Exam 2

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. Fires are responsible for most hospital incidents. Between 15% and 25% of falls result in fractures or soft tissue injury. A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. Ensure appropriate lighting in hallways and entrances to the home. Remove extension cords from open spaces. Remove throw rugs from high traffic areas. Check the batteries in all smoke detectors. Store prescription medications on the counter.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

Consultation and diagnostic tests are included in which level of health care? Primary care Secondary care Tertiary care Extended care

Secondary care

Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone? Spiritual needs Intellectual needs Emotional needs Sociocultural needs

Sociocultural needs

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? clears a path from bed to bathroom places bed at lowest setting has client sit in bed for a few moments before standing provides slippers for ambulation

provides slippers for ambulation

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized? Ensuring that the client's nurse is held accountable and educated about best practice Identifying systemic factors on the unit that may have contributed to the event Reinforcing the standards for nursing care to staff members who were involved Communicating the potential consequences of the near miss to the client involved

Identifying systemic factors on the unit that may have contributed to the event

The staff at a day-surgery clinic are meeting because there have been two significant medication errors committed over the past few weeks. To prevent future medication errors, what is the priority action for the nurse's to take? Cluster the timing of medication administration to reduce the number of times that a client is given medications Have every medication checked, co-administerd and co-signed by another nurse Collaborate with the health care providers to determine if clients are prescribed any nonessential medications Take measures to ensure that nurses are not disturbed when obtaining and administering medications

Take measures to ensure that nurses are not disturbed when obtaining and administering medications

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. Permit the client to remove the stockings indefinitely and speak to the health care provider about the necessity of having the client wear them. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. Tell the client he can remove them for 20 or 30 minutes during this shift.

Tell the client he can remove them for 20 or 30 minutes during this shift.

Question 4 of 5 The nurse is implementing the principles of the high-level wellness model to plan the care of a client with complex needs. What characteristic of the client will best support their wellness within this model of health? The client describes themselves as being "deeply spiritual but not religious" The client has ample financial and social support resources The client has successfully recovered from various acute illnesses in recent years The client is willing and able to accept responsibility for their own life

The client is willing and able to accept responsibility for their own life

Which are factors that impact how a client defines health? Select all that apply. Family Culture Music Community Society

Family Culture Community Society

A hospital is introducing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). What activity will benefit most directly from this initiative? Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost. New partnerships are established between the hospital and local schools of nursing. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees. New systems are introduced to increase communication between nurses and the members of other health disciplines.

New systems are introduced to increase communication between nurses and the members of other health disciplines.

A nurse is immunizing children against measles. This is an example of what level of preventive care? Tertiary Secondary Chronic Primary

Primary

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first? Reduce distressing environmental stimuli to maximize client safety Leave to notify the health care provider concerning a change in client status Promptly document the change in client status Apply limb restraints to ensure client safety

Reduce distressing environmental stimuli to maximize client safety

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention? assess blood pressure every 4 hours discuss family history of hypertension provide care transition at discharge for speech therapy conduct mental status assessment every 2 hours

provide care transition at discharge for speech therapy

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse? "Check breathing and heart rate." "At what time did the child ingest the substance?" "What do you think that the child might have ingested?" "Induce vomiting while you wait for emergency personnel to arrive."

"Check breathing and heart rate."

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To preserve the client's functional ability to grasp and pick up objects." "To prevent the legs from rotating outward." "To prevent foot drop." "To help client to turn independently."

"To preserve the client's functional ability to grasp and pick up objects."

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply. Full range of motion with each joint Able to lift head from pillow No masses, deformities, or muscle atrophy No swelling, heat, tenderness, pain, nodules, or crepitation Walks 20 feet

No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program? pick an activity the client enjoys to promote adherence obtain a pre-exercise medical examination for clearance choose a specific single-exercise activity understand that the activity will have positive benefits.

obtain a pre-exercise medical examination for clearance

Which scenario is an example of a characteristic of Stage 2 of illness? A person tells his family that he is sick and allows family members to take care of him. A person begins rehabilitation following a stroke that left him paralyzed on one side. A person experiences a headache and sore throat and takes an aspirin. A person visits a health care provider to receive treatment for symptoms of an infection.

person tells his family that he is sick and allows family members to take care of him.

