EAQ Fundamentals of Nursing Practice Quiz Questions

Under which type of health care services would the student nurse include sports medicine? a. Primary care b. Tertiary care c. Preventive care d. Restorative care

d. Restorative care The student nurse would include sports medicine under restorative care. It is not categorized as primary, tertiary, or preventive health care services.

The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty? a. Caring b. Veracity c. Advocacy d. Confidentiality

c. Advocacy The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client's needs are met and by protecting the client's rights. Caring is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy. Confidentiality is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure.

Which are the elements of discovery of a lawsuit? Select all that apply. One, some, or all responses may be correct. A. Experts B. Medical errors C. Proof of negligence D. The depositions of witnesses E. petition-elements of the claim

A. experts B. medical records D. the deposition of witnesses Experts, medical records, and the depositions of witnesses are elements of discovery of a lawsuit. Proof of negligence is a part of a trial. Petition and elements of the claim are a part of the pleadings phase.

When questioning the staff about a change in the client's plan of care, which would the nurse demonstrate? a. Authority b. Autonomy c. Responsibility d. Accountability

a. Authority The nurse who asks questions about a change in a client's plan of care shows that he or she has the power to make decisions. This is an example of the nurse's authority over other staff members. Independence in making choices about client care and work is autonomy. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability means that individuals are answerable for their actions. The nurse demonstrates accountability by checking on the client and family after discharge.

Which would the nurse document for a client with drooping of the eyelid over the pupil? a. Ptosis b. Ectropion c. Entropion d. Nystagmus

a. Ptosis Eyelids that droop over the pupil is called ptosis, which is how the nurse would document the finding. Ectropion is when the eyelid margins turn out. Entropion is similar, but is when the eyelid margins turn in and sometimes can cause irritation of the conjunctiva and cornea. Nystagmus is an involuntary oscillation of the eyes, and usually occurs after an eye injury.

Which disease process places a client at increased risk for infection? Select all that apply. One, some, or all responses may be correct. a. Leukemia b. Lymphoma c. Emphysema d. Schizophrenia e. Osteoarthritis

a. Leukemia b. Lymphoma c. Emphysema Disease processes that increase the client's risk for infection include leukemia, lymphoma, and emphysema, which lead to a diminished immune system. Schizophrenia and osteoarthritis do not impair a person's immune system.

Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be correct. a. Lifestyle b. Occupation c. Chronic diseases d. Frequent traveling e. Diagnostic procedures

a. Lifestyle b. Occupation d. Frequent traveling Adults are at risk for infection in the community via lifestyle choices such as high-risk behaviors that can lead to human immunodeficiency virus (HIV) and sexually transmitted infections. Occupational hazards include those who work in the mining or health care industries. Frequent travelers can be exposed to infections from other parts of the country or world. Chronic diseases such as pneumonia, skin breakdown, and diagnostic procedures happen in the health care setting.

Which are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. One, some, or all responses may be correct. a. Ptosis and blurred vision b. Agitation and hyperactivity c. Confusion and disorientation d. Increased sensitivity to pain e. Decreased auditory alertness

a. Ptosis and blurred vision e. Decreased auditory alertness Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation. *read carefully*

Which definition of assault would the nurse include in teaching a group of parents about child abuse? a. Threat to do bodily harm to another person b. An unintentional act committed by one person against another person c. A legal wrong committed against the public that is punishable by federal law d. The application of force to another person without lawful justification

a. Threat to do bodily harm to another person Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by federal law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery. Assault is not defined as an unintentional act committed by one person against another.

Which pulse site is used for the Allen test? a. Ulnar b. Popliteal c. Brachial d. Femoral

a. Ulnar The radial site is used for the Allen test. The popliteal pulse is used to assess status of circulation to lower leg. The status of the circulation in the lower arm and blood pressure are assessed using the brachial pulse. The femoral pulse is used to assess the character of the pulse during physiological shock or cardiac arrest when other pulses are not palpable.

Which activities would the nurse consider to be a part of the tertiary level of preventive care? Select all that apply. One, some, or all responses may be correct. a. Using a sheltered colony b. Providing selective placement c. Using environmental sanitation d. Providing work therapy in hospitals e. Preventing complications and sequelae

a. Using a sheltered colony b. Providing selective placement d. Providing work therapy in hospitals Using a sheltered colony, providing selective placement, and providing work therapy in hospitals belong to the tertiary level of preventive care. Using environmental sanitation is a primary level of preventive care. Preventing complications and sequelae is a secondary level of preventive care.

Which would be the respiratory rate in a 2-year-old child? a. 20 breaths/min b. 30 breaths/min c. 40 breaths/min d. 50 breaths/min

b. 30 breaths/min The normal range for the respiratory rate in a 2-year-old child (toddler) is between 25 and 32 breaths/min. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40 breaths/min. The normal respiratory rate in infants is 50 breaths/min.

Which is appropriate for the nurse to include in the education of the ethical principal of nonmaleficence to a group of nursing students? a. Treat all clients equitably and fairly. b. Act in ways to prevent harm to clients. c. Tell the client the truth about their health. d. Help the clients make informed choices.

b. Act in ways to prevent harm to clients. Nonmaleficence means to act in ways that prevent client harm or even the risk of harm. Telling the truth to clients about their health refers to veracity. Helping clients make informed choices promotes autonomy. Justice involves treating all clients equitably and fairly.

Which is the action of an antidiuretic hormone (ADH)? a. Reduces blood volume b. Decreases water loss in urine c. Increases urine output d. Initiates the thirst mechanism

b. Decreases water loss in urine ADH is released by the posterior pituitary gland. It is released mainly in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma. It acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.

Which domain of the Nursing Interventions Classification (NIC) taxonomy includes care that supports homeostatic regulation? a. Domain 1 b. Domain 2 c. Domain 3 d. Domain 4

b. Domain 2 Domain 2 of the NIC taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

Which principal components are associated with the nurse's time management skills? Select all that apply. One, some, or all responses may be correct. a. Autonomy b. Goal setting c. Priority setting d. Interruption control e. Right communication

b. Goal setting c. Priority setting d. Interruption control Goal setting, priority setting, and interruption control are the principal components of time management. Autonomy is an important component of the decision-making process. Right communication is considered one of the rights of delegation.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family? a. Orem's theory b. Peplau's theory c. Leininger's theory d. Henderson's theory

b. Peplau's theory Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

The registered nurse (RN) is teaching the nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? a. "I should serve food that is easy to eat." b. "I should assist the client with eating." c. "I should monitor weight and food intake once a month." d. "I should offer food supplements that are tasty and easy to swallow."

c. "I should monitor weight and food intake once a month." The nurse would monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse would serve food that is easy to eat and provide assistance with eating. The nurse would also offer food supplements that are tasty and easy to swallow.

Which physical skin finding indicates opioid abuse? a. Diaphoresis b. Red, dry skin c. Needle marks d. Spider angiomas

c. Needle marks Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

Which statement is true for attachment in the newborn? a. Attachment occurs over the first 28 days. b. Attachment begins in the first week of birth. c. Attachment is the overlapping of soft skull bones. d. Attachment is the interaction between parent and child.

d. Attachment is the interaction between parent and child. Attachment is the interaction between the parent and child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast-feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns who had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? a. Primary b. Secondary c. Superinfection d. Nosocomial

d. Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between caring for different clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

Which activity places a client at risk for hyperthermia? a. Snowmobiling b. Skiing in the winter c. Hiking Alaskan mountains d. Performing strenuous activity in high humidity

d. Performing strenuous activity in high humidity When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

Arrange the stages of Freud's psychoanalytical model of personality development in the correct order. 1. Anal 2. Oral 3. Genital 4. Phallic or oedipal 5. Latency

oral- anal- phallic/oedipal- latency- genital The first stage of Freud's theory is the oral stage, from birth to 12 to 18 months. The anal stage is the second stage, from 12 to 18 months to 3 years of age. Children between the ages of 3 and 6 years are considered to be in the phallic or oedipal stage. The latency stage lasts from age 6 years to age 12 years. The genital stage is the sixth stage; it starts in puberty and continues to adulthood.

Which statement defines the term "family resiliency"? a. Each family is unique. b. The family has an ability to cope with stressors. c. An interfamilial structure and support system exist. d. The family has the ability to transcend lifestyle changes.

b. The family has an ability to cope with stressors. Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults; however, the family is capable of transcending inevitable lifestyle changes.

When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water-soluble vitamin? Select all that apply. One, some, or all responses may be correct. a. Biotin b. Niacin c. Folic acid d. Riboflavin e. Vitamin C

a. Biotin b. Niacin c. Folic acid d. Riboflavin e. Vitamin C Water-soluble vitamins include biotin, niacin, folic acid, riboflavin, vitamin C, thiamine, pyridoxine, cyanocobalamin, and pantothenic acid. These along with fat-soluble vitamins are decreased during malnutrition along with elevated liver enzymes.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment finding(s) observed by the nurse would relate to this diagnosis? Select all that apply. One, some, or all responses may be correct. a. Fainting b. Headache c. Weakness d. Lightheadedness e. Shortness of breath

a. Fainting c. Weakness d. Lightheadedness Head trauma may cause blood loss, and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.

Which finding during assessment prompts the nurse to don a protective gown? a. Open sore b. Abrasions of the skin c. Excessive wound drainage d. Productive, moist coughing

c. Excessive wound drainage Excessive wound drainage may require more protection than gloves, so a protective gown should be donned by the nurse. An open sore and abrasions to the skin should be approached with gloved hands. A moist, productive cough should prompt the nurse to provide a mask to the client.

Which is the most independently functioning nurse? a. Nurse educator b. Nurse researcher c. Nurse administrator d. Advanced practice registered nurse

d. Advanced practice registered nurse The advanced practice registered nurse is the most independently functioning nurse. The nurse educator, nurse researcher, and nurse administrator all must be associated with an organization to pursue their professional prospects.

Which possible legal complication might the nurse face in a situation in which intravenous (IV) therapy was administered to the wrong client? a. Assault b. Battery c. Malpractice d. False imprisonment

c. Malpractice If the nurse administers IV therapy to a wrong client, the nurse may face the charge of malpractice. Assault is any action that places the client or the nurse in fear of harmful or offensive contact without consent. Battery is any intentional touching without consent. False imprisonment occurs with unjustified restraint of a person without legal warrant.

Which key factor would the nurse consider when assessing how a client will cope with body image changes? a. Suddenness of the change b. Obviousness of the change c. Extent of the change d. Perception of the change

d. Perception of the change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

According to quality and safe education for nurses (QSEN) which defines patient centered care? A. understanding that the client is the source of control when providing care B. functioning effectively within nursing and interprofessional teams to deliver quality care C. using data to evaluate outcomes of care processes and designing methods to improve health care D. minimizing the risk for harm to clients and health care workers through improved professional performance

A. Understanding that the client is the source of control when providing care The QSEN competency called patient-centered care requires the nurse to understand that the client is the source of control. The nurse would respect the values, beliefs, and preferences of the client to provide quality care. The QSEN competency called teamwork and collaboration states that the nurse would function effectively within nursing and interprofessional teams to provide quality care. Quality improvement involves using data to evaluate the outcomes of care processes and design methods to improve the health care delivery system. Safety focuses on minimizing the risk for harm to clients and health care workers through improved professional performance.

Which chemical buffers excessive acetoacetic acid? a. Potassium b. Sodium bicarbonate c. Carbon dioxide d. Sodium chloride

b. Sodium bicarbonate Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H2CO3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.

How many levels of critical thinking exist for nursing judgment? Record your answer using a whole number. ______

3: basic, complex, commitment There are three levels of critical thinking in nursing judgment. The first level is basic critical thinking, in which the nurse has faith that the expert has the right answer to each problem. The second level is complex critical thinking. The nurse examines and analyzes information provided by the expert. The nurse engaging in this critical thinking may discover that another option is available with which to solve an issue. The third level of critical thinking is commitment. The nurse at this level can make choices without help from others. The nurse at this level of critical thinking takes full responsibility for every action in which he or she engages.

