Chapter 1: Professional Nursing Practice
What is the first step in becoming culturally competent? -Exploring one's own cultural beliefs -Visiting as many cultures as possible -Maintaining eye contact at all times -Using touch as a method of maintaining rapport
- Exploring one's own cultural beliefs Explanation: Exploring one's own cultural beliefs and how they might conflict with the beliefs of the patients being cared for is the first step toward becoming culturally competent. Specific areas to be considered when providing care include the amount of space and distance needed to feel comfortable, eye contact, attitudes related to time, the use of touch, observance of civil and religious holidays, and the cultural meanings associated with food.
The nurse is caring for a group of clients. What priority nursing intervention illustrates planned nursing care prioritized according to Maslow's hierarchy of needs? -Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises. -Discourage a terminally ill client from participating in a plan of care, to minimize fears about death. -Help a client walk to the shower because the shower area is vacant at this time. -Interrupt a family's visit with client with depression to assess blood pressure measurement.
-Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises. Explanation: Assigning priorities to nursing diagnoses and collaborative problems is a joint effort by the nurse and the client or family members. Any disagreement about priorities is resolved in a way that is mutually acceptable. Consideration must be given to the urgency of the problems, with the most critical problems receiving the highest priority. Maslow's hierarchy of needs provides one framework for prioritizing problems, with importance being given first to physical needs like pain medication needs; once those basic needs are met, higher-level needs like client participation in care or taking advantage of an empty shower area can be addressed. The disruption of a family visit is not necessary unless the client is unstable.
A nurse is using an evidence-based practice tool to plan care for a patient with acute abdominal pain who is admitted to the health care facility. Which tool would the nurse most likely expect to use? -Care map -Multidisciplinary action plan -Clinical guideline -Algorithm
-Algorithm Explanation: Evidence-based practice tools used for planning care include care maps, multidisciplinary action plans, clinical guidelines, and algorithms. Algorithms are used more frequently in acute situations to determine a particular treatment based on patient information or a response. Care maps, clinical guidelines, and multidisciplinary action plans help facilitate coordination of care and education throughout hospitalization and after discharge.
A nurse has been using the nursing process as a framework for planning and providing client care. What action would the nurse do during the evaluation phase of the nursing process?
-Document a client's improved air entry with incentive spirometry use. Explanation: During the evaluation phase of the nursing process, the nurse determines the client's response to nursing interventions. An example of this is when the nurse documents whether the client's spirometry use has improved the condition. A client does not do the evaluation. Removing staples and providing information on follow-up appointments are interventions, not evaluations.
Therapeutic communication techniques between client and nurse facilitate continuity of care. Which of the following identifies the value of therapeutic communication? Select all that apply. -Allows the nurse to display interest in the client and the communication -Helps the nurse to assist the client to explore and understand his or her problems -Enables the nurse to give the client advice that will improve health care -Allows the nurse to develop and state the goals for the client -Provides the nurse a mechanism by which he or she can solve the client's problems
-Allows the nurse to display interest in the client and the communication -Helps the nurse to assist the client to explore and understand his or her problems Explanation: To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate therapeutically and effectively with a client. Therapeutic communication involves several different techniques. The nurse must be a effective listener and show interest in the client during the conversations. Being therapeutic allows the nurse to promote the client's exploration and understanding of his or her problems. Nurses do not give clients advice, nor do they develop goals for them. Often nurses assist clients to develop their own goals, which can help clients better understand and solve their own problems.
The client has become confused and attempts to climb out of bed. What interventions will the nurse provide prior to applying restraints? -Call the health care provider to prescribe sedation for the patient. -Arrange a schedule for staff to sit with the client. -Place the client in a chair at the nurses' station with a sheet tied around the client's waist. -Place all four side rails of the bed in the upright position.
-Arrange a schedule for staff to sit with the client. Explanation: The nurse should arrange a schedule for the staff to sit with the client. Calling for sedation is not the first step with caring for a client with confusion. The chair with a sheet and the side rails are restraints. The use of restraints (including physical and pharmacologic measures) is another issue with ethical overtones because of the limits on a person's autonomy when restraints are used. It is important to weigh carefully the risks of limiting autonomy and increasing the risks of injury by using restraints against the risks of injury if not using restraints, which have been documented as resulting in physical harm and death. The ANA advocates that restraints only be used when no other viable option is available. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have designated standards for the use of restraints.
