Exam 4 NUR 304
Sharing eating utensils with a person who has a contagious illness increases the risk of illness. This type of health risk arises from: Lifestyle. Community. Family history. Personal hygiene habits
Personal hygiene habits
IN CLASS: An example of a secondary health prevention activity would be a. Chemotherapy IV infusion b. Hepatitis B vaccine series c. Gallbladder surgery d. Flexible sigmoidoscopy at age 50
d. Flexible sigmoidoscopy at age 50 Correct answer: D The American Cancer Society recommends that beginning at age 50, both men and women at average risk for developing colorectal cancer should use one of several screening exams. Health-screening activities are included in the definition of secondary health prevention. d. = a screening A=tertiary B=primary C= tertiary
IN CLASS: 1. Which of the following might be a cause of stress for young adults? Select all that apply A. Being single B. Career C. Sexuality D. Activity
•Answer: A, B, C •Rationale: Depending on the situation of the young adult, being pressured about their single status, career choices, and sexuality are all stressors that can impair the health of the young adult.
A 6-week-old infant grasps a rattle placed in the hand. The parent is impressed with this skill. What should the nurse teach the parent about this behavior? 1 This is the palmar grasp reflex and is expected at this age. 2 This is the pincer grasp, which disappears within several months. 3 Grasping is a voluntary behavior usually observed in older infants. 4 Grasping is an atypical behavior, and further evaluation is required.
1 This is the palmar grasp reflex and is expected at this age. The palmar grasp reflex is expected at 6 weeks of age, begins to fade at 2 months, and disappears by 4 months. The pincer grasp is a fine motor voluntary behavior that begins around 8 months of age. Grasping is involuntary behavior; it is a reflex response that is not expected in older infants. The palmar grasp reflex is typical, not atypical, for a 6-week-old infant.
♕a nurse is showing a patient newly diagnosed with type II DM how to use a glucometer and make a daily journal of his glucose values for his next doctor visit. which level of prevention is the nurse practicing? primary prevention secondary prevention tertiary prevention quaternary prevention
secondary prevention--they already have it and you are showing them
♕ a patient has surgery for a fractured wrist due to a motor vehicle accident and is currently participating in a daily rehab session. At the surgeon's office, which level of prevention is this patient practicing? primary prevention secondary prevention tertiary prevention quaternary prevention
tertiary prevention
A nurse is focusing on the interactive processes of family life and is asking the patient questions. Match the questions the nurse will ask to the interactive process. a. Intimacy expression b. Social support c. Roles d. Family nurturing 1. Who is the "peacekeeper" of the family? 2. How are house rules established? 3. How often does the family hug each other? 4. Who at your workplace is close to the family?
1. Who is the "peacekeeper" of the family?==c. Roles 2. How are house rules established?==d. Family nurturing 3. How often does the family hug each other?==a. Intimacy expression 4. Who at your workplace is close to the family?==b. Social support
♕The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the A.Patient's individual cultural beliefs B.Values of her own culture C.Spanish speaking community D.Work history
A: Obtaining information about the patient's cultural beliefs will help the nurse provide care tailored to the patient's needs.
♕Care that encompasses conventional medicine and complementary therapies is considered: A.Alternative B.Conventional C.Holistic D.Integrative
D: Integrative therapy is using more than one type or approach to health care
♕To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client: A."Have you ever been married?" B."Where do you currently work?" C.Has anyone ever taught you about contraception?" D."Who do you have for support during this pregnancy?"
D: The nurse should ask the client, "Who do you have for support during this pregnancy" to determine how the client will be able to cope with the current pregnancy.
The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? Loss of autonomy caused by health problems Physical appearance, family, friends, and school Self-esteem issues, changing family structure Search for identity with peer groups and separation from family
Stressors that apply to preadolescents are self-esteem issues and a changing family structure. A loss of autonomy caused by health problems applies to the older adult. Stressors that apply to children are physical appearance, family, friends, and school.
♕when assessing an older adult who is showing sx of anxiety, insomnia, anorexia, malconfusion, one of the FIRST assessments includes which of the following? The amount of family support A 3-day diet recall A thorough physical assessment Threats to safety in her home
a thorough physical assessment---b/c they have all those issues going on
15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? a. A patient 35 years old b. A patient 68 years old c. A patient with a college degree d. A patient with a high-school diploma
ANS: B About 9 out of 10 people in the United States experience challenges in using health care information. Patients who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions. A 35-year-old patient and patients with high-school and college education are not identied in the vulnerable populations.
IN CLASS: 2. You are in the process of admitting an ethnically diverse patient. To plan culturally competent care, you will conduct a cultural assessment that includes: A. biocultural history. B. ethnohistory. C. negotiation. D. ethnocentrism.
B. ethnohistory.
1. Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support
ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.
in class When completing the nursing data on a client, to complete the admission and develop a plan of care, the nurse will need to: A. test the family unit's ability to cope. B. evaluate communication patterns. C. identify family unit form and attitudes. D. gather health data from all family members.
C. identify family unit form and attitudes.
Which of the following family assessments are most important for successful family caregiving? (Select all that apply.) Educational level of family members Cultural food preferences Collaboration between family members Social support Conflict resolution practices
Collaboration between family members Social support Conflict resolution practices For successful family caregiving, members of the family must collaborate and use conflict resolution strategies to divide the workload, make decisions, identify recreational activities, etc. A support system is important to help individual members and the entire family deal with the some of the high demands and challenges of family caregiving.
15. A young male patient is diagnosed with testicular cancer. Which action will the nurse take first? a. Provide information to the patient. b. Allow time for the patient's friends. c. Ask about the patient's priority needs. d. Find support for the family and patient.
c. Ask about the patient's priority needs. Take time to understand a patient's meaning of the precipitating event and the ways in which stress is a 洅ecting his life. For example, in the case of a woman who has just been told that a breast mass was identi 밄ed on a routine mammogram, it is important to know what the patient wants (priority needs) and needs most from the nurse. Providing information, allowing time with friends, and 밄nding support may be implemented after 밄nding out what the patient wants or needs.
The patient reports episodes of sleepwalking to the nurse. Through understanding of the sleep cycle, the nurse recognizes that sleepwalking occurs during which sleep phase? a. Rapid Eye Movement (REM) Sleep b. Stage 1 non-rapid eye movement (NREM) sleep c. Stage 4 NREM sleep d. Transition period from NREM to REM sleep
c. Stage 4 NREM SleepStage 4 NREM sleep is the deepest stage of sleep. It is difficult to rouse the sleeper in this stage. During this stage sleepwalking and enuresis (bed-wetting) sometimes occur
♕a nurse is presenting a program to workers in a factory covering safety topics including wearing hearing protectors while working in the factory. which level of prevention is the nurse practicing? primary prevention secondary prevention tertiary prevention quaternary prevention
primary prevention -------- secondary prevention means they already have it
IN CLASS: 2. Which of the following might be a cause of stress for the older adult? A. Financial security B. Planned retirement C. Housing D. Adjusting to decreasing health and physical strength
•Answer: A, C, D •Rationale: Stressful situations for older adults include making sure they have enough money to provide all their needs; selecting the correct housing to ensure future needs, especially if the older adult's mobility is limited; and adjusting to decreasing health and physical strength, as limitations become more apparent when health and physical strength decreases. ================ b. -retirement by itself is a stressor but since it is planned, it is not
2. A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: A. maturational. B. situational. C. sociocultural. D. posttraumatic.
•B. situational.---the situation has changed
♕intimate partner violence is linked to which of the following factors. select all that apply. alcohol abuse marriage pregnancy unemployment drug use
alcohol abuse pregnancy unemployment drug use
EMTALA***
***Emergency Medical Treatment and Active Labor Act (MTALA)—if they go to emergency room, they have to be seen (regardless if they can pay for it or not, race, pediatrics, obstetrics, etc no matter the specialty of hospital) • Ex: even though UMH not child hospital, child going into emergency room must be seen, stabilized and THEN transported to a unit to treat them
The clinic nurse is teaching an adolescent about lifestyle modifications to prevent hyperlipidemia. Which statement by the adolescent indicates a need for further teaching? 1 "I'll start eating more red meat." 2 "I'm going to eat a lot of low-fat yogurt." 3 "I'll try to stop eating so much processed food." 4 "I'll start eating whole-grain bread instead of white."
1 "I'll start eating more red meat." Red meats are high in fat. The monounsaturated and polyunsaturated fats can increase high density lipoprotein and decrease low density lipoprotein cholesterol. For this reason, an increase in the consumption of red meat is not advisable. Most whole grains, breads, pastas, and cereals are naturally low in fat. Adolescents should be taught to choose lean meats, beans, and low-fat dairy products and to limit their intake of processed foods such as crackers, cookies, cakes, and higher fat snacks.
A nurse is using different strategies to meet older patients' psychosocial needs. Match the strategy the nurse is using to its description. a. Respecting the older adult's uniqueness b. Improving level of awareness c. Listening to the patient's past recollections d. Accepting describing of patient's perspective e. Offering help with grooming and hygiene 1. Body image 2. Validation therapy 3. Therapeutic communication 4. Reality orientation 5. Reminiscence
1. Body image--e. Offering help with grooming and hygiene 2. Validation therapy--d. Accepting describing of patient's perspective 3. Therapeutic communication--a. Respecting the older adult's uniqueness 4. Reality orientation--b. Improving level of awareness 5. Reminiscence--c. Listening to the patient's past recollections
♕A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room 2. Adequate staffing is available for all residents 3. Social activities are available for all residents 4. The center provides three meals daily with a set menu and serving schedule 5. Staff encourage family involvement in care planning and assisting with physical care
2. Adequate staffing is available for all residents 3. Social activities are available for all residents 5. Staff encourage family involvement in care planning and assisting with physical care
A nurse is assessing growth and development in a 6-month-old infant. What behaviors does the nurse expect the infant to demonstrate? 1 Sitting alone, displaying pincer grasp, and waving bye-bye 2 Pulling up to a standing position, releasing a toy by choice, and playing peek-a-boo 3 Crawling, transferring a toy from one hand to the other, and displaying fear of strangers 4 Turning over completely, sitting momentarily without support, and reaching to be picked up
4 Turning over completely, sitting momentarily without support, and reaching to be picked up Turning over completely, sitting momentarily without support, and reaching to be picked up are age appropriate actions in 6-month-old infants. The ability to sit alone, display a pincer grasp, and wave bye-bye; pull up to a standing position, release a toy by choice, and play peek-a-boo; and crawl, transfer a toy from hand to hand, and display fear of strangers should have developed by 10 months of age.
The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. Even though several ethical principles are at work in this case, what are the principles from highest to lowest priority? 1. Accountability: You as the nurse are accountable for the wellbeing of this patient. 2. Respect for autonomy: This patient's autonomy will be violated if he does not receive the liver transplant. 3. Ethics of care: The caring thing that a nurse could provide this patient is resources for a liver transplant. 4. Justice: The greatest question in this situation is how to determine the just distribution of resources. 4, 1, 3, 2 2, 4, 3, 1 4, 2, 3, 1 4, 3, 2, 1
4, 2, 3, 1 Understanding the concept of justice helps to enrich the conversation about how to act and lifts the conversation above and beyond the circumstances of the patient. If justice is compromised, respect for autonomy will be hard to maintain. The nurse will be able to care for the patient, but unfortunately her commitment to care does not give her the power to resolve the difficult issue of limited resources. Other concepts are valid but not as relevant to the case.
♕The comment "All Accelerated Option Nursing Students are overachievers" can be considered: A.A bias B.An archetype C.A stereotype D.Discrimination
C: The above comment is stereotyping that all accelerated nursing students are over achievers
Which statement made by a new graduate nurse about the teachback technique requires intervention and further instruction by the nurse's preceptor? "After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient's understanding." "The Teach Back technique is an ongoing process of asking patients for feedback." "Using Teach Back will help me identify explanations and communication strategies that my patients will most commonly understand." "Using pictures, drawings, and models can enhance the effectiveness of the Teach Back technique."
"After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient's understanding." Teach Back is not a test of patient knowledge or ability to use devices but a confirmation of how well the nurse explained concepts to patients.
Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? "I'll give the baby a bottle to help her fall asleep." "We'll place the baby on her back to sleep." "We put the baby's stuffed animals in the crib to make her feel safe." "I know the baby will not need to be fed until morning."
"We'll place the baby on her back to sleep." This is based on the current evidence that shows that parents need to place an infant on his or her back to prevent suffocation. Bottles, stuffed animals, and pillows should not be placed in the bed with an infant.
a. Elevated cholesterol levels b. Nausea and vomiting c. Benign prostatic hyperplasia d. Skin in inflammation e. Mild anxiety f. Unsafe and should not be used 1.Aloe 2. Garlic 3. Valerian 4. Ginger 5. Saw palmetto 6. Chaparral
)1.Aloe---d. Skin in inflammation 2. Garlic---a. Elevated cholesterol levels 3. Valerian---e. Mild anxiety (herb used a lot to treat insomnia) 4. Ginger---b. Nausea and vomiting 5. Saw palmetto---c. Benign prostatic hyperplasia; (saw palmetto is used as a dietary supplement for urinary symptoms associated with an enlarged prostate gland (also called benign prostatic hyperplasia or BPH), as well as for chronic pelvic pain 6. Chaparral---f. Unsafe and should not be used Chaparral is UNSAFE. There are several reports of serious poisoning, acute hepatitis, and kidney and liver damage, including kidney and liver failure. Chaparral can cause side effects including stomach pain, nausea, diarrhea, weight loss, fever, and liver and kidney damage.
The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How should the nurse respond? 1 "Introduce one food at a time every 4 to 7 days." 2 "Mix the pureed food with the formula two or three times a day." 3 "Try to maintain the formula intake regardless of solid food intake." 4 "Offer pureed foods by spoon after the bottle of formula is finished."
1 "Introduce one food at a time every 4 to 7 days." The introduction of one new food at a time permits the identification of any food allergies that might be present; intake of multiple new foods makes identification of the causative foods more difficult if there is a reaction. Mixing the food with formula can create feeding problems; if the infant does not like the taste of a food, it may be associated with the formula. Formula intake should be decreased as solid food intake increases, or the infant will be receiving excessive calories. Although pureed foods may be offered by spoon once the formula is finished, solid foods should be given when the infant is hungry to encourage intake.
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections? 1 "Wear cotton underpants." 2 "Void at least every 6 hours." 3 "Increase foods containing alkaline ash in the diet." 4 "Wipe from back to front after toileting."
1 "Wear cotton underpants." Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Voiding frequently helps to flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections; holding urine for 6 hours can lead to urinary tract infections. Foods high in acid, not alkaline, ash help to acidify urine; this urine is less likely to support bacterial growth. Alkaline urine promotes bacterial growth. Wiping from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection.
Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1 Attention span 2 Primary language 3 Coping mechanisms 4 Activity and coordination
1 Attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.
The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? 1 Low birthweight 2 Facial abnormalities 3 Chronic lung problems 4 Hyperglycemic reactions
1 Low birthweight Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.
♕Middle-age adults frequently find themselves trying to balance responsibilities related to employment, family life, care of children, and care of aging parents. People finding themselves in this situation are frequently referred to as being a part of: 1 The sandwich generation. 2 The millennial generation. 3 Generation X. 4 Generation Y.
1 The sandwich generation. (b/c between)
A nurse is discussing nursing actions that can lead to breaches of nursing practice. Match the example to the term it describes. a. Nurse posts about patient's loud and unruly family members. b. Nurse immediately applies restraints to make patient stay in bed. c. Nurse leaves bed in high position, causing patient to fall and break hip. d. Nurse states that she will wrap a bandage over patient's mouth if he won't be quiet. e. Nurse applies abdominal bandage after refusal. f. Nurse gets angry at patient and nurse leaves the hospital. 1. Assault 2. Battery 3. Abandonment 4. False imprisonment 5. Invasion of privacy 6. Malpractice
1. Assault--d. Nurse states that she will wrap a bandage over patient's mouth if he won't be quiet. 2. Battery--e. Nurse applies abdominal bandage after refusal. 3. Abandonment--f. Nurse gets angry at patient and nurse leaves the hospital. 4. False imprisonment--b. Nurse immediately applies restraints to make patient stay in bed. 5. Invasion of privacy--a. Nurse posts about patient's loud and unruly family members. 6. Malpractice--c. Nurse leaves bed in high position, causing patient to fall and break hip.
A nurse is using Campinha-Bacote's model of cultural competency to improve cultural care. Which actions describe the components the nurse is using? a. In-depth self-examination of one's own background b. Ability to assess factors that influence treatment and care c. Sufficient comparative understanding of diverse groups d. Motivation and commitment to continue learning about cultures e. Cross-cultural interaction that develops communication skills 1. Cultural skills 2. Cultural desires 3. Cultural awareness 4. Cultural knowledge 5. Cultural encounters
1. Cultural skills---b. Ability to assess factors that influence treatment and care 2. Cultural desires--d. Motivation and commitment to continue learning about cultures 3. Cultural awareness--a. In-depth self-examination of one's own background 4. Cultural knowledge--c. Sufficient comparative understanding of diverse groups 5. Cultural encounters--e. Cross-cultural interaction that develops communication skills
A nurse is assessing young and middle-aged adults for work-related conditions. Match the job to the work-related conditions that the nurse is assessing. a. Liver disease b. Carpal tunnel syndrome c. Asbestosis d. Farmer's lung e. Bladder cancer 1. Insulators 2. Dry cleaners 3. Dye workers 4. Office computer workers 5. Agricultural workers
1. Insulators--c. Asbestosis 2. Dry cleaners--a. Liver disease 3. Dye workers--e. Bladder cancer 4. Office computer workers--b. Carpal tunnel syndrome 5. Agricultural workers---d. Farmer's lung
The nurse is caring for a group of patients who have sleeping disruptions. Match the condition to the intervention the nurse will use. a. Use continuous positive airway pressure. b. Offer a small meal several hours before bedtime. c. Administer antidepressants. d. Administer modafinil (Provigel). e. Do not startle. f. Administer benzodiazepine-like drugs. 1.Cataplexy 2.Narcolepsy 3.Insomnia 4.Hiatal hernia 5.Sleepwalking 6.Obstructive sleep apnea
1.Cataplexy--c. Administer antidepressants. 2.Narcolepsy--d. Administer modafinil (Provigel)-> promotes wakefullness 3.Insomnia--f. Administer benzodiazepine-like drugs. 4.Hiatal hernia--b. Offer a small meal several hours before bedtime. 5.Sleepwalking--e. Do not startle. 6.Obstructive sleep apnea--a. Use continuous positive airway pressure.
For which client(s) should the nurse consider family members as the primary source of information? Select all that apply. 1 Older adult 2 Infant or child 3 During traumatic emergency 4 When critically ill, disoriented 5 In an outpatient clinic visit
2 Infant or child 3 During traumatic emergency 4 When critically ill, disoriented The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary source of information. A client who is brought to the emergency department after a trauma may not be in a position to explain the circumstances that led to the visit. In this case, the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.
♕With the exception of pregnant or lactating women, the young adult has usually completed physical growth by the age of: 1 18. 2 20. 3 25. 4 30.
2 20.
A client in her 37th week of gestation calls the nurse at the clinic and reports, "My ankles are so swollen." Which intervention should the nurse recommend? 1 Limiting fluid intake during the day 2 Elevating her legs more frequently during the day 3 Restricting salt intake for the remainder of her pregnancy 4 Taking a mild diuretic that the healthcare provider will prescribe
2. Elevating her legs more frequently during the day Dependent edema in the ankles is a common occurrence during the latter part of pregnancy. It results from increased pressure of the uterus on the pelvic veins. Elevating the legs encourages venous return. Limiting fluid intake can be harmful; increased circulating blood volume during pregnancy must be maintained. Salt is necessary to retain fluid for the increased circulating blood volume during pregnancy. Diuretics are not utilized during pregnancy; they may decrease the circulating blood volume.
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1 Recording these expected findings 2 Obtaining an order for an oxytocic medication 3 Asking the client when she last changed the perineal pad 4 Notifying the primary healthcare provider that the client may be hemorrhaging
3 Asking the client when she last changed the perineal pad The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported or recorded without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.
When does the anterior fontanel of an infant close? 1 At 4 to 10 months 2 At 8 to 12 months 3 At 12 to 18 months 4 At 18 to 26 months
3 At 12 to 18 months The anterior fontanel usually closes between 12 and 18 months.
Which event is considered as the hallmark of late puberty in young girls? 1 Breast enlargement 2 Adult type sexual hair 3 First menstrual period 4 Physiologic leukorrhea
3 First menstrual period First menstrual period is considered the hallmark of late puberty in young girls. Breast enlargement along with change in pubic hair to adult type sexual hair covering the mons pubis and labia majora occurs during mid-puberty stage. Physiologic leukorrhea (increased normal vaginal discharge) marks the uterine development early in puberty.
♕a nurse is preparing to preform a cultural assessment of a patient. which of the following questions is an example of a contrast question? 1. Tell me about your ethnic background 2. Have you had this problem in the past? 3. Where do other members of your family live? 4. How different is this problem from the one you had previously?
4. How different is this problem from the one you had previously?
♕What are the Five Rights of Delegation (select all that apply) A.Right Task B.Right Circumstance C.Right Person D.Right Place E.Right Direction F.Right Supervision G.Right Day
A, B, C, E, & F (Review the five rights of delegation)
♕Which of the following patients are involved in the tertiary level of prevention? Pick all that apply. A.A 55 year old male who is rehabilitating from a stroke B.A 15 year old female receiving the Human Papillomavirus vaccine C.An overweight patient participating in a weight loss program D.A diabetic patient who is learning how to self-administer insulin injections E.A 45 year old female who is scheduled for a mammogram
A, C, D: remember as part of tertiary prevention, the patient already has the disease or problem and making corrective actions to prevent further problems or to return to a healthy state.
♕At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful? A.Normalization of blood pressure B.Decreased peripheral skin temperature C.Increased heart rate D.Increased blood pressure •
A: At the end of a imagery guided session the blood pressure should become normal or within the normal range.
♕A cancer patent incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? A.Acupuncture B.Yoga C.Reiki D.Biofeedback
A: Read the question carefully, we didn't say cancer patient's could not have this therapy performed, only that it has a higher risks for infection; and out of the choices presented this patient should seek a formally trained professional for this type of alternative therapy.
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ADVENTITIOUS QUESTION ON HURRICANE
16. A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Precontemplation b. Contemplation c. Preparation d. Action
ANS B This patient is planning to make the change within the next 6 months and is in the contemplation stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).
3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene? a. Most older people have dependent functioning. b. Most older people have strengths we should focus on. c. Most older people should be involved in care decision. d. Most older people should be encouraged to have independence
ANS: A Most older people remain functionally independent despite the increasing prevalence of chronic disease; therefore, this misconception should be addressed. It is critical for you to respect older adults and actively involve them in care decisions and activities. You also need to identify an older adult's strengths and abilities during the assessment and encourage independence as an integral part of your plan of care.
3. A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? a. Accessibility of health care services b. Outcomes of health conditions c. Prevalence of complications d. Incidence of diseases
ANS: A While health disparities are the dierences among populations in the incidence, prevalence, and outcomes of health conditions, diseases and related complications, health care disparities are dierences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications.
10. A nurse is teaching a patient about meridians. Which technique is the nurse preparing the patient to receive? a. Acupuncture b. Naturopathic c. Latin American traditional healing d. Native American traditional healing
ANS: A Acupuncture regulates or realigns the vital energy (qi), which 밄ows like a river through the body in channels that form a system of 20 pathways called meridians. Naturopathic therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mind-body therapies with an orientation toward assisting the person's internal capacity for self-healing (vitalism). Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses. The goal is to create a balance between the patient and his or her environment, thereby sustaining health.
9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? a. Provides care to transgender patients b. Provides care to restore relationships c. Provides care to patients that is individualized d. Provides care to surgical patients
ANS: A Although cultural competence and patient-centered care both aim to improve health care quality, their focus is slightly dierent. The primary aim of cultural competence care is to reduce health disparities and increase health equity and fairness by concentrating on people of color and other marginalized groups, like transgender patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores an emphasis on personal relationships; it aims to elevate quality for all patients.