Which point is included in the World Professional Association for Transgender Health (WPATH) document regarding core principles of care for transgender clients? A. Designating unisex or single-stall restrooms B. Seeking informed consent before providing treatment C. Posting the client's bill of rights and nondiscrimination policies visibly D. Reflecting the client's choice of terminology in communication and documentation

B. Seeking informed consent before providing treatment One of the core principles of health care professionals who care for transgender clients as per the document published by WPATH. The Joint Commission recommends designating unisex/single stall restrooms, post the client's bill of rights and nondiscriminatory policies visibly, and use the client's choice of terminology in communication and documentation

Which information is accurate regarding exemplary professional practice according to the revised magnet model? A. "Strong professional practice is established, and accomplishments of the practice are demonstrated." B. "A vision for the future and the systems and resources to achieve the vision are created by nursing leaders." C. "Focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes." D. "Structures and processes provide an innovative environment in which staff are developed and empowered and professional practice flourishes."

A. "Strong professional practice is established, and accomplishments of the practice are demonstrated." Exemplary professional practice is evident when a strong professional practice is established, and accomplishments of the practice are demonstrated. The characteristic of transformational leadership is a vision for the future in which the systems and resources to achieve the vision are created by nursing leaders. The characteristic of empirical quality outcomes is that the focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes. The characteristic of structural empowerment includes structures and processes to provide an innovative environment in which staff are developed and empowered and professional practice flourishes.

Which are the steps of evidence-based practice (EBP) in order? 1. Evaluating the practice decision 2. Asking the relevant clinical question 3. Collecting the most relevant and best evidence 4. Critically appraising the evidence collected 5. Sharing the outcomes of EBP changes with others 6. Integrating all evidence with one's clinical expertise and client preferences

Asking the relevant clinical question- Collecting the most relevant and best evidence.- Critically appraising the evidence collected- Integrating all evidence with one's clinical expertise and client preferences- Evaluating the practice decision-Sharing the outcomes of EBP changes with others The first step in EBP is to ask the relevant clinical question. The second is to collect the most relevant and best evidence. After the collection, critically appraise the evidence gathered. Integrate all the evidence into one's clinical expertise and client preferences and values to make a practice decision or change. Then evaluate the practice decision or change. The last step is to share the outcomes of EBP changes with others.

Which is the correct order of the phases of the nursing process? 1. Diagnosis 2. Planning 3. Evaluation 4. Assessment 5. Implementation

Assessment- Diagnosis- Planning- Implementing- Evaluation The first phase of the nursing process is assessment of the client data. During this phase, the nurse collects the biological data of the client. Next, during the nursing diagnosis phase, the nurse makes a diagnosis on the basis of the client data, and then the nurse makes plans to address the issues and evaluates the expected outcomes. These plans are carried out in the implementation phase. Finally, in the evaluation phase, the outcomes are evaluated and shared with others.

The nurse is conducting a client interview. Which response by the nurse is an example of back channeling? a. "All right, go on... " b. "What else is bothering you?" c. "Tell me what brought you here." d. "How would you rate your pain on a scale of 0 to 10?"

a. "All right, go on... " Back channeling involves the use of active listening prompts such as "Go on... ," "all right," and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his or her health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How would the nurse respond to the technician? a. "I can't receive them right now. Please wait a few minutes or come back." b. "Please leave the medications and sign-out sheet in a location where I can see them." c. "Please bring them to me, and I will be sure to put them away in a couple of minutes." d. "I am busy right now. Please give them to the unlicensed health care worker."

a. "I can't receive them right now. Please wait a few minutes or come back." The transfer of controlled substances from one authorized person to another must occur according to protocol. In this situation the controlled substance must be returned to the pharmacy and delivered at a later time. The controlled substances cannot be left unattended. The nurse cannot delay the securing of controlled substances; if time is not available when the medications are delivered, they must be returned to the pharmacy. The unlicensed health care worker does not have the authority to receive controlled substances.

Which statement is a characteristic of the concrete operations stage of Piaget's theory of cognitive development? a. A child is able to describe a process without actually doing it. b. A child faces difficulty in conceptualizing time. c. A child believes that everyone experiences the world exactly as he or she does. d. A child believes that his or her actions and appearance are constantly being scrutinized.

a. A child is able to describe a process without actually doing it. In the concrete operations stage, a child is able to perform mental operations and describe a process without actually doing it. In the preoperational stage, a child faces difficulty in conceptualizing time, and he or she believes that everyone experiences the world exactly as he or she does. In the formal operations stage, an individual believes that his or her actions and appearances are scrutinized constantly.

Which refers to the professional obligation of the nurse to assume responsibility for actions? a. Accountability b. Individuality c. Responsibility d. Bioethics

a. Accountability Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession; this is referred to as accountability. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biological and medical procedures and treatments.

Which characteristics would a slow-to-warm up child display? Select all that apply. One, some, or all responses may be correct. a. Adapts slowly with frequent communication b. Is regular and predictable in his or her habits c. Is highly active, irritable, and irregular in his or her habits d. Reacts with mild but passive resistance to novelty e. Reacts negatively and with mild intensity to new stimuli

a. Adapts slowly with frequent communication d. Reacts with mild but passive resistance to novelty e. Reacts negatively and with mild intensity to new stimuli A slow-to-warm up child adapts slowly with frequent communication and reacts to novelty with mild but passive resistance. A slow-to-warm up child also reacts negatively and with mild intensity to new stimuli. An easy child is regular and predictable in his or her habits. A difficult child is highly active, irritable, and irregular in his or her habits.

hich critical thinking skill will help a student nurse avoid making assumptions about clients? a. Analysis b. Inference c. Evaluation d. Explanation

a. Analysis Use of analysis allows the student nurse to be open-minded while looking at the client's information and to avoid making assumptions. Inference skills focus on the meaning of the findings and its significance. Evaluation involves looking at all situations objectively and using criteria to determine the results of nursing actions. Explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.

Which is a stressor? a. Any stimuli that can produce tension and cause instability within the system. b. Exists within the client system, such as the physiological and behavioral responses to illnesses. c. Exists outside the client system; external stressors include changes in health care policies or increased crime rates. d. A term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

a. Any stimuli that can produce tension and cause instability within the system. A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in health care policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

Which piece of equipment must the nurse ensure remains sterile during care of the client? a. Bedpan b. Stethoscope c. Suction catheter d. Blood pressure cuff

c. Suction catheter Suction catheters that enter the respiratory tract are to remain sterile to prevent transmission of infection directly to the respiratory tract. Bedpans, stethoscopes, and blood pressure cuffs are to be clean, but not sterile, for effective and safe care.

Which examples mentioned by the nursing student regarding quasi-intentional torts need correction? Select all that apply. One, some, or all responses may be correct. a. Assault b. Battery c. Malpractice d. Invasion of privacy e. Defamation of character

a. Assault b. Battery c. Malpractice All willful acts that violate the rights of other people are called intentional torts. Assault and battery are intentional torts. Malpractice is an example of an unintentional tort. Invasion of privacy and defamation of character are example of quasi-intentional torts. These torts are characterized by acts of violation that directly cause harm to the clients.

Which tort involves intentional touching without the client's consent? a. Battery b. Invasion of privacy c. False imprisonment d. Defamation of character

a. Battery Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary health care provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? a. Bruit b. Ectropion c. Entropion d. Borborygmi

a. Bruit A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outward away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines.

Which statement describes a client in the stage of contemplation in the stages of change? a. Considers change within the next 6 months b. No intention of making changes within the next 6 months c. Actively engages in strategies to change behavior; this lasts up to 6 months d. Displays sustained change over time; this begins 6 months after action has started and continues indefinitely

a. Considers change within the next 6 months In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time, beginning 6 months after action has started and continuing indefinitely, the client has reached the maintenance stage.

A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? a. Contact an interpreter provided by the hospital. b. Contact the client's family member to translate for the client. c. Communicate with the client using Spanish phrases the nurse learned in a college course. d. Communicate with the client with the use of a hospital-approved Spanish dictionary.

a. Contact an interpreter provided by the hospital. Interpreters provided by the health care organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate health care information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

The nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent? a. Delegation b. Implementation c. Case management d. Interprofessional teamwork

a. Delegation Delegation is the assignment of a nursing task to someone else who is able or qualified to perform the task. Implementation is a part of the nursing process where the nurse carries out the care plan for a client. Case management is the collaborative effort of care planning and advocacy to make sure that a client's and family's needs are met. The interprofessional team is made up of professionals from several different disciplines who work together in the provision of care to the client.

Which describes the purpose of the Nurse Practice Acts? a. Describe and define the legal boundaries of nursing practice within each state b. Reflect the knowledge and skills possessed by nurses practicing in their profession c. Legal requirements that describe the minimum acceptable nursing care d. Protect individuals from losing their health insurance when changing jobs by providing portability

a. Describe and define the legal boundaries of nursing practice within each state The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.

Which factor would the nurse assess in a client reporting constipation? Select all that apply. One, some, or all responses may be correct. a. Diet b. Fluid intake c. Use of laxatives d. Date of last bowel movement e. Use of opioid pain medications

a. Diet b. Fluid intake c. Use of laxatives d. Date of last bowel movement e. Use of opioid pain medications If a client complains of constipation, the nurse would inquire about factors related to constipation including diet, fluid intake, laxative use, date of last bowel movement, and whether or not the client is taking opioid pain medications.

Which worker(s) would the nurse consider to be at high risk of developing dermatitis? Select all that apply. One, some, or all responses may be correct. a. Dry cleaners b. Dye workers c. Lathe operators d. Hospital workers e. Agricultural workers

a. Dry cleaners b. Dye workers Dry cleaners and dye workers are at high risk of developing dermatitis due to exposure to substances such as solvents and dye stuffs. Lathe operators are at high risk of developing cancer. Hospital workers are at greater risk of latex allergies. Agricultural workers are at high risk of skin cancer.

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? a. Elevate the head of the bed between 30 and 45 degrees. b. Decrease flow rate at night. c. Check for residual daily. d. Irrigate regularly with warm tap water.

a. Elevate the head of the bed between 30 and 45 degrees. To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not prevent aspiration.

Which would the nurse consider to be the center of decision-making when providing client care? a. Ethics b. Nursing skills c. Analytical skills d. Research-based practice

a. Ethics A professional nurse always follows the ethics of care and considers caring to be the center of decision-making. The nurse must know what behavior is ethically appropriate while caring for a client. The nurse's effectiveness in performing tasks is important to client care; however, client satisfaction comes from the effective dimension of care. Because ethics of care are unique to each client, the nurse would not base decision-making only on analytical skills. The nurse would not provide client care based only on intellectual principles or research knowledge. Caring is the most important factor because it considers client preferences and values.

The nurse is discussing discharge plans with a client. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." Which interviewing technique did the nurse use? a. Exploring b. Reflecting c. Refocusing d. Acknowledging

a. Exploring Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.

Which physiological changes are expected during the first trimester of pregnancy? Select all that apply. One, some, or all responses may be correct. a. Fatigue b. Increased libido c. Morning sickness d. Breast enlargement e. Braxton Hicks contractions

a. Fatigue c. Morning sickness d. Breast enlargement Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

Which statements have been correctly stated about Nightingale's theory of nursing? Select all that apply. One, some, or all responses may be correct. a. Focus of nursing is caring through the environment b. Limits nursing to the administration of medications and treatment c. Suggests that every nurse would know all about the disease process d. Oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition e. Focuses on helping the client deal with the symptoms and changes in function related to an illness

a. Focus of nursing is caring through the environment d. Oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition e. Focuses on helping the client deal with the symptoms and changes in function related to an illness Nightingale's theory of nursing focuses on nursing by caring through the environment. Nightingale's theory is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Nightingale's theory does not limit nursing to the administration of medications and treatment. Nightingale's theory suggests that nurses do not need to know all about the disease process, which differentiates nursing from medicine.