A patient who adheres to the dietary laws of Judaism is in traction and confined to bed. The patient needs assistance with the evening meal of chicken, rice, beans, a roll, and a carton of milk. Which nursing approach is most representative of promoting wellness? -Remove items from the overbed table to make room for the dinner tray. -Push the overbed table toward the bed so that it will be within the patient's reach when the dinner tray arrives. -Ask a family member to assist the patient with the tray and the overbed table, then straighten the area in an attempt to provide a pleasant atmosphere for eating. -Ask whether the patient would like to make any substitutions in the foods and fluids received.
-Ask whether the patient would like to make any substitutions in the foods and fluids received. Explanation: Wellness involves being proactive and being involved in self-care activities aimed toward a state of physical, psychological, and spiritual well-being. With this in mind, health care providers must aim to promote positive changes that are directed toward health and well-being. The sense of wellness has a subjective aspect that addresses the importance of recognizing and responding to patient individuality and diversity in health care and nursing. Although all of the actions listed would promote the patient's comfort, addressing the patient's religious dietary needs is most representative of promoting wellness.
A client has been diagnosed with small cell lung cancer. The client has met with the oncologist and is now weighing the relative risks and benefits of chemotherapy and radiotherapy. This client is demonstrating which ethical principle in making a final decision? -Beneficence -Confidentiality -Autonomy -Justice
-Autonomy Explanation: Autonomy entails the ability to make a choice free from external constraints. Beneficence is the duty to do good and the active promotion of benevolent acts. Confidentiality relates to the concept of privacy. Justice states that cases should be treated equitably.
A nurse is providing care for a client who is postoperative day one following a bowel resection for the treatment of colorectal cancer. How can the nurse best exemplify the QSEN competency of quality improvement? - By liaising with the members of the interdisciplinary care team -By critically appraising the outcomes of care that is provided -By integrating the client's preferences into the plan of care -By documenting care in the electronic health record in a timely fashion
-By critically appraising the outcomes of care that is provided Explanation: Evaluation of outcomes is central to the QSEN competency of quality improvements. Each of the other listed activities is a component of quality nursing care, but none clearly exemplifies quality improvement activities.
A nurse is unsure how best to respond to a client's vague complaint of "feeling off." The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition? -By eliciting input from a variety of trusted colleagues -By examining the way that she thinks and applies reason -By evaluating her responses to similar situations in the past -By thinking about the way that an "ideal" nurse would respond in this situation
-By examining the way that she thinks and applies reason Explanation: Critical thinking includes metacognition, the examination of one's own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.
Which of the following is a cognitive or mental activity that nurses use in critical thinking? -Using bias to achieve goals -Drawing on past clinical experiences and knowledge to explain what is happening -Setting priorities with broad time constraints -Determining nurse-specific outcomes
-Drawing on past clinical experiences and knowledge to explain what is happening Explanation: Intellectual skills used in critical thinking include drawing on past clinical experiences and knowledge to explain what is happening, priority setting with timely decision making, and determining client-specific outcomes. Bias is not used to achieve goals.
There are central characteristics of nursing practice that are applicable across the wide variety of contexts in which nurses practice. A nurse can best demonstrate these principles by performing which of the following actions? -Teaching the public about the role of nursing -Taking action to control the costs of health care -Ensuring that all of their actions exemplify caring -Making sure to carry adequate liability insurance
-Ensuring that all of their actions exemplify caring Explanation: Caring is central to the practice of the registered nurse. Caring supersedes the importance of teaching about nursing, carrying insurance, or controlling costs.
A patient with a "Do Not Resuscitate" (DNR) order requires large doses of a narcotic for pain that rates a 10 on a 0-10 scale. After the patient requests pain medication, the nurse assesses a respiratory rate of 12 breaths per minute. What intervention by the nurse would be considered ethical? -Ask the patient to wait 20 minutes and reassess. -Give half of the prescribed dose. -Give the pain medication without fear of respiratory depression. -Withhold the pain medication and contact the physician.