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include? helping the client change positions every 4 hours providing skin care before repositioning placing the client in good alignment with joints slightly flexed using a sheet to drag and lift the client

placing the client in good alignment with joints slightly flexed

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation? Fowler's supine Sims' prone

prone

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include? Correct placement of booster seats for the car Gun safety in the home Appropriate positioning in a crib The use of skid-proof mats for the bath tub

Appropriate positioning in a crib

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? Arrange an audiology consult to evaluate hearing Assess the client for signs and symptoms of osteoporosis Perform a vision test with Snellen chart Arrange for a skilled home care assessment

Arrange for a skilled home care assessment

Which nursing intervention is an example of tertiary preventive care? Assisting with speech therapy a client with a traumatic brain injury Blood pressure screenings at a senior center Administration of immunizations to a 6-month-old child Teaching stress reduction classes at a wellness center

Assisting with speech therapy a client with a traumatic brain injury

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse documents the presence of what health problem? Chorea Ataxia Tremors Athetosis

Ataxia

The nurse is teaching the caregiver of a school-age child (5-9 years old) about safety. Which teaching will the nurse include? Place all household cleaners out of reach. Peer pressure causes children of this age to take risks. Supervise your child on the changing table. Buy protective sporting equipment.

Buy protective sporting equipment.

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize? Notify the organization's leader that a disaster has been called Provide simple explanations to maximize client safety Identify the resources available for the nursing unit Establish the nurse's role during a disaster

Establish the nurse's role during a disaster

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon? Exacerbation Morbidity Risk factor Infection

Exacerbation

When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model? High-level wellness model Holistic health model Clinical model Health belief model

Health belief model

Which is the most accurate definition of health?

Health is a state of complete physical, mental, and social well-being.

Which definition of health is the best?

Health is a state of complete well-being.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply. Provide step-by-step instructions to the client before the transfer begins. Lower the bed to the lowest position allowing the client's soles to contact the floor. Ensure that the client's bedrails are up prior to transfer. Make sure the client's weaker leg is nearest to the chair. Provide the client with nonskid slippers to put on prior to standing up.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins.

A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply. Plan to put the stockings on the client right before bedtime. Launder the stockings at least every three days. Remove the stockings and massage the legs once each day. Measure each leg and take an average to determine size to order. Order at least two pairs of stockings.

Order at least two pairs of stockings. Launder the stockings at least every three days.

An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching? Locate the parent in a room near the kitchen. Combine medications into a few pill bottles for ease of use. Put a small nightlight in the hall and stairway. Decorate the parent's room with small rugs and wall hangings.

Put a small nightlight in the hall and stairway.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? : Activate the fire alarm on the unit. Rescue anyone who is in immediate danger.

Rescue anyone who is in immediate danger.

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? Nurse-client relationship Confidentiality Privacy Safety

Safety

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk? She may be developing nutritional deficiencies from poor dietary habits. She has lost interest in academics because she has a boyfriend now. She may be the victim of cyber-bullying. She may be beginning her menses.

She may be the victim of cyber-bullying.

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client? Residual prevention Primary prevention Secondary prevention Tertiary prevention

Tertiary prevention

Which model is most useful in examining the cause of disease in an individual, based upon external factors? The Health Belief Model The Health-Illness Continuum The High-Level Wellness Model The Agent-Host-Environment Model

The Agent-Host-Environment Model

A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital for the second time in 2 months with wheezing, dyspnea, and use of accessory muscles when breathing. Which type of situation does the nurse identify is occurring with this client?

The client is having an exacerbation of the COPD.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. The client is wearing the oxygen around the neck. The IV is not infusing at the correct rate. The client's television is turned off. There is spilled water on the floor. The skin is a bluish-color.

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color.

A nurse is assessing a client for potential variables that influence the client's health. When assessing the client's self-concept, which area should the nurse include? Select all that apply. The client's cultural background The client's degree of interaction with family members The client's feelings about self as a person The client's educational level The client's view of self physically

The client's feelings about self as a person The client's view of self physically

Which statement is true regarding Friedman's theory of family-centered nursing care? Illness of one family member strengthens the roles of the sick member in the family structure. The role of the family is essential in every level of nursing practice. The focus on health should be directed at improving the health of the sickest member of the family. The family is composed of independent members who live and function individually.

The role of the family is essential in every level of nursing practice.

