EAQ NCLEX

Which would the nurse document for a client with drooping of the eyelid over the pupil? 1. Ptosis 2. Ectropion 3. Entropion 4. Nystagmus

1. 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 irrigation of the conjunctiva and cornea. Nystagmus is an involuntary oscillation of the eye, and usually occurs after an eye injury.

Which assessment is expected when a client is placed in lithotomy position during physical examination? 1. Heart 2. Rectum 3. Female genitalia 4. Musculoskeletal system

3. 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.

Which is appropriate for the nurse to include in the education of the ethical principle of nonmaleficence to a group of nursing students? 1. Treat all clients equitably and fairly 2. Act in ways to prevent harm to clients 3. Tell the client the truth about their health 4. Help the clients make informed choices

2. 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.

Under which type of health care services would the nursing student include subacute care? 1. Tertiary care 2. Continuing care 3. Restorative care 4. Secondary acute care

1. Tertiary care * The nursing student would include subacute care under tertiary care. Subacute care is not a part of continuing care, restorative care, or secondary acute care health care services.

Which caring intervention helps provide comfrot, dignity, respect, and peace to a client? 1. Listening 2. Spiritual caring 3. Providing presence 4. Relieving pain and suffering

4. Relieving pain and suffering * Relieving pain and suffering is not just about giving medications but includes providing comfort, dignity, respect, and peace to a client. Listening helps obtain meaning interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps convey closeness and a sense of caring.

The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty? 1. Caring 2. Veracity 3. Advocacy 4. Confidentiality

3. 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 characteristics 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 nursing practice is associated with a self-regulation skill? 1. Reflecting on one's experience 2. Reflecting on one's own behavior 3. Supporting one's findings and conclusions 4. Clarifying any data that one is uncertain about

1. 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.

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)? 1. National Institutes of Health (NIH) 2. American Medical Informatics (AMIA) 3. Center for Medicare and Medicaid Services (CMS) 4. Health Information Management Systems Society (HIMSS)

3. Center for Medicare and Medicaid Services (CMS) * CMS rules specify how health care facilities and providers make meaningful use of the EHRs and technologies to receive payment from Medicare and Medicaid. The NIH uses translational bioinformatics for medical research. The AMIA and the HIMSS have been involved in identifying nursing informatics competencies

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? 1. Analysis 2. Inference 3. Explanation 4. Interpretation

3. Explanation * Explanation requires knowledge and experience for choosing strategies for care for clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. the skill of interference is associated with noticing relationship in the findings. Interpretation is associated with order data collection.

Which critical thinking skill is being used when the nurse applies knowledge and experience to client care? 1. Analysis 2. Evaluation 3. Explanation 4. Interpretation

3. Explanation * When the nurse is using experience to care for clients, the critical thinking skill of explanation is being applied. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

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? 1. Mastoid 2. Occipital 3. Submental 4. Preauricular

4. 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.

Under which type of health care services would the student nurse include sports medicine? 1. Primary care 2. Tertiary care 3. Preventive care 4. Restorative care

4. 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 is conducting a client interview. Which response by the nurse is an example of back channeling? 1. "All right, go on..." 2. "What else is bothering you?" 3. "Tell me what brought you here.? 4. "How would you rate your pain on a scale of 0 to 10?"

1. "All right go on..." *Back channeling involves the use of active listen 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.

Which antipyretic medication may cause Reye syndrome in children? 1. Aspirin 2. Naproxen 3. Ibuprofen 4. Dantrolene

1. Aspirin * Aspirin increases the risk of swelling in the brain and liver, which are the main symptoms of Reye Syndrome in children. Aspirin is not recommended in children. Medications such a naproxen and ibuprofen do not include swelling in the brain and liver; therefore, these medications may not cause Reye syndrome. Dantrolene does not include swelling in the brain and liver; instead, it decreases calcium levels during malignant hyperthermia conditions.

