Exam 1

Why is clinical reasoning important in nursing practice?

The practice of professional nursing requires strong clinical reasoning skills due to a rapidly changing healthcare environment, technological advances, the complexity of client problems, and shortened hospital stays.

Wellness nursing diagnosis: No Problem Is Present

Use when the patient is in transition from one level of wellness to a higher level. Two conditions must be present: The patient's present level of wellness is effective. The patient wants to move to a higher level of wellness.

Syndrome nursing diagnosis: Several Related Problems Are Present

Use when you notice that the patient has more than one nursing diagnosis with the same etiology (cause, contributing factors).

Which statement is correct about critical thinking and the nursing process? The nursing process is a critical-thinking, problem-solving model. When using the nursing process, critical thinking is not needed. Everything a nurse does requires critical thinking. Nursing process is the only form of critical thinking used in nursing.

critical thinking problem solving

A nurse receives an order to deliver a unit of blood if the client's hemoglobin falls below 7.0 g/dL. The nurse enters the room to obtain consent and the client says, "I choose not to take blood; it's not supported by my religion." The nurse makes a note and does not deliver the blood. Which aspect of critical thinking is this nurse using to guide client care? clients roles clients culture individual difference multiple and carying concerns

culture

At the end of a meditation session, which physical assessment finding would suggest that the relaxation technique was successful? Decreased blood pressure Decreased peripheral skin temperature Increased respiratory rate Increased bowel motility

decreased BP

As the nurse prepares a plan of care for Olan, which consideration best describes the foundation of the nursing plan? Create a situation of improving health so Olan can begin walking around the block two or three times every day. Focus on his nutritional status, encouraging high-protein meals. Contact his family, including them in the plan of care. Remove Olan from his current location, placing him in a care facility. Determine what Olan feels would be his optimal state of health and create a plan around that.

determin what olan feels would be his optimal state of Health

Throughout the day, John has to urinate every 2 to 3 hours. Although it's only a small amount each time, there is a feeling of urgency. He has limited the amount of liquid he drinks, but it doesn't seem to help. What could be causing this issue? Dehydration An enlarged prostate gland Decreased kidney filtration Medication Check Answer

elarged prostate gland

Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this.Drag and drop the step of the nursing process this represents.

evaluation

A nurse with only a few months of experience is feeling frustrated about their inability to make clinical judgment decisions without the assistance of the charge nurse. What could be a reason that this is occurring? experience is needed to detect subtle changes in a clients condition substandard education in nursng school lead o a lack of clinical judgment caring for too many clients at a time decreases clinical judgement the nurse turn to the charge nurse because of lack of confidence

experience is needed

A nurse is concerned about his personal level of wellness. Since beginning a new job on a busy nursing unit, he's been unable to sleep well and feels stressed all the time. What suggestions could you make for health balance? Select all that apply. Develop a regular exercise program. Eat a balanced diet. Listen to relaxing music on the way to and from work. Meditate or pray daily. See a healthcare provider for a sedative.

first four

Marjorie becomes bedridden after a fall that resulted in a hairline fracture of her pelvis. She begins to develop a cough of yellow sputum and requires higher amounts of oxygen at night to maintain adequate oxygen levels. Which physiological changes of aging contribute to her current condition? Select all that apply. Weakened immune system Decreased muscle strength Decreased cardiac output Decreased skin elasticity Decreased intercostal muscle strength

immune sys, muscle strength, skin elasticity

Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall.Drag and drop the step of the nursing process this represents.

implenmentation

Mrs. Clancy is a nursing home resident at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner.Drag and drop the step of the nursing process this represents.

implenmentation

Asking questions that begin with "What if ...?" or "How can we ...?" are characteristic of a nurse who has which critical-thinking quality? independent thinking intellectual curiosit intellectual courage perseverance

intellectual curiosity

A client says to the nurse, "I feel so sick and weak, I don't think I'll ever be able to go home." Which response by the nurse is therapeutic? "Let's get you up and walking more; that will help." "It sounds like you are frustrated. What do you mean by 'sick and weak'?" "What can I do to help you feel better?" "I'm sure you are frustrated; you must miss being home."

it sounds like you are frustrated

As the nurse continues to see Olan each week, she begins to see an improvement in his state of health. His "good days" are more frequent and his "bad days" are rare. He has met a neighbor, also a veteran, and they have morning coffee each day, a time for sharing stories. Which statements by Olan demonstrate reasons for this change? Select all that apply. "I went to the clinic and they increased my medications." "I'm sleeping through the night, only getting up once to go to the bathroom." "My son contacted me and we have started talking again." "I've found God and recommitted my life to Him." "Food tastes good and I've gained some weight."