-Give the pain medication without fear of respiratory depression. Explanation: End-of-life issues shift the focus from curative care to palliative and end-of-life care. Focusing on the caring as well as the curing role may help nurses deal with these difficult moral situations. Needs of patients and families require holistic and interdisciplinary approaches. End-of-life issues that often involve ethical dilemmas include pain control, "do not resuscitate" orders, life support measures, and administration of food and fluids. However, because the patient has a legal order to not be resuscitated, the nurse should respect the patient's autonomy and preference of pain relief over possible lethal complications.
Which type of nursing diagnosis has a goal to increase well-being and enhance specific health behaviors? -Health promotion -Risk -Syndrome -Problem-focused
-Health promotion Explanation: Health promotion nursing diagnoses look for ways to enhance health. Risk nursing diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired Skin Integrity related to inactivity. Syndrome diagnoses are used when the diagnosis is associated with a cluster of other diagnoses. Problem-focused nursing diagnoses identify existing problems.
The decision-making part of the problem-solving activities of nurses has become increasingly multifaceted and requires critical thinking. There are many reasons why this is so in today's health care arena. Choose all that apply. -Increasingly complex issues faced by nurses -Advanced technology -Greater acuity of clients -A younger population -Complex disease processes
-Increasingly complex issues faced by nurses -Advanced technology -Greater acuity of clients -A younger population -Complex disease processes Explanation: In today's health care arena, nurses face increasingly complex issues and situations resulting from advanced technology, greater acuity of clients in both hospital and community settings, an aging population, and complex disease processes, as well as ethical issues and cultural factors. The decision-making part of the problem-solving activities of nurses has become increasingly multifaceted and requires critical thinking.
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)? -It makes judgments based on conjecture. -It is based on the medical model. -It considers only the client's needs. -It is guided by professional standards and codes of ethics.
-It is guided by professional standards and codes of ethics. Explanation: Critical thinking is guided by professional standards and codes of ethics. It is based on principles of the nursing process and scientific methods. Critical thinking makes judgments based on evidence rather than conjecture. It considers client, family, and community needs.
A group of nursing students are reviewing the various types of advanced practice nurses. The students demonstrate the need for additional review when they identify which of the following as an advanced practice nurse? -Certified nurse midwife -Nurse practitioner -Clinical nurse specialist -Nurse manager
-Nurse manager Explanation: -A nurse manager who may or may not have a graduate level degree would not be considered an advanced practice nurse. An advanced practice nurse includes nurse practitioner, clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist.
Nursing students are reviewing information about expanded nursing roles. They demonstrate understanding of the information when they identify which of the following as roles of an advanced practice nurse? Select all that apply. -Certified nurse-midwife -Certified critical care nurse -Nurse practitioner -Clinical nurse specialist -Certified registered nurse anesthetist -Certified medical-surgical nurse
-Nurse practitioner -Clinical nurse specialist -Certified registered nurse anesthetist -Certified nurse-midwife Explanation: Advanced practice nurses are nurses with advanced specialized education, usually at the graduate level. They include certified nurse midwives, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Certified critical care nurses and certified medical-surgical nurses have passed the certification examination but are not routinely considered advanced practice nurses.
A nurse is preparing a presentation for a local community group addressing the influences on health care delivery. Which will the nurse include in presentation when describing disease patterns? -Most infectious diseases have been controlled or eradicated. -The prevalence of chronic illness is decreasing due to the emphasis on healthy living. -Obesity along with conditions associated with it has become a major health concern. -People with acute illnesses are considered the largest group of health care consumers.