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? 1. Contact an interpreter provided by the hospital 2. Contact the clients family member to translate for the client 3. Communication with the client using Spanish phrases the nurse learned in a college coarse 4. Communication with the client with the use of a hospital approved Spanish dictionary

1. 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 clients care. The other options do not ensure accurate interpretation of language.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assess the respiratory rate. Which is the purpose of the nurses' action? 1. Data collection 2. Data validation 3. Data clustering 4. Data interpretation

1. Data collection *The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that must be supported by data obtained during the physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. The grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

The nurse on the medical-surgical unit tells others staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink to much." Which does this nurse's comment reflect? 1. Demonstration of a personal bias 2. Problem-solving based on assessment 3. Determination of client acuity to set priorities 4. Consideration of the complexity of client care

1. Demonstration of a personal bias * When nurses make judgmental remarks and clients needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments would be objective, not subjective and biased. There is no information about the clients acuity to come to this conclusion regarding priorities. The statement does not reflect information about complexity of care.

Which describes the purpose of the Nurse Practice Acts? 1. Describe and define the legal boundaries of nursing practice within each state 2. Reflect the knowledge and skills possessed by nurses practicing in their profession 3. Legal requirements that describe the minimum acceptable nursing care 4. Protect individuals from losing their health insurance when changing jobs by providing portability

1. Describe and define the legal boundaries of nursing practice within each state * The Nurse Practice Act 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 is the role of the nurse explaining the reason for the intravenous infusion and kit to the client? 1. Educator 2. Manager 3. Advocate 4. Caregiver

1. Educator * The nurse assumes the role of educator when explaining to the client that need for an intravenous infusion. The nurse as a manager oversees the budget of a specific nursing unit or agency and is also responsible for coordinating the activates of the staff providing nursing care. As an advocate, the nurse protects the human and legal rights of the client. The nurse empowers the client with information required to make important health care decisions. The nurse is a caregiver when helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? 1. Elevate the head of the bed between 30 and 45 degrees 2. Decrease flow rate at night 3. Check for residual daily 4. Irrigate regularly with warm tap water

1. 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 an 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.

The nurse is discussing discharge plans with a client. The client stated, "I'm worried about going home." The nurse responds, "Tell me more about this." Which interviewing technique did the nurse use? 1. Exploring 2. Reflecting 3. Refocusing 4. Acknowledging

1. Exploring * Exploring is a technique used to obtain more information to better understand the nature of the clients statement. Reflecting is a technique used to either reiterate the content or feeling message. In content flection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalized 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 is the goal of school health nursing programs? 1. Health promotion 2. Disease management 3. Chronic care management 4. Environmental surveillance

1. 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 management. The occupational health nurse may conduct environment surveillance for health promotion and accident prevention in the work setting.

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? 1. Immediately involve pastoral services while caring for the client 2. Involve the family member in the client's care instead of pastoral support 3. Listen to the client's request for support and then carry on with the clinical work 4. Falsely promise that pastoral services have been contacted and plan to see the client

1. 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 of giving false promises can cause loss of trust by the client.

A client does not take his or her medication regularly and is depressed. Which inference can the nurse make about the client's motivational level? 1. Not motivated 2. Intrinsically motivated 3. Extrinsically motivated with self determination 4. Extrinsically motivated without self-determination

1. Not motivated *If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking the medications on his or her own rather then because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when he or she may take medication regularly when reminded to do so or when pressured by others.

Which member of the inter-professional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? 1. Nurse 2. Pharmacist 3. Music therapist 4. Primary health care provider

1. 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 inter-professional team evaluates the physical, emotional, and spiritual needs of the client and provides referrals to other members of the team. The primary health care provider assesses the client 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 nursing theory is the inspiration for self-care? 1. Orem's theory 2. Leininger's theory 3. Henderson's theory 4. Neuman's theory

1. Orem's theory * Orem's self-care deficit theory focuses on the client's self-care needs. Orem defines self-care as a learned, goal oriented activity directed toward the self in the interest of maintaining life, health, development, and well-being. Leininger's theory is based on providing care consistent with nursing's emerging science and knowledge, with caring as the central focus. Henderson's theory involves working interdependently with other health care workers. Neuman's theory is based on stress and the client's reaction to the stressor.

