to describe spiritual practices is an assessment of spiritual practices. Asking about concerns assesses spiritual distress, and asking about feeling at peace assesses the need for forgiveness.

Nursing students are asked to provide interprofessional care during their clinical experience. Which member of the health care team will the student contact for an uninsured patient? A. Nurse practitioner B. Admissions coordinator C. Social worker D. Hospital chaplain

c. Social workers assist patients and families in dealing with the social, emotional, and environmental factors that affect their well-being. They make referrals to appropriate community resources, participate in discharge planning to obtain equipment and supplies, and assist with health care finances. Nurse practitioners assist in managing the medical and nursing needs of a patient, the admissions coordinator performs administrative intakes and may assign beds, and the hospital chaplain attends to patients' spiritual needs.

A nurse who was raised as a strict Roman Catholic but is no longer practicing stated they could not assist patients with spiritual distress because they recognize only a "field of power" in each person. The nurse says to her colleague, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel really isolated from them and God—if there is a God." These statements reveal which unmet spiritual need? A. Meaning and purpose B. Forgiveness C. Love and relatedness D. Strength for everyday living

c. The data point to an unmet spiritual need to experience love and belonging, given the nurse's estrangement from their family and God after leaving the church. The other options may represent other needs this nurse has, but the nurse's statements do not support them.

A patient with dysphagia has been admitted with a third episode of aspiration pneumonia in less than a year. The health care provider insists that for safety, the patient must have a feeding tube placed. The patient declines the tube and later asks the nurse if they should reconsider. What is the most appropriate nursing response? A. "The feeding tube will prevent aspiration and is the safest option for you." B. "You could swallow thickened liquids and puréed foods more easily." C. "Tell me your understanding of what may happen without the feeding tube." D. "You said cooking and dining with your family is important, and I understand your decision."

c. The nurse assesses the patient's understanding of the cause and consequences of aspiration and pneumonia. The nurse can provide further information on pneumonia and sepsis if needed, while supporting the patient's decision. The patient has already declined treatment; therefore, the nurse assesses whether the patient understands the decision before discussing the intervention. The nurse may suggest safer swallowing options or consultation with a speech therapist after assessing the patient's knowledge.

A patient who lost their home, spouse, and children in a fire is depressed and states that they have no reason to live. The patient states, "My family was my life." The nurse documents a health problem of Spiritual Distress based on the patient's inability to find meaning and purpose in their current situation. What is the priority nursing action for this patient? A. Asking the patient which spiritual advisor they would like you to call B. Recommending that the patient engage in spiritual or religious readings C. Determining what has given the patient meaning and purpose in the past D. Reminding the patient that God is a loving and personal God

c. The nurse prioritizes determining what, in addition to their family, has given the patient's life meaning and purpose in the past. This helps the patient focus on their strengths. This assessment data can be used to further plan individualized spiritual care.

A home care nurse is observing the patient's family member perform a wound irrigation and dressing change for a postoperative wound dehiscence containing purulent drainage. In which situation will the nurse provide additional education? A. The family member places the old dressing in a separate bag at the bedside. B. The patient takes an analgesic a half-hour prior to the dressing change. C. The family member states they washed their hands an hour ago. D. The patient returns to bed during the dressing change.

c. The nurse teaches the patient and family to effectively wash their hands before and after having direct contact with the patient, before performing invasive procedures, when handling dressing or touching open wounds, and when administering medications or feeding the patient. All other options are correct.

A nurse in a gynecology practice is assessing a patient reporting vaginal discharge that "smells bad and is green and foamy." She also reports burning upon urination and dyspareunia. The nurse suggests the patient and partner will need treatment for which STI? A. Human papillomavirus (HPV) B. Syphilis C. Trichomoniasis D. Herpes simplex virus

c. Trichomoniasis causes a foul-smelling vaginal discharge that is thin, foamy, and green in color; it also causes itching of the vulva and vagina, burning on urination, and dyspareunia. HPV causes a profuse watery vaginal discharge, dyspareunia, intense pruritus, and vulvar irritation. Syphilis causes a single painless genital lesion 10 days to 3 months after exposure and generalized skin rash, enlarged lymph nodes, and fever that may appear 2 to 4 weeks after appearance of primary lesion and may last for several years. Herpes presents as single or multiple painful vesicles that rupture and form ulcer-like lesions, which form scabs as they heal.