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? Repositioning lift Transfer chair Gait belt Powered stand-assist

Transfer chair

The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model? Factors that predispose a person to infectious diseases How health is a constantly changing state What people believe to be true about their health How people interact with their environments

What people believe to be true about their health

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply. use a wide stance and lift with the large leg muscles face in the direction of the activity he is performing hold his breath only when lifting heavy objects adjust the height of the work area

adjust the height of the work area face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles

A 90-year-old widower lives alone in her home. The nurse knows that older clients are at increased risk for falls. What other factors contribute to increased risk for falls in clients? Select all that apply. history of a fall 5 years ago installed carpeting ataxic gait diuretics

ataxic gait history of a fall 5 years ago diuretics

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse? instruct the client to hold on to the side rails for support and reach for the stretcher leave the friction-reducing sheet in place once the client is transferred keep the client covered with the top covers and bedsheets grasp the friction-reducing sheet at the hips and knees of the client

leave the friction-reducing sheet in place once the client is transferred

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? chest leg back arm

leg

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: bioterrorism mass trauma terrorism.

mass trauma terrorism.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: nuclear terrorism. bioterrorism. mass trauma terrorism. chemical terrorism.

mass trauma terrorism.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? using back muscles to gently and gradually pull the client to the side standing at the top of the bed and having a colleague stand at the bottom of the bed positioning a friction-reducing sheet under the client to facilitate movement placing the bed in its lowest position to reduce the client's risk for falls

positioning a friction-reducing sheet under the client to facilitate movement

The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use? full-body lift assist lateral lift assist powered full-body lift

powered full-body lift

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? shifted center of gravity kyphosis scoliosis increased need for calcium and vitamin D

scoliosis

The nurse is planning care for a client with the identified activity intolerance. What assessment concerns the nurse for a client with this health issue? shortness of breath after walking up five stairs joint stiffness after sitting for 1 hour a change in pulse from 80 to 84 beats/min after walking up 20 stairs walking with a slow and uncoordinated movement

shortness of breath after walking up five stairs

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? supine prone Sims' slight Trendelenburg

slight Trendelenburg

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as: ataxia. spasticity. disequilibrium. hemiparesis.

spasticity.

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce the risk of client handling injuries. Which action(s) would the nurse include as contributing to this risk? Select all that apply. using assistive devices standing for long periods lifting when tired engaging in repetitive movements using uncoordinated lifts

using uncoordinated lifts lifting when tired engaging in repetitive movements standing for long periods

A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise? isokinetic isometric range-of-motion isotonic

isotonic

The nurse is caring for a bedbound client who reports not being able to rest comfortably on their back. In which position will the nurse place the client to improve sleep? Sims supine lateral prone

lateral

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take? Inject the client while being restrained with antipsychotic medication. Call for assistance to remove the client from the area. Step in front of the client so that the other client will be protected. Forcefully remove the client and place in four-point restraints.

Call for assistance to remove the client from the area.

A nurse is planning a health fair in the community to highlight promotion and prevention of the leading cause of death in the United States. Which disease process should the nurse address? Lung cancer Coronary artery disease Cerebrovascular accidents Emphysema

Coronary artery disease

To be an effective change agent for wellness, the nurse must: consume a healthy diet. lead a sedentary lifestyle. skip breakfast to reduce calories. drink caffeinated beverages.

consume a healthy diet.

A 47-year-old woman is traveling overseas on vacation with her husband. He has a sore throat that has been diagnosed as Streptococcus. The woman is the: reservoir. agent. host. environment.

host.

The nurse instructor has completed a session detailing major factors differentiating exacerbations from remissions. The instructor determines the session is successful when the students point out which factor(s) can contribute to exacerbations? Select all that apply. dietary log shows improvement on food choices skin turgor indicates good hydration status immune system is functioning poorly sleep has been disrupted due to family issues client is facing a potential eviction

immune system is functioning poorly sleep has been disrupted due to family issues client is facing a potential eviction

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply. increased joint mobility full range of motion independent maintenance of correct alignment scissors gait head, shoulders, and hips aligned in bed Fasciculations

independent maintenance of correct alignment head, shoulders, and hips aligned in bed full range of motion

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise? aerobic isotonic isometric anaerobic

isometric

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? Arrange for a skilled home care assessment Perform a vision test with Snellen chart Arrange an audiology consult to evaluate hearing Assess the client for signs and symptoms of osteoporosis

Arrange for a skilled home care assessment

The occupational nurse is teaching employees about maintaining good posture. Which teaching will the nurse include? (Select all that apply.) Bend the knees slightly to avoid straining joints. Alternate placing weight on one foot versus the other. Keep the shoulders even and centered above the hips. Push the buttocks out and hold the abdomen up to properly align the spine. Maintain the hips at an even level.