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. Which describes the muscle functionality of the client? a. Full range of motion with gravity b. Full range of motion with gravity eliminated c. Full range of motion against gravity with full resistance d. Full range of motion against gravity with some resistance

a. Full range of motion with gravity In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good).

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? a. Hand washing before and after providing client care b. Cleaning all equipment with an approved disinfectant after use c. Wearing personal protective equipment (PPE) when providing client care d. Using medical and surgical aseptic techniques at all times

a. Hand washing before and after providing client care Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all the other interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

Which is the goal of school health nursing programs? a. Health promotion b. Disease management c. Chronic care management d. Environmental surveillance

a. Health promotion The goal of school health nursing programs is health promotion through the school curriculum. A class on nutritional planning for parents contributes to health promotion. Disease management is one of the many programs of community health centers. These centers provide primary care to a specific client population within a community. Nurse-managed clinics provide nursing care with a focus on acute and chronic care management. The occupational health nurse may conduct environmental surveillance for health promotion and accident prevention in the work setting.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events," according to Swanson's theory of caring? a. Knowing b. Enabling c. Doing for d. Being with

b. Enabling The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process of being with is defined as being emotionally present for someone else.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105°F (40.6°C), orally. Which condition would the nurse suspect in the client? a. Heat stroke b. Heat exhaustion c. Accidental hypothermia d. Malignant hyperthermia

a. Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95°F (35°C), the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention in this situation? a. Immediately involve pastoral services while caring for the client. b. Involve the family member in the client's care instead of pastoral support. c. Listen to the client's request for support and then carry on with the clinical work. d. Falsely promise that pastoral services has been contacted and plan to see the client.

a. Immediately involve pastoral services while caring for the client. The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social, and psychological needs and the pathophysiology of clients living with advanced diseases. The nurse involves pastoral services while caring for the client. Involving a family member may decrease anxiety in the client but may not fulfill the wishes of the client. Just listening to the client's request without implementation or giving false promises can cause loss of trust by the client.

Which component of nursing process would the nurse note evidence of swelling and skin discoloration of the client's lower extremities? a. Input b. Output c. Content d. Feedback

a. Input Input is the data or information that comes from a client's assessment, such as how the client interacts with the environment and the client's physiological function. Output is the end product of a system. The content is the information about nursing interventions for clients with specific health care problems. Feedback involves the assessment of how a system functions.

Which opposing conflict does a young adult face according to Erikson's theory of psychosocial development? a. Intimacy versus isolation b. Identity versus role confusion c. Autonomy versus sense of shame and doubt d. Generativity versus self-absorption and stagnation

a. Intimacy versus isolation According to Erikson's theory of psychosocial development, a young adult is likely to face intimacy versus isolation. An adolescent is likely to face identity versus role confusion. A toddler of 1 to 3 years of age is likely to face autonomy versus sense of shame and doubt. A middle-aged adult is likely to face generativity versus self-absorption and stagnation.

Which theorist(s) suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptation to their environments? a. King b. Peplau c. Nightingale d. Benner and Wrubel

a. King According to King's theory, the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. According to Peplau's theory, the goal of nursing is to develop an interaction between nurse and client. According to Nightingale's theory, the goal of nursing is to facilitate the reparative processes of the body by manipulating a client's environment. According to Benner and Wrubel, the goal of nursing is to focus on a client's need for caring as a means of coping with stressors of illness.

Which category would the error fall when the nurse makes a nursing diagnosis without validating data obtained from the client? a. Labeling b. Collecting c. Clustering d. Interpreting

a. Labeling The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting level include inaccurate data, missing data, and disorganization. Errors at the clustering level include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the interpreting level, errors include failure to consider conflicting cues and failure to consider cultural influences or developmental stage.

The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? a. Lips b. Sclera c. Conjunctiva d. Mucus membrane

a. Lips The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.

The nurse is assessing an older adult during a regular checkup. Which finding(s) during the assessment is/are normal? Select all that apply. One, some, or all responses may be correct. a. Loss of turgor b. Urinary incontinence c. Decreased night vision d. Decreased mobility of ribs e. Increased sensitivity to odors

a. Loss of turgor c. Decreased night vision d. Decreased mobility of ribs In older adults, the skin loses its turgor or elasticity, and there is fat loss in the extremities. Visual acuity declines with age; therefore decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? a. Nurse b. Pharmacist c. Music therapist d. Primary health care provider

a. Nurse In a palliative care setting, the health care team would comprise professionals of various disciplines to help achieve care outcomes. The nurse on the interprofessional team evaluates the physical, emotional, and spiritual needs of the client. The nurse also advocates for the client and provides referrals to other members of the team. The primary health care provider assesses the clinical manifestations of the client. The pharmacist supports the care of the client and the needs of the family. Music therapists help increase the comfort of the client.

Which nurse participates in the development of nursing policies and procedures? a. Nurse educator b. Clinical nurse specialist (CNS) c. Certified nurse-midwife d. Certified registered nurse anesthetist

a. Nurse educator Nurse educators participate in the development of nursing policies and procedures. The CNS is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. The CNS is not known for participating in the development of nursing policies and procedures. The certified nurse-midwife (CNM) is an APRN who is also educated in midwifery and certified by the American College of Nurse-Midwives. The CNM is not known for participating in the development of nursing policies and procedures. The certified registered nurse anesthetist (CRNA) is an APRN with advanced education in a nurse anesthesia-accredited program. The CRNA is not known for participating in the development of nursing policies and procedures.

Which purpose does a community health center serve in preventive and primary care services? a. Outpatient clinics that provide primary care to a specific population b. Aim to increase worker productivity, decrease absenteeism, and reduce the use of costly medical care c. Emphasize program management, interdisciplinary collaboration, and community health principles d. Include a complete program designed for health promotion and accident or illness prevention in the workplace

a. Outpatient clinics that provide primary care to a specific population Community health centers are outpatient clinics that provide primary care to a specific population, such as clients with young children or clients with diabetes. Occupational health services aim to increase worker productivity, decrease absenteeism, and reduce the use of costly medical care. School health services emphasize program management, interdisciplinary collaboration, and community health principles. Occupational health services include a complete program designed for health promotion and accident or illness prevention in the workplace.

A client with diabetes mellitus experiences a sudden fall in blood glucose levels while traveling by air. The client is not carrying any medications or a copy of a personal medical record. Which type of health information technology would be beneficial for this client? a. Personal health record (PHR) b. Clinical health care informatics c. Electronic medical record (EMR) d. Regional health information organization (RHIO)

a. Personal health record (PHR) The PHR is an electronic health record that consists of health data and the treatment provided for the client. The client can enter the data and maintain these health records. It is easy to carry and helps health care providers provide treatment in emergency conditions. Health care facilities maintain an EMR for each client. The client does not have access to these records in the air. Clinical health care informatics seeks to transform client health by educating and training health care professionals. It does not help provide emergency treatment to the client while traveling. RHIO oversees the exchange of the client's information among the client's health care providers and across geographic areas.

To ensure client and visitor safety during transport of a client with influenza A (H1N1) for a computed tomography, the nurse would take which precaution? a. Place a surgical mask on the client. b. Other than standard precautions, no additional precautions are needed. c. Minimize close physical contact. d. Cover the client's legs with a blanket.

a. Place a surgical mask on the client. Nurses would provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their rooms. Special precautions such as face masks would be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

Under which health care services pyramid level would the nursing student include family planning? a. Primary care b. Continuing care c. Restorative care d. Secondary acute care

a. Primary care The nursing student would include family planning under primary care. Family planning is not a part of continuing care, restorative care, or secondary acute care services.

Which nursing practice is associated with a self-regulation skill? a. Reflecting on one's experience b. Reflecting on one's own behavior c. Supporting one's findings and conclusions d. Clarifying any data that one is uncertain about

a. Reflecting on one's experience Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures. These episodes are longer than 24 hours. Which fever pattern would the nurse anticipate? a. Relapsing b. Sustained c. Remittent d. Intermitte

a. Relapsing Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38 oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent.

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct. a. Self-worth b. Achievement c. Security needs d. Belonging needs e. Self-actualization

a. Self-worth b. Achievement The fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct. a. Using pincer grasp well b. Picking up small objects c. Showing hand preference d. Crawling on the hands and knees e. Pulling oneself to standing or sitting

a. Using pincer grasp well b. Picking up small objects c. Showing hand preference The fine motor skills evident in 8- to 10-month-old infants include the accurate use of the pincer grasp and picking up small objects. At this stage, infants may also demonstrate a hand preference. Crawling on the hands and knees and pulling oneself to a standing or sitting position are considered gross motor skills.

Which purpose does block and parish nursing serve in preventive and primary care services? a. Services are provided to older clients or those who are unable to leave their homes. b. Primary care is provided to a specific client population that lives in a specific community. c. Nursing services are delivered with a focus on health promotion and education as well as on chronic disease. d. Services are aimed at increasing worker productivity, decreasing absenteeism, and reducing the use of expensive medical care.

a. Services are provided to older clients or those who are unable to leave their homes. Block and parish nursing provides services to older clients or those who are unable to leave their homes. Community health centers provide primary care to a specific client population living in a specific community. Nurse-managed clinics provide nursing services with a focus on health promotion and education as well as on chronic disease. Occupational health services provide services that aim to increase worker productivity, decrease absenteeism, and reduce the use of expensive medical care.

The nurse assessed a client's pulse rate and recorded the score as 3+. Which describes the strength of the pulse? a. Strong b. Bounding c. Expected d. Diminished

a. Strong A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

Which statement regarding Roy's theory of nursing needs correction? a. The Roy adaptation model views the environment as an adaptive system. b. The need for nursing care occurs when the client cannot adapt to internal and external environmental demands. c. The goal of nursing is to help the client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. d. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

a. The Roy adaptation model views the environment as an adaptive system. The Roy adaptation model views the client as an adaptive system. The need for nursing care occurs when a client cannot adapt to internal and external environmental demands. Roy's model believes the goal of nursing is to help a client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

Which assessment finding is associated with depression? a. The client has islands of intact memory. b. The client has impaired recent and remote memory. c. The client has impaired recent and immediate memory. d. The client needs step-by-step instructions for simple tasks.

a. The client has islands of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

A client is likely to undergo reconstructive surgery for which purpose? a. To restore function and/or appearance b. To replace an organ or tissue c. To relieve or reduce symptoms d. To remove or excise an organ or tissue

a. To restore function and/or appearance The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; surgery to relieve or reduce symptoms is known as palliative; and surgery to remove or excise an organ or tissue is known as resection.

Which intervention reflects the nurse's approach of "family as a context"? a. Trying to meet the client's comfort b. Evaluating the client family's coping skills c. Determining the client family's energy level d. Trying to meet the client family's nutritional needs

a. Trying to meet the client's comfort In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

Which assessment finding of the skin refers to elasticity? a. Turgor b. Edema c. Texture d. Vascularity

a. Turgor Turgor refers to the elasticity of the skin. Edema indicates fluid buildup in the tissues. Texture refers to the character of the skin. Vascularity refers to the circulation of the skin.

Which organization has a publication that includes the objective, "Aiming to develop a system to identify clients who are lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)"? a. U.S. Department of Health and Human Services (USDHHS) b. The Centers for Disease Control and Prevention (CDC) c. The Joint Commission (TJC) d. The World Professional Association for Transgender Health (WPATH)

a. U.S. Department of Health and Human Services (USDHHS) Developing a system to identify clients who are LGBTQ is a goal stated in the USDHHS's Healthy People 2020. The CDC's publications have goals that differ from this one. TJC's field guide lists recommendations for health care agencies for designing a safe environment for LGBT client care. WPATH summarizes core principles that nurses and other health care providers should follow when caring for transgender clients.