Students enrolled in a sexuality course are discussing people who achieve sexual arousal by looking at the body of someone other than a sexual partner. How would the students correctly name this behavior? A. Masochism B. Pedophilia C. Voyeurism D. Sadism

c. Voyeurism is the achievement of sexual arousal by looking at the body of someone other than a person's own sexual partner. Masochism refers to gaining sexual pleasure from the humiliation of being abused. Pedophilia is a term used to describe the practice of adults gaining sexual fulfillment by performing sexual acts with children. Sadism refers to the practice of gaining sexual pleasure while inflicting abuse on another person.

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse, "I feel no connection to God" and "I'm worried that I've found no real meaning in life." What is the nurse's best response to this patient? A. Give the patient a hug and tell them that their life still has meaning. B. Arrange for a spiritual advisor to visit the patient. C. Ask if the patient would like to talk about their feelings. D. Call in a close friend or relative to talk to the patient.

c. When caring for a patient who is in spiritual distress, the nurse should listen to the patient first, then ask whether the patient would like to visit with a spiritual advisor. Arranging for a spiritual advisor first may not be respectful of the patient's wishes. A hug and false reassurances do not address the problem of spiritual distress. Talking to friends or relatives may be helpful, but only if the patient agrees.

Inpatient psychiatric care focuses on all the following except A. brief interventions. B. discharge planning. C. independent living skills. D. symptom management

c. independent living skills

The primary purpose of psychiatric rehabilitation is to A. control psychiatric symptoms. B. manage clients' medications. C. promote the recovery process. D. reduce hospital readmissions.

c. promote the recovery process

Managed care provides funding for psychiatric rehabilitation programs to A. develop vocational skills. B. improve medication compliance. C. provide community skills training. D. teach social skills.

c. provide community skills training

A nurse is caring for patients of diverse cultures in a community health clinic. Which concepts will the nurse incorporate to guide the plan of care? Select all that apply. A. The United States has become less inclusive of same-sex couples. B. Cultural diversity is limited to people of varying cultures and races. C. Cultural diversity is separate and distinct from health and illness. D. People may be members of multiple cultural groups at one time. E. Culture guides what is acceptable behavior for people in a specific group. F. Cultural practices may evolve over time but mainly remain constant.

d, e, f. A person may belong to multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, mainly remaining constant as long as they satisfy a group's needs. The United States has become more inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biologic sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, an integral component of health and illness, includes culture, ethnicity, and race.

A nurse asks the AP to prepare the hospital room for a new ambulatory patient. Which aspect of the room will the nurse ask the AP to correct? A. The bed linens are folded back. B. A hospital gown is on the bed. C. Equipment for taking vital signs is in the room. D. The bed is in the highest position.

d. A properly prepared hospital room includes a bed in the lowest position for an ambulatory patient, an open bed with top linens folded back, routine and special equipment and supplies assembled, and the physical environment of the room adjusted.

A patient with brain cancer questions whether they should agree to palliative radiation treatments despite possible memory loss, or enjoy their remaining time with friends and family. What is the most appropriate response by the nurse? A. "I can't advise you. This is such an individual decision." B. "If you receive the radiation, might you live a bit longer?" C. "What does your family think you should do?" D. "What is most important to you with the time you have left?"

d. Advocacy is the protection and support of another's rights. The nurse assesses the patient's goals and advocates to support their wishes. Nurses do not make ethical decisions for patients; rather; the nurse facilitates patient decision making by interpreting and providing information, encouraging verbalization of feelings, and facilitating communication with family, primary nurse, health care provider, or clergy.