19. A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states "I would be better oӄ dead." The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient's spouse will have to go to work. Which action should the nurse take? a. Develop a plan of care for the family. b. Contact psychiatric services for a referral. c. Assure the patient that things will work out. d. Focus the plan of care solely on maximizing patient function.
ANS: A Because of the eӄects of chronic illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well being. Psychiatric services may be a part of that plan but do not represent the entire plan. Oӄering false assurance is never acceptable. Focusing only on the patient will not help the family adjust.
2. A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? a. "Biofeedback will help me with my thoughts and physiological responses to stress." b. "Biofeedback will direct my energies in an intentional way when stressed." c. "Biofeedback will allow me to manipulate my stressed out joints." d. "Biofeedback will let me assess and redirect my energy 밄elds." ANS: A
ANS: A By using electromechanical instruments, a person can receive information or feedback on his or her stress level. Having this knowledge allows the patient to develop awareness and voluntary control over his or her physiological symptoms. Biofeedback does not address energy 밄elds; healing touch, reiki, and therapeutic touch are energy 밄elds. Directing energies is therapeutic touch. Manipulation of body alignment and joints is done by a chiropractor.
4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions? a. Flea bites and lice infestation b. Left at a grocery store c. Refuses to take a bath d. Cuts and bruises
ANS: A Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and untreated injuries.
5. A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering and for malpractice. Which key point will the prosecution attempt to prove against the nurse? a. The CPR procedure was done incorrectly. b. The patient would have died if nothing was done. c. The patient was resuscitated according to the policy. d. The older patient with brittle bones might sustain fractures when chest compressions are done.
ANS: A Certain criteria are necessary to establish nursing malpractice. The prosecution would try to prove that a breach of duty had occurred (CPR done incorrectly), which had caused injury. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR and that the patient was resuscitated according to policy. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards, the way other nurses would have performed in the same situation. The fact that the patient sustained injury as a result of age and physical status does not mean the nurse breached any duty to the patient. The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived.
7. A nurse is assessing a child that lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely? a. Ears b. Eyes c. Head d. Hands
ANS: A Children of homeless families are often in fair or poor health and have higher rates of asthma, ear infections, stomach problems, and mental illness. Eyes, head, and hands are not as important as the ears.
7. The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to and resolution in this assignment? a. Scrutinize personal values. b. Call for an ethical committee consult. c. Decline the assignment on religious grounds. d. Convince the family to challenge the directive.
ANS: A Clarifying values—your own, your patients', your co-workers'—is an important and e††ective part of ethical discourse. Calling for a consult, declining the assignment, and convincing the family to challenge the patient's directive are not ideal resolutions because they do not address the reason for the nurse's discomfort, which is the con††ict between the nurse's values and those of the patient. The nurse should value the patient's decisions over the nurse's personal values.
15. A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next? a. Ask the nursing assistive personnel to observe while the nurse performs catheter care. b. Leave the room and ask the nursing assistive personnel to go back and perform proper catheter care. c. Tell the nursing assistive personnel that catheter care is sloppy. d. Remove the catheter.
ANS: A If the sta岳꫰ member's performance is not satisfactory, give constructive and appropriate feedback. You may discover the need to review a procedure with staff and other demonstration. Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. Telling that catheter care is sloppy does not correct the problem. The catheter does not need to be removed.
1. Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is most compromised when only one nurse anesthetist is on call? a. Justice b. Fidelity c. Benenifcence d. Nonmaleficence
ANS: A Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmale††cence refers to avoidance of harm; bene††cence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Each of these principles is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resources.
11.The nurse is completing an assessment on an older-adult patient who is having diffculty falling asleep. Which condition will the nurse further assess for in this patient? a. Depression b. Mild fatigue c. Hypertension d. Hypothyroidism
ANS: A Older adults and other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent awakening, feelings of sleeping poorly, and daytime sleepiness. A person who is moderately fatigued usually achieves restful sleep, especially if the fatigue is the result of enjoyable work or exercise. Hypertension often causes early-morning awakening and fatigue. Alcohol speeds the onset of sleep. Hypothyroidism decreases stage 4 sleep.
10. The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention
ANS: A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Primary prevention includes health education programs, immunizations, and physical and nutritional ӄtness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the eӄects of long-term disease or disability through interventions directed at preventing complications and deterioration. While risk factor modiӄcation is an integral component of health promotion, it is not a type of preventive care.
16. A young-adult patient is brought to the hospital by police after crashing the car in a high-speed chase when trying to avoid arrest for spousal abuse. Which action should the nurse take? a. Question the patient about drug use. b. Order the patient a cup of coffee to calm nerves. c. Discretely assess the patient for sexually transmitted infections. d. Deal with the issue at hand, not asking about previous illnesses.
ANS: A Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for the nurse to investigate the possibility of drug abuse more carefully. Caᨌeine is a naturally occurring legal stimulant that stimulates the central nervous system and is not the choice for calming nerves. Although sexually transmitted infections occur in the young adult, this is not an action a nurse should take in this situation. The nurse may obtain important information by making speci᧴c inquiries about past medical problems, changes in food intake or sleep patterns, and problems of emotional lability.
The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the beneӄts of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs
ANS: A The health belief model addresses the relationship between a person's beliefs and behaviors. The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health promotion model focuses on the following three areas: (1) individual characteristics and experiences, (2) behavior-specific knowledge and affect, and (3) behavioral outcomes, in which the patient commits to or changes a behavior. Maslow's' hierarchy of needs is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health.
15.The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient's experiencing sleep deprivation. Which action will be best for the nurse to take? a. Expedite the process of obtaining a medical-surgical room for the patient. b. Pull the curtains shut, dim the lights, and decrease the number of visitors. c. Obtain an order for a hypnotic medication to help the patient sleep. d. Ask everyone in the unit to try to be quiet so the patient can sleep.
ANS: A The most effective treatment for sleep deprivation is elimination or correction of factors that disrupt the sleep pattern. Obtaining a private room in the medical-surgical unit for the patient will help with decreasing stimuli and promoting more rest than an individual can obtain in an emergency department even with the interventions mentioned
18. A nurse is assigned to care for the following patients who all need vital signs taken right now. Which patient is most appropriate for the nurse to delegate vital sign measurement to the nursing assistive personnel (NAP)? a. Patient scheduled for a procedure in the nuclear medicine department b. Patient transferring from the intensive care unit (ICU) c. Patient returning from a cardiac catheterization d. Patient returning from hip replacement surgery
ANS: A The nurse does not assign vital sign measurement or other tasks to NAP when patients are experiencing a change in level of care. The patient awaiting the procedure in nuclear medicine is the only patient who has not experienced a change in level of care. According to the rights of delegation, tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal risk can be delegated to assistive personnel. The patient in this question with the most predictable condition is the patient awaiting the nuclear medicine procedure. Once the nurse determines that the other patients are stable, the nurse could delegate their future vital sign measurement to the NAP. However, it is important for the nurse to assess patients coming from the ICU, the cardiac cath lab, and surgery when they first arrive on the unit.
16.The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment? a. Visual analog scale b. Cataplexy scale c. Polysomnogram d. RAS scale
ANS: A The visual analog scale is utilized for assessing sleep quality. Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day; there is no cataplexy scale for sleep assessment. A polysomnogram involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during nighttime sleep; this is used in a sleep laboratory study. Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness; however, there is no assessment tool called the RAS scale.
18. A nurse is assessing the patient's meaning of illness. Which area of focus by the nurse is priority? a. On the way a patient reacts to disease b. On the malfunctioning of biological processes c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions
ANS: A To provide culturally congruent care, you need to understand the dierence between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. The way a patient interacts to family/social interactions is communication processes and family dynamics.
11. A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? a. Shaman b. Vitalist c. Ayurvedic d. Curanderismo
ANS: A Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. Naturopathic therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mindbody therapies with an orientation toward assisting the person's internal capacity for self-healing (vitalism). One of the oldest systems of medicine (Ayurvedic) has been practiced in India since the 밄rst century AD. Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses.
24.The nurse is evaluating outcomes for the patient with insomnia. Which key principle will the nurse consider during this process? a. The patient is the best evaluator of sleep. b. The nurse is the best evaluator of sleep. c. Effective interventions are the best evaluators of sleep. d. Observations of the patient are the best evaluators of sleep.
ANS: A With regard to problems with sleep, the patient is the source for evaluating outcomes. The patient is the only one who knows whether sleep problems have improved and what has been successful. Interventions are not the best indicator; achievement of goals according to the patient is the best. Observations do provide needed data, but in the case of insomnia, the patient is the source for evaluating the restfulness of sleep.
2. The nurse hears a health care provider say to the charge nurse that a certain nurse cannot care for patients because the nurse is stupid and won't follow orders. The health care provider also writes in the patient's medical records that the same nurse, by name, is not to care for any of the patients because of incompetence. Which torts has the health care provider committed? (Select all that apply.) a. Libel b. Slander c. Assault d. Battery e. Invasion of privacy
ANS: A, B Slander occurred when the health care provider spoke falsely about the nurse, and libel occurred when the health care provider wrote false information in the chart. Both of these situations could cause problems for the nurse's reputation. Invasion of privacy is the release of a patient's medical information to an unauthorized person such as a member of the press, the patient's employer, or the patient's family. Assault is any action that places a person in reasonable fear of harmful, imminent, or unwelcome contact. No actual contact is required for an assault to occur. Battery is any intentional touching without consent.
1. A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) a. Cancer b. Diabetes c. Infections d. Allostasis e. Low blood pressure
ANS: A, B, C Stress causes prolonged changes in the immune system, which can result in impaired immune function, and this increases the person's susceptibility to changes in health, such as increased risk for infection, high blood pressure, diabetes, and cancers. Allostasis is a return to a state of balance; allostatic load occurs with prolonged stress.
2. A nurse is assessing the realms of family life. Which processes will the nurse assess? (Select all that apply.) a. Developmental b. Interactive c. Integrity d. Coping e. Life
ANS: A, B, C, D The five realms of family life that should be assessed include: developmental, interactive, integrity, coping, and health, not life.
1. A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) a. Electrolyte imbalance b. Sensory deprivation c. Hypoglycemia d. Drug effects e. Dementia
ANS: A, B, C, D Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due to a physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication e⤀ㄆects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction.
1. A nurse is assessing threats concerning the family. Which areas will the nurse include in the assessment? (Select all that apply.) a. Homelessness b. Domestic violence c. Presence of illness d. Changing economic status e. Rise of homosexual families
ANS: A, B, C, D Social scientists have identified five trends as threats facing the family. These include (1) Changing economic status, (2) homelessness, (3) domestic violence, (4) the presence of acute or chronic illness or trauma, and (5) end-of-life care. Homosexual families are not a threat facing the family; in fact, many homosexual couples now de쪻ne their relationship in family terms.
1. A nurse uses the five rights of delegation when providing care. Which "rights" did the nurse use? (Select all that apply.) a. Right task b. Right person c. Right direction d. Right supervision e. Right circumstances f. Right cost-effectiveness
ANS: A, B, C, D, E The fie rights of delegation are right task, circumstances, person, direction, and supervision. Cost-effectiveness is not a right.
1.The nurse is caring for a patient who has not been able to sleep well while in the hospital, leading to a disrupted sleep-wake cycle. Which assessment findings will the nurse monitor for in this patient? (Select all that apply.) a. Changes in physiological function such as temperature b. Decreased appetite and weight loss c. Anxiety, irritability, and restlessness d. Shortness of breath and chest pain e. Nausea, vomiting, and diarrhea f. Impaired judgmen
ANS: A, B, C, F The biological rhythm of sleep frequently becomes synchronized with other body functions. Changes in body temperature correlate with sleep pattern. When the sleep-wake cycle becomes disrupted, changes in physiological function such as temperature can occur. Patients can experience decreased appetite, loss of weight, anxiety, restlessness, irritability, and impaired judgment. Gastrointestinal and respiratory/cardiovascular symptoms such as shortness of breath and chest pain are not symptoms of a disrupted sleep cycle.