last four

Which action best demonstrates assertive communication when reporting a change in the client's status? recording change in EHR telling provider you need to order more bo medication ask provider do you think his bp is high telling the provider his blood presure was up to (xyz) this morning would you like to change his medication

last one

What is the best way for a nurse to develop clinical judgment skills? Practice memorizing clinical assessment findings. Look for clinical changes and question why. Ask for assistance when abnormalities are found. Learn more about the clinical judgment process.

look for changes

At the nurse's next visit with Olan, she finds him "on a bad day." Where would the nurse place him today on the Dunn's health grid? High-level wellness in a favorable environment Emergent high-level wellness in an unfavorable environment Protected poor health in a favorable environment Poor health in an unfavorable environment None of the categories applies

poor health- unfav environment

A nurse is caring for a client with a history of diabetes and feels as if something is "not right." The nurse takes the client's blood glucose level. The nurse is acting on which type of knowledge? practical theoretical self ethical

practical

The nurse recognizes that a client's respiratory rate has increased from 16 to 24 over the last 2 hours. What action should the nurse take? Record the findings only. Prioritize the need for further inquiry. Evaluate the effectiveness of the solutions. Generate the best solutions.

prioritize the need for further inquiry

Samantha tells the nurse, "I'm really worried about my procedure and cannot learn about my medications now."Which factor is being expressed?

rediness

Which nonverbal behavior best enhances communication? Keeping a neutral facial expression Maintaining a distance of 6 to 8 inches Sitting down to speak with the patient Asking open-ended questions

sitting down

A client is speaking with a nurse and says, "I don't understand, I exercise every day and eat a balanced diet, yet I'm always getting sick. My husband, on the other hand, eats poorly and never exercises and he never gets sick." What would be the nurse's best response? "Everyone is different, and I guess your husband is just lucky." "There are many factors that impact health and illness; let's discuss some." "It depends on the immune system; yours must not be as strong." "It sounds like you are depressed about being sick."

there are many factors

Which processes did the nurse use while working with Olan that best promoted this therapeutic relationship? Select all that apply. Forced own preferences Took time to communicate Limited visitation time Developed thorough assessment skills Identified the client's main concerns

time, developed, identified

Olan is a retired 67-year-old veteran. He has advanced lung disease from years of smoking cigarettes and working in a chemical plant. On a good day, he can walk slowly around the block with minimal oxygen, but on a bad day he can only make it to his recliner chair in front of the television. He is malnourished and lives on his veteran benefits in a small one-bedroom apartment. He has no contact with family. A home care nurse is assigned to his case.As the nurse working with Olan, which skills are important in developing a professional relationship? Select all that apply. Take time to talk and communicate. Focus on the priorities and concerns of the client. Establish trust. Be caring, respectful, and understanding. Implement the medication plan of care as a priority.

time, foucus, trust, caring

Client: "My neighbor just called and my dog died" (crying loudly).Nurse: "Tell me about your dog" (touching the client's shoulder).Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

using silence

John has taken the same blood pressure medication at the same dosage for 10 years. At his last routine physical, his blood pressure was higher than normal. Which statement best describes the reason for this change? His medication was outdated and therefore less potent. He was anxious when his blood pressure was taken. The blood pressure was not taken correctly. Vessels develop increased peripheral resistance with age, causing a rise in blood pressure. Check Answer

vessels decelop increased peripheral resistance with age

Which is a description of the frail elderly? a person over 85 a person who takes many medication vulnerability to a downwrd spiral in response to any health problem an elderly person who has started to lose functional abilty

vulnerabilty

What factors influence the health-illness continuum? Select all that apply. persoal pereptions genetic makeup gender age family support

1,2,3,4

Older adults make up approximately what percentage of the total population in the United States? 1 5 15 50

15

What is a cue? What are four ways you can recognize a cue?

Significant data(also called cues) Usually unhealthy responses. theoretical knowledge One cue should alert you to look for others that might be related to it (forming a pattern). Influence your conclusions about the client's health status.

When determining the right goal, what should the nurse consider? Select all that apply. That the goal is obtainable by the nurse Active learner involvement in planning Agreed-upon mutual goals Realistic objectives Exclusion of the significant other's input

active learner, agreed-upon, relistic odjectives

While helping Marjorie with her morning care, the nurse notices several skin tears and bruises on her arms. Marjorie notices the nurse looking at them and says, "My skin used to look smooth and pretty, but now it gets damaged so easily." What steps should the nurse make? Select all that apply. Provide a foam mattress for the bed. Pad the corners of hard objects in the room. Encourage wearing long sleeves. Avoid contact with tape and adhesive bandages. Use gentle soaps and lotions.