Which would indicate a duty to warn a third party? A. A client with delusions states, "I'm going to get them before they get me." B. A hostile client says, "I hate all police." C. A client says they plan to blow up the federal government. D. A client states, "If I can't have my girlfriend back, then no one can have her."

d. Client states, "If I can't have my girlfriend back, then no one can have her."

A patient states they feel very isolated from their family and church, and even from God, "in this huge medical center so far from home." When preparing expected outcomes for this patient, which most appropriately measures relief of the patient's spiritual distress? A. The patient will express satisfaction with the compatibility of their spiritual beliefs and everyday living. B. The patient will identify spiritual beliefs that meet their need for meaning and purpose. C. The patient will express peaceful acceptance of limitations and failings. D. The patient will identify spiritual supports available to them in this medical center.

d. Each of the four options represents appropriate spiritual goals, but identifying spiritual supports available to this patient in this medical center at this point in time, is the most appropriate and realistic.

A nurse in a gynecology clinic is obtaining a health history on a patient reporting pain during sexual activity. Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? A. "Do you currently have a new partner?" B. "Have you been diagnosed with a neurologic disorder?" C. "Do you take antihypertensive medication?" D. "Do you regularly use antihistamines?"

d. Factors contributing to dyspareunia include diabetes; hormonal imbalances; vaginal, cervical, or rectal disorders; antihistamine, alcohol, tranquilizer, or illicit drug use; and cosmetic or chemical irritants to genitals.

The Roman Catholic family of an infant born with hydrocephalus requests a baptism for their infant. The nurse advocates for the family's wishes to be honored for which reason? A. Baptism frequently helps postpone or prevent death or suffering. B. It is legally required that the nurse provide for this care when requested. C. It is a nursing function to assure the salvation of the infant. D. Not facilitating the baptism may increase the family's sorrow and suffering.

d. Failure to ensure that an infant baptism is performed when parents desire it may greatly increase the family's sorrow and suffering. Whether baptism postpones or prevents death and suffering is a religious belief that is insufficient to bind all nurses. There is no legal requirement regarding baptism, and although some nurses may believe part of their role is to ensure the salvation of the infant, this function could be rejected by many.

A nursing student is caring for a patient admitted with chest pain related to aortic valve stenosis. The student notes the patient, who had been calm and cooperative the day before, has become contemplative and withdrawn, stating, "I've never thought much about dying, but my chances of making it through tomorrow's surgery are 50-50." How does the student best respond when the clinical professor asks the student why this behavior likely surfaced later in the patient's admission? A. Patients usually want to maintain privacy about their spiritual needs. B. People are better able to focus on spiritual needs after their spiritual advisor visits. C. Family members and close friends often initiate spiritual concerns. D. Illness increases spiritual concerns, which may initially be difficult to verbalize.

d. Illness may increase spiritual concerns, which many patients find difficult to initially express. The other options presume patients are purposefully secretive or must speak with a spiritual advisor, friends, or family to promote discussion of spiritual concerns. Spirituality is anything that pertains to a person's relationship with a nonmaterial life force or higher power; there is no universal definition, as the experience is individual and personal.

A patient died during routine outpatient surgery, and the nurse was accused of having failed to monitor and interpret vital signs. Which fact must be established to prove them guilty of malpractice or negligence? A. The surgeon testifies the nurse's action was pure negligence, saying that the patient could have been saved. B. This patient should not have died since they were healthy, physically active, and involved in the community. C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome. D. The nurse had a duty to monitor the patient, and due to the nurse's failure to perform this duty, the patient died.

d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) caused the injury. Damages are the actual harm or injury resulting to the patient.

A nurse follows a prescription written by the health care provider to administer a medication to which the patient is allergic. How does the nurse interpret their liability for administering this medication? A. The nurse is not responsible because they were following the provider's orders. B. The nurse is responsible because they administered the medication. C. The health care provider is responsible because they ordered the drug. D. The nurse, health care provider, and pharmacist bear responsibility for their actions.

d. Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed.