How are profits use din a for-profit care organization? 1. Profits are paid out to shareholders 2. Profits are used to buy new equipment 3. Profits are used to build additional facilities 4. Profits are invested in improving health care services

1. Profits are paid out to shareholders * Health care organizations can be classified as for-profit and not-for-profit based on how the profits are distributed. In a for-profit organization, the profits are generated for the shareholder. In a not-for-profit organization, the profits are used to buy new equipment, build additional facilities, and improved health care services.

Which signs and symptoms are observed in the human body with a decrease in body temperature? Select all that apply. One, some, or all responses may be correct. 1. Shivering 2. Profuse sweating 3. Flushed appearance 4. Dilation of blood vessels 5. Contraction of blood vessels

1. Shivering 5.Contraction of blood vessels *A client who has decreased body temperature may experience shivering due to contraction of the blood vessels in the body. The client who has decreased body temperature may not experience profuse sweating, flushed appearance, and dilated blood vessels. These signs and symptoms appear with an increase in body temperature.

A client has been placed used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? 1. The local hazardous waste collection site 2. The regular household trash 3. The local health department for disposal 4. The Environmental Protection Agency (EPA) through the mail

1. The local hazardous waste collection site * Each stated (province) has its own waste management guidelines for proper disposal of sharps containers, as well as hazardous waste collection sites. Clients cannot place needles in the regular household trash because sharps were considered medical waste. The local health department does not collect sharps containers. Sharps containers are not mailed directly to the EPA.

A client is likely to undergo reconstructive surgery for which purpose? 1. To restore function and/or appearance 2. To replace an organ or tissue 3. To relieve or reduce symptoms 4. To remove or excise an organ or tissue

1. 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 form 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 pulse site is used to perform Allen test? 1. Ulcer 2. Brachial 3. Femoral 4. Dorsalis pedis

1. Ulnar * The ulnar pulse site is used to perform Allen test. The brachial pulse site is used to asses the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

According to Quality and Safety Education for Nurses (QSEN), which defines patient-centered care? 1. Understanding that the client is the source of control when providing care 2. Functioning effectively within nursing and interprofessional teams to deliver quality care 3. Using data to evaluate outcomes of care processes and designing methods to improve health care 4. Minimizing the risk for harm to clients and health care workers through improved professional performance.

1. 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 sources 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 improves the health care delivery system. Safety focuses on minimizing the risk for harm to clients and health care workers through improved professional performance.

The nurse is assessing a client who underwent abdominal surgery 10 day ago. The client complains of pain in the abdomen. Which type of pain would the client experience. 1. Visceral pain 2. Somatic pain 3. Referred pain 4. Intractable pain

1. Visceral pain * Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other then its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.

Which is the definition of a tort? 1. The application of force to the body of another by a reasonable individual 2. An illegality committed by one person against the property or person of another 3. Doing something that a reasonable person under ordinary circumstances would not do 4. An illegality committed against the public and punishable by the law through the courts

2. An illegality committed by one person against the property or person of another * An individual is held legally responsible for actions committed against another individual or an individuals property. The application for force to the body of another is battery, which involves physical harm. Doing something that a reasonable person under ordinary circumstances would not do is the definition of negligence. An illegality committed against the public and punishable by the law through the courts is the definition of a crime.

The nurse records the clients weight and body mass index (BMI) at a health range, but the client states, "I wish I were as thin as my coworkers." Which culturally bound condition is the client at risk for? 1. Neurasthenia 2. Anorexia nervosa 3. Shenjing shuairuo 4. Ataque de nervios

2. Anorexia nervosa * Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latin0-Caribbean culture-bound syndrome and is not associated with body image.