Which action would the nurse take to minimize ambiguity and confusion when entering a client's data in the electronic health record? a. Use consistent, codified terminology. b. Record the data in the client's presence. c. Enter the data in the client's native language. d. Upload scanned copies of the client's records.

a. Use consistent, codified terminology. An electronic health record is a client's official digital health record and is shared among multiple facilities and agencies. The nurse must use consistent, codified terminology to eliminate ambiguity and confusion. Recording the data in the presence of the client will not help another health care professional understand the data. Health care providers review electronic health records for continuing a client's treatment. The nurse would enter client data by using a clear codified scheme, not in the client's native language. The nurse would not upload scanned copies of client records because others may not understand the nurse's handwriting and may get confused.

Which statement about a case manager is correct? a. "A case manager identifies and implements new and more effective approaches to problems." b. "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." c. "A case manager helps clients identify and clarify health problems and chooses appropriate courses of action to solve these problems." d. "A case manager applies a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families."

b. "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families. A change agent helps identify and implement new and more effective approaches to problems. A counselor helps clients identify and clarify health problems and choose appropriate courses of action. A caregiver applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families.

The nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include? a. "You do not need to wear them while you are awake, but it is important to wear them at night." b. "You will need to apply them in the morning before you lower your legs from the bed to the floor." c. "If they bother you, you can roll them down to your knees while you are resting or sitting down." d. "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

b. "You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

The registered nurse is teaching a nursing student about Piaget's theory of cognitive development. Which age group corresponds with concrete operations? a. 2 to 7 years b. 7 to 11 years c. Birth to 2 years d. 11 years to adulthood

b. 7 to 11 years According to Piaget's theory of cognitive development, the concrete operations period applies to the age group of 7 to 11 years of age. The preoperational period applies to the age group of 2 to 7 years. The sensorimotor period applies to the age group of birth to 2 years. The formal operations period applies to the age group of 11 years to adulthood.

Which is exploratory research? a. A study that tests how well a program, practice, or policy is working b. A study designed to develop a hypothesis about the relationships among phenomena c. A study that explores the interrelationships among variables of interest without any active intervention by the researcher d. A study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur

b. A study designed to develop a hypothesis about the relationships among phenomena Exploratory research is an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena. Evaluation research is a study that tests how well a program, practice, or policy is working. Correlational research is a study that explores the interrelationships among variables of interest without any active intervention by the researcher. Descriptive research is a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur.

When ammonia is excreted by healthy kidneys, which mechanism usually is maintained? a. Osmotic pressure of the blood b. Acid-base balance of the body c. Low bacterial levels in the urine c. Normal red blood cell production

b. Acid-base balance of the body The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels.

While assessing the pupils of a client, a health care professional notices pupillary dilatation. Which drug would have resulted in this condition? a. Heroin b. Atropine c. Morphine d. Pilocarpine

b. Atropine The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.

Which basic health care ethic does the nurse follow when signing the client's consent form as a witness? a. Justice b. Autonomy c. Beneficence d. Nonmaleficence

b. Autonomy Autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent. This ensures that the client is involved in the decision-making process appropriately. Justice refers to fairness. The given situation does not deal with fairness. Beneficence refers to taking positive actions to help others. This involves keeping the interests of the client before self-interest. Nonmaleficence is the avoidance of harm or hurt. Weighing the pros and cons of the new treatment plan would involve nonmaleficence.

The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client? a. Apnea b. Bradypnea c. Tachypnea d. Hyperpnea

b. Bradypnea In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

In which role does the nurse oversee the budget of a specific nursing unit or agency? a. Nurse educator b. Nurse manager c. Nurse researcher d. Nurse practitioner

b. Nurse manager The nurse manager is responsible for the budget of a specific nursing unit or agency. The nurse educator works primarily in schools of nursing, staff development departments of health care agencies, and client education programs. The nurse researcher investigates problems to improve nursing care. The nurse practitioner provides health care to a group of clients usually in an outpatient, ambulatory care, or community-based setting.

A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? a. Sodium b. Calcium c. Potassium d. Phosphorus

b. Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium/phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. The major route of sodium excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.

After reviewing a client's reports, the primary health care provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. One, some, or all responses may be correct. a. Peptic ulcer b. Chronic renal failure c. Cognitive impairment d. Congestive heart failure e. Chronic obstructive lung disease

b. Chronic renal failure d. Congestive heart failure e. Chronic obstructive lung disease Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore these clients do not require palliative care.

The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? a. Client A (94.2 F/34.5 C) b. Client B (85.3 F/29.6 C) c. Client C (89.4 F/31.9 C) d. Client D (91.5 F/33.1 C) Hypothermia is classified as mild hypothermia (body temperature of 34°C-36°C [93.2°F-96.8°F]), moderate hypothermia (body temperature of 30°C-34°C [86°F-93°F]), and severe hypothermia (body temperature below 30°C [86°F]). Client B, with a body temperature of 29.6°C (85.3°F) is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 30°C (86°F). Clients A, C, and D do not have a temperature less than 30°C (86°F); therefore they may not need rewarming through cardiopulmonary bypass.

b. Client B (85.3 F/29.6 C) Hypothermia is classified as mild hypothermia (body temperature of 34°C-36°C [93.2°F-96.8°F]), moderate hypothermia (body temperature of 30°C-34°C [86°F-93°F]), and severe hypothermia (body temperature below 30°C [86°F]). Client B, with a body temperature of 29.6°C (85.3°F) is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 30°C (86°F). Clients A, C, and D do not have a temperature less than 30°C (86°F); therefore they may not need rewarming through cardiopulmonary bypass.

The nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. One, some, or all responses may be correct. a. Consent has been obtained from the spouse. b. Consent has been given specifically by a court. c. Self-consent has been granted by a court order. d. Consent has been given by a grandparent. e. Consent has been obtained from at least one parent of the minor.

b. Consent has been given specifically by a court. c. Self-consent has been granted by a court order. e. Consent has been obtained from at least one parent of the minor. An unemancipated minor is allowed to consent to an abortion if one of three conditions is fulfilled. The minor may give consent if consent has been obtained from at least one parent. The minor may also give consent if consent has been given specifically by a court or self-consent has been granted by a court order. The spouse or grandparents of unemancipated minors are not allowed to give consent for abortions.

Which role does the nurse play when helping clients identify and clarify health problems and choose appropriate courses of action to solve those problems? a. Educator b. Counselor c. Change agent d. Case manager

b. Counselor As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. The nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care.

Which theory describes the phenomenon of grief or caring? a. Grand theories b. Descriptive theories c. Prescriptive theories d. Middle-range theories

b. Descriptive theories Descriptive theories describe a phenomenon such as grief or caring. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories discuss interventions and expected outcomes for a specific phenomenon. They describe phenomena, speculate on why they occur, and describe their consequences. Middle-range theories have a more narrow scope than grand theories; these theories integrate theory-based research with nursing practices.

Which domain of the nursing intervention phase includes electrolyte and acid-base management? a. Domain 1 b. Domain 2 c. Domain 3 d. Domain 4

b. Domain 2 Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiological complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

Who is the appropriate authority to provide consent for an unemancipated pediatric client about to undergo a medical procedure? a. The court b. Either of the child's parents c. One of the child's grandparents d. The pediatric client

b. Either of the child's parents For unemancipated pediatric clients, the parents are required to provide consent. Either parent may do so. The court intervenes in situations where the parents refuse to allow a child to undergo treatment. A grandparent may provide consent only if the situation is an emergency and the parents are not present. The client is underage and unemancipated; therefore, if at all possible, consent must be obtained from one of the child's parents in a non-life-threatening situation.

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? a. Skin condition b. Fluid and electrolyte balance c. Food intake d. Fluid intake and output

b. Fluid and electrolyte balance Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.

Which statement indicates that the nurse is in the advanced beginner stage of Benner? a. Learns about the profession through a specific set of rules and procedures b. Identifies the basic principles of nursing care through careful observation c. Understands the organization and specific care required by certain clients d. Assesses the entire situation and transfers knowledge gained from multiple previous experiences

b. Identifies the basic principles of nursing care through careful observation According to the levels of proficiency set forth by Benner, the nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. The nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, the nurse will be able to understand the organization and specific care required by certain clients. The nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

The nurse changing the dressing on the client's perineum would fall into which zone? a. Public zone b. Intimate zone c. Personal zone d. Vulnerable zone

b. Intimate zone Changing a client's dressing on the perineum falls under the intimate zone. For this action, the appropriate interpersonal distance between the nurse and the client would be between 0 and 18 inches. The nurse lecturing a class of students or speaking at a community forum lies within a public zone. A personal zone refers to the nurse sitting on the client's bedside, taking a client's history, or teaching a client individually. The vulnerable zone is where special care is needed.

Which statement accurately describes correlational research? a. It tests how well a program, practice, or policy is working. b. It explores the relationships among variables of interest without any active intervention by the researcher. c. The investigator controls the study variable and randomly assigns subjects to different conditions to test the variable. d. It measures the characteristics of people, situations, or groups and the frequency with which certain events or characteristics occur.

b. It explores the relationships among variables of interest without any active intervention by the researcher. Correlational research explores the relationships among variables of interest without any active intervention by the researcher. Evaluation research tests how well a program, practice, or policy is working. Experimental research is a study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable. Descriptive research measures the characteristics of people, situations, or groups and the frequency with which certain events or characteristics occur.

Which is the definition of descriptive research? a. It tests how well a program, practice, or policy is working. b. It measures the characteristics of persons, situations, or groups. c. It is designed to establish facts and relationships concerning past events. d. It explores the interrelationships among variables of interest without any active intervention.

b. It measures the characteristics of persons, situations, or groups. Descriptive research is defined as a study that measures the characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. Evaluation research tests how well a program, practice, or policy is working. Historical research is designed to establish facts and relationships concerning past events. Correlational research explores the interrelationships among variables without any active intervention by the researcher.

Which instructions would the nurse provide an individual about the role an individual plays in health and wellness and its effect? Select all that apply. One, some, or all responses may be correct. a. Using passive strategies for health promotion enables one to benefit from the activities of others. b. Lifestyle choices affect his or her quality of life and well-being. c. Individuals should take responsibility for health and wellness by making proper lifestyle choices. d. Individuals should realize that illness prevention has a positive economic effect on their lives. e. Individuals should understand that it is enough to make positive lifestyle choices to prevent illness.

b. Lifestyle choices affect his or her quality of life and well-being. c. Individuals should take responsibility for health and wellness by making proper lifestyle choices. d. Individuals should realize that illness prevention has a positive economic effect on their lives. A client would understand that making appropriate lifestyle choices can affect his or her quality of life and well-being. An individual would take responsibility for his or her health and wellness by making proper lifestyle choices. The client would also realize that illness prevention has a positive economic effect by decreasing health care costs. Passive health promotion strategies enable people to benefit from the activities of others. These strategies do not require the involvement of the clients. The client would understand that making positive lifestyle choices and discarding negative lifestyle choices contribute to illness prevention.

Which database can be used to find studies related to allied health sciences? a. EMBASE b. MEDLINE c. National Guidelines Clearinghouse d. Cochrane Database of Systematic Reviews

b. MEDLINE The MEDLINE database includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. EMBASE includes biomedical and pharmaceutical studies. The National Guidelines Clearinghouse includes a repository for structured abstracts about clinical guidelines and their development. It also includes a condensed version of the guidelines. The Cochrane Database includes full text of regularly updated systematic reviews prepared by the Cochrane Collaboration as well as completed reviews and protocols.

When teaching a health promotion class at a retirement home, which information would the nurse include about ways to decrease infection in older adults? a. Use handkerchiefs. b. Obtain flu vaccinations. c. Decrease dietary protein. d. Limit daily activity.

b. Obtain flu vaccinations. Older adults should obtain regular flu and pneumonia vaccinations to decrease the risk of infection. Disposable tissues should be used instead of handkerchiefs to prevent contamination. Not using disposable tissues leads to reuse of contaminated handkerchiefs. Dietary protein should be increased, and the client should include daily activity because this helps increase immunity.