all answers are correct

The diagnosis step of the nursing process includes which activity? Assessing and diagnosing Evaluating goal achievement Performing and documenting nursing actions Analyzing data

analyzing data

A frail elderly man lives at a senior independent living apartment complex. He is weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. His personal hygiene is poor. He moves very slowly when doing even small tasks, such as eating a meal. Which interventions are most appropriate for this person?Select all that apply. Arrange for an aide to assist with activities of daily living. Refer the client to a senior center for an adapted physical activity program. Assess the patient for symptoms of depression and memory loss. Arrange for nutritious meals to be delivered to the patient's home. Contact his children to move in with him.

arrange an aide, asses, arrange meals

Nurse (while standing at the door with arms crossed, looking at the family and not the client): "We've made arrangements to transfer you to hospice care."The client thinks, "That nurse doesn't care about me."Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

body language

Marjorie is an 80-year-old female. After a car accident 3 years ago, she lost her driver's license because of her poor vision. Her husband died shortly afterward and she could no longer care for herself. Her daughter placed her in an assisted living facility that provides meals and 24-hour supervision and care.Marjorie tells the nurse that she feels "worthless" and wants to become more active. What would be the nurse's best suggestion? Walk around the block three times a day. Participate in chair aerobics in the recreational center. Lift weights in the gym after meals. Take dancing lessons at the city dance hall.

chair aerobics

What is the leading cause of death in older adults? Heart disease Car accidents Pneumonia Chronic illnesses

chronic illnesses

The nurse needs to teach the side effects of chemotherapy to a Jim, a 68-year-old newly diagnosed with colon cancer.Which learning domain is being addressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

cognitive

John retired from work last month after 38 years with the same corporation. He's been looking forward to retirement at the age of 65, but is concerned that the days are beginning to wear on him. Physically he does "okay." His hypertension is under control with medications and he runs 2 miles three mornings a week. He is planning a trip overseas this summer with Martha, his wife of 43 years.John has noticed that his knees feel stiff and painful in the mornings as he gets out of bed, so he decides to give up his morning run. What suggestion would be best for John? "Joint pain is common at this age, but biking is less impactful on the joints." "Take pain medicines daily when you wake up to make the run less uncomfortable." "Seek medical attention; you may have an injury." "Consider running at bedtime so the pain will be less intense." Check Answer

common problem

A client has been moved to an assisted living facility by her family due to declining health and inability to care for herself. The nursing staff notices she is having a hard time adjusting and appears to be confused and depressed. What can be suggested by the nurse?

create an area in her room with picture and other items from home

The nurse is assisting the client back to bed after using the restroom. The nurse recognizes that the client's breathing is labored and asks the client if this is normal with activity. Which step of the Clinical Judgment Measurement Model is the nursing performing? generate solutions prioritize hpotheses recognize cues evaluate outcomes

recognize cues

Which would be considered critical-thinking skills when assessing a newly admitted client who has Alzheimer disease and pneumonia? Select all that apply. Questioning the client's family or caregivers, as well as the client, for clarification of information Separating random information from pertinent information Carefully reading the physician's notes and orders and prioritizing how to proceed with the nursing plan Placing oneself in the caregiver's situation and offering compassion for their needs Assessing the client's airway

1,2,3

A nurse is instructing nursing students about incorporating critical thinking into client care. Which attributes should the nurse include during this lesson? Select all that apply. needs to find truth openness to other options use of reasoned thinking capacity to reflect on situations ability to delegate tasks to other ability to convey important information

1,2,3,4

When teaching an older adult about maintaining functional ability and promoting independence, what information should be included? Safety issues, such as changes in stamina and reflexes Illness prevention and immunizations Importance of physical exercise Facilitating empowerment Choosing an appropriate caregiver

1,2,3,4

What should the nurse include to promote effective communication with the healthcare team? report any concers to proper person discuss any clinical error with coworkers point out indivdual errors in team meetins questions the healthcare provider readarding unclear orders speak about the issues in a timid manner

1,2,4

A 44-year-old female client who was just admitted states, "I must be under too much stress at work and home. I just do not feel well." Which physical findings are consistent with the client's statement? Select all that apply. Blood pressure is 178/96 mm Hg. Palms of her hands are sweaty. Pupils are constricted and reactive to light. Legs are continually moving in the bed. Mucous membranes are dry.