Which is the action of an antidiuretic hormone (ADH)? 1. Reduces blood volume 2. Decreases water lose in urine 3. Increases urine output 4. Initiates the thirst mechanism

2. Decreases water loss in urine * ADH is released by the posterior pituitary gland. It is released mainly in response to wither 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 factor is used to assess the quality of health care provided to a client? 1. Fall-prevention measures employed for the client 2. Functional health status of the client after discharge 3. Hand hygiene practiced by the health care personnel 4. Teamwork and coordination among health care personnel

2. Functional health status of the client after discharge * Health care providers determine the quality of care provided to the client by measuring outcomes that show how the clients health status has changed. one method of measuring the quality of health care provided to the client after discharge. The nursing staff would take necessary fall prevention measures for the client; however, this is not a measurable outcome. All health care personnel would practice hand hygiene to prevent infection, which is a quality measure, not an outcome of health care. Teamwork and coordination among health care personnel are important to provide efficient health care to the client. They are not outcomes of health care.

The nurse changing the dressin on the clients perineum would fall into which zone? 1. Public zone 2. Intimate zone 3. Personal zone 4. Vulnerable zone

2. Intimate zone * Changing a clients 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 19 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 clients bedside, taking a clients history, or teaching a client individually. The vulnerable zone is where special care is needed.

Which statement accurately describes a health care policy as it relates to health care economics? 1. It related to maintaining standards of health care and achieving outcomes related to the goals of health care. 2. It provides overarching goals and helps in setting priorities and values for the distribution of health resources. 3. It governs the insurance industry and plays a very important role in the application of health care funding and reform. 4. In involves the collaboration of health care workers and other resources required to perform all required client care activities.

2. It provides overarching goals and helps in setting priorities and values for the distribution of health resources. * A health care policy provides overarching goals and helps in setting priorities and values for the distribution of health resources. Health care quality related to issues surrounding standards of care and health care outcomes. Health care coordination involves the collaboration between health care professionals and other resources, which are required to deliver client care. Health care law is a governing factor in health care economics and plays a vital role in the application of health care funding and reform.

Which database can be used to find studies related to allied health sciences? 1. EMBASE 2. MEDLINE 3. National Guidelines Clearinghouse 4. Cochrane Database of Systemic Reviews

2. MEDLINE *The MEDLINE database includes studies in medicine, nursing dentistry, psychiatry, veterinary medicine, and allied health. EMBASE includes biochemical and pharmaceutical studies. The National Guideline 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 systemic reviews prepared by the Cochrane Collaboration as well as completed reviews and protocols.

Which is an appropriate action for the registered nurse regarding assisted suicide? 1. Nurses may have an open attitude towards the clients end of life 2. Nurses participate in assisted suicide violates the code of ethics 3. Nurses may listen to the clients expression of fear and attempt to control the clients pain 4. Nurses can participate in assisted suicide only if the individual could make an oral and written request

2. Nurses participate in assisted suicide violates the code of ethics * According to the American Nurses Association (ANA), the nurses participation in assisted suicide would violate there code of ethics. According to the American Association of Colleges of Nurses (AACN) and the International Council or Nurses, the nurse may have an open attitude towards the clients end of life. According to the AACN and the International Council of Nurses, nurses may listen to the clients expressions of fear and attempt to control the clients pain. According to the Oregon Death with Dignity Act (1994), the primary health care provider in the state of Oregon can participate in assisted suicide only if an individual with a terminal disease makes an oral and written request to end his or her life in a humane and dignified manner.

Which is the subset of clinical health care informatics? 1. Clinical informatics 2. Nursing informatics (NI) 3. Public health informatics 4. Clinical research informatics

2. Nursing informatics (NI) * 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 group benefits from Medicare? 1. Self-insured employers 2. People who are 65 years or older 3. Members of low-income families 4. Children who are not poor enough for Medicaid

2. People who are 65 years or older *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.

Which cation regulates intracellular osmolarity? 1. Sodium 2. Potassium 3. Calcium 4. Calcitonin

2. 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.

The nurse is assessing a client after surgery. Which assessment finding would the nurse obtain from the primary source? 1. X-ray reports 2. Severity of pain 3. Results of blood work 4. Family caregiver interview

2. Severity of pain * The primary source of information during an assessment is the client. The nurse gathers information about the clients 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 clients family caregiver is secondary source of information.

Which statement defines the term "family resiliency?" 1. Each family is unique 2. The family has an ability to cope with stressors 3. An interfamilial structure and support system exist 4. The family has the ability to transcend lifestyle changes

2. 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 extents 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.