Which client assessment finding would the nurse document as subjective data? a. Blood pressure 120/82 beats/min b. Pain rating of 5 c. Potassium 4.0 mEq d. Pulse oximetry reading of 96%

b. Pain rating of 5 Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

Which terminology system would the nurse use to enter nursing diagnoses, interventions, and outcomes in electronic health records? a. Omaha system b. Perioperative Nursing Data Set (PNDS) c. Nursing Interventions Classification (NIC) d. North American Nursing Diagnosis Association (NANDA) International

b. Perioperative Nursing Data Set (PNDS) The nurse would use a clear coding scheme while recording data in electronic health records because it helps prevent confusion and ambiguity. The PNDS provides codes for nursing diagnoses, interventions, and outcomes of treatment. The Omaha system provides codes for problem classification and intervention and a problem-rating scale for outcomes. NIC provides codes only for interventions. NANDA International provides codes only for nursing diagnoses.

Which cation regulates intracellular osmolarity? a. Sodium b. Potassium c. Calcium d. Calcitonin

b. Potassium A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. One, some, or all responses may be correct. a. Acute illness b. Pregnancy c. Drug abuse d. Chronic illness e. Sexual orientation

b. Pregnancy c. Drug abuse e. Sexual orientation Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? a. Sims position b. Prone position c. Supine position d. Knee-chest position

b. Prone position Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

Which is the purpose of respite care? a. Assisting the client with meals and personal care b. Providing short-term relief to the family caregiver c. Providing skilled nursing interventions for the client d. Providing counseling and treatment for behavioral problems

b. Providing short-term relief to the family caregiver Hospice programs focus on providing pain relief to the client. Some hospice programs also provide short-term relief or "time off" for the family caregiver. This enables the caregiver to leave the home to attend other activities while the client is looked after by a responsible person. Services in an assisted living facility include meals and personal care to the clients. A skilled nursing facility or an intermediate care facility provides skilled interventions such as intravenous administration of fluids, wound care, or long-term ventilator management. Psychiatric facilities provide counseling and treatment to clients for behavioral problems.

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? a. Ambulation b. Repositioning c. Purse-lipped breathing d. Deep breathing and coughing

b. Repositioning Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain. Ambulation is not specifically used to decrease postoperative pain. Purse-lipped breathing is primarily used to improve ventilation. Deep breathing and coughing are used to clear the respiratory tract.

Which characteristic indicates that nursing is a profession? a. Trained to perform specific tasks b. Required to follow a code of ethics c. Required to have a collection of specific skills d. Has limited autonomy in decision-making and practice

b. Required to follow a code of ethics Nursing is a profession because it follows a code of ethics, which is the philosophical ideals of right and wrong that defines the principles the nurse uses to care for the clients. Nursing is not just a collection of specific skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner. Nursing is a profession because nurses have autonomy in decision-making and practice in accordance with the state and federal laws and regulations. Nursing is a profession because its members must not only possess basic nursing education but extended education to explore new methods of health care.

The nurse is assessing a client after surgery. Which assessment finding would the nurse obtain from the primary source? a. X-ray reports b. Severity of pain c. Results of blood work d. Family caregiver interview

b. Severity of pain The primary source of information during an assessment is the client. The nurse gathers information about the client's pain from the primary source, the client. Medical records such as x-ray reports and results of blood work are secondary sources of information. The client's family caregiver is a secondary source of information.

Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes? a. Neuman's system theory b. Swanson's theory of caring c. Orem's self-care deficit theory d. Mishel's theory of uncertainty in illness

b. Swanson's theory of caring Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.

Which does beneficence in health ethics refer to? a. The agreement to keep promises b. Taking positive actions to help others c. The ability to answer for one's actions d. Avoiding harming or hurting an individual

b. Taking positive actions to help others Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Accountability refers to the ability to answer for one's actions. Nonmaleficence refers to avoiding harm to an individual.

In which situation would the nurse consider family members as the primary source of information? Select all that apply. One, some, or all responses may be correct. a. The client is an older adult. b. The client is an infant or child. c. The client is brought in as an emergency d. The client is critically ill and disoriented. e. The client visits the outpatient department.

b. The client is an infant or child. c. The client is brought in as an emergency d. The client is critically ill and disoriented. The nurse interviews the parents who care for the infant or child. Thus the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.

Which is the primary focus of nursing care in the "family as context" approach? a. The relationship among family members b. The health and development of an individual c. The ability of the family to meet its basic needs d. The family's process of caregiving for a sick member

b. The health and development of an individual In the "family as context" approach, the primary focus is the health and development of an individual in a specific environment. The relationship and family processes are the primary focus when the family is viewed as the client. When the family is viewed as the context, the focus is on the ability of the family to meet the basic needs of the individual, not its own needs. The process followed by the family when caring for the sick family member is assessed when the family is viewed as the client.

Which is the main focus of community health nursing? a. To meet the acute care needs of a population b. To improve the quality of health in a population c. To influence political processes affecting public policies d. To assess the health care needs of an individual or family

b. To improve the quality of health in a population Community health nursing is a nursing practice focusing on the health care of individuals, families, and groups within a community. Its main focus is to improve the quality of life and health of a population by preserving, protecting, promoting, or maintaining health. The acute and chronic care of an individual or family is provided by community-based nursing. Instead of focusing on institutional care, community-based nursing brings health care within the reach of the community. Factors influencing health services, such as a political process affecting public policies, are handled by public health nursing. Community-based nursing focuses on the fulfillment of the health care needs of an individual or family.

Which is the subset of clinical health care informatics? a. Clinical informatics b. Nursing informatics (NI) c. Public health informatics d. Clinical research informatics

b. nursing informatics NI is the subset of clinical health care informatics. This is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. Clinical health care informatics is a subdomain of clinical informatics. Public health informatics is one of the major domains of informatics that uses computer science and technology to improve public health. Clinical research informatics is a subdomain of clinical informatics.

Which statement demonstrates understanding of a computer-based client information system? a. "More medication errors are made when this system is used." b. "It is disappointing that nurses are not allowed to use this system." c. "Client information is immediately available when this system is used." d. "I will have less time to provide direct care to my clients with this system."

c. "Client information is immediately available when this system is used." The intent of these systems is to streamline documentation and recordkeeping for all appropriate health team members, including nurses. There is a reduction in medication errors with this type of system. Data are immediately available to appropriate health team members without the need to depend on record or chart availability. By streamlining documentation and recordkeeping, these systems increase opportunities for more direct client care by nurses.

Which is the most therapeutic response by the nurse to a client who is joking about dying? a. "Why are you always laughing?" b. "Your laughter is a cover for your fear." c. "Does it help to joke about your illness?" d. "The person who laughs on the outside cries on the inside."

c. "Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

The nurse has provided instructions about back safety to a client. Which statement by the client indicates understanding of these instructions? a. "I will carry objects about 18 inches from my body." b. "I will sleep on my stomach with a firm mattress." c. "I will carry objects close to my body." d. "I will pull rather than push when moving heavy objects."

c. "I will carry objects close to my body." By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

The nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage these people from bringing all that alternative medicine stuff to their family members. Which response by the nurse is correct? a. "Hospital policies should put a stop to this." b. "Everyone should conform to the prevailing culture." c. "Nontraditional approaches to health care can be beneficial." d. "You are right because they may have a negative effect on people's health."

c. "Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative effect on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

Which point listed by the nursing student is accurate regarding the loss of a client's medication records? a. "Loss of medical records may lead to libel charges." b. "The registered nurse would maintain accurate nursing records." c. "There is an assumption that the care provided to the client was negligent." d. "The health care facility needs to demonstrate why the medical records were lost."

c. "There is an assumption that the care provided to the client was negligent." In case a client's medical record is lost, there is an assumption that the care provided to the client was negligent. Loss of medical records may lead to a malpractice claim. The entire institution is responsible for maintaining medical records. Primary health care providers need to demonstrate why the medical records were lost.

Which would be a normal blood pressure of a 12-year-old client? a. 95/65 mm Hg b. 105/65 mm Hg c. 110/65 mm Hg d. 119/75 mm Hg

c. 110/65 mm Hg A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.

According to Freud's developmental theory, which age is considered the phallic stage? a. Birth to 18 months old b. 18 months to 3 years old c. 3 to 6 years old d. 6 to 12 years old

c. 3 to 6 years old According to Freud's developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage. Eighteen months to 3 years of age is the anal stage. Six to 12 years of age is the latent stage.

The registered nurse is teaching a nursing student about Erikson's theory of psychosocial development. To which age group does industry versus inferiority apply? a. 3 to 6 years b. 1 to 3 years c. 6 to 11 years d. Birth to 1 year

c. 6 to 11 years According to Erikson's theory of psychosocial development, industry versus inferiority applies to the 6 to 11 years of age group. Initiative versus guilt applies to the 3 to 6 years of age group. Autonomy versus sense of shame and doubt applies to the 1 to 3 years of age group. Trust versus mistrust applies to the birth to 1 year of age group.

The nurse is planning to provide self-care health information to several clients. Which client would the nurse anticipate will be most motivated to learn? a. A 55-year-old client who had a mastectomy and is very anxious about her body image b. An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking c. A 56-year-old client who had a heart attack last week and is requesting information about exercise d. A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

c. A 56-year-old client who had a heart attack last week and is requesting information about exercise A client who is requesting information is indicating a readiness to learn. When the nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse would encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container? a. Bubble wrap/packaging wrap b. A garbage bag in the trash can c. A cardboard box with a firmly secured lid c. A plastic liquid detergent bottle with a screw-top lid

c. A plastic liquid detergent bottle with a screw-top lid Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque, sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

Which describes a living will? a. A legal document that allows registered nurses to offer special skills to the public b. An order that directs primary health care providers to refrain from reviving clients c. A written document that directs treatment according to the client's wishes, in case of a terminal illness or condition d. A legal document that designates a person or persons chosen by a client to make health care decisions on his or her behalf

c. A written document that directs treatment according to the client's wishes, in case of a terminal illness or condition A living will is a written document that directs treatment on the basis of the client's wishes if he or she has a terminal illness or condition. A license allows registered nurses to offer special skills to the public. A do-not-resuscitate (DNR) order prevents primary health care providers from reviving clients or performing cardiopulmonary resuscitation (CPR). A durable power of attorney is a legal document that designates a person or persons chosen by a client to make health care decisions on his or her behalf when the client is unable to do so.

The nurse is preparing an intraoperative care plan for a client. Which intervention would be excluded from the care plan? a. Ensuring the client's skin integrity b. Reviewing the preoperative instructions c. Administering a general anesthetic to the client d. Placing the client in the correct position on the operating table

c. Administering a general anesthetic to the client Only anesthesiologists who are specially trained can administer anesthesia. The nurse would exclude this intervention from the nursing care plan. In the operating room, the nurse would ensure the client's skin integrity to prevent complications such as pressure sores. The nurse would review the preoperative care plan to establish or amend the plan if changes are required. The nurse would place the client in the correct position to prevent the client from injury during the operation.

Which describes the role of the nurse in this situation when he or she informs the health care provider the client is requesting pain medication after surgery? a. Educator b. Manager c. Advocate d. Administrator

c. Advocate The nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager uses appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services within a health care agency.

How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? a. A willful act violating a client's rights b. A civil wrong made against a person or property c. An act that lacks intent but involves volitional action d. An unintentional act that includes negligence and malpractice

c. An act that lacks intent but involves volitional action A quasi-intentional tort lacks intent but involves volitional actions such as invasion of privacy and defamation of character. An intentional tort is a willful act that violates another's rights. This includes assault, battery, and false imprisonment. A tort is a civil wrong made against a person or property. An unintentional tort involves negligence and malpractice.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? a. Red blood cell count b. Sputum culture c. Arterial blood gas d. Total hemoglobin

c. Arterial blood gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

Which nursing process would the nurse undertake when collecting the medical history of a client? a. Diagnosis b. Evaluation c. Assessment d. Implementation

c. Assessment The documentation of the client's information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the health care provider understand the client's history a make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client's problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client's problems and then the plan is implemented.