1,2,4,5

which techniques should the nurse use when communicating with someone who has cognitive deficits? Select all that apply. use simple short sentences say yes yes thats okat repeat your words exacty avoid using specific language provide many choices

1,3

During a client's appointment at the women's clinic, she states her menstrual flow is very heavy, occurs about every 3 weeks, and is accompanied by severe abdominal cramping. The breast exam is normal, and the results of the Pap smear are normal; however, the client's hemoglobin level is low, and the nurse suspects the heavy menstrual bleeding may be causing anemia. Which information is considered primary data? heavy menstrual flow every 3 weeks with sever abdominal cramping normal breast exam normal pap smear evidence of link between anemia and heavy menstruation low hemoglobin

1,4

The nurse suspects that an older adult client may have sensory difficulty. Which strategies will the nurse use to improve communication? Select all that apply. use sing language provide eyeglasses place hearing aid obtain interpreter insert dentures

2,3,5

The nurse is presenting a workshop on stress and adaptation to a group of teenagers. A teenager approaches the nurse and says, "Sometimes I feel stressed when I have to take a test. I feel my heart is going faster and I have a hard time focusing. I'm scared I'm going to fail. Do you think that is normal?" What is the most appropriate response by the nurse? "As long as you are getting through the test, I think you will be just fine." "A little stress is not necessarily a bad thing. It can help you to focus." "You may need to develop some additional stress-reducing activities." "I think you should talk to your teacher about getting accommodations for testing."

3

What length of time delineates a chronic illness? 1wk 1mo 6mo 1yr

6 mo

List five skills or attitudes that reflect critical thinking.

Intellectual autonomy. Critical thinkers do not believe everything they are told Intellectual curiosity. show an attitude of curiosity and inquiry Intellectual humility. ask for help when they do not know Intellectual empathy. understand the feelings and perceptions of others. Intellectual courage. consider and examine fairly their own values and beliefs, as well as beliefs of others Intellectual perseverance. do not jump to conclusions Fair-mindedness. make impartial judgments Confidence in reasoning. rely on inductive and deductive processes to have confidence in their own reasoning.

Which factors should the nurse take into account when interviewing clients? Select all that apply. gender personal space economic level level of education developmental level sociocultrural factors

1,2,5,6

A nurse becomes irritated with a client who is requesting more ice chips and refers to the client as "the ice man in 201" to other nursing staff. In which important component of nursing has the nurse failed to engage? caring empathy problem solving ethical knowledge

caring

After a teaching session with Jim about his chemotherapy, the nurse asks him to review what he learned. Finding some errors in his understanding, the nurse says, "Don't forget; it is also important to watch for bleeding and swollen gums in your mouth."Which factor is being expressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

feedback

Identify the examples of acute illness. Select all that apply. cholecystitis pyelonephritis appendicitis osteroarthritis asthma

1,2,3

Which are included in the five rights of teaching? Select all that apply. Patient Goal Context Time Method

Right time Right goal Right context Right method

A nurse who is obtaining a health history through an interview asks, "What can you tell me about your previous knee replacement surgery?" Which type of question is this? closed open-ended chief complaint contributing history

open-ended

Actual nursing diagnosis: Problem Is Present

A problem response that exists at the time of the assessment. Signs and symptoms (cues) that are present.

Give examples of each type of assessment (initial, ongoing, comprehensive, focused)

initial: ongoing: as needed/ follow up comprehensive: first time at physicians office focused: ER addmitted patient

What is a CAM (complementary and alternative medicine) therapy a nurse can teach the client that involves a heightened awareness of the mind, body, and spirit? meditation minfullness biofeedback visualization

meditation

The nurse is concerned that an older adult is experiencing depression. Which findings support this concern? Select all that apply. a lack of energy sleep pattern distrubance a lack of appetite sluggish speech change in bowel patterns

1,2,3,4

Which statements by the nurse support an older adult's personhood and dignity? Select all that apply. can i get you another blanket sweetie im happy to care for you today. what would you like me to call you tell me more about your life when you were a young girl are you tring to think of the word table let me pull up a chair so we can better talk to each other

2,3,4,5

Risk (Potential) nursing diagnosis: Problem May Occur

A problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it. No signs/symptoms of the problem, but the risk factors are present that increase the patient's vulnerability.

What are the five types (statuses) of nursing diagnoses?

Actual nursing diagnosis: Problem Is Present Risk (Potential) nursing diagnosis: Problem May Occur Possible nursing diagnosis: Problem May Be Present Syndrome nursing diagnosis: Several Related Problems Are Present Wellness nursing diagnosis: No Problem Is Present

Problems that occur when adpation fails

Common problems can occur when adaptation fails as a result of repeated stimulation and elevation of hormones during stress. The most common disorders that occur include stress-induced organic responses; somatoform disorders, such as hypochondriasis, somatization, pain disorder, and malingering; and psychological disorders, such as anxiety, depression, post-traumatic stress disorder, crisis, and burnout.

What is the ultimate purpose of full-spectrum nursing?

Full-spectrum nursing is a unique blend of thinking, doing, and caring. It is performed by nurses who fully develop and apply nursing knowledge, critical thinking, clinical reasoning, and the nursing process to client situations to make sound clinical judgments.