-Obesity along with conditions associated with it has become a major health concern. Explanation: In recent years, obesity has become a major health concern and the multiple comorbidities that accompany it add significantly to its associated mortality. Although many infectious diseases have been controlled or eradicated, some such as tuberculosis, acquired immunodeficiency syndrome and sexually transmitted infections are on the rise. The prevalence of chronic illnesses and disability is increasing because of the lengthened lifespan in the United States and the advances in care and treatment. People with chronic illnesses constitute the largest group of health care consumers in the United States.vv
A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include? -A discussion of a centralized organizational structure -Participation in decision making that is shared by all involved -Accountability that is primarily attributed to the patient -Nurses and physicians playing major roles in clinical decisions
-Participation in decision making that is shared by all involved Explanation: The collaborative practice model involves all care providers, including nurses, physicians, and ancillary health personnel as well as the patient functioning within a decentralized organizational structure to collaboratively make clinical decisions. The collaborative model promotes shared participation, responsibility, and accountability in a health care environment that strives to meet the complex health care needs of the public.
The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement? -Assessment -Planning -Implementation -Evaluation
-Planning Explanation: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
A client has been admitted for a liver biopsy because the physician believes the client may have liver cancer. The family has told both the nurse and the physician that if the client is terminal, the family does not want the client to know. The biopsy results are positive for an aggressive form of liver cancer and the client asks the nurse repeatedly what the results of the biopsy show. What strategy should the nurse use to give ethical care to this client? -Obtain the results of the biopsy and provide them to the client. -Tell the client that only the physician knows the results of the biopsy. -Promptly communicate the client's request for information to the family and the physician. -Tell the client that the biopsy results are not back yet in order to temporarily appease him.
-Promptly communicate the client's request for information to the family and the physician. Explanation: Strategies nurses could consider include the following: not lying to the client, providing all information related to nursing procedures and diagnoses, and communicating the client's requests for information to the family and physician. Ethically, the nurse cannot tell the client the results of the biopsy and cannot lie to the client.
Which situation would require the nurse to use critical thinking and decision-making skills in providing genetics-related nursing care? -Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis -Providing family counseling to a same-sex couple that just adopted a 5-year-old with attention deficit hyperactivity disorder (ADHD) -Providing education related to lead poisoning to a single parent of a 4-year-old child -Providing education related to growth and development to a blended family with children of different ages
-Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis Explanation: Cystic fibrosis is an autosomal recessive genetic disorder. Parents of a child diagnosed with cystic fibrosis have a 50% chance of having another child with cystic fibrosis. Once the nurse assesses the family history, it is appropriate nursing action to for the nurse to make a referral for genetic testing or counseling. Although ADHD may have a genetic component, there is no genetics-related issue in this situation. Lead poisoning is not a genetic disorder. There is no indication that any of the children in the blended family have a genetics-related problem.
Which of the following delineates actions that are legally permitted for a particular profession based on specific educational qualifications -Scope of practice -Job description -Code of ethics -Occupational Health and Safety Administration (OSHA)
-Scope of practice Explaantion: Scope of practice is used to delineate actions that are legally permitted for a particular profession, based on specific educational qualifications. The job description represents qualifications and duty of employment. The Code of Ethics represents ethical standards. The code is an ideal framework for nurses to use in ethical decision-making. Under the Occupational Safety and Health Act of 1970, employers are responsible for providing a safe and healthy workplace for their employees.
According to the Maslow hierarchy of needs, which of the following is the highest level of needs? -Safety and security -Physiological needs -Self-actualization -Sense of belonging
-Self-actualization Explanation: The Maslow hierarchy of needs ranks human needs by priority, with physiologic needs at the bottom and self-actualization at the top. According to Maslow's model, lower-level needs must be met before an individual begins to attend to a higher-level need. Between physiologic needs and self-actualization in ascending order are safety and security, belongingness and affection, and esteem and self-respect.
The nurse is working at an institution that uses a collaborative practice model. Which of the following would most likely be reflected at this institution? -Centralized organizational structure -Physician as the primary decision-maker -Isolated participation from the patient -Shared accountability for care
-Shared accountability for care Explanation: A collaborative practice model involves nurses, physicians, and ancillary health personnel functioning within a decentralized organizational structure, collaboratively making clinical decisions. Collaborative practice is further enhanced with integration of the health or medical record and with joint reviews of patient care records. The collaborative model promotes shared participation, responsibility, and accountability in a health care environment.