The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. Which standard of practice would the nurse perform? a. Planning b. Diagnosis c. Assessment d. Implementation

c. Assessment When the nurse collects comprehensive data relevant to the client's health or the situation, it is considered assessment. In the given scenario, the nurse is assessing the client to minimize pain. Planning refers to instances when the nurse develops a plan to attain expected outcomes. Diagnosis refers to instances when the nurse analyzes the assessment data to determine the diagnoses or issues. Implementation refers to instances when the nurse implements the identified plan.

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels? a. Contusion b. Thrombosis c. Atherosclerosis d. Tourniquet effect

c. Atherosclerosis In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

Which is an example of private indemnity health insurance? a. Medicare b. Medicaid c. Blue Cross Blue Shield Association d. State Children's Health Insurance Program

c. Blue Cross Blue Shield Association Private indemnity health insurance is purchased as a group policy by an employer for its employees or by individuals themselves. The Blue Cross Blue Shield Association is an example of a private indemnity health insurance provider. Medicare is a federally funded program. Medicaid and State Children's Health Insurance Program are state programs.

Which describes the rationale for not discussing a client's condition with another individual not directly involved in the client's care? a. Libel b. Negligence c. Breach of confidentiality d. Defamation of character

c. Breach of confidentiality The release of information to an unauthorized person or gossiping about a client's activities constitutes a breach of confidentiality and an invasion of privacy. Libel occurs when a person writes false statements about another that may injure the individual's reputation. Negligence is a careless act of omission or commission that results in injury to another. Defamation of character is the publication of false statements that injure a person's reputation.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find? a. Large area of petechiae b. Red birthmark that has recently become lighter in color c. Brown or black mole with red, white, or blue areas d. Patchy loss of skin pigmentation

c. Brown or black mole with red, white, or blue areas Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades with time. A patchy loss of skin pigmentation indicates vitiligo.

A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents which opportunistic infection? a. Cytomegalovirus b. Histoplasmosis c. Candida albicans d. Human papillomavirus

c. Candida albicans White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeast-like fungal infection. This condition is also known as " thrush." Cytomegalovirus may cause a serious viral infection in persons with human immunodeficiency virus (HIV), resulting in retinal, gastrointestinal, and pulmonary manifestations. Histoplasmosis is an infection caused by inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy. Human papillomavirus typically manifests as warts on the hands and feet, as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids, with some forms associated with cancerous and precancerous conditions.

Which ethical principles govern the nurse's behavior when making difficult decisions about a client's care at the point of care? a. Bioethics b. Metaethics c. Clinical ethics d. Research ethics

c. Clinical ethics Clinical ethics help in decision-making in issues that involve bedside client care and other client-related issues. The principles of bioethics govern ethical issues in biological sciences and technology. Metaethics is a branch of philosophy that deals with fundamental questions about concepts. Research ethics are applicable toward research subjects, whether human or animal.

A client who underwent a physical examination reports itching after 2 days. Which condition would the nurse suspect? a. Eczema b. Hypersensitivity c. Contact dermatitis d. Anaphylactic shock

c. Contact dermatitis A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

Which of these stages of health behavior will the nurse suspect in a client who is in a state of ambivalence? a. Preparation b. Maintenance c. Contemplation d. Precontemplation

c. Contemplation The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude toward a change; the client is most likely to accept that change in the next 6 months. The stage of preparation is exhibited when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about changes in his or her behavior.

Which competency in community-based practice is the nurse exercising when helping a client clarify health problems and choose appropriate courses of action? a. Educator b. Caregiver c. Counselor d. Epidemiologist

c. Counselor When the nurse helps a client identify and clarify health problems and choose appropriate courses of action to solve these problems, he or she is acting as a counselor. The nurse acts as an educator by establishing relationships with community service organizations. The nurse acts as an epidemiologist when he or she is involved in case finding, health teaching, and tracking incident rates of an illness. The nurse acts as a caregiver when he or she provides appropriate, individualized nursing care for specific clients and their families.

When would a medical examiner decide whether a postmortem examination needs to be conducted? a. A death under normal circumstances b. A client dies more than 48 hours after admission to the hospital c. Death within 24 hours of admission to the hospital d. A client gives a written consent before death for an autopsy to be performed

c. Death within 24 hours of admission to the hospital If a client dies within 24 hours of admission to the hospital, the medical examiner is required to decide whether a postmortem examination will be conducted. If a client dies under suspicious circumstances, the medical examiner decides whether a postmortem examination is necessary. The medical examiner does not make the decision regarding postmortem examination if the client dies more than 48 hours after being admitted to the hospital. A client may give a written consent before death to perform an autopsy. Such instances are not subject to the review of the medical examiner.

Which point needs correction regarding descriptive theories? a. The first level of theory development is a descriptive theory. b. The role of a descriptive theory is to explain, relate, and in some situations predict nursing phenomena. c. Descriptive theories help direct specific nursing activities. c. These theories describe phenomena, speculate on why they occur, and describe their consequences.

c. Descriptive theories help direct specific nursing activities. Descriptive theories do not direct specific nursing activities. Instead, they help explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.

The nurse working in a cardiac center is preparing to enter client data using health information technology. The nurse needs to refer to these data during subsequent follow-up client visits. Which type of record would the nurse use to enter the client's data? a. Personal health record (PHR) b. Electronic health record (EHR) c. Electronic medical record (EMR) d. Regional Health Information Organization (RHIO) health record

c. Electronic medical record (EMR) The EMR is a client's health record within a health care provider's facility. These records are not intended to be shared between multiple facilities and agencies. The PHR is self-recorded and maintained by the client. An EHR is an individual's official, digital health record; it is shared among multiple facilities and agencies. RHIO health records are client records that can be exchanged among providers and across geographic areas.

Which step in the nursing process would involve promoting a safe environment for the client? a. Planning b. Diagnosis c. Assessment d. Implementation

d. Implementation The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.

To prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care? a. Increase fluid intake. b. Restrict fluids. c. Encourage early mobility. d. Elevate the knee gatch of the bed.

c. Encourage early mobility. In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.

A client with chronic renal failure stops responding to the treatment. On examination, the primary health care provider determines that the client is terminally ill. Which is the correct nursing intervention in this situation? a. Suggest that the family members get a second opinion. b. Suggest that the family members continue to try different treatments. c. Encourage the family members to provide palliative care to the client. d. Inform the family members that the disease is no longer curable and the client will die shortly.

c. Encourage the family members to provide palliative care to the client. Clients who are terminally ill and no longer respond to treatment are in need of palliative care. Palliative care promotes client comfort and provides important interventions to support the client and family at the end of life. There is no need to get a second opinion from another primary health care provider, because the client is terminally ill. Continuing to attempt different treatments until the death of the client may cause more client suffering. It is not advisable to inform the family members that the client will die soon because it may lead to emotional stress. The palliative care team will help prepare the family for the client's death.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. a. Impaired vision b. Cognitive impairment c. Environmental hazards d. Inappropriate footwear e. Improper use of assistive devices

c. Environmental hazards d. Inappropriate footwear e. Improper use of assistive devices Environmental hazards, inappropriate footwear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.

The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle? a. Every 3 days b. Every 5 days c. Every 7 days d. Every 9 days

c. Every 7 days Best practice guidelines indicate that noncoring needles be changed at least every 7 days to decrease the risk for infection. Changing a noncoring needle every 3 to 5 days is too frequent and increases the risk for infection as well as client discomfort. Changing a noncoring needle every 9 days increases the risk for infection due to the prolonged length of time the needle is in place.

Which of these programs is least likely to focus on medication delivery process modification? a. Evaluation research b. Quality improvement c. Experimental research d. Performance improvement

c. Experimental research Experimental research is least likely to focus on medication delivery process modification. Quality improvement, evaluation research, and performance improvement are all likely to focus on medication delivery process modification to make the process better for the client.

Which assessment is expected when a client is placed in the lithotomy position during physical examination? a. Heart b. Rectum c. Female genitalia d. Musculoskeletal system

c. Female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

While inspecting the external eye structure of a client, the nurse finds bulging of the eyes. Which condition would be suspected in the client? a. Eye tumors b. Hypothyroidism c. Hyperthyroidism d. Neuromuscular injury

c. Hyperthyroidism Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

Which type of breathing pattern is manifested with hypercarbia? a. Eupnea b. Tachypnea c. Hypoventilation d. Kussmaul respiration

c. Hypoventilation Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration are interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul respiration.

Which point mentioned by the nursing student needs correction regarding grand theories of nursing? a. Require further specification through research b. Systematic and broad in scope and complex c. Include Mishel's theory of uncertainty in illness d. Do not provide guidance for specific nursing interventions

c. Include Mishel's theory of uncertainty in illness Mishel's theory of uncertainty in illness is not an example of a grand theory; it is a middle-range theory. Neuman's systems model is a grand theory. Grand theories require further specification through research. Grand theories are systematic and broad in scope and complexity. Grand theories do not provide guidance for specific nursing interventions; instead they provide the structural framework for broad and abstract ideas about nursing.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns would be expected in this client? a. Spoon-shaped nails b. Transverse depressions in nails c. Softening of nail beds and flat nails d. Red or brown linear streaks in nail bed

c. Softening of nail beds and flat nails Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron-deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.

The nurse is preparing to teach a community health program for senior citizens. Which physical findings would the nurse include that are typical in older adults? a. Increased skin elasticity and an increase in testosterone production b. Impaired fat digestion and an increase in pepsin production c. Increased blood pressure and decreased cardiac output d. An increase in body warmth and some swallowing difficulties

c. Increased blood pressure and decreased cardiac output With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse medication reactions.

A client tells the nursing assistant "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." Which conclusion would the nurse make about the nursing assistant's answer? a. It shows empathy. b. It uses distraction. c. It gives false reassurance. d. It makes a value judgment.

c. It gives false reassurance. A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

Which group benefits from Medicare? a. Self-insured employers b. People who are 65 years or older c. Members of low-income families d. Children who are not poor enough for Medicaid

c. Members of low-income families Medicare is a health insurance program for people 65 years or older. The payment for the plan is deducted from monthly individual Social Security checks. A preferred provider organization (PPO) plan is a contractual agreement between a set of providers and self-insured employers. It offers comprehensive health services at a discount to companies under contract. The Medicaid plan is a federally funded, state-run program that provides health insurance for low-income families. It finances a large portion of care for poor children, their parents, pregnant women, and disabled very poor adults. The State Children's Health Insurance Programs (SCHIP) is a federally funded, state-run program for children who are not poor enough for Medicaid.

According to Freud's developmental theory, which developmental age is called the latent stage? a. Toddler b. Preschool c. Middle childhood d. Adolescence

c. Middle childhood According to Freud's developmental theory, middle childhood age is the latent stage. Children in early childhood and toddlers are in the anal stage. Preschool-age children are in the phallic stage. Adolescents are in the genital stage.

The nurse has provided discharge instructions to a client who received a prescription for a walker. The nurse determines that the teaching has been effective when the client does which? a. Picks up the walker and carries it for short distances b. Uses the walker only when someone else is present c. Moves the walker no more than 12 inches (30.5 cm) during use d. States that a walker will be purchased on the way home from the hospital

c. Moves the walker no more than 12 inches (30.5 cm) during use Safety is always a consideration when teaching a client how to use an assistive device. The correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before the client leaves the hospital.

Which nursing action is legally required? a. Providing health teaching regarding family planning b. Offering first aid at the scene of an automobile collision c. Reporting incidents of suspected child abuse to the appropriate authorities d. Administering resuscitative measures to an unconscious child pulled from a swimming pool

c. Reporting incidents of suspected child abuse to the appropriate authorities The law requires the reporting of possible child abuse, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.