Factors that influence successful adaptation

How someone adapts to stress is determined by many factors and can include overall health status, support systems, hardiness, and other personal factors. A realistic perception of the stress better allows someone to adapt to its impact. Living alone without a solid support system can also be detrimental to adaptation.

Why is the diagnosis step so critical to the other phases of the nursing process?

The purpose of diagnosing is to identify the client's health status. Accuracy is essential because the diagnosis is the basis for planning client-centered goals and interventions.

What is the difference between theoretical and practical knowledge?

Theoretical knowledge—knowing why—consists of information, facts, principles, and evidence-based theories Practical knowledge—knowing what to do and how to do it— It consists of processes and procedures

After demonstrating the application of a leg splint, the nurse says to the client, "Here, now you try."Which factor is being expressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

active involvment

Which is a factor that most contributes to increased life expectancy in older adults? healthier lifestyle and better nutrition advances in medicine increased family size increased activity in the young

advances in medicine

The nurse is trying to impress on Jonathan, an obese 28-year-old, the importance of losing weight to improve his health.Which learning domain needs to be addressed first?

afective

The client states, "I don't care if I get better; my father died of heart disease and so will I." Which learning domain needs to be addressed initially? Cognitive Affective Readiness Timing

affective

Stages of general adaptation syndrome

alarm (fight or flight), resistance (adaptation), and recovery or exhaustion

Which action made by the nurse indicates the use of clinical judgment? Analyzing a client's temperature changes and assessing for signs of infection Filling out food selections on the menu with the client to determine food preferences Ensuring the bed is in a low and locked position and the call light is in reach prior to leaving the client's room Asking the client to verify their name and date of birth prior to medication administration

analyzing

As Marjorie is trying to brush her teeth at the bathroom sink, she loses her balance and falls. What actions by the nursing care facility could have prevented this injury? Select all that apply. Assistance with all activities Use of grab bars in the bathroom An emergency call light that is accessible in all areas Use of a walker Not allowing her to brush her teeth Check Answer

assistance, call light, grab bars

Client: "My stomach hurts."Nurse: "I'll get you some pain medicine."Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

exploring the issue

The nurse prepares to apply oxygen on a client who is short of breath and has a low pulse oximetry reading. Which step of the Clinical Judgment Measurement Model is the nursing performing? generate solutions prioritize hpotheses recognize cues evaluate outcomes

generate solutions

As Marjorie ages and becomes more frail, her family decides to move her to a nursing care facility. She has been hospitalized twice in the past 6 months for pneumonia and does not wear her oxygen device at night. As the nurse is helping Marjorie into her wheelchair to go to the dining hall for breakfast, she notices how loose her pants are. She decides to weigh her and finds she has lost 8 pounds in the past month. What should be the nurse's next action? Change her diet to include more fattening foods. Determine whether any medications she's taking would cause weight loss. Make her clean her plate with each meal. Monitor her daily calorie intake for a week. Check Answer

monitor calorie intake

Lu tells the nurse, "I'm looking forward to losing weight with my new diet and getting my life back on track."Which factor is being expressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

motivation

During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this? subjective objective secondary reported

objective

Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying client needs.Drag and drop the step of the nursing process this represents.

planning interventions

The nurse needs to teach 13-year-old Brittany how to give herself insulin injections.Which learning domain is being addressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

psychomotor

Client: "I don't want to learn about my new medications right now."Nurse: "All right." (Documents that the patient refused, and reports this in handoff report.)Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

restating, validating, clarifying message

Client: "You told me so much about my diabetes, I'm not sure I'll remember it."Nurse: "Don't worry, we'll give you everything in writing."Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

summarization

Which statement is an example of elderspeak? what time would you like dinner do you know when your daughter is coming i will bring your medication in a few minutes sweetie when do we want to take our bath

sweetie

The nurse is speaking with a client who is a victim of abuse. Which question asked by the nurse would obtain the most information? when did you first notice the problem do you know why your spouse continues to hurt you tell me what happened to encourage you to seek counseling are there any triggers that you know of that cause the abuse

tell me what happened

Define clinical reasoning.

the process of synthesizing knowledge and information from numerous sources and incorporating experience to develop a plan of care for a particular client

What are the four main concepts of the full-spectrum model of nursing?

thinking, doing, caring, clinent situation

The nurse is speaking with a 69-year-old female patient. What should the nurse explain about osteoporosis? osteoporosis affect mostly men women are at high risk for osteoporosis because of the lack of calcium intake and changes caused by menopause osteoporosis is uncommon you're fine as long as you drink milk

women are at high risk

Which statement about the nursing process is correct? Works alongside an individualized plan of care Results in outcomes designed by the client Is composed of a linear process with unique, distinct steps Includes only the care that the nurse will deliver

works alonside individualized paln of care

What is ageism?