1. A nurse is describing the therapeutic effects of imagery. Which information should the nurse include in the teaching session? (Select all that apply.) a. Controls pain b. Decreases nightmares c. Improves social anxiety disorders d. Helps with irritable bowel syndrome e. Reduces relapses in alcohol treatment
ANS: A, B, D Imagery helps control or relieve pain, decrease nightmares, and improve sleep. It also aids in the treatment of chronic conditions such as irritable bowel syndrome. Increased anxiety and fear sometimes occur when imagery is used to treat post-traumatic stress disorders and social anxiety disorders. Meditation successfully reduces relapses in alcohol treatment programs
A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system b. Identiӄes actual and potential risk factors c. Has coined the term "illness behavior" d. Minimizes the eӄects of illnesses e. Experiences compassion fatigue
ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the eӄects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Nurses did not coin the phrase "illness behavior." While nurses can experience compassion fatigue, it does not help in meeting patient goals.
1. A nurse is using Campinha-Bacote's model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) a. Cultural skills b. Cultural desire c. Cultural transition d. Cultural knowledge e. Cultural encounters
ANS: A, B, D, E Campinha-Bacote's model of cultural competency has five interrelated components: cultural awareness; cultural knowledge; cultural skills; cultural encounters; and cultural desire. Cultural transition is not a component of this model. Awareness Skills Knowledge Encounters Desire
3.The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate the patient has a good understanding of the teaching? (Select all that apply.) a. "Drinking co᯿అee at 7 PM could interrupt my sleep." b. "Staying up late for a party can interrupt sleep patterns." c. "Exercising 2 hours before bedtime can decrease relaxation." d. "Changing the time of day that I eat dinner can disrupt sleep." e. "Worrying about work can disrupt my sleep." f. "Taking an antacid can decrease sleep."
ANS: A, B, D, E Ca᯿అeine, alcohol, and nicotine consumed late in the evening produce insomnia. Worry over personal problems or situations frequently disrupts sleep. Alterations in routines, including changing mealtimes and staying up late at night for social activities, can disrupt sleep. Exercising 2 hours before bedtime actually increases a sense of fatigue and promotes relaxation. Taking an antacid does not decrease sleep.
1. A nurse is a member of the ethics committee. Which purposes will the nurse ful††ll in this committee? (Select all that apply.) a. Education b. Case consultation c. Purchasing power d. Direct patient care e. Policy recommendation
ANS: A, B, E An ethics committee devoted to the teaching and processing of ethical issues and dilemmas exists in most health care facilities. It is generally multidisciplinary and it serves several purposes: education, policy recommendation, and case consultation. It does not have purchasing power or provide direct patient care.
2. A nurse is using the RESPECT mnemonic to establish rapport, the "R" in RESPECT. Which actions should the nurse take? (Select all that apply.) a. Connect on a social level. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures
ANS: A, C The "R" in RESPECT stands for rapport and includes the following behaviors: connect on a social level; seek the patient's point of view; and consciously attempt to suspend judgment. The "S" stands for support and includes the behavior of helping the patient overcome barriers. The "P" stands for partnership and includes the following behaviors: be exible with regard to issues of control and stress that you will be working together to address medical problems. The "C" stands for cultural competence and includes the behavior of knowing your limitations in addressing medical issues across cultures.
2.The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply.) a. NREM sleep contributes to body tissue restoration. b. During NREM sleep, biological functions increase. c. Restful sleep preserves cardiac function. d. Sleep contributes to cognitive restoration. e. REM sleep decreases cortical activity.
ANS: A, C, D Sleep contributes to physiological and psychological restoration. NREM sleep contributes to body tissue restoration. It allows the body to rest and conserve energy. This benefits the cardiac system by allowing the heart to beat fewer times each minute. During stage 4, the body releases growth hormone for renewal and repair of specialized cells such as the brain. During NREM sleep, biological functions slow. REM sleep is necessary for brain tissue restoration and cognitive restoration and is associated with a change in cerebral blood flow and increased cortical activity.
14. A nurse is assessing a patient's ethnohistory. Which question should the nurse ask? a. What language do you speak at home? b. How dierent is your life here from back home? c. Which caregivers do you seek when you are sick? d. How dierent is what we do from what your family does when you are sick?
ANS: B An ethnohistory question is the following: How dierent is your life here from back home? Caring beliefs and practice questions include the following: Which caregivers do you seek when you are sick and How dierent is what we do from what your family does when you are sick? The language and communication is the following: What language do you speak at home?
6. The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice
ANS: B The nurse is upholding autonomy. Autonomy refers to the freedom to make decisions free of external control. Respect for patient autonomy refers to the commitment to include patients in decisions about all aspects of care. Consequentialism is focused on the outcome and is a philosophical approach. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.
13. A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? a. "You are practicing under the license of the hospital's insurance." b. "You are expected to perform at the level of a professional nurse." c. "You are expected to perform at the level of a prudent nursing student." d. "You are practicing under the license of the nurse assigned to the patient."
ANS: B Although nursing students are not employees of the health care facility where they are having their clinical experience, they are expected to perform as professional nurses would in providing safe patient care. Dierent levels of standards do not apply. No standard is used for nursing students other than that they must meet the standards of a professional nurse. Student nurses do not practice under anybody's license; nursing students are liable if their actions exceed their scope of practice or cause harm to patients.
4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? a. Communicates effectively in a multicultural context b. Functions effectively in a multicultural context c. Visits a foreign country d. Speaks a different language
ANS: B Cultural competence refers to a developmental process that evolves over time that impacts ability to eectively function in the multicultural context. Communicates eectively and speaking a dierent language indicates linguistic competence. Visiting a foreign country does not indicate cultural competence.
5. A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? a. Complementary b. Allopathic c. Alternative d. Mind-body
ANS: B Despite the success of allopathic or biomedicine (conventional Western medicine), many conditions such as chronic back and neck pain, arthritis, gastrointestinal problems, allergies, headache, and anxiety continue to be difficult to treat. Complementary, alternative, and mind-body types of medicines can be used in tandem with allopathic medicines but are distinctly different.
1. A nurse is caring for a young adult. Which goal is priority? a. Maintain peer relationships. b. Maintain family relationships. c. Maintain parenteral relationships. d. Maintain recreational relationships
ANS: B Family is important during young adulthood. Challenges may include the demands of working and raising families. Peer is more important in the adolescent years. Young adults are much freer from parental control. While recreation is important, the family and work are the priorities in young adults.
1. A nurse is assessing the family unit to determine the family's ability to adapt to the change of a member having surgery. Which area is the nurse monitoring? a. Family durability b. Family resiliency c. Family diversity d. Family forms
ANS: B Family resiliency is the ability of the family to cope with expected and unexpected stressors; it's the families' ability to adapt to changes. Family diversity is the uniqueness of each family unit. Every person within a family unit has specific needs, strengths, and important developmental considerations. Family durability is a system of support and structure within a family that extends beyond the walls of the household. Family forms are patterns of people considered by family members to be included in the family.
9. A nurse is planning care for a 30 year old. Which goal is priority? a. Refine self-perception. b. Master career plans. c. Examine life goals. d. Achieve intimacy.
ANS: B From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals and relationships. Between the ages of 23 and 28, the person refines self-perception and ability for intimacy.
13. A nurse is using caring-healing relationships to support whole person/whole systems healing. Which type of nursing is the nurse using? a. Holistic nursing b. Integrative nursing c. Interprofessional nursing d. Complementary and alternative nursing
ANS: B Grounded in six principles, integrative nursing is de 밄ned as "a way of being-knowing-doing that advances the health and well-being of persons, families, and communities through caring-healing relationships." Integrative nurses use evidence to inform traditional and emerging interventions that support whole person/whole systems healing. Holistic nursing treats the mind-body-spirit of the patient, using interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery. Integrative health care, a strategy that is gaining popularity, involves interprofessional group practices where patients receive care simultaneously from more than one type of practitioner; nurses must interact with other health care professionals for any type of nursing. An integrative nurse will use complementary and alternative therapies to provide integrative nursing.
12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer a. 4, 1, 2, 3 b. 3, 4, 1, 2 c. 2, 3, 4, 1 d. 1, 2, 3, 4
ANS: B Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents).
1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? a. Lives in a nursing home b. Lives with a spouse c. Lives divorced d. Lives alone
ANS: B In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women, 71% of older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all older adults resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death rather than divorce.
3. Which goal is priority when the nurse is caring for a middle-aged adult? a. Maintain immediate family relationships. b. Maintain future generation relationships. c. Maintain personal career relationships. d. Maintain work relationships.
ANS: B Many middle-aged adults find particular joy in helping their children and other young people become productive and responsible adults. While immediate family is important, this goal is priority in young adults, not as important in middle-aged adults. During this period, personal and career achievements have often already been experienced; therefore, these goals are not priority.
6. A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? a. Identity issues b. Self-esteem issues c. Physical appearance d. Major changing life events
ANS: B Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Adolescent stressors include identity issues with peer groups and separation from their families. Children identify stressors related to physical appearance, families, friends, and school. Adult stressors centralize around major changes in life circumstances.
11. The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion
ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional ӄtness activities for healthy people. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the eӄects of long-term disease or disability through interventions directed at preventing complications and deterioration.
A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the "H"? a. Health b. Healers c. History d. Homeland
ANS: B The "H" in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners? While health, history, and homeland are important, they are not components of "H."
6. The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs
ANS: B The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health belief model addresses the relationship between a person's beliefs and behaviors. The health promotion model notes that each person has unique personal characteristics and experiences that aӄect subsequent actions. The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.
7.The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching? a. "I can't wait to get the baby home to play with the brothers and sisters." b. "I will ask my mom to come after the first week, when the baby is more alert." c. "I can get the baby on a sleeping schedule the first week while my mom is here." d. "I won't be able to nap during the day because the baby will be awake."
ANS: B The patient indicates an understanding when asking the mother to come after the ᯿贄rst week. The neonate up to the age of 3 months averages about 16 hours of sleep a day, sleeping almost constantly during the ᯿贄rst week. The baby will sleep rather than play. The baby will not be on a sleeping schedule the ᯿贄rst week home. The mother will be able to nap since the baby sleeps 16 hours a day.
11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? a. Caucasians b. Poor people c. Alaska Natives d. American Indians
ANS: B To improve results, the nurse should focus on the highest disparity. Poor people received worse care than high-income people for about 60% of core measures. American Indians and Alaska Natives received worse care than Caucasians for about 30% of core measures
3. A nurse is working in an intensive care unit (critical care). Which type of nursing care delivery model will this nurse most likely use? a. Team nursing b. Total patient care c. Primary nursing d. Case-management
ANS: B Total patient care is found primarily in critical care areas. Total patient care involves an RN being responsible for all aspects of care for one or more patients. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among sta岳꫰ members. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs.
16. During a severe respiratory epidemic, the local health care organizations decide to give health care workers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision? a. Deontology b. Utilitarianism c. Ethics of care d. Feminist ethics
ANS: B Utilitarianism focuses on the greatest good for the most people; the organizations decide to ensure that as many health care workers as possible will survive to care for other members of the community. Deontology de††nes actions as right or wrong based on their "right-making characteristics" such as ††delity to promises, truthfulness, and justice. Feminist ethics looks to the nature of relationships to guide participants in making di††cult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible. The ethics of care and feminist ethics are closely related, but ethics of care emphasizes the role of feelings.
4. When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this step? a. So fact is separated from opinion b. So different perspectives are respected c. So judgmental attitudes can be provoked d. So the group identifies the one correct solution
ANS: B Values are personal beliefs that in††uence behavior. To negotiate di††erences of value, it is important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values di††er from yours. Ethical dilemmas are a problem in that no one right solution exists. It is not to separate fact from opinion. Judgmental attitudes are not to be used, much less provoked.
10. A nurse is using the family as context approach to provide care to a patient. What should the nurse do next? a. Assess family patterns versus individual characteristics. b. Assess how much the family provides the patient's basic needs. c. Use "family as patient" and "family as context" approaches simultaneously. d. Plan care to meet not only the patient's needs but those of the family as well.