Which component of ethical decision-making refers to the duties and activities the nurse is employed to perform? a. Authority b. Autonomy c. Responsibility d. Accountability

c. Responsibility Responsibility refers to all duties and activities the nurse is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

Which site is best used to assess a client for jaundice? a. Skin b. Palm c. Sclera d. Conjunctiva

c. Sclera The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family of a terminally ill client who has died? a. Primary health care provider b. Pharmacist c. Social worker d. Occupational therapist

c. Social worker The social worker on the interprofessional team helps the family members prepare for the client's death and during the grief and bereavement process. The nurse involves the social worker in consoling the family members in this situation. The primary health care provider and pharmacist may not be involved in consoling the family members after the client's death, nor may the occupational therapist be involved at this stage

The nurse finds the orders from the primary health care provider inappropriate. Clarification from the health care provider does not resolve the nurse's doubts. Whom would the nurse contact and inform next? a. Risk manager b. Nursing student c. Supervising nurse d. Nurse administrator

c. Supervising nurse The nurse would go to the supervising nurse or follow the established chain of command if he or she finds any discrepancies in the primary health care provider's orders. All nurses must act as risk managers, depending upon the situation. The nurse in question would follow the established chain of command to address his or her doubts. A nursing student is still a novice and is too inexperienced to handle such matters. The nurse administrator manages client care and the delivery of specific nursing services within a health care agency; the nurse administrator is not the appropriate person to ask for help in solving the problem at hand.

Which statement made by a nursing student about Swanson's theory of caring needs correction? a. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. b. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. c. Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. d. Swanson's theory of caring was developed by conducting extensive interviews with clients and their professional caregivers.

c. Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. Swanson's theory of caring provides a basis for identifying and testing nurse caring behaviors to determine if caring will improve client health outcomes. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring was developed by conducting extensive interviews with clients and their professional caregivers.

Which definition of battery would the nurse include when teaching staff about legal terminology used in child abuse? a. Maligning a person's character while threatening to do bodily harm b. A legal wrong committed by one person against property of another c. The application of force to another person without lawful justification d. Behaving in a way that a reasonable person with the same education would not

c. The application of force to another person without lawful justification Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons, not property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

Which is the rationale for performing sponge, needle, and instrument counts in the operating room? a. The hospital is not liable if a client is injured resulting from a retained sponge or instrument. b. The nursing student is liable for client injuries resulting from a retained sponge or instrument. c. The nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. d. The primary health care provider is responsible for providing an accurate count of sponges and instruments.

c. The nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. The nurse would perform sponge and instrument counts in the operating room as part of routine surgical standards to help prevent injuries and lawsuits. If a client suffers from an injury resulting from a retained sponge or instrument, the hospital is liable if the nurse recorded an accurate count. A nursing student is not allowed to perform vital tasks such as counting sponges and instruments in the operating room. Even though the primary health care provider may insert sponges and instruments in a client, the provider relies on the nurse to maintain an accurate count at the end of the procedure.

A client presents to the health care facility with abdominal pain. Which question would the nurse ask the client to obtain information about concomitant symptoms? a. "Can you describe the pain?" b. "Where exactly do you feel the pain?" c. "Which activities make the pain worse?" d. "What other discomfort do you experience?"

d. "What other discomfort do you experience?" Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the correct response by the nurse? a. "You must keep up a strong appearance for him." b. "I think he'd have difficulty dealing with that now." c. "Don't you think he knows that without you telling him?" d. "You should share your feelings with him while you can."

d. "You should share your feelings with him while you can." It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him" impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now" denies that this is a time for closeness and honesty. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

The nurse notes that a client has mild hypothermia based on which body temperature? a. 29°C b. 30°C c. 33°C d. 35°C

d. 35°C Hypothermia occurs when the body temperature falls below 36.2°C. Based on the severity, it is classified as mild, moderate, and severe. Mild hypothermia refers to a body temperature of 34°C to 36°C (93.2°F-96.8°F). In this case, the client's body temperature is 35°C, which indicates mild hypothermia. Moderate hypothermia refers to a body temperature of 30°C to 34°C (86°F-93°F), and severe hypothermia refers to a body temperature below 30°C (86°F). The client does not have severe hypothermia; therefore, the client does not have a body temperature of 29°C. The client does not have moderate hypothermia; therefore, the client does not have a body temperature of 30°C or 33°C.

The nurse suspects that a client has interacted with poison ivy because assessment findings reveal vesicles on the arms and legs. Which is the description of a vesicle? a. A lesion filled with purulent drainage b. An erosion into the dermis c. A solid mass of fibrous tissue d. A lesion filled with serous fluid

d. A lesion filled with serous fluid A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule, an erosion into the dermis is known as an excoriation or ulcer, and a solid mass of fibrous tissue is known as a papule.

The nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which? a. A food allergy b. Noncompliance with medications c. Side effects from medications d. A nutritional deficiency

d. A nutritional deficiency All of the signs listed are classic for a poor nutritional state lacking in basic nutrients such as vitamins and protein. A specific food allergy or medication is not described; therefore there is not enough information to assume the signs and symptoms are related to either or to noncompliance with medications.

Which point requires correction regarding the use of restraints? a. Less restrictive interventions must have been unsuccessful before applying restraints. b. All other alternatives must have been tried and exhausted before applying restraints. c. Restraints may be applied to ensure the physical safety of the resident or other residents. d. A written order for restraints is not required.

d. A written order for restraints is not required. Restraints can be used only on the written order of a health care provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents.

Why would organizations promote transparency in health care? a. Creates effective insurance policies b. Helps determine whether medications are being diverted c. Facilitates recruitment of competent team members d. Allows continuous feedback for improving client outcomes

d. Allows continuous feedback for improving client outcomes Transparency means to be clear and unambiguous in the daily operations of a health care organization. Transparency allows continuous feedback for the consumers, which helps improve the clinical outcomes of the clients. Transparency is not related to the diversion of medications for a nontherapeutic purpose. Transparency may not contribute to better recruitment in the organization. Transparency in a health care organization is unrelated to insurance policies.

Which physical assessment technique involves listening to the sounds of the body? a. Palpation b. Inspection c. Percussion d. Auscultation

d. Auscultation Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs.

Which theory is based on the model of primacy of caring? a. Roy's theory b. Watson's theory c. Neuman's theory d. Benner and Wrubel's theory

d. Benner and Wrubel's theory The model of primacy of caring is the basis of Benner and Wrubel's theory. This theory focuses on client's need for caring as a means of coping with stressors of illness. According to Roy's theory, the goal of nursing is to help the client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. This theory promotes health, restoring the client to health, and preventing illness. Neuman's theory is based on stress and the client's reaction to the stressor.

The nurse is helping a client and her or his family to set and meet goals. Which professional role is the nurse displaying? a. Educator b. Advocate c. Manager d. Caregiver

d. Caregiver As a caregiver, the nurse helps the client and her or his family set goals. The nurse also assists them in meeting these goals with a minimal financial cost, time, and energy. The educator role is used to explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or client behavior, and evaluate the client's progress in learning. The advocator role helps protect the client's human and legal rights and provides assistance in asserting these rights if the need arises. In the manager role, the nurse coordinates the activities of members of the nursing staff and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency.

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which would be the reason for this temperature drop? a. Increased basal metabolic rate b. Decreased involuntary shivering c. Increased voluntary movements d. Decreased nonshivering thermogenesis

d. Decreased nonshivering thermogenesis Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

After abdominal surgery, a client reports pain. Which action would the nurse take first? a. Reposition the client. b. Obtain the client's vital signs. c. Administer the prescribed analgesic. d. Determine the characteristics of the pain.

d. Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

The nurse is reviewing a client's plan of care. Which is the determining factor in the revision of the plan? a. Time available for care b. Validity of the problem c. Method for providing care d. Effectiveness of the interventions

d. Effectiveness of the interventions When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

How will the nurse researcher categorize research in which subjects are given chlorhexidine and povidone-iodine as antiseptics? a. Evaluation research b. Descriptive research c. Correlational research d. Experimental research

d. Experimental research The nurse will categorize this study as experimental research. In experimental research, the investigator gives variables randomly to the subjects. In this case subjects are given chlorhexidine and povidone-iodine to test their efficacy in reducing infection. Evaluation research is an initial study that refines a hypothesis, such as testing a new exercise in older clients with dementia. In a descriptive study, the characteristics of a person or a situation are measured. For example, a researcher may examine nurses' bias while caring for obese clients. Correlational research is used to find out the relationship between different variables without the interference of a researcher. An example is determining the educational status of nurses and their satisfaction with their jobs.

Which legal complication might the nurse face for using a restraint without a legal warrant on a client? a. Libel b. Negligence c. Malpractice d. False imprisonment

d. False imprisonment If the nurse uses restraints without a legal warrant on a client, he/she may be charged with false imprisonment. Libel is the written defamation of character. Negligence is any conduct that falls below the standard of care. Malpractice is a type of negligence that is regarded as professional negligence.

Which feature, according to Benner, is observed in the nurse at the "proficient" level? a. Learns by means of a set of rules b. Identifies the principles of nursing care c. Identifies problems related to the health care system d. Focuses on managing care rather than managing skills

d. Focuses on managing care rather than managing skills The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills. The novice nurse learns by means of a set of rules, which are usually stepwise and linear. The advanced beginner has observational experience and is able to identify the principles of nursing care. The expert nurse is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse.

The nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How would the nurse proceed? a. Use the new product sample when changing the dressing. b. Cleanse the site with alcohol first and then with povidone-iodine. c. Cleanse the site with the new product first and then follow the agency's protocol. d. Follow the agency's policy unless it is contradicted by a primary health care provider's prescription.

d. Follow the agency's policy unless it is contradicted by a primary health care provider's prescription. Agency policy determines procedures; if the procedure is out of date or problematic, the nurse would contact the primary health care provider for a change in the prescription. The nurse cannot use another product without a primary health care provider's prescription. The nurse will be risking liability if agency policy is not followed, unless the prescription is changed by the primary health care provider.

Which opposing conflict would a middle-aged adult face according to Erikson's theory of psychosocial development? a. Integrity versus despair b. Intimacy versus isolation c. Identity versus role confusion d. Generativity versus self-absorption and stagnation

d. Generativity versus self-absorption and stagnation According to Erikson's theory of psychosocial development, a middle-aged adult is likely to face the opposing conflict generativity versus self-absorption and stagnation. An older adult is likely to face the opposing conflict integrity versus despair. A young adult may face the opposing conflict intimacy versus isolation. An adolescent may face the opposing conflict identity versus role confusion.

Which statement is true about the nursing model of team nursing? a. The registered nurse (RN) is responsible for all aspects of client care. b. Client care can be delegated to other members of the health care team. c. The registered nurse (RN) works directly with the client, family members, and health care team members. d. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

d. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model of total client care, the RN is responsible for all aspects of client care; care can be delegated from the RN to other members of the health care team; and the RN works directly with the client, family members, and members of the health care team.

An abscess develops in an obese adult after abdominal surgery. The wound is healing by secondary intention. Which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs? a. Low in fat and vitamin D b. High in calories and fiber c. Low in residue and bland d. High in protein and vitamin C

d. High in protein and vitamin C Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

Which step in the research process is similar to the assessment step of the nursing process? a. Analyzing the results b. Conducting the study c. Developing hypothesis d. Identifying the problem

d. Identifying the problem Identifying the problem, which includes reviewing literature, formulating a theoretical framework, and identifying the study variables is similar to assessment in the nursing process. Analyzing the results of research is similar to the evaluation phase of the nursing process. Conducting the study is similar to the implementation phase of the nursing process. Developing the hypothesis coincides with the diagnosis phase of the nursing process.

Which step of the nursing process does the nurse follow after being asked by the health care provider to administer a tetanus toxoid injection to a client with an open wound? a. Diagnosis b. Evaluation c. Assessment d. Implementation

d. Implementation The nurse will administer the tetanus as per the primary health care provider's regimen. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis is analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

The nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. Which is the category of the diagnostic error? a. Labeling b. Collecting c. Clustering d. Interpreting

d. Interpreting An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.