Bend the knees slightly to avoid straining joints. Maintain the hips at an even level. Keep the shoulders even and centered above the hips.

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death? First Fifth Eighth Tenth

Fifth

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. Fowler Supine Modified supine Semi-Fowler Upright

Fowler Semi-Fowler Upright

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply. Hyperextension of fingers Adduction of fingers Abduction of fingers Flexion of fingers Extension of fingers

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client? Tertiary prevention Primary prevention Secondary prevention Residual prevention

Tertiary prevention

The nurse is caring for a client who works in a warehouse and has been having low back pain. Which statement by the client indicates the need for more education regarding safe lifting? "I try to rest between periods of lifting." "I hold the boxes away from my body so I do not drop them on my feet." "I bend with my knees when I pick up boxes." "I stand with my feet apart so I have a better stance when I lift."

"I hold the boxes away from my body so I do not drop them on my feet."

Upon hourly rounding, a nurse finds that a fire has broken out in a client's room. Which intervention is the priority? Confine the fire. Raise an alarm. Extinguish the fire. Rescue the client.

Rescue the client.

Consultation and diagnostic tests are included in which level of health care? Secondary care Extended care Tertiary care Primary care

Secondary care

A nurse is promoting body movements for a client during range-of-motion exercises. Which movement(s) provide for flexion? Select all that apply. extending the leg and lifting the thigh toward the abdomen, then returning the leg to the original position curling the toes downward and then straightening them out bending the hand or foot backward and forward turning the sole of the foot toward the midline, then turning the sole of the foot outward moving the head from side to side, then touching the chin to each shoulder bending the leg and bringing the heel toward the back of the leg, then returning the leg to the straight position

bending the hand or foot backward and forward bending the leg and bringing the heel toward the back of the leg, then returning the leg to the straight position curling the toes downward and then straightening them out extending the leg and lifting the thigh toward the abdomen, then returning the leg to the original position

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. Exercise decreases rate of carbon dioxide excretion. Exercise increases efficiency of the metabolic system. Exercise increases resting heart rate and blood pressure. Exercise decreases appetite. Exercise increases intestinal tone. Exercise increases blood flow to kidneys.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys.

A nurse is caring for an older adult client who has osteoporosis. Upon further examination the client reports smoking one pack of cigarettes per day, social alcohol consumption, a low-fat low-carb diet, and walks for exercise at least once a week. What primary intervention would the nurse recommend to help the client prevent further bone loss? Add moderate weight-lifting exercises at least 3 times per week. Join a smoking cessation support group to eliminate this risk factor. Increase regular weight-bearing exercises such as brisk walking, dancing, and yoga to at least 3 times per week. Increase dietary intake to include foods with beneficial fats such as avocados, chia seeds, and dark chocolate.

Increase regular weight-bearing exercises such as brisk walking, dancing, and yoga to at least 3 times per week.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply. Use a nightlight. Remove clutter from walkways. Consider the use of a raised toilet seat. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of an electronic personal alarm. Avoid climbing on a chair or table to reach items that are too high.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.

The nurse is assessing an infant who has developed one extremity that is shorter than the other. The nurse will suspect what causative factor? Bone tumor Hypocalcemia Hip fracture Hip dislocation

Hip dislocation

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? Hold your cane on the right side. Hold the cane 6 in (15 cm) in front of you. Lean into the cane as it supports you. You may switch hands with your cane if you become tired.

Hold your cane on the right side.

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? replacing pillows and positioning devices lowering the height of the bed prior to moving the client placing the client in good alignment with joints slightly flexed turning the client as a complete unit to avoid twisting the spine

lowering the height of the bed prior to moving the client

A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness? The disease is no longer present. The symptoms of the illness reappear. New symptoms occur at this time. Symptoms are not experienced.

Symptoms are not experienced.

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg).

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: "My child should wear a helmet every time he rides a bike." "The helmet should rest 1 in (2.5 cm) above the eyebrows." "I should be able to fit two fingers between my chin and the chin strap." "My child needs a helmet if in a secured passenger bike seat."