A 50-year-old client seen for a routine physical asks why a stool specimen for occult blood testing has been ordered. Which is the correct nursing response? 1. "You will need to ask your health care provider; it is not part of the usual tests for people your age." 2. "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3. "It is performed routinely starting at your age as part of an assessment for colon cancer." 4. "There must have been a positive finding after a digital rectal examination performed by your health care provider."

3. "It is performed routinely starting at your age as part of an assessment for colon cancer." * The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40 years. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

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? 1. Educator 2. Manager 3. Advocate 4. Administrator

3. 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 used appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services with a health care agency.

Which of these programs is least likely to focus on medication delivery process modification? 1. Evaluation research 2. Quality improvement 3. Experimental research 4. Performance improvement

3. 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 physical skin finding indicated opioid abuse? 1. Diaphoresis 2. Red, dry skin 3. Needle marks 4. Spider angiomas

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

Which site is best used to assess a client for jaundice? 1. Skin 2. Palm 3. Sclera 4. Conjunctiva

3. 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 conjunctive are inspected to assess pallor.

Which variable is an example of an external variable? 1. Spiritual factors 2. Developmental issues 3. Socioeconomic factors 4. Perception of functioning

3. Socioeconomic factors *Socioeconomic factors are considered to be external variable. Spiritual factors, development issues, and the perception of functioning are internal variables.

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? 1. "You must keep up a strong appearance for him." 2. "I think he'd have difficulty dealing with that now." 3. "Don't you think he knows that without you telling him?" 4. "You should share your feelings with him while you can."

4. "You should share your feelings with him while you can." * It is difficult to work through loss; however, encouraging the sharing of feeling 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 not 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 honestly. 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? 1. 29 C 2. 30 C 3. 33 C 4. 35 C

4. 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 - 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 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 is assessing a clients degree of edema and finds 8mm of depth. Which would be correct of depth. Which would be correct to document? 1. 1+ 2. 2+ 3. 3+ 4.4+

4. 4+ * Edema of 8mm is documented at 4+. If the edema has a depth of 2mm, then it is documented as 1+. If the edema has a depth of 4mm, it is documented at 2+. If the edema has a depth of 6mm, then it is documented as 3+.

Which potential health problem would the nurse include in the young adults discharge teaching? 1. Kidney disfunction 2. Cardiovascular diseases 3. Eye problems, such as glaucoma 4. Accidents, including their prevention

4. Accidents, including their prevention *Accidents are common during young adulthood because of immature judgement and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

Which theory is based on the model of primacy of caring? 1. Roy's theory 2. Watson's theory 3. Neuman's theory 4. Benner and Wrubel's theory

4. Benner and Wrubel's theory * The model of primacy of caring is the basis of Benner and Wrubel's theory. This theory focuses on clients 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. Watsons theory of transpersonal caring defines the outcome of nursing activity regarding 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 clients reaction to the stressor.

The nurse applies a cold pack to relieve musculoskeletal pain. Which rational explains the analgesic properties of cold therapy? 1. Promoting analgesic and circulation 2. Numbing the nerves and dilating the blood vessels 3. Promoting circulation and reducing muscle spasms 4. Causing local vasoconstriction, preventing edema and muscle spasm

4. Causing local vasoconstriction, preventing edema and muscle spasm *Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and muscle spasms. Cold does promote analgesic but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, this reducing pain.

Which interview technique is the nurse using when asking a client to score his or her pain on a scale from 0 to 10? 1. Probing 2. Back channeling 3. Open-ended questioning 4. Closed-ended questioning

4. Closed-ended questioning *Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. When a client says something, a response by the nurse such as "All right" or "Go on" is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of the story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.

How will the nurse researcher categorize research in which subjects are given chlorhexidine and povidone-iodine as antiseptics? 1. Evaluation research 2. Descriptive research 3. Correlational research 4. Experimental research

4. 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 the 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. Correlation research is used to find out the relationship between different variables without the interference of a 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? 1. Libel 2. Negligence 3. Malpractice 4. False imprisonment

4. 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 opposing conflict would a middle aged adult face according to Erikson's theory of psychosocial development? 1. Integrity versus despair 2. Intimacy versus isolation 3. Identify versus role confusion 4. Generativity versus self-absorption and stagnation

4. 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.