Which action indicates that the nurse is actively listening to the client? a. Stating personal opinions when the client is speaking b. Refraining from telling personal stories to the client c. Reading the client's health record during the conversation d. Interpreting what the client is saying and restating it for clarification

d. Interpreting what the client is saying and restating it for clarification The nurse is listening actively if what the client says is taken in. The nurse who is listening attentively interprets and reiterates what the client is saying in his or her own words. The nurse who states personal opinions when the client is speaking is being judgmental. A good listener would be able to establish rapport by exchanging personal stories with the client. If the nurse reads the client's health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

Which statement about Orem's theory needs to be corrected? a. It determines self-care needs. b. It explains the types of nursing care. c. It aids in the design of nursing interventions. d. It describes factors supporting the health of the family.

d. It describes factors supporting the health of the family. Orem's theory explains the factors within a client's living situation. These factors may support or interfere with the client's self-care abilities, but they do not refer to the family's health. This theory interprets data that determine a client's self-care needs, self-care deficits, and self-care abilities. Orem's theory explains, predicts, or describes nursing care that will help the client in bettering his or her health. The theory also aids in the design of nursing interventions for the promotion of self-care by the client during times of illness, such as asthma, diabetes mellitus, or arthritis.

The nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? a. Family in later life b. Family with adolescents c. Unattached young adult d. Launching children and moving on

d. Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescence stage of the family life cycle involves establishing flexible boundaries to accommodate the growing child's independence. Individuals experiencing the unattached young adult stage begin to differentiate themselves from their families of origin. The young adult establishes himself or herself at work while the young adult's parents experience the launching children and moving on stage.

The nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect? a. Clubbing b. Paronychia c. Koilonychia d. Normal finding

d. Normal finding The client's nail, which has a slight convex curve at the angle from the skin to nail base of about 160 degrees, is normal. In clubbing, there is a change in the angle between the nail and the nail base larger than 180 degrees. Paronychia is the inflammation of the skin at the base of nail. Koilonychia is the concave curves on the nail.

Which kind of health service would the nurse offer in a health promotion or primary care program? a. Home care b. Immunization c. Sports medicine d. Nutrition counseling

d. Nutrition counseling Health promotion or primary care focuses on improved health outcomes for the entire population. It includes nutrition counseling and health education. Home care is the provision of enabling medically related professional and paraprofessional services and equipment to clients and their families at home. Preventive care is more disease oriented. It focuses on reducing and controlling risk factors for diseases through immunizations and occupational health programs. Sports medicine is a form of restorative care. The goal of this program is to help individuals regain maximum functional status through promotion of independence and self-care.

The nurse working in a Catholic hospital discourages clients from using contraceptives per hospital policy. Which category of ethics is the nurse following? a. Societal ethics b. Research ethics c. Professional ethics d. Organizational ethics

d. Organizational ethics Organizational ethics help ensure smooth ethical operation of an organization. These ethical codes include sets of rules and regulations to guide the actions and behavior of the members of the organization. Societal ethics are norms that serve a large community and involve legal and regulatory mechanisms. Research ethics are applicable to those conducting research involving human and animal subjects. Professional ethics involve a set of ethical standards and expectations for members of that profession, but unlike organizational ethics, they may apply to many different companies.

A client complains of pain in the ear. While examining the client, the nurse finds swelling in front of the left ear. Which lymph node would the nurse expect to be involved? a. Mastoid b. Occipital c. Submental d. Preauricular

d. Preauricular The preauricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing? a. Action b. Preparation c. Maintenance d. Precontemplation

d. Precontemplation The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to 6 months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins 6 months after the change has started and continues indefinitely.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse would identify which ocular problem common to persons at this client's developmental level? a. Tropia b. Myopia c. Hyperopia d. Presbyopia

d. Presbyopia Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

Which would the nurse consider the most significant influence on a client's perception of pain when interpreting findings from a pain assessment? a. Age and sex b. Physical and physiological status c. Intelligence and economic status d. Previous experience and cultural values

d. Previous experience and cultural values Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain, so it can be tolerated better, but it does not affect the perception of intensity. Economic status has no effect on pain perception.

Which is the primary focus of the nurse when providing evidence-based care to the client? a. Practice trends b. Research studies c. Clinical experience d. Problem-solving approach

d. Problem-solving approach Evidence-based practice is first and foremost a problem-solving approach to care. This problem-solving approach incorporates application of current best practice along with knowledge from research studies and clinical expertise.

The nurse at a community health care center focuses on providing primary preventive care. Which is the focus of primary preventive care? a. Rehabilitating the client b. Treating early stages of disease c. Preventing complications from illness d. Promoting health in healthy individuals

d. Promoting health in healthy individuals Primary prevention precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.

Which explanation regarding the term "just culture" is accurate? a. Agreement to keep promises b. Taking positive actions to help others c. Ability to answer for one's actions d. Promoting open discussion whenever error occurs without fear of recrimination

d. Promoting open discussion whenever error occurs without fear of recrimination The term just culture refers to the promotion of open discussion whenever errors occur without fear of recrimination. Fidelity refers to the agreement to keep promises. Beneficence refers to taking positive actions to help others. Accountability refers to the ability to answer for one's actions.

Which physical assessment of the skin indicates that a client is addicted to phencyclidine? a. Burns b. Vasculitis c. Diaphoresis d. Red and dry skin

d. Red and dry skin Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.

Which of these is true about SOAP progress note method? a. The A in SOAP stands for action. b. The P in SOAP stands for problem. c. SOAP progress notes have a nursing origin. d. SOAP progress notes include assessment information.

d. SOAP progress notes include assessment information. SOAP progress notes include assessment information or diagnoses based on data. The A in SOAP stands for assessment, not action. The P stands for plan, not problem. SOAP progress notes originate from medical records.

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern would the assessment include? a. Value-belief pattern b. Role-relationship pattern c. Cognitive-perceptual pattern d. Self-perception-self-tolerance pattern

d. Self-perception-self-tolerance pattern The nurse is applying Gordon's self-perception-self-tolerance pattern to assess the client. This functional pattern describes the client's self-worth, emotional patterns, and body image. The value-belief pattern describes patterns of values, beliefs, spiritual practices, and goals that guide the client's choices or decisions. The role-relationship pattern describes patterns of role engagements and relationships. The cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability.

The nurse recognizes which mental process is associated with deterioration that accompanies aging? a. Judgment b. Intelligence c. Creative thinking d. Short-term memory

d. Short-term memory During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.

The home health care nurse visits a client who lives with her two grandchildren. Which term would the nurse use to define this family form? a. Nuclear family b. Extended family c. Single-parent family d. Skip-generation family

d. Skip-generation family A skip-generation family is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

Where is the nurse positioned when performing a Romberg test? a. Sitting next to the client b. Standing behind the client c. Standing in front of the client d. Standing to the side of the client

d. Standing to the side of the client The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to rescue an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side.

Which integumentary finding is related to skin texture? a. Elasticity b. Vascularity c. Fluid buildup d. Surface character

d. Surface character Assessing for texture refers to evaluating the character of the surface of the skin. Assessing for elasticity refers to determining the turgor of the skin. Assessing for vascularity refers to determining skin circulation. Fluid buildup in the tissues indicates edema.

A community health care nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? a. The children are underimmunized and at risk for childhood illnesses. b. The children are more likely to drop out of school and become unemployable. c. The children have access to health care only through the emergency department. d. The children do not have a physical shelter and may sleep outdoors or in vehicles.

d. The children do not have a physical shelter and may sleep outdoors or in vehicles. Public health organizations use the term absolute homelessness to describe people who have no physical shelter. These children sleep outdoors, in vehicles, abandoned buildings, or other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety. Children experiencing both absolute and relative homelessness tend to be underimmunized and are at risk for childhood illnesses. Both types of homeless children are unable to meet residency requirements for public schools and are more likely to drop out of school and be rendered unemployable. A lack of finances leads both types of homeless children to seek health care only in emergency conditions.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. Which is it important for the nurse to inform the client of? a. The client is acting irresponsibly. b. This action violates the hospital policy. c. The client must obtain a new primary health care provider for future medical needs. d. The client must accept full responsibility for possible undesirable outcomes.

d. The client must accept full responsibility for possible undesirable outcomes. The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for the illness and possible injury or undesirable outcomes. Health care professionals have a responsibility to inform the client and, if possible, have the client sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current primary health care provider will refuse to provide care to the client in the future.

According to Avedis Donabedian, which is the most important validator of quality and effectiveness of health care in a hospital? a. The number of clients admitted in a hospital b. The values and goals presented by the hospital c. The number of health care workers in the hospital d. The client outcomes achieved by the care provided

d. The client outcomes achieved by the care provided Avedis Donabedian was a physician and founder of the Donabedian model of care. According to him, the client outcomes obtained by health care delivery determine the quality and effectiveness of the health care. The number of clients admitted to a hospital does not indicate the quality of the health care delivered in the hospital. The values and goals presented by the hospital define the quality of the medical system. Similarly, the number of health care workers in the hospital does not determine the quality or effectiveness of the health care system.

Which statement is true for collaborative problems in a client? a. They are the identification of a disease condition. b. They include problems treated primarily by nurses. c. They are identified by the primary health care provider. d. They are identified by the nurse during the nursing diagnosis stage.

d. They are identified by the nurse during the nursing diagnosis stage The nurse assesses the client to gather information for reaching diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary health care provider based on the results of diagnostic tests.

Which is the goal of Healthy People 2020? a. To ensure the well-being of clients cared for in a hospital setting b. To encourage the nurse to do good for the client c. To have the nurse act as an advocate for clients who are not capable of self-determination d. To eliminate health disparities related to race, ethnicity, and socioeconomic status

d. To eliminate health disparities related to race, ethnicity, and socioeconomic status The primary goal of Healthy People 2020 is to eliminate health disparities related to race, ethnicity, and socioeconomic status. This helps increase the quality of health care and help people live longer. Nonmaleficence is the ethical concept that emphasizes the importance of preventing harm and ensuring the client's well-being. Beneficence is the ethical concept that encourages the nurse to do good for the client. According to the American Nurses Association (ANA) Code of Ethics for Nurses (2010), if the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate within the professional scope of nursing practice.

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow. 1. Self-esteem 2. Self-actualization 3. Safety and security 4. Physiological needs 5. Love and belonging needs

physiological needs- safety and security needs- love and belonging needs- self-esteem needs- self-actualization

Arrange the services of the Health Services Pyramid in ascending order from the base of the pyramid to the top. 1. Clinical preventive services 2. Primary health care services 3. Tertiary health care services 4. Population-based health care services 5. Secondary health care services

population-based health care services- clinical prevention services- primary health care services- secondary health care services- tertiary healthcare services The first level is population-based health care services with the goals of disease prevention, health protection, and health promotion. It provides the basis for the second level which is clinical preventive services. Achievements in these two levels of the pyramid contribute to the improvement in health care delivered by the higher levels. The third level is the primary health care services, which focuses on improved health outcomes for the entire population. It requires collaboration among health professionals, health care leaders, and community members. The fourth level is secondary health care. It includes acute medical-surgical care and diagnostic procedures. The highest level of the pyramid is tertiary health care, which includes intensive care.

Which is the correct order of phases a client experiences in the event of a change in body image? 1. Acceptance 2. Shock 3. Withdrawal 4. Rehabilitation 5. Acknowledgement

shock- withdrawal- acknowledgement- acceptance- rehabilitation When a client experiences a change in body image, the client adjusts to the condition in five phases. The initial reaction is that of shock. The client is in shock and tries to depersonalize it by discussing it as happening to someone else. As the client and family begin to recognize the reality of the change, they enter the withdrawal phase. They become anxious and refuse to discuss the subject. Then the client enters the acknowledgment phase. The client and family begin to acknowledge the condition and move through a period of grieving. By the end of the acknowledgment phase, they are ready to accept the loss and move into the acceptance phase. They realize the need for rehabilitation. During the rehabilitation phase, the client is ready to learn to use the prosthesis or change lifestyles or goals.