A newly admitted long-term care client refuses to attend afternoon group activities or social events offered by the facility. According to Maslow's theories on human needs, what is the reason the client refuses to participate in activities? -The client needs to increase feelings of positive self-esteem. -The client eats the meals served in the room. -The client likes to go to have a nap in afternoon and go to bed early in the evening. -The client is adjusting to sharing a bathroom and feels in control with bowel elimination.
-The client likes to go to have a nap in afternoon and go to bed early in the evening. Explanation: According to Maslow, the client would need to be sure that basic physiologic and safety and security needs were being met before becoming interested in meeting love and belonging (social) needs. The client needs to have physical needs met like food, sleep, and bowel elimination before requiring increased self-esteem through social activities.
The nurse is caring for a client with a newly diagnosed allergy to peanuts. What immediate goal should the nurse apply to a nursing diagnosis of "deficient knowledge related to appropriate use of an EpiPen"? -The client will demonstrate correct injection technique with today's teaching session. -The client will closely observe the nurse demonstrating the injection. -The nurse will teach the client's family member to administer the injection. -The client will return to the clinic within 2 weeks to demonstrate the injection.
-The client will demonstrate correct injection technique with today's teaching session. Explanation: -Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this client is that the client will demonstrate correct administration of the medication today. The goal should specify that the client administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.
A client comes to the clinic and reports being ill for several weeks but does not have insurance and has delayed care. What does the nurse understand about the overall healthcare reform goals that will address issues such as this client? -The goal of healthcare reform is to provide care to women, infants, and children. -The goal of healthcare reform is to provide more healthcare programs to address illness. -The goal of healthcare reform is to provide quality healthcare for those that can afford it. -The goal of healthcare reform is to provide affordable healthcare to more citizens.
-The goal of healthcare reform is to provide affordable healthcare to more citizens. Explanation: The overall goal of healthcare reform is to provide affordable healthcare to more U.S. citizens. Other goals are to reduce the insurance companies' control of healthcare and to provide more assistance to senior citizens on fixed incomes. Providing care to women, infants, and children and offering more healthcare programs to address illness may be results of healthcare reform but are not themselves the overall goal. Healthcare reform seeks to provide quality healthcare that is affordable to as many U.S. citizens as possible, not to only provide it to those who can already afford it.
Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the client. Which of the following is the best example of a collaborative practice model? -The nurse and the physician jointly making clinical decisions. -The nurse accompanying the physician on rounds. -The nurse making a referral on behalf of the client. -The nurse attending an appointment with the client.
-The nurse and the physician jointly making clinical decisions. Explanation: The collaborative model, or a variation of it, promotes shared participation, responsibility, and accountability in a health care environment that is striving to meet the complex health care needs of the public. Collaborative practice goes beyond a nurse simply accompanying a physician. Making referrals and accompanying a client do not demonstrate interprofessional collaboration because they are independent nursing actions.
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client? -A 6 cm x 4 cm wound with malodorous, yellow exudate -The client's wound will heal by 1 cm by the end of 5 days. -The client's wound has healed by 0.5 cm on day 3 of wound care. -Turn the client every 2 hours.
-Turn the client every 2 hours. Explanation: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.
The nurse admits a client to an oncology unit that is a site for a study on the efficacy of a new chemotherapeutic drug. The client knows that placebos are going to be used for some participants in the study but does not know that he is receiving a placebo. When is it ethically acceptable to use placebos? -Whenever the potential benefits of a study are applicable to the larger population -When the client is unaware of it and it is deemed unlikely that it would cause harm -Whenever the placebo replaces an active drug -When the client knows placebos are being used and is involved in the decision-making process
-When the client knows placebos are being used and is involved in the decision-making process Explanation: Placebos may be used in experimental research in which a client is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. Placebos may not ethically be used solely when there is a potential benefit, when the client is unaware, or when a placebo replaces an active drug.
A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this client. What key component of critical thinking is most likely missing from this student's practice? -Compliance with direction -Respect for authority -Analyzing information and situations -Withholding judgment
-Withholding judgment Explanation: Key components of critical thinking behavior are withholding judgment and being open to options and explanations from one client to another in similar circumstances. The other listed options are incorrect because they are not the essence of this nurse's unjustifiable refusal.