"I should be able to fit two fingers between my chin and the chin strap."

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area? Diagnosis of disease Self-concept Health promotion Illness prevention

Health Promotion

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized? Ensuring that the client's nurse is held accountable and educated about best practice Reinforcing the standards for nursing care to staff members who were involved Identifying systemic factors on the unit that may have contributed to the event Communicating the potential consequences of the near miss to the client involved

Identifying systemic factors on the unit that may have contributed to the event

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? Supervise your child on the changing table. Buy protective sporting equipment. Peer pressure causes children of this age to take risks. Place all household cleaners out of reach.

Peer pressure causes children of this age to take risks.

As part of a prenatal class, the nurse is educating a group of clients on car seat safety. The nurse is providing which of the following? Educational illness prevention Primary illness prevention Secondary illness prevention Tertiary illness prevention

Primary illness prevention

What have the models of health promotion and illness prevention been used for? To create a forum for improving rehabilitative care. To help health care providers understand health-related behaviors. To formulate care plans for people with disabilities. To define a medical framework for the care of people with disabilities.

To help health care providers understand health-related behaviors.

A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply. Face in the direction in which you are moving the load. Flex the knees to improve balance and strength. Standing with your feet close together will improve your balance. Pull objects toward you rather than pushing them away. Work as closely to the objects you are moving as possible.

Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Face in the direction in which you are moving the load.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? "I will rescue clients from harm before doing anything else." "I will close the door to the room where the fire is after clients have been removed." "After clients are evacuated from the room with the fire, the alarm can be sounded." "Only certain members of the health care team can extinguish a fire."

"Only certain members of the health care team can extinguish a fire."

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? "Keep knees and legs very straight." "Sleep with your head tilted to one side to take pressure off your neck." "Your feet should be at 45-degree angles from the legs." "Picture yourself with good posture standing; that is how good lying posture works."

"Picture yourself with good posture standing; that is how good lying posture works."

The nurse is caring for a very active, athletic adolescent recently diagnosed with multiple sclerosis. The client appears to be withdrawn and depressed when the nurse asks how the client is doing today. Using the health belief model, what step(s) will the nurse take to create a plan of care for this client? Select all that apply. Assure the client that there is nothing to be worried about because many people are diagnosed with this disease, and alert the family to the possibility of depression. Assure the client that they will be able to live a full life, provide education on how to adjust to the new diagnosis, and include the family in any life-changing decisions. Encourage the client to participate in as many activities as they can tolerate and provide information for health counseling. Conduct an in-depth interview of the client's previous health issues, how the client reacted to the illness, and what support system the client has. Review possible outcomes of the diagnosis with the client, allowing the client to express concerns while providing support.

Encourage the client to participate in as many activities as they can tolerate and provide information for health counseling. Review possible outcomes of the diagnosis with the client, allowing the client to express concerns while providing support. Conduct an in-depth interview of the client's previous health issues, how the client reacted to the illness, and what support system the client has.

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? Use assistive devices if either of the nurses will need to lift more than 60 lb (27.2 kg). To ensure safety, do not allow the client to assist with the transfer. If the client is in pain, administer analgesics in advance of the transfer. Avoid using handling aids unless absolutely necessary.

If the client is in pain, administer analgesics in advance of the transfer.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Increase the resident's physical activity to reduce evening restlessness. Limit the resident's fluid intake in order to reduce his or her urge to void. Collaborate with the resident's health care provider to have his or her diuretics discontinued. Investigate the possibility of discontinuing his or her catheter.

Investigate the possibility of discontinuing his or her catheter.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply. Ensure that the client's bedrails are up prior to transfer. Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Make sure the client's weaker leg is nearest to the chair. Provide step-by-step instructions to the client before the transfer begins.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins.

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning? hyperextension of the hips plantar flexion of the feet skin breakdown of the sacrum flexion contracture of the neck

plantar flexion of the feet

An 85-year-old white woman walks 1 mile (1.6 km) every morning and every evening. She continues to smoke but has cut back to half a pack per day. She had a total oophorectomy at age 45 secondary to stage I ovarian cancer. This client is currently not on any medications. Which is not a primary risk factor for osteoporosis for this client? sedentary lifestyle Caucasian race smoking oophorectomy at age 45

sedentary lifestyle