age discrimination

The nurse is assessing for conditions that will impact the quality of life in an older adult. Which questions should the nurse ask? Select all that apply. "Do you ever have trouble with bladder control?" "Are you able to travel abroad?" "How many hours of sleep do you get each night?" "Do you ever lose your balance or have you fallen?" "How is your appetite?"

bladder control, sleep, lose balance, appetite

The nurse speaks with Olan about his life growing up in a rural Kentucky community. Which statements contribute to his current health beliefs? Select all that apply. "When we were sick, we had to be half-dead before my parents would get the doctor." "As a younger man, I was laid off from my job many times and did not have insurance." "I've smoked at least two packs of cigarettes a day since the war. I finally quit a year ago." "The doctors at the veteran's health clinic are very welcoming." "My kids stopped talking to me years ago, when their mother and I divorced." Check Answer

first four

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process? "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." "Mr. Sullivan will be able to walk the length of the hallway before discharge." "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance." "Ambulate Mr. Sullivan in the hallway three times today, please."

"i wish"

An older client with a history of congestive heart failure was just admitted to the hospital for chest pain. The patient asks a nurse, "Why did the chest pain begin after I thought someone was trying to break into my house?" What is the nurse's best response? "Fear causes an increase of the body's heart rate and blood pressure, which can place additional stress on your damaged heart and cause chest pain." "Fear causes the parasympathetic system to use all available adrenaline, leaving you so tired that you developed chest pain." "The decrease in the need for oxygen during the fight-or-flight response experienced with fear is most likely the reason that you developed chest pain." "Fear causes an increase in glucose levels, which limits blood flow and causes chest pain."

1

The nurse is communicating with an older adult client, but it appears the client is not understanding what the nurse is explaining. What should the nurse assess to determine communication barriers? Select all that apply. level of orientation visual distrubances earing impairment difficulty eith ambulation changes in tast of food

1,2,3

The postsurgical client on the medical-surgical unit has suffered a stroke and is now being transferred to the ICU. How can the nurse assigned to this client help make this transition as easy as possible on the family? Select all that apply. provide for teaching needs ensure safety and confort communicate with the new unit assure the faily and client everything is ok alert insure company

1,2,3

What does the nurse know is true about conducting the nursing assessment? Select all that apply. assessments must be completed within 24 hours of inpatient admission assessments cannot be delegated all clients are assessed for pain, nutrional status and risk for falls vital signs can always be conducted by nap assessments are not required for client whi are not being admitted

1,2,3

Which are examples of cue clusters for a nursing diagnosis? Select all that apply. all that apply. Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis Sore throat, fever, inability to ambulate, medical diagnosis of depression Dry skin, painful urination, epistaxis Urinary incontinence, lower abdominal pain, bladder spasm

1,2,5

State whether each of the following represents a nursing diagnosis, medical diagnosis, or collaborative problem: After giving birth, all women are at risk for developing postpartum hemorrhage. A patient has signs and symptoms of appendicitis, which must be treated with surgery and antibiotics. A client is at risk for constipation because they postpone defecation and also do not consume enough dietary fiber and fluids. The problem can be prevented by patient teaching, which the nurse is licensed to do.

1. collaborative 2. medical 3.nursing

Which techniques are barriers to communication with clients? Select all that apply. allowing silence expressing approval providing false hope asking why questions interpreting body language

2,3,4

An older adult female is being cared for by her young adult grandson in her rural farmhouse since her husband died last year. She has debilitating arthritis and failing eyesight, so her grandson drives her to her doctor appointments and manages her bank account. Which factors place her at a higher risk of abuse? Select all that apply. having a family memer care for her dependence on others difficulty managing money health issues isolation

2,3,4,5

Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis? A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently. A medical diagnosis is made by a physician, and a nursing diagnosis is created by a nurse. A medical diagnosis involves interventions and medical treatment, and a nursing diagnosis involves client comfort and activities of daily living. A medical diagnosis determines the nursing diagnosis, while the nursing diagnosis has no bearing on the medical diagnosis.

A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently.

adaptive coping behaviors

Adaptive (effective) coping consists of making healthy choices that reduce the negative effects of stress. Finding support, exercising regularly, finding hobbies, and seeking the advice of others can be effective coping strategies. Overeating, oversleeping, drinking alcohol, and posting on social media are behaviors that can lead to further illness.

Stress management techniques

Additional stress-management techniques include the use of relaxation, acupuncture, chiropractic adjustments, therapeutic touch, reflexology, listening to music, engaging in art activity, dance, and sports. Drinking is not considered a healthy form of stress management.

What is the difference between a cue and an inference?