The nurse manager reviews the medical record of a patient who has accused a nurse of negligence after requiring a "needless" admission to the intensive care unit postoperatively. Which entry in the electronic health record requires follow-up by the manager? Exhibit: Electronic health record (EHR) Nursing Notes: Postoperative follow-up 12:20 pm: patient still reporting incisional pain of 10/10, provider contacted, increased morphine from 1 mg to 2 mg every hour 2: 15 pm: dime-sized, dark red-brown blood stain on dressing; area circled 2:30 pm: patient reports incisional pain, 7/10, 2 mg morphine administered 2:45 pm: vital signs T 99.2°, P 120, RR 20, BP 84/48; will continue to monitor A. Inappropriately recorded vital signs B. Pain treated without appropriate assessment C. Failure to follow up on tachycardia and hypotension D. Lack of interpretation of vital signs and follow-up

d. Nurses are responsible for gathering assessment data including vital signs and interpreting them considering the patient's condition and trends. The nurse did not document interventions from the health care provider for typical symptoms of shock, including tachycardia and hypotension.

A patient who stated their religion as Jewish at the intake interview was served a kosher meal ordered from a restaurant on a paper plate because the hospital had no provision for kosher food or dishes. The patient became angry and accused the nurse of insulting him, emphatically stating, "I want to eat what everyone else does—and give me decent dishes." After analyzing the data, the nurse returns to the patient and makes which of these statements? A. "I'm terribly sorry, I should have ordered kosher food and dishes as well." B. "Did someone on the staff behave condescendingly or critically?" C. "It seems difficult to please you today." D. "We did not ask about your dietary preferences; tell me what you usually eat."

d. On the basis of the patient's stated religion, the nurse assumed they would want a kosher diet. This is a form of stereotyping. When evaluating the outcome of the situation, the nurse returns to the first step of the nursing process and assesses the patient's dietary practices and preferences.

A school nurse is providing sex education classes for adolescents. Which statement would the nurse include when describing normal sexual functioning? A. "People are born with a certain amount of sexual drive, which can be depleted in later years." B. "If you want to be a great athlete, sexual abstinence is necessary during training." C. "A nocturnal emission (wet dream), is an indicator of a sexual disorder." D. "It is natural for women to have as strong a desire for sex and enjoy it as much as men."

d. Physiologic studies indicate that, in some respects, the female's sex drive is not only as strong but may be even stronger than that of the male. The more consistently sexually active a person is, the longer the activity continues into the later years of life. Physiologically, the achievement of orgasm is rarely more demanding than most activities encountered in daily life; there is no scientific evidence that sex "weakens" a person. Erotic dreams that culminate in orgasms are normal common physiologic phenomena in at least 85% of men.

A parent brings their preteen daughter to the pediatric office for an annual checkup. The parent asks when they should tell the child about menses. What information will the nurse provide? A. "You can discuss this when you are ready." B. "It isn't necessary to discuss menstruation until age 13." C. "Most preteens have heard about menses from their friends. There is no rush." D. "Menses begins between ages 10 and 13 years, so now is a good time."

d. Puberty begins for most girls with development of secondary sex characteristics, and menarche begins at about age 12 years but may occur anywhere between ages 8 and 17 years. Information regarding body changes is needed to alleviate fears and should be given to the child before puberty begins. The focus should be on the daughter's needs, not the parent's need.

The charge nurse overhears a nurse state, "That patient is 78 years old—too old to learn how to change a dressing." How should the charge nurse respond? A. "Please don't impose your view of the patient's culture on them." B. "I wish you would try to demonstrate more cultural sensitivity." C. "Try to be open to your patient's culture, to make the biggest impact." D. "Grouping all older adults as having trouble learning is a form of stereotyping."

d. Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. The information in this scenario does not suggest the nurse is not open to her patient's culture.

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into their home health care practice. Which attribute best reflects agreement with the code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity

d. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations.

A surgeon will not attempt a life-saving repair of a ruptured aneurysm unless the patient agrees to receive blood transfusions. Although receiving blood products is against the patient's religious beliefs, the surgeon ordered four units of packed red blood cells. What action will the nurse take first? A. Administer the blood transfusion B. Call the patient's family and ask them to reason with the patient C. Discuss obtaining a court order to save the patient's life D. Maintain the patient's comfort and support their decision

d. The nurse does not force patients to participate in care that conflicts with their values. Imposing such care may engender feelings of guilt and alienation from a religious or cultural group and create a threat to the patient's well-being.