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 clients immediate nutritional needs? 1. Low in fat and vitamin D 2. High in calories and fiber 3. Low i residue and bland 4. High in protein and vitamin C

4. 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 nursing process would involves promoting a safe environment for the client? 1. Planning 2. Diagnosis 3. Assessment 4. Implementation

4. 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 clients health and situation during the assessment stage.

Which interval variable influences health benefits and practices? 1. Family practices 2. Culture background 3. Socioeconomic factors 4. Intellectual background

4. Intellectual background * Intellectual background is an internal factor that affects the clients health beliefs and practices. A clients knowledge, educational background, and past experiences influence how a client thinks about health. Family practices, cultural background, and socioeconomic factors are among the external factors that influence health beliefs and practices.

The nurse concludes that a client with a body temperature of 98.6 F is experiencing which condition? 1. Hypothermia 2. Hyperpyrexia 3. Hyperthermia 4. Normothermia

4. Normothermia * A body temperature of 98.6 F is normal. The nurse concludes that the client has a normothermia. The client does not have low body temperature or hypothermia. The clients body temperature does not exceed the normal range; therefore, the client does not have hyperpyrexia or hyperthermia.

Which concept refers to respecting the rights of others? 1. Maturity 2. Systematicity 3. Inquisitiveness 4. Open-mindedness

4. Open-mindedness * Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on ones own judgements and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

Which activity places a client at risk for hyperthermia? 1. Snowmobiling 2. Skiing in the winter 3. Hiking Alaskan mountains 4. Performing strenuous activity in high humidity

4. 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.

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurse observe? 1. Instruct the client to position one arm on each shoulder of the nurses 2. Direct the client to extend the legs and remain still during the procedure 3. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed 4. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client

4. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client * Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses would assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurse as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction in which the client is being moved.

Which integumentary finding is related to skin texture? 1. Elasticity 2. Vascularity 3. Fluid buildup 4. Surface character

4. 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 indicated edema.

Which accurately describes hospice care? 1. A resident's temporary or permanent home, where the surroundings have been made as homelike as possible 2. Offers an attractive long-term care setting with an environment akin to the client's home, which offers the client greater autonomy 3. Service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult 4. System of family-centered care that allows clients to remain at home in comfort while easing the pain of terminal illness

4. System of family-centered care that allows clients to remain at home in comfort while easing the pain of terminal illness *Hospice care is a system of family-centered care that allows clients to remain at home in comfort while easing the pain of terminal illness. A nursing center is a resident's temporary or permanent home, where the surroundings are made as homelike as possible. Assisted living offers an attractive long-term care setting with an environment that is like the client's home and offers the client greater autonomy. Respite care is a service that provides short-term relief for people providing home care to an ill, disable, or frail older adult.

Refusing to followed the prescribed treatment regimen, a client plans to leave the hospital against medical advise. Which is it important for the nurse to inform the client of? 1. The client is acting irresponsibly 2. This action violates the hospital policy 3. The client must obtain a new primary health care provider for future medical needs 4. The client must accept full responsibility for possible undesirable outcomes

4. 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.

While assessing a client for the dorsalis pedis pulse, the nurse documents the reading at 1+. Which can be inferred from this finding? 1. There is absence of a pulse 2. The pulse strength is normal 3. The pulse strength is bounding 4. The pulse strength is barely palpable

4. The pulse strength is barely palpable * A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented at 2+. If the pulse strength is bounding, then it is documented as 4+.

Which nursing process would the nurse undertake when collecting the medical history of a client? 1. Diagnosis 2. Evaluation 3. Assessment 4. 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 and make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the clients 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 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? 1. Value-belief pattern 2. Role-relationship pattern 3. Cognitive-perceptual pattern 4. Self-perception-self-tolerance pattern

Self-perception-self-tolerance pattern * The nurse is applying Gordon's self-perception-self-tolerance 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 clients 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.