Clustering cues and collecting any missing data inferences and identify problem etiologies, as well as decide which type of problem the cue cluster represents.

Define critical thinking in your own words.

Critical thinking is an analysis process. It is a combination of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to seek truth.

Physiological responses to stress

Physiological responses to stress include dilated pupils, muscle tension, stiff neck, headaches, nail biting, skin pallor, skin lesions, diaphoresis, dry mouth, nausea, weight or appetite changes, increased blood glucose, increased heart rate, cardiac dysrhythmias, hyperventilation, chest pain, water retention, increased urinary frequency or decreased urinary output, diarrhea or constipation, and flatulence.

Physiological stressors

Physiological stressors are stressors that affect body structure or function. They can be broken down into the following categories: chemical (tobacco), physical (cold exposure), nutritional (high-fat diet), biological (bacteria), genetic, and lifestyle (obesity). Active lifestyle, sexual difficulties, and vacation are considered psychological/social stressors, not physiological stressors.

psychological responses to stress

Psychological responses to stress may be physical (development of a rash, irregular heartbeats, etc.), cognitive (impairment of learning and focus), emotional (anger, fear and depression are most common), or behavioral (acting out or withdrawing from normal practices).

Possible nursing diagnosis: Problem May Be Present

Use when your intuition and experience direct you to suspect that a diagnosis is present, but you do not have enough data to support the diagnosis.

Client: "I'm so terrified about this diagnosis. I'm afraid I'll never see my children grow up."Nurse, while checking the IV pump: "Oh? How old are your children?"Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

active listening

What are some types of elder abuse? Select all that apply. sexual neglect emotional financial abdandoment

all

The nurse identifies that an older adult client has self-care deficits because of fatigue and a change of mental status. What action is most appropriate? arrange for care as needed and teach caregivers how and when to seek prefessional help recognize and treat depression and other problems state that the client will maintain independence longer and delay theaging process evaluate changes in mobility, fatigue, or mental status

arrange for care as needed

Client: "I don't want another IV; you can just forget about that!"Nurse: "It's needed for your antibiotics, but if you don't want it, that's fine."Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

assertivness

Mary is a 17-year-old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asks her how being hospitalized is impacting her senior year of high school. Drag and drop the step of the nursing process this represents.

assesment

Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours.Drag and drop the step of the nursing process this represents.

assessment

When should the nurse begin discharge planning for a client?

at time of addmissions assessment

Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions.Drag and drop the step of the nursing process this represents.

diagnosis

After performing an assessment on Olan "on a good day," where would the nurse place him on the Dunn's health grid? High-level wellness in a favorable environment Emergent high-level wellness in an unfavorable environment Protected poor health in a favorable environment Poor health in an unfavorable environment None of the categories applies.

emergent hih-level wellness in unfav envirnment

How can telehealth be beneficial to healthcare? it allows the client to be empowered for slef-management more clients ca be seen by the healthcare provider individuals living in poverty can have access to care typically no avaliable to them access is readily avaliable to everyone regardless of abilty to pay

empowered for self-magement

Client: "You told me you would speak to my doctor about getting my pain medication increased. Were you able to do that?"Nurse: "Oh, I decided we could wait until the doctor makes his rounds this evening and ask then."Which technique would improve the therapeutic communication?Make the Connection. Drag and drop the proper term that is best exemplified by each case scenario.

establishing trust

The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient's family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information.Drag and drop the step of the nursing process this represents.

evaluation

A client comes to the emergency department with severe shortness of breath and difficulty breathing. He is restless and anxious. Which response made by the nurse offers reassurance and builds trust? Select all that apply. "I'll give you some medication to help with your breathing." "Would you like your family to stay here with you as I step out?" "Please try not to think about the breathing." "This must be a frightening situation for you." "Tell me more about what you are doing when your breathing is most difficult."

family, frightening, tell me more

The nurse determines that weekly visits are no longer needed for Olan. The goals of the plan of care have been met and exceeded. Which statement is true about Olan's future? He will continue to live at this highest level of functioning. He will return to his previous level of functioning once the weekly visits stop. His improvement of health was a result of the nurse's visits. He will fluctuate between health and illness for the rest of his life. His health may deteriorate slightly after the visits end. Check Answer

fluctuate

Which are the most common and costly chronic disease processes in the older adult? osteoporosis, dementia, cancer heart disease, stroke, diabetes pneumonia, depression, stroke skin tear, infection, diabetes

heart disease

Which is an example of a nurse who is using clinical judgment? The nurse collects the vital signs and auscultates the client's lungs, recording the data in the electronic record. The nurse is performing a procedure following a skill list that is in the policy and procedure manual. The nurse identifies some abnormal assessment findings and reports them to the next shift nurse during handoff report. The nurse identifies abnormal findings, investigates if the findings are new or old, and adjusts the plan of care accordingly.