ANS: B When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within a speci쪻c environment (i.e., the patient's family). Although the focus is on the individual's health status, the nurse assesses how much the family provides the individual's basic needs. Family patterns are in the realm of "family as patient" approach. Often, the nurse will use the two simultaneously (family as context and family as patient) with the approach of "family as system." "Family as patient" involves planning to meet the needs of the patient and those of the family as well.
1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? a. Hispanic b. Asian Americans c. Non-Hispanic Caucasians d. Non-Hispanic African-Americans
ANS: B While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Caucasians, or non-Hispanic African-Americans.
3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.) a. How should your sickness be treated? b. What do you call your problem? c. How does this illness work inside your body? d. What do you fear most about your sickness? e. What name does it have?
ANS: B, C, E The questions for etiology include "What do you call your problem?" and "What name does it have?" Recommended treatment is asked by the question "How should your sickness be treated?" Pathophysiology is asked by the question "How does this illness work inside your body?" The course of illness is asked by the question "What do you fear most about your sickness?"
4.A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) a. Take a nap in the afternoon. b. Sleep where you sleep best. c. Use sedatives as a last resort. d. Watch television right before sleep. e. Decrease ᯿贄uids 2 to 4 hours before sleep. f. Get up if unable to fall asleep in 15 to 30 minutes.
ANS: B, C, E, F The nurse should instruct the patient to sleep where he or she sleeps best, to use sedatives as a last resort, to decrease ᯿贄uid intake to cut down on bathroom trips, and, if unable to sleep in 15 to 30 minutes, to get up out of bed. Naps should be eliminated if they are not part of the individual's routine schedule, and if naps are taken, they should be limited to 20 minutes or less a day. Television can stimulate and disrupt sleep patterns
4. A nurse is teaching the staff about professional negligence or malpractice. Which criteria to establish negligence will the nurse include in the teaching session? (Select all that apply.) a. Injury did not occur. b. That duty was breached. c. Nurse carried out the duty. d. Duty of care was owed to the patient. e. Patient understands benets and risks of a procedure.
ANS: B, D Certain criteria are necessary to establish nursing malpractice: (1) the nurse (defendant) owed a duty of care to the patient (plainti), (2) the nurse did not carry out or breached that duty, (3) the patient was injured, and (4) the nurse's failure to carry out the duty caused the injury. If an injury did not occur and the nurse carried out the duty, no malpractice occurred. When a patient understands benets and risks of the procedure, that is informed consent, not malpractice.
3. A nurse is providing prenatal care to a first-time mother. Which information will the nurse share with the patient? (Select all that apply.) a. Regular trend for postpartum depression b. Protection against urinary infection c. Strategies for empty nest syndrome d. Exercise patterns e. Proper diet
ANS: B, D, E Prenatal care includes a thorough physical assessment of the pregnant woman during regularly scheduled intervals. Information regarding STIs and other vaginal infections and urinary infections that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are important for a pregnant woman. Empty nest syndrome occurs as children leave the home. Postpartum depression is rare.
1. In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? a. Restorative care factors b. Strong financial resource factors c. Maturational and situational factors d. Immaturity and intelligence factors
ANS: C Maturational factors and situational factors can a 洅ect people di 洅erently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong 밄nancial resources, or is immature or intelligent.
9. A nurse is caring for an older adult. Which goal is priority? a. Adjusting to career b. Adjusting to divorce c. Adjusting to retirement d. Adjusting to grandchildren
ANS: C Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.
15. The nurse is caring for a dying patient. Which intervention is considered futile? a. Giving pain medication for pain b. Providing oral care every 5 hours c. Administering the influenza vaccine d. Supporting lower extremities with pillows
ANS: C Administering the in††uenza vaccine is futile. A vaccine is administered to prevent or lessen the likelihood of contracting an infectious disease at some time in the future. The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions the term refers to interventions unlikely to produce bene††t for a patient. Care delivered to a patient at the end of life that is focused on pain management, oral hygiene, and comfort measures is not futile.
7. A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which response from the nurse is best? a. It is probably an ayurvedic clinic. b. It is probably a homeopathic clinic. c. It is probably an integrative medical clinic. d. It is probably a naturopathic medical clinic.
ANS: C An integrative medical program allows health care consumers to be treated by a team of providers consisting of both allopathic and complementary practitioners. Several therapies are always considered alternative because they are based on completely di 洅erent philosophies and life systems from those used by allopathic medicine. Alternative therapies include ayurvedic, homeopathic, and naturopathic
18. A nurse is planning care for a patient that uses displacement. Which information should the nurse consider when planning interventions? a. This copes with stress directly. b. This evaluates an event for its personal meaning. c. This protects against feelings of worthlessness and anxiety. d. This triggers the stress control functions of the medulla oblongata.
ANS: C Ego-defense mechanisms, like displacement, regulate emotional distress and thus give a person protection from anxiety and stress. Everyone uses them unconsciously to protect against worthlessness and feelings of anxiety. Ego-defense mechanisms help a person cope with stress indirectly and o 洅er psychological protection from a stressful event. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.
20.The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care? a. Anxiety b. Fatigue c. Insomnia d. Sleep deprivation
ANS: C Insomnia is experienced when the patient has chronic di᯿ᜇculty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep. It is the most common sleep-related complaint and includes symptoms such as irritability, excessive daytime sleepiness, not being able to fall asleep, and fatigue. Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Fatigue is an overwhelming sustained sense of exhaustion with decreased capacity for physical and mental work at a usual level. Sleep deprivation is a condition caused by dyssomnia and includes symptoms caused by illness, emotional distress, or medications.
17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? a. Taking a bath b. Getting dressed c. Making a phone call d. Going to the bathroom
ANS: C Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential to independent living.
17. A nurse determines that a middle-aged patient is a typical example of the "sandwich generation." What did the nurse discover the patient is caught between? a. Job responsibilities or family responsibilities b. Stopping old habits and starting new ones c. Caring for children and aging parents d. Advancing in career or retiring
ANS: C Middle-aged adults also begin to help aging parents while being responsible for their own children, placing them in the sandwich generation. It does not include job and family responsibilities; old habits and new ones; or career and retiring.
2. A nurse reviews the current trends affecting the family. Which trend will the nurse find? a. Mothers are staying at home. b. Adolescent mothers usually live on their own. c. More grandparents are raising their grandchildren. d. Teenage fathers usually have stronger support systems.
ANS: C More grandparents are raising their grandchildren. The majority of women work outside the home, and about 60% of mothers are in the workforce. The majority of adolescent mothers continue to live with their families. Teenage fathers usually have poorer support systems and fewer resources to teach them how to parent.
14. A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response will the nurse most expect from this patient? a. "I should consider participating in a health fair about safe sun practices." b. "I'll make an appointment with my doctor right away for a full skin check." c. "I've had this mole my whole life. So what if it changed color? My skin is ᧴ne." d. "I have a mole that has been bothering me. I'll call my family doctor for an appointment to get it checked
ANS: C Most typically young adults would say that their skin is ᧴ne. Young adults often ignore physical symptoms and often postpone seeking health care. Making an appointment right away with the doctor and participating in health fairs are not typical behaviors of young adults for the same reason.
18. A patient is taking an antidepressant medication. The nurse discovers that the patient uses herbs. Which herb will cause the nurse to intervene? a. Aloe b. Garlic c. Chamomile d. Saw palmetto
ANS: C Potential drug interactions with chamomile include drugs that cause drowsiness like antidepressants. Aloe, garlic, and saw palmetto do not interfere with antidepressants.
12. A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion
ANS: C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the eӄects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional ӄtness activities.
16. A nurse is teaching the sta 洅 about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing? a. Ego defense model b. Immunity model c. Neuman Systems Model d. Pender's Health Promotion Model
ANS: C The Neuman Systems Model uses a systems approach, and it helps you understand your patients' individual responses to stressors and also families' and communities' responses. Every person develops a set of responses to stress that constitute the "normal line of defense." This line of defense helps to maintain health and wellness. Ego defense mechanisms are unconscious coping mechanisms. Immunity is a body's natural protection mechanism. Pender's Health Promotion Model focuses on promoting health and managing stress.
5. A nurse is working in a facility that has fewer directors with managers and staff able to make shared decisions. In which type of organizational structure is the nurse employed? a. Delegation b. Research-based c. Decentralization d. Philosophy of care
ANS: C The decentralized management structure often has fewer directors, and managers and sta岳꫰ are able to make shared decisions. The American Nurses Association defines delegation as transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. Research-based means care is based upon evidence. A philosophy of care includes the professional nursing sta岳꫰'s values and concerns for the way they view and care for patients. For example, a philosophy addresses the purpose of the nursing unit, how sta岳꫰ works with patients and families, and the standards of care for the work unit.
8. The nurse is interviewing a patient who is being admitted to the hospital. The patient's family went home before the nurse's interview. The nurse asks the patient, "Who decides when to come to the hospital?" What is the rationale for the nurse's action? a. To assess the family form b. To assess the family function c. To assess the family structure d. To assess the family generalization
ANS: C To assess the family structure, the nurse asks questions that determine the power structure and patterning of roles and tasks (e.g., "Who decides where to go on vacation?"). When focusing on family form, the nurse should begin the family assessment by determining the patient's definition of family. Family function is the ability of the family to provide emotional support and to cope with health problems or situations. The question asked by the nurse will not assess that. Nurses do not assess family generalization.
8. An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant's report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? a. Suggest acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.
ANS: C Unconsciously repressing an anxiety-producing emotional con 밄ict and transforming it into nonorganic symptoms (e.g., di 甇culty sleeping, loss of appetite) describes conversion. The nurse must assess the patient fully for emotional con 밄ict and stress before implementing any nursing interventions (acupuncture or exercise program). Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor.
10. A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? a. Deontology b. Ethics of care c. Utilitarianism d. Feminist ethics
ANS: C Utilitarianism is a system of ethics that believes that value is determined by usefulness. This system of ethics focuses on the outcome of the greatest good for the greatest number of people. Deontology would not look to consequences of actions but on the "right-making characteristic" such as ††delity and justice. The ethics of care emphasizes the role of feelings. Relationships, which are an important component of feminist ethics, are not addressed in this case.
11. The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregiver
ANS: C When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources. In family as context, the primary focus is on the health of an individual member. In family as patient, family processes and relationships are the primary focus. Family as caregiver is not an approach to familyfocused nursing but is a term used to describe a family member caring for another family member.
4. A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregivers
ANS: C When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources. When you view the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). When you view the family as patient, the family processes and relationships (e.g., parenting or family caregiving) are the primary focuses of nursing care. There is no approach for family as caregivers; rather it is a term to describe family members caring for other family members usually at home.
15. A female nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while working as a nursing assistant. Which advice is best for the nursing faculty member to give to the nursing student? a. "Just be careful when you are doing new procedures and make sure you are following directions by the nurse." b. "Review your procedures before you go to work, so you will be prepared to do them if you have a chance." c. "The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened." d. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission"
ANS: D When nursing students work as nursing assistants or nurse's aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse's aide or assistant. The nursing student should always follow the directions of the nurse, unless doing so violates the institution's guidelines or job description under which the nursing student was hired, such as inserting a nasogastric tube or giving an intramuscular medication. The nursing student should be able to safely complete the procedures delegated as a nursing assistant, and reviewing those not done recently is a good idea, but it has nothing to do with the situation. The focus of the discussion between the nursing faculty member and the nursing student should be on following the job description under which the nursing student is working.
16. A nurse is prioritizing care for four patients. Which patient should the nurse see first? a. A patient needing teaching about medications b. A patient with a healed abdominal incision c. A patient with a slight temperature d. A patient with difficulty breathing
ANS: D An immediate threat to a patient's survival or safety must be addressed first, like difficulty breathing. Teaching, healed incision, and slight temperature are not immediate needs.