Which of the following patient age groups is currently one of the fastest growing age groups in the population? -adults 65 years of age and over -adults 18 to 45 years of age -children under 5 years of age -children 5 to 18 years of age
-adults 65 years of age and over Explanation: The decline in birth rate and the increase in lifespan have resulted in proportionately fewer school-age children and more senior citizens. Both the number and proportion of Americans 65 years of age and older have grown substantially in the past century. In 2013, an estimated 44.7 million older adults resided in the United States; this number is expected to grow to 79.7 million by 2040.
A client has been a resident of a long-term care facility for several years. The client's condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client's family has a legal document outlining the client's wishes in regard to measures such as this. What is this document? -advance directive -consent form -durable power of attorney -do-not-resuscitate order
-advance directive Explanation: An advance directive provides the means for clients to communicate their wishes regarding life-sustaining treatment and other medical care, so that their significant others will know what decisions the clients desire. The two types of advance directives are the living will and durable power of attorney for healthcare. Informed consent is voluntary permission granted by a client or the client's healthcare proxy for a treatment, procedure, or surgery to be performed. A form is used to obtain this consent. A durable power of attorney is a legal document that appoints a person to act as an agent for another person. A DPOA for healthcare appoints a person to make medical decisions for a client who is incapacitated and unable to make decisions for himself or herself. Do-not-resuscitate (DNR) orders involve a written medical order for end-of-life instructions. If a DNR order is written, the client wishes to have no resuscitative action taken if he or she experiences a cardiac arrest.
Several days this week, a nurse takes time after work to read to a visually impaired client who has no family close by. This behavior demonstrates that ethical values: -concern the treatment of others. -are consistent. -take priority over other values. -are well thought out.
-concern the treatment of others. Exlanation: Ethical values are rules or principles a person uses to make decisions about right and wrong. These values are consistent, they take priority over other values, they concern the treatment of others (as shown by this nurse taking personal time to show kindness to her client), and they are well thought out.
An ER nurse must quickly assess two clients who were in a car accident and determine whose needs take priority. In this situation, critical thinking allows the nurse to: -consider all factors, interpret the information, and make decisions relevant to each client's care. -minimize the time spent with each client, so the overall operations of the ER will be more efficient. -communicate each client's status more efficiently to the attending physician. -delegate tasks to other ER staff, thereby freeing up more time to care for clients presenting with true emergencies.
-consider all factors, interpret the information, and make decisions relevant to each client's care. Explanation: Nurses use critical thinking skills in all practice settings. Nurses continually assess their clients' needs and frequently confront situations that require multiple interventions. Developing good critical thinking skills will make nurses more efficient and effective at resolving these situations.
The physician has ordered cimetidine for a client with gastric ulcers, and the nurse administers the first dose. The nurse's actions are noted in the medical record. This notation is an example of which aspect of implementing the plan of care? -documentation -intervention -monitoring -assessment
-documentation Explanation: An important element of implementation is documentation. By law, nurses must document all nursing actions, observations, and client responses in a permanent record.
A nurse is a member of which entity within the larger healthcare environment? -healthcare team -healthcare delivery system -health maintenance organization -physician hospital organization
-healthcare team Explanation: The healthcare team includes nurses, physicians, pharmacists, psychologists, social workers, healthcare administrators, and various other health professionals, such as physical therapists. The healthcare delivery system is the entire range of services available to clients. A health maintenance organization is a type of managed care insurance plan. A physician hospital organization is a corporate structure involving a hospital and groups of physicians.
Which communication technique is helpful in health teaching about relevant aspects of a client's well-being and self-care? -Silence -Reflection -Informing -Humor
-informing Explanation: Informing is helpful in health teaching or client education about relevant aspects of the client's well-being and self-care. Silence involves periods of no verbal communication among participants for therapeutic reasons. Reflection validates the nurse's understanding of what the client is saying and signifies empathy, interest, and respect for the patient. Humor promotes insight by bringing repressed material to consciousness, resolving paradoxes, tempering aggression, and revealing new options.
Patient health education provided by the nurse -is an independent function of nursing practice. -requires a physician's order. -must be approved by the physician. -must focus on wellness issues.