A nurse and AP are planning to receive a patient who sustained a traumatic head injury in a motor vehicle accident. Which activity can the nurse safely delegate to the AP? A. Collecting information for a health history B. Performing a physical assessment C. Contacting the health care provider for medical orders D. Preparing the bed and collecting needed supplies

d. The nurse may delegate preparation of the bed and collection of needed supplies to assistive personnel but performs the other activities listed.

A nurse is caring for a patient who has been hospitalized for dehydration secondary to a urinary tract infection. The patient states, "I'm leaving. There are too many germs here, and I'll probably get sicker than when I came in." As this patient has capacity for decision making, which response is most consistent with the nurse's legal accountability? A. "Only the primary health care provider can authorize your discharge from a hospital." B. "Let me gather your belongings and prepare the discharge paperwork." C. "I will inform the health care provider that you want to leave and request a psychiatric consult." D. "Your choice carries risks for complications, so I must ask you to sign a release form."

d. The patient is legally free to leave the hospital against medical advice (AMA); however, patients who leave AMA must sign a form releasing the health care provider and hospital from legal responsibility for their health status. This signed form becomes part of the medical record.

A hospice nurse is caring for a patient with end-stage cancer. Which action demonstrates the nurse's commitment to promoting the patient's autonomy? A. Competently administering pain medication B. Giving undivided attention when listening to patient concerns C. Keeping a promise to obtain a counselor D. Supporting the patient in obtaining a durable power of attorney

d. The principle of autonomy obligates nurses to provide information and support patients' and their surrogates' need to make decisions that advance their interests. Acting with justice means giving each person their due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients.

The parent of a young school-age child wants them to learn about healthy dietary choices related to diabetes. Which method of value transmission would be most helpful? A. Depriving the child of their favorite toy when they consume foods not on their diet B. Lecturing the child on the merits of healthy and unhealthy food choices C. Allowing the child to experiment and discuss the outcomes on their blood glucose D. Offering healthy meals and snacks and acting as a role model for healthful eating

d. Through modeling by observing parents, peers, and significant others, children learn what is of high or low value. When punishment is used to transmit values, children create negative associations with those values. Using lecturing and moralizing modes of value transmission, usually taught by parents or an institution (e.g., church or school), offers little opportunity for the child to weigh different values. Using a laissez-faire approach to value transmission, where no single set of values is presented as best, is not appropriate for a young child; this approach could permit permanent consequences of diabetes to develop.

A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? A. "Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." B. "The hormonal contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing implantation of the fertilized eggs." C. "Abstinence is an effective method of contraception and may be used as a periodic or continuous strategy to prevent pregnancy and STIs." D. "Withdrawal is an effective method of birth control that reduces risk for STIs."

d. Withdrawal offers no protection against sexually transmitted infections. An injection of depot medroxyprogesterone acetate (DMPA) can prevent pregnancy for 12 weeks, is 99.7% effective, and provides contraception immediately if administered on the first day of the female's period. The NuvaRing works by inhibiting ovulation in much the same way as oral contraceptives. Used appropriately, the vaginal ring is 99.3% effective in protecting against pregnancy. Abstinence is the most effective form of birth control, preventing pregnancy and STIs 100% of the time when practiced consistently and appropriately.

The mentally ill homeless population benefits most from A. case management services. B. outpatient psychiatric care to manage psychiatric symptoms. C. stable housing in a residential neighborhood. D. a combination of housing, rehabilitation services, and community support.

d. a combination of housing, rehab services, and community support

The nurse gives the client quetiapine (Seroquel) in error when olanzapine (Zyprexa) was ordered. The client has no ill effects from the quetiapine. In addition to making a medication error, the nurse has committed which? A. Malpractice B. Negligence C. Unintentional tort D. None of the above

d. none of the above