19. A nurse is teaching a patient about the use of biofeedback. Which goal should the nurse add to the care plan? a. Opens emotional channels b. Uses music to calm the mind c. Holds various postures with breathing d. Controls autonomic physiological functions
ANS: D Biofeedback is a process providing a person with visual or auditory information about autonomic physiological functions of the body such as muscle tension, skin temperature, and brain wave activity through the use of instruments. Breathwork can open emotional channels. Music therapy uses music to address physical, psychological, cognitive, and social needs of certain individuals. Yoga focuses on body musculature, holding of postures, and proper breathing mechanisms.
1. A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy 밄eld therapies. Which techniques did the nurse suggest? a. Prayer and tai chi b. The "zone" and acupressure c. Massage therapy and ayurveda d. Reiki therapy and therapeutic touch
ANS: D Both yoga and breathwork are mind-body therapies, whereas both reiki and therapeutic touch therapies are energy 밄eld therapies. Tai chi is mind-body intervention. Acupressure and massage are body-based methods. Ayurvedic is a type of whole medical system.
2. A nurse is overseeing the care of patients with severe diabetes and patients with heart failure to improve cost-effectiveness and quality of care. Which nursing care delivery model is the nurse using? a. Team nursing b. Total patient care c. Primary nursing d. Case management
ANS: D Case management is unique because clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with speci▃륒c, complex health problems or are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members.
12.The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate? a. Close the door to decrease noise from unit activities. b. Adjust temperature in the patient's room to 21° C (70° F). c. Ensure that the night-light in the patient's room is working. d. Encourage the discontinuation of a soda and chocolate nightly snack.
ANS: D Discontinuing the soda and chocolate nightly snack will be most beneficial for this patient since it has two factors that will cause difficulty falling asleep. Coffee, tea, colas, and chocolate act as stimulants, causing a person to stay awake or to awaken throughout the night. Personal preference influences the temperature of the room, as well as the lighting of the room. Noise can be a factor in the unit and can awaken the patient, but caffeine can make it difficult to fall asleep.
13. The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which information should the nurse include in the teaching session? a. Pregnancy is not a time to be having sexual activity. b. Urinary frequency will occur early in the pregnancy. c. Breast tenderness should be reported as soon as possible. d. Late in the pregnancy Braxton Hicks contraction may occur.
ANS: D During the third trimester (late pregnancy), increases in Braxton Hicks contractions (irregular, short contractions), fatigue, and urinary frequency (not early) occur. Normally, women commonly have morning sickness, breast enlargement and tenderness, and fatigue. Women need to be reassured that sexual activity will not harm the fetus.
9. A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? a. Teleology b. Deontology c. Utilitarianism d. Feminist ethics
ANS: D Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is ignored or invisible. Deontology refers to making decisions or "right-making characteristics," bioethics focuses on consensus building, while utilitarianism and teleology speak to the greatest good for the greatest number
9. The nurse is working on a committee to evaluate the need for increasing the levels of ӄuoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion
ANS: D Fluoridation of municipal drinking water and fortiӄcation of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt speciӄc health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.
1. A registered nurse (RN) is the group leader of practical nurses and nursing assistive personnel. Which nursing care model is the RN using? a. Case management b. Total patient care c. Primary nursing d. Team nursing
ANS: D In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among sta岳꫰ members.
16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? a. Document staff satisfaction. b. Focus on the family. c. Implement change on a grand scale. d. Reduce disparities
ANS: D Organizations can implement equity-focused quality improvement by recognizing disparities and committing to reducing them. Sta diversity is a priority for equity-focused quality improvement, not sta satisfaction. While the family is important, the focus is on the patients. Organizations should start by implementing a change on a small scale (pilot testing), learning from each test, and rening the intervention through performance improvement cycles (e.g., plan, do, study, and act).
6. During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing? a. Passivity b. Focusing c. Mindfulness d. Receptivity
ANS: D Receptivity is de 밄ned as the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical. Passivity is the ability to stop unnecessary goal-directed and analytical activity. Focusing is the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period. Mindfulness is not a cognitive skill needed in relaxation therapy but is needed for meditation.
14. A nurse has a transactional leader as a manager. Which finding will the nurse anticipate from working with this leader? a. Increased turnover rate b. Increased patient mortality rate c. Increased rate of medication errors d. Increased level of patient satisfaction
ANS: D Research has found that on nursing units where the nurse manager uses transactional leadership there is an increased level of patient satisfaction, a lower patient mortality rate, and a lower rate of medication errors. Turnover rate is decreased since staff retention is increased with transformational leadership.
18. The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. a. 6, 1, 2, 5, 4, 3 b. 5, 6, 2, 3, 4, 1 c. 1, 2, 5, 4, 3, 6 d. 2, 5, 6, 1, 3, 4
ANS: D Step 1. Gather as much information as possible that is relevant to the case. Step 2. Examine and determine your values about the issues. Step 3. Verbalize the problem. Step 4. Consider possible courses of action. Step 5. Negotiate the outcome. Step 6. Evaluate the action.
5.A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session? a. NREM Stage 1, 2, 3, 4, REM b. NREM Stage 1, 2, 3, 4, 3, 2, 1, REM c. NREM Stage 1, 2, 3, 4, REM, 4, 3, 2 REM d. NREM Stage 1, 2, 3, 4, 3, 2, REM
ANS: D The cyclical pattern usually progresses from stage 1 through stage 4 of NREM, followed by a reversal from stages 4 to 3 to 2, ending with a period of REM sleep. The others are incorrect sequences
5. The nurse learns about cultural issues involved in the patient's health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating? a. Marginalized groups b. Health care disparity c. Transcultural nursing d. Culturally congruent care
ANS: D The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that ts a person's life patterns, values, and system of meaning, provides meaningful and benecial nursing care. Marginalized groups are populations left out or excluded. Health care disparities are dierences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities (culture that is universal) and the dierences among them (culture that is specic to particular groups).
9.A single parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent? a. "Most preschoolers sleep soundly all night long." b. "It is important that the 5-year-old get a nap every day." c. "On average, the preschooler needs to sleep 10 hours a night." d. "Preschoolers may have trouble settling down after a busy day."
ANS: D The preschooler usually has diffculty relaxing or settling down after long, active days. By the age of 5, naps are rare for children, except those for whom a siesta is a custom. Preschoolers frequently awaken during the night. On average, a preschooler needs about 12 hours of sleep.
16. A nurse is emphasizing the use of touch to decrease "skin hunger" in caring for patients. Which age group is the nurse primarily describing? a. Infants b. Children c. Middle age d. Older adults
ANS: D Touch is a primal need, as necessary as food, growth, or shelter. Touch is like a nutrient transmitted through the skin, and "skin hunger" is like a form of malnutrition that has reached epidemic proportions in the United States, especially among older adults. While infants, children, and middle age may be a 洅ected, it is the older adult who is most a 洅ected.
Which of the following properly applies an ethical principle to justify access to health care? (Select all that apply.) Access to health care reflects the commitment of society to principles of beneficence and justice. If low income compromises access to care, respect for autonomy is compromised. Access to health care is a privilege in the United States, not a right. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. Providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.
Access to health care reflects the commitment of society to principles of beneficence and justice. Correct If low income compromises access to care, respect for autonomy is compromised. Correct Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. Correct Justice is the ethical principle that justifies the agreement to ensure access to care for all, but it does not necessarily clarify how to resolve issues of limited resources such as money or organs available for transplant. Privilege is not an ethical principle. Nonmaleficence means "first do no harm." A lack of care because of poor access causes harm (i.e., no preventive services, no early detection, no risk reduction) and therefore is ethically troubling. The principal of fidelity implies that we agree to ensure access to care even for people whose beliefs and behaviors may differ from our own, including drug addicts.
The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life Nurses play an essential role in the safe use of complementary therapies Nurses learn how to provide all of the complementary modalities during their basic
All of the statements are true except that nurses do not learn how to provide all of the complementary modalities during their basic education. Nurses play an essential role in the safe use of complementary therapies in our emerging health care system. They have an appreciation for many types of interventions and can understand the patient's need to become more involved in his or her health care decisions and choices. They also understand the patient's desire to take a more active role in his or her healing and health promotion processes. Culturally relevant care that uses a full complement of intervention strategies that are supported with evidence is a central tenet of contemporary nursing practice.
The staff on the nursing unit are discussing implementing interprofessional rounding. Which of the following statements correctly describe interprofessional rounding? (Select all that apply.) Allows team members to share information about patients to improve care Provides an opportunity for early patient discharge planning Improves communication among health care team members Allows each of the health care team members to identify separate patient goals Allows each health care provider an opportunity to delegate a task
Allows team members to share information about patients to improve care Provides an opportunity for early patient discharge planning Improves communication among health care team members Allowing team members to share information about patients to improve care, providing an opportunity for early patient discharge planning, and improving communication among team members all focus on the benefits of interprofessional rounding. This type of rounding has been found to decrease medication errors and improve quality of patient care. During interprofessional rounding all team members focus on the same patient goals.
2. A home health nurse is providing care to a middle-aged couple with children at home. The patient has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.) a. Adherence to treatment and rehabilitation regimens b. Coping mechanisms of patient and family c. Need for community services or referrals d. Knowledge base of patient only e. Use of a doula for care
Along with the current health status of the chronically ill middle-aged adult, you need to assess the knowledge base of both the patient and family. In addition, you must determine the coping mechanisms of the patient and family; adherence to treatment and rehabilitation regimens; and the need for community and social services, along with appropriate referrals. A doula is a support person to be present during labor to assist women who have no other source of support.
9. A nurse is preparing to make a mandatory report of intimate partner violence (IPV) with regard to the caregiver of a pediatric client. Which actions are appropriate? (Select all that apply.) A) Tell the child about the possibility of filing a mandatory report B) Determine whether it will be safe to inform the child about the report C) Ask about the child's incidence of using drugs D) Ask the victim whether she has a plan to keep herself and the child safe E) Ask the victim if she would like to file a report at the same time as you file yours
Ans: B, D, EFeedback: The nurse should take the following actions when making a mandatory report of IPV: (1) Talk with the adult victim (not the child) about the possibility of filing a mandatory report. (2) Consider the safety concerns of filing. (3) Determine whether it will be safe to inform the children about the report. (4) Share concerns of safety with the Child Protective Agency. (5) Ask about the perpetrator's behaviors with questions such as the following: What is the worst thing he or she has done? Does he or she own a gun? Has he or she been arrested? Does he or she use drugs (not does the child use drugs)? Do you think he or she is capable of hurting you or your children? (6) Address safety planning with the nonoffending victim. (7) Consider filing in concert with the adult victim.
IN CLASS: 2. A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to A. Assign only bed-making and feeding skills. B. Assess the knowledge of the certified nursing assistant. C. Remind the staff member that she is working under the license of the RN. D. Allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform.
B. Assess the knowledge of the certified nursing assistant.
IN CLASS 1. A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies A. Team nursing. B. Primary nursing. C. Functional nursing. D. Decentralized management.
B. Primary nursing.
1. You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. an increased appetite. B. an increased heart rate. C. a decrease in perspiration. D. a decrease in respiratory rate.
B. an increased heart rate.
♕The nurse realizes that the primary goal of a cultural assessment is to: A.Minimize client distress resulting from unmet cultural expectations B.Identify care that complements the client's cultural expectations C.Identify cultural beliefs and traditions that are important to the nurse. D.Blend Western nursing practice with the client's cultural expectations
B: Identify care that complements the clients cultural expectations may help the nurse complete a cultural assessment for the patient
♕A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to A. Assign only bed-making and feeding skills. B. Assess the knowledge of the certified nursing assistant. C. Remind the staff member that she is working under the license of the RN. D. Allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform.
B: Need to assess the knowledge of the certified nursing assistant.
♕Which of the following ways can nurses promote health? A.Prescribing medications B.Telephone counseling C.Scolding patients when non-compliant D.Interpreting diagnostic exams
B: Nurses can promote health through telephone counseling
♕A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies A. Team nursing. B. Primary nursing. C. Functional nursing. D. Decentralized management.
B: Primary care nurses are given a caseload of patients.
♕As a child, a young woman was told repeatedly she was "stupid". As an adult, she excels as a nurse and attains her Doctorate of Nursing Practice. This response can be viewed as which of the following adaptive mechanisms? A.Projection B.Compensation C.Sublimation D.Displacement
B: She compensating for the negative insults she received by proving these individuals wrong.
A nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his physical and laboratory findings are within normal limits. Because of these findings, nursing interventions are directed toward activities related to: Instructing him to return in 2 years. Instructing him in secondary prevention. Instructing him in health promotion activities. Implementing primary prevention with vaccines.
C Although young adults generally have a minimum of major health problems, lifestyles such as tobacco or alcohol abuse, risky sexual activity, obesity, and lack of physical activity put them at risk for health problems. Instructing them in health promotion activities can decrease lifestyle related health issues in the young adult.
♕Which statement best describes the health-illness continuum? A.Health is the absence of disease; illness is the presence of disease. B.Health and illness are along a continuum that cannot be divided. C.Health is remission of disease; illness is exacerbation of disease. D.Health is not having illness; illness is not having health.
C: The best statement that describes the health-illness continuum is that health and illness are along a continuum that cannot be divided.
♕Which statement by the nurse is best when communicating with a patient with clinical depression? A."It's a beautiful day today; you'll feel better if you look out the window." B."You're having a bad day; I'm sure you'll feel better soon." C."Life seems overwhelming at times; would you like to discuss how you're feeling?" D."You are very lucky to have such a supportive family."
C: covered in the chapter of stress and coping (statement C also ask the patient to discuss their feelings)
A nurse assesses patients and uses assessment findings to identify patient problems and develop an individualized plan of care. The nurse is displaying: Organizational skills. Use of resources. Priority setting. Clinical decision making.
Clinical decision making. Clinical decision making depends on the application of the nursing process. You first complete a patient assessment so you are able to make accurate judgment about the patient's nursing diagnoses and health problems. The next step is to complete a plan of care for the patient. You use critical thinking in the clinical decision process.
A family has decided to care for a grandparent with terminal cancer in the daughter's home. Family caregiving is new to the family. When helping this family as they begin to plan for their caregiving roles, what are the two top priority assessments to best learn about family functioning? (Select all that apply.) Communication Decision making Development Economic status Family structure
Communication Decision making Understanding how the family communicates and makes decisions are priority assessments. This information will help to establish goals of care, how care will be provided, who provides the care, which resources are needed, and when to ask for additional help. Although the other factors are important, these two have priority and will assist in understanding the impact of other factors on family function and caregiving in this situation.
It can be difficult to agree on a common definition of the word quality when it comes to quality of life. Why? (Select all that apply.) Average income varies in different regions of the country. Community values influence definitions of quality, and they are subject to change over time Individual experiences influence perceptions of quality in different ways, making consensus difficult. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. Statistical analysis is difficult to apply when the outcome cannot be quantified.
Community values influence definitions of quality, and they are subject to change over time Individual experiences influence perceptions of quality in different ways, making consensus difficult. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. A person's average income and whether the person is employed are incorrect answers because income level is not necessarily a determining factor in measuring quality of life, but the ability to do meaningful work usually does influence the definition.
IN CLASS: Which of the following healing modalities would be inappropriate for the patient receiving chemotherapy to use? a. acupuncture b. meditation c. biofeedback d. yoga
Correct answer: A Patient's receiving chemotherapy are at risk of developing thrombocytopenia. Even the small needles used in acupuncture may cause undue bleeding if the thrombocytopenia is significant.
IN CLASS: The client has received a prescription for a metered-dose inhaler from the care provider. Before the client leaves the clinic, the nurse instructs the client on how to use the inhaler. The nurse is tending to the client's need in which stage of illness behavior? a. Dependence on others b. Sick role behavior c. Seeking professional care d. Recovery
Correct answer: A The client has accepted the diagnosis and treatment and is being given instructions regarding follow-through.
IN CLASS: The patient newly diagnosed with Type II DM needs to make lifestyle changes. In relationship to the trans-theoretical model of change, which nursing action would best support the patient during the "contemplation" stage? a. Showing the patient how to use the finger-stick blood glucose monitor b. Providing information about various types of exercise to facilitate weight loss c. Teaching the patient about the purpose for having his HbA1C tested monthly d. Telling the patient that if he doesn't change his lifestyle, he will die
Correct answer: B Providing information about exercise would help the patient to decide what changes would best fit his personal goals. The contemplation stage involves the decision-making process. ------------------- This person just go diagnosed They haven't started it a.Action C. Maintenance d. We wouldn't say that
IN CLASS: The client with multiple sclerosis can no longer walk or urinate on her own. She spends her day sewing quilts, reading, and communicating via e-mail with a support organization. This client is a. Healthy b. Ill c. In poor health d. Well
Correct answer: D The data suggests that despite physical incapacities, the client continues to live life as fully as possible. --------- Not healthy b/c she has MS but not ill b/c she can do other things; not in poor health so must be well ------if that person is waiting for that day to come they would be in POOR HEALTH
IN CLASS: 2. Which of the following might be a cause of stress for the middle-aged adult? A. Financial security B. Planned retirement C. Arrival of grandchildren D. Caring for children and aging parents
D. Caring for children and aging parents •Rationale: Known as the sandwich generation, middle-aged adults are caring for both their children and their aging parents, which may cause additional stressors in their lives.
IN CLASS: Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups. These disparities are often exacerbated by: A. bias. B. stereotyping. C. prejudice. D. all of the above.
D. all of the above.
♕According to the stages of development, an 85 year old patient may have difficulty with: A.Learning to tie his shoes B.Finding meaningful work C.Achieving personal gains D.Activities of daily living
D: Again read the question carefully, it did not state this patient had any medical issues and think about all elderly people 85 years old (Activities of daily living may include the other choices, therefore it's the best answer).
A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) Difficulty paying his bills Seeing his pastor as a means of support Age of patient (46 years) Stress from the divorce and the loss of a job Family practice of not routinely seeing a health care provider
Difficulty paying his bills Correct Family practice of not routinely seeing a health care provider Correct External factors impacting health practices include family beliefs and economic impact. The way that patients' families use health care services generally affects their health practices. Their perceptions of the seriousness of diseases and their history of preventive care behaviors (or lack of them) influence how patients think about health. Economic variables may affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system.
1. A nurse is assessing a middle-aged patient's barriers to change in eating habits. Which areas will the nurse assess that are external barriers? (Select all that apply.) a. Lack of facilities b. Lack of materials c. Lack of knowledge d. Lack of social supports e. Lack of short- and long-term goals
External barriers to change include lack of facilities, materials, and social supports. Internal barriers are lack of knowledge, insuᨌcient skills, and unde᧴ned short- and long-term goals.
A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. When the nurse visits, the focus is on symptom management for the grandmother and helping the family with coping skills. This approach is an example of which of the following? Family as context Family as patient Family as system Family as structure
Family as patient When the family as patient is the approach, the patient's needs and family processes and relationships (e.g., parenting or family caregiving) are the primary focuses of nursing care.
Which of the following are possible outcomes with clear family communication? (Select all that apply.) Family goals Increased socialization Decision making Methods of discipline Improved education Impaired coping
Family goals Increased socialization Decision making Clear and direct family communication helps the family establish goals and make decisions, especially those decisions related to method of discipline.
At 1200 the registered nurse (RN) says to the nursing assistive personnel (NAP), "You did a good job walking Mrs. Taylor by 0930. I saw that you recorded her pulse before and after the walk. I saw that Mrs. Taylor walked in the hallway barefoot. For safety, the next time you walk a patient, you need to make sure that the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500." Which characteristics of positive feedback did the RN use when talking to the nursing assistant? (Select all that apply.) Feedback is given immediately. Feedback focuses on one issue. Feedback offers concrete details. Feedback identifies ways to improve. Feedback focuses on changeable things. Feedback is specific about what is done incorrectly only.
Feedback focuses on one issue. Feedback offers concrete details. Feedback identifies ways to improve. Feedback focuses on changeable things. These are characteristics of positive feedback. The other options (1 and 6) are not appropriate because the RN did not provide feedback immediately (the NAP performed the task in the morning, but the feedback was not given until the afternoon) and you should give both positive feedback and feedback to improve the incorrectly done tasks.
When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? Fidelity Beneficence Nonmaleficence Respect for autonomy
Fidelity means keeping promises. Keeping the promise in this case includes not just tending to the clinical need but evaluating the effectiveness of the interventions.
Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (Select all that apply.) Improved health among the staff Increased patient safety Improved staff satisfaction Improved staff relationships Fewer overtime assignments
Increased patient safety Improved staff satisfaction Current research has been able to determine that reducing stress by using relaxation strategies in the workplace leads to improved staff relationships, communication, and satisfaction.
A patient with type 2 diabetes is experiencing a lot of work-related stress and is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevating, and his doctors want him to attend some stress-management classes. He says, "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? (Select all that apply.) Increases in antidiuretic hormone (ADH) Increases in cortisol Increases in aldosterone Increases in adrenocorticotropic hormone (ACTH) Increases in epinephrine
Increases in cortisol Increases in adrenocorticotropic hormone (ACTH) Increases in epinephrine With stress the general adaptation syndrome is present. Glucose levels rise because ACTH stimulates cortisol, and gluconeogenesis occurs; the body creates new glucose from nonglucose sources (proteins and fats); cortisol alone increases gluconeogenesis; the sympathetic nervous system causes increased epinephrine, which elevates blood glucose. In the person with diabetes, these physiological responses can cause blood glucose levels to elevate beyond normal. ADH and aldosterone affect sodium and/or water balance and do not affect blood glucose.
A nurse is teaching a patient about wound care that will need to be done daily at home after the patient is discharged. This is which priority nursing need for this patient? Low priority High priority Intermediate priority Nonemergency priority
Intermediate priority Teaching patients wound care for discharge is an intermediate priority. Intermediate priorities are nonemergency, nonlife-threatening, actual or potential needs that the patient and family members are experiencing.
Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select all that apply.) Regular participation in a book club Lack of interest in exercise Difficulty falling asleep Lack of desire to go to work Anxiety while working
Lack of interest in exercise Difficulty falling asleep Lack of desire to go to work Anxiety while working Nurses are particularly susceptible to the development of secondary traumatic stress and burnout—the components of compassion fatigue. Symptoms include decline in health, emotional exhaustion, irritability, restlessness, impaired ability to focus and engage with patients, feelings of hopelessness, inability to take pleasure from activities, and anxiety.
Which of the following are considered social determinants of health? (Select all that apply.) Lack of primary health care providers in a zip code Poor-quality public school education that prevents a person from developing adequate reading skills Lack of affordable health insurance Employment opportunities that do not provide paid vacation or sick leave The number of times a person exercises during a week Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home
Lack of primary health care providers in a zip code Poor-quality public school education that prevents a person from developing adequate reading skills Lack of affordable health insurance Employment opportunities that do not provide paid vacation or sick leave Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home The social determinants of health are the circumstances in which people are born and grow up; the neighborhood in which they live, work, and age; and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.
♕a nurse incorporates which priority nursing intervention into a plan of care for sleep for a hospitalized patient? a. have patient follow hospital routines b. avoid waking patient for nonessential tasks c. give prescribed sleeping medications at dinner d. turn tv on low to late-night programming
PROMOTING SLEEP--want to avoid waking patients up for nonessential reasons/tasks
♕a patient registered at a local fitness center and purchased a pair of exercise shoes. The patient is in what stage of behavior change? Pre-contemplation contemplation Preparation Action
Preparation
♕ a nurse is presenting a program to new mothers about back to sleep initiative to prevent babies choking while sleeping and CPR. Which level of prevention is nursing practicing? primary prevention secondary prevention tertiary prevention quaternary prevention
Primary prevention ---------- secondary means at risk of disease tertiary (person actively in rehab program as example)
Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply.) Massage therapy Traditional Chinese medicine Progressive relaxation Breathwork and guided imagery Therapeutic touch
Progressive relaxation Breathwork and guided imagery These were identified as nurse-accessible complementary therapies. Massage therapists are licensed by local governmental agencies, and additional educational preparation is required to practice. Traditional Chinese medicine practitioners also attend training/educational programs, typically accredited by the Accreditation Commission for Acupuncture and Oriental Medicine.