identifies abnormal findings

John retired from work last month after 38 years with the same corporation. He's been looking forward to retirement at the age of 65, but is concerned that the days are beginning to wear on him. Physically he does "okay." His hypertension is under control with medications and he runs 2 miles three mornings a week. He is planning a trip overseas this summer with Martha, his wife of 43 years.John has noticed that his knees feel stiff and painful in the mornings as he gets out of bed, so he decides to give up his morning run. What suggestion would be best for John? "Joint pain is common at this age, but biking is less impactful on the joints." "Take pain medicines daily when you wake up to make the run less uncomfortable." "Seek medical attention; you may have an injury." "Consider running at bedtime so the pain will be less intense." Check Answer

joint pain

Which environmental factors should the nurse consider when interviewing a client? Select all that apply. noise ordoes presence of famil room temp open public environment

nosie ordors room temp

Marjorie notices that she is less able to control her urine. She speaks with the nurse about it, saying, "It used to be an issue only when I coughed or laughed and now it's all the time." Which step should the nurse make? Insert a Foley catheter. Use padded briefs. Change undergarments more frequently. Encourage use of the restroom more frequently.

padded briefs

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center."Drag and drop the step of the nursing process this represents.

planning outcomes

The nurse, Linda, identifies some concerns about her client's financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge.Drag and drop the step of the nursing process this represents.

planning outcomes

What term is used when a person takes multiple medications and may need support and teaching about health management? dementia ageism edentulism polypharmacy

polypharmacy

A client is admitted to the hospital after suffering a stroke. They have been able to manage their home and self-care independently but now are unable to speak clearly, are paralyzed, and become frustrated as they attempt to communicate their needs. What stressor is most concerning for them as they enter the hospital? loss of privacy and control loss of family support fear of other clients loneliness

privacy and control

What is the nursing process? a problem slving process give the nurse a linear guid to creat a nursing plan to act as a foundation for providing effective care based on sound kowledge to allow for accurate diagnoses and treatment plans

problem solving process

The nurse is caring for a 72-year-old client with uncontrolled diabetes and hypertension. He lives with family members who prepare healthy meals and encourage him to be active with friends and at the community center, but he disregards their advice and prefers to eat fast food. Where would the nurse place the client on Dunn's health grid? High-level wellness in a favorable environment Emergent high-level wellness in an unfavorable environment Protected poor health in a favorable environment Poor health in an unfavorable environment

protected poor health in fav environment

The nurse is performing an assessment on a client. What should be included in this process? Ability to pay for hospital stay Who brought the patient to the hospital Level of education Religious and spiritual needs

religion and spiritual needs

The nurse schedules another teaching session for Julio. He says, "We just did that yesterday."Which factor is being expressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

repition

Define clinical judgment in your own words.

requirement to use processes to achieve desired client outcomes

The nurse enters the room to discuss ostomy care with the client, who is lying in bed. Which form of nonverbal language is most appropriate when speaking with the client? sit down to speak at eye level cross arms avoid using touch when supporting 'refrain from amking eye contact

sit down

An older adult client begins crying after being informed of her terminal illness. Which intervention by the nurse is best? Sit quietly with the client while she composes her thoughts. Inform the client that a chaplain is available if she would like to speak to one. Tell the client there are always options and suggest she not give up hope. Remind the client that she has lived a long and happy life.

sit quietly

The nurse is honoring the client's individual health-illness beliefs by using which statement? "Your weight is below what it should be. I'll incorporate more calories into your diet." "Tell me what it means to you to be in optimal health." "You can feel better if you work hard at it. It is obtainable." "You'll want to reduce the stress in your life, because it's causing your illness."

tell me what is means to you to be in optimal health

The nurse continues a teaching plan for Brittany's insulin injections. Brittany says, "It's been several days since I did this last. I'm not sure I remember what to do."Which factor is being expressed?Make the Connection. Drag and drop proper term that is best exemplified by each case scenario.

timing

Give at least two more examples of data you might obtain with each of the following senses. One example is provided for each. Touch (e.g., bladder distention) Vision (e.g., facial expression of pain) Smell (e.g., fecal odor) Hearing (e.g., bowel sounds)

touch: vision: smell: body ordor, fruity breath hearing:

The nurse is providing feedback for a client after several teaching sessions about wound care and dressing changes he will have to perform at home. Which feedback statement would be best? "I can see that you are not retaining the information we discussed. Let's go over it again." "You must remember that when you contaminate, infection can occur." "You did an excellent job washing your hands this time. Let's go over your dressing placement again." "I'll give you a pamphlet to review once you get home."

you did an excellent job