-is an independent function of nursing practice. Explanation: Health education is an independent function of nursing practice and is included in all state nurse practice acts. Teaching, as a function of nursing, is also included in all state nurse practice acts. Health education is a primary responsibility of the nursing profession. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.
A nurse in a hospice facility cares for clients with terminal illnesses and witnesses a great deal of pain and emotional distress. Which factor that affects healthcare ethics determines how the nurse must respond when a client asks for help in ending his or her suffering? -legislative and judicial decisions -advances in scientific research -advances in technology -healthcare reform
-legislative and judicial decisions Explanation: Society's struggles with ethical issues result in legislative and judicial decisions that affect ethical decisions. Nurse practice acts prohibit nurses from assisting clients to die. The other options are factors that do not affect the nurse's ethical position.
A nurse, working in a health clinic, treats a variety of conditions on a daily basis. One disorder that is rapidly increasing and is the leading cause of secondary morbidity is: -Kidney disease -Coronary heart disease -Obesity -Pneumonia
-obesity Explanation: Currently about 30 % of adults and 16% of children are classified as obese (CDC, 2009). Obesity is the leading cause of secondary illnesses ranging from cancer to diabetes.
Which type of nursing diagnosis identifies an existing condition that the client is experiencing? -problem-focused -health promotion -risk -syndrome
-problem-focused Explanation: The problem-focused diagnosis identifies an existing problem such as Urinary Retention or Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The risk diagnosis identifies potential problems for which the client is at risk. The syndrome diagnosis describes specific diagnoses that occur as a group.
A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client's healthcare needs? -using a systematic method to plan and implement care to reach desired outcomes -contacting the physician before performing any tasks -consulting with other nurses to determine the first step of care -reading the client's records and doing research on the client's conditions before deciding on a course of action
-using a systematic method to plan and implement care to reach desired outcomes Explanation: Clients present with multiple healthcare needs that the caregiver must approach in an organized, systematic manner to provide efficient and effective care. The nursing process for making clinical decisions grew from problem-solving techniques and the scientific process.
The nurse is caring for a client with respiratory distress caused by pneumonia who recently became homeless after losing his job. He also tells the nurse that the stress of losing both his job and his home has caused his wife to move in with one of their adult children. The nurse hears him say, "I just don't know what to do. I wish I were a better human being. I've never really done anything right." The nurse will attend to this client's needs in what order?
1.The client's respiratory distress 2.The client's homelessness 3.The client's estrangement from his wife 4.The client's feeling about himself 5.The client knowing what to do Explanation: According to Maslow, priorities are established according to a grouped level of needs. On the first level are physiologic needs such as breathing, food, and water. The second level is safety and security needs which include security of body, employment and resources and would include the client's homelessness. The third level are love and belongingness needs and include friendship, family and sexual intimacy and would be the level at which the client's estrangement from this wife would be addressed. The fourth level is esteem and self-esteem needs and would be where the nurse would address the client's feelings about himself. The fifth level are self-actualization needs and include morality and problem solving which is where the nurse would assist the client in setting his own priorities.
Which term is defined as a formal systematic study of moral beliefs? -Ethics -Veracity -Fidelity -Morality
Ethics Explanation: Ethics is the formal, systematic study of moral beliefs. Veracity is the obligation to tell the truth and not to lie or deceive others. Fidelity is keeping promises. Morality is the adherence to informal personal values.
Which element is involved in the planning phase of the nursing process? -Identify collaborative problems -Complete health history -Identify measurable outcomes -Carry out the nursing orders
Identify measurable outcomes Explanation: The planning step of the nursing process involves identifying measurable outcomes, selecting nursing interventions, and documenting the planning steps. The implementation step involves carrying out nursing orders. The diagnosis step involves identifying collaborative problems. Completing a health history is done in the assessment step.
Which type of nursing diagnosis identifies potential problems that may arise due to the client's disease, condition, or situation? -risk -actual -health promotion -syndrome
risk Explanation: Risk nursing diagnoses identify potential problems and use the stem "risk for" as in Risk for Impaired Skin Integrity related to inactivity. The actual diagnosis identifies an existing problem such as Urinary Retention or Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The syndrome diagnosis describes specific diagnoses that occur as a group.