A family has decided to care for their father who is in the last stages of a debilitating neurological illness. Although he is alert, he cannot speak clearly or carry out self-care activities; he indicates that he wants to remain involved in family life as long as possible and loves spending time with his wife and two teenage children. Which best defines family caregiving? (Select all that apply.) Designing a nurturing family to raise children Providing physical and emotional care for a family member Establishing a safe physical environment for a family Monitoring for side effects of illness and treatments Reducing the use of community resources
Providing physical and emotional care for a family member Establishing a safe physical environment for a family Monitoring for side effects of illness and treatments Family caregiving involves routinely providing services and personal care activities for a family member by spouses, siblings, or parents. Caregiving activities include safety, personal care (bathing, feeding, or grooming), monitoring for complications or side effects of medications, providing instrumental activities of daily living (shopping or housekeeping), and the ongoing emotional support and decision making that is necessary. Use of community resources to help with tasks such as family errands, grocery shopping is beneficial for the family caregiver.
21.The nurse is preparing an older-adult patient's evening medications. Which treatment will the nurse recognize as relatively safe for diffculty sleeping in older adults? a. Ramelteon (Rozerem) b. Benzodiazepine c. Antihistamine d. Kava
Ramelteon (Rozerem), a melatonin receptor agonist, is well tolerated and appears to be e᯿అective in improving sleep by improving the circadian rhythm and shortening time to sleep onset. It is safe for long- and short-term use particularly in older adults. The use of benzodiazepines in older adults is potentially dangerous because of the tendency of the drugs to remain active in the body for a longer time. As a result, they also cause respiratory depression, next-day sedation, amnesia, rebound insomnia, and impaired motor functioning and coordination, which leads to increased risk of falls. Caution older adults about using over-the-counter antihistamines because their long duration of action can cause confusion, constipation, and urinary retention. Kava promotes sleep in patients with anxiety; it should be used cautiously because of its potential toxic e᯿అects on the liver.
How can a nurse work on developing cultural awareness? (Select all that apply.) Reflect on his or her past learning about health, illness, race, gender, and sexual orientation Develop greater self-knowledge about personal biases Recognize consciously the multiple factors that influence his or her own world view Engage in an in-depth self-examination of his or her own background Learn as many facts as possible about an ethnic group
Reflect on his or her past learning about health, illness, race, gender, and sexual orientation Correct Develop greater self-knowledge about personal biases Correct Recognize consciously the multiple factors that influence his or her own world view Correct Engage in an in-depth self-examination of his or her own background Correct Remember that developing cultural awareness is a life-long process. It is a foundation of becoming culturally competent. Learning as many facts as possible about an ethnic group does not involve developing awareness about personal views, attitudes, and perceptions about ethnicity
The nurse is providing health teaching for a patient using herbal compounds such as kava for sleep. Which points need to be included? (Select all that apply.) Can cause urinary retention Should not be used indefinitely May have toxic effects on the liver May cause diarrhea and anxiety Are not regulated by the U.S. Food and Drug Administration (FDA)
Should not be used indefinitely May have toxic effects on the liver Are not regulated by the U.S. Food and Drug Administration (FDA) Herbal products help promote sleep. These products need to be used cautiously because they are not regulated by the U.S. Food and Drug Administration. They should not be used long term and can interact with prescribed medications. Kava needs to be used cautiously because it can be toxic to the liver.
A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) The loss of his work role The risk of social isolation A determination if the wife will need to start working How the wife expects household tasks to be divided in the home in retirement he age the patient chose to retire
The loss of his work role How the wife expects household tasks to be divided in the home in retirement
Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a person's roles and responsibilities during middle adulthood. When assessing the health-related knowledge base of both the middle-age patient with a chronic illness and his family, your assessment includes which of the following? (Select all that apply.) The medical course of the illness The prognosis for the patient Socioeconomic status Coping mechanisms of the patient and family The need for community and social services
The medical course of the illness The prognosis for the patient Coping mechanisms of the patient and family The need for community and social services When assessing the patient with a chronic illness, it is important that the nurse know how much the patient and his family knows about how the illness has progressed and the long-term prognosis for the patient. This includes understanding the patient and families' ability and readiness to accept the illness and the outlook for the patient. Understanding the coping mechanisms used by the patient and family will help the nurse determine how to proceed to teach and counsel the patient and family regarding his treatment regimen and whether or not there is a need and acceptance for community or social services to assist the patient and family
A new nurse is caring for a hospitalized obese patient who is homeless. This is the first time the patient has been admitted to the hospital, and the patient is scheduled for surgery. Which of the following is a universal skill that will help the nurse work effectively with this patient? The nurse shifts her focus to understanding the patient by asking her, "Describe for me the course of your illness." The nurse tells the patient, "Your choices of foods and unwillingness to exercise are adding to your health problems." The nurse asks the patient, "Tell me about the main problems you have had with your health from not having a home." The nurse explains, "Because you have obesity, it is important to know the effects it has on wound healing because of reduced tissue perfusion."
The nurse asks the patient, "Tell me about the main problems you have had with your health from not having a home." This response enables the nurse to elicit the patient's explanation of her health problems and their causes. The nurse saying "Describe for me the course of your illness"uses a biomedical explanatory model instead of the patient's explanatory model. The nurse saying "Your choices of foods and unwillingness to exercise are adding to your health problems" shows the nurse's disrespect and unwillingness to understand the patient's perceptions and health beliefs.
The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following are characteristics or traits of transformational leadership displayed by award winner? (Select all that apply.) The nurse manager regularly rounds on staff to gather input on unit decisions. The nurse manager sends thank-you notes to staff in recognition of a job well done. The nurse manager sends memos to staff about decisions that the manager has made regarding unit policies. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvements. The nurse develops a philosophy of care for the staff.
The nurse manager regularly rounds on staff to gather input on unit decisions. The nurse manager sends thank-you notes to staff in recognition of a job well done. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvements. Nurse managers who practice transformational leadership are focused on change and innovation. They motivate and empower their staff with the focus on team development. The manager will spend time on the unit with the staff, sharing ideas and listening to staff input. The manager is enthusiastic about opportunities to enhance the team and shows appreciation and recognizes team members for good work. The manager holds the team accountable and provides support for the team members in the stressful health care environment.
A patient is admitted through the emergency department (ED) after a serious car accident. The nurse assesses the patient and quickly learns that he speaks little English. Spanish is his primary language. The nurse speaks some Spanish. Which interventions would be appropriate at this time? (Select all that apply.) The nurse requests a professional interpreter. Since this is an emergent situation, the nurse will interpret and identify the patient's priority needs The nurse determines the interpreter's qualifications and makes sure that the interpreter can speak the patient's dialect. The nurse uses short sentences to explain the treatments provided in the ED The nurse directs questions to the patient by looking at the patient instead of at the interpreter.
The nurse requests a professional interpreter. The nurse determines the interpreter's qualifications and makes sure that the interpreter can speak the patient's dialect. The nurse uses short sentences to explain the treatments provided in the ED The nurse directs questions to the patient by looking at the patient instead of at the interpreter. In any situation the nurse should use an interpreter and not the family to convey information to the patient. As the nurse you need to question the interpreter about his or her ability to speak the patient's dialect. It is your responsibility to introduce the interpreter to the patient. You are communicating with the patient and should direct your questions and responses to the patient and not the interpreter. Short sentences make it easier for the patient to understand complex information
A nurse has worked in a home health agency for a number of years. She goes to visit a patient who has diabetes and who lives in a public housing facility. This is the first time the nurse has cared for the patient. The patient has four other family members who live with her in the one-bedroom apartment. Which of the following, based on Campinha-Bacote's (2002) model of cultural competency, is an example of cultural awareness? The nurse begins a discussion with the patient by asking, "Tell me about your family members who live with you?" The nurse asks, "What do you believe is needed to make you feel better?" The nurse silently reflects about how her biases regarding poverty can influence how she assesses the patient. The nurse uses a therapeutic and caring approach to how she interacts with the patient.
The nurse silently reflects about how her biases regarding poverty can influence how she assesses the patient. Cultural awareness involves becoming more self-aware of your biases and attitudes about human behavior and considering these factors when you interact with patients.
After a nurse receives a change-of-shift report on his assigned patients, he prioritizes the tasks that need to be completed. This is an example of a nurse displaying which practice? Organizational skills Use of resources Time management Evaluation
Time management Correct Completing a priority to-do list is a useful time-management skill. Change-of-shift report can help you sequence activities on the basis of what you learn about the patients' conditions and the care the patient has received.
♕a grandfather living in Japan worries about his two young grandsons who disappear after the tsunami. This is an example of which crisis? situational crisis matritional crisis maturational crisis adventitious crisis developmental crisis
adventitious crisis ---------------- adventitious= social crisis or natural disaster situational= accident or death ADVENTITIOUS QUESTION ON HURRICANE**
IN CLASS: The nurse is completing an admission assessment. Which interview question best reflects a belief related to holistic healthcare? a. "Can you tell me the names of the medications you are taking?" b. "Can you tell me how you normally handle stress?" c. "Can you tell me how long you have had your symptoms?" d. "Can you tell me your age and where you live?"
b. "Can you tell me how you normally handle stress?" By asking the patient how she handles stress, the nurse is eliciting information about the patient's personality traits, health practices, and possibly spirituality, as well as the potential use of alternative modalities. Have person talk to you how they handle stress on everyday basis...how can I help you get back to that place
A 72 year old patient asks the nurse about using an over the counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? a. Antihistamines are better than prescription medications because these can cause a lot of problems b. Antihistamines should not be used because they can cause confusion and increase your risk of falls c. Antihistamines are effect sleep aids because they do not have many side effects d. Over the counter medications when combined with sleep-hygiene measures are a good plan for sleep
b. Antihistamines should not be used because they can cause confusion and increase your risk of falls. Older adults should avoid the use of over the counter antihistamines. These medications have a long duration of action in older adults and can cause confusion, constipation, urinary retention, and increased risk of falls.
2. Place the order of blood flow from right side of heart to pulse oximetry measurement. ORDER: a. O2 blood flow pumps from left side of heart to peripheral arteries b. Deoxygenated blood flows to pulmonary capillaries c. Hemoglobin saturated w/ O2 flows to pulmonary veins d. O2 diffuses from alveoli to blood
b. Deoxygenated blood flows to pulmonary capillaries d. O2 diffuses from alveoli to blood c. Hemoglobin saturated w/ O2 flows to pulmonary veins a. O2 blood flow pumps from left side of heart to peripheral art
IN CLASS: Light sleep and slowing brain and body processes are associated with which stage of NREM sleep? a. I b. II c. III d. IV
b. II These are characteristics of a person in Stage II of NREM sleep. --------------- Stages go by level of sleep you are I—lightest stage closest to consciousness IV—deep sleep
IN CLASS: The nurse is caring for a hospitalized patient who normally works the night shift at his job. The patient states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is a."You are sleep deprived, but that will resolve in a few days." b."You are experiencing hypersomnia, so it will be important for you to walk in the hall more often." c."There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" d."I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep."
c."There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" They are not use to those conditions
IN CLASS: For which sleep disorder would the nurse most likely need to include safety measures in the patient's plan of care? a.snoring b.enuresis c.narcolepsy d.hypersomnia
c.narcolepsy-----The person doesn't even know when they fell asleep b/c it is a BRAIN DISORDER Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. This could put the person at risk for harm depending on the activity in which he is engaged
IN CLASS: A nursing unit in the hospital has begun a "Silent Night" program, to promote a quiet, restful nighttime environment for patients. This program is most likely based on the theory of a. Dorothea Orem b. Margaret Newman c. Jean Watson d. Florence Nightingale
d. Florence Nightingale According to Nightingale's beliefs, a quiet nighttime environment would most likely contribute to the healing process.
IN CLASS: What is the goal of using a client history assessment tool to gather data about nutrition, exercise, leisure activities, spirituality, and home environment? a. To gather data required by insurers and regulatory agencies b. To assist the physician in developing a medical diagnosis c. To gather data about the causes of the client's illness d. To increase the client's awareness of lifestyle choices and his or her role in wellness
d. To increase the client's awareness of lifestyle choices and his or her role in wellness
♕the patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C measurement over past 90 days has increased. The patient states that his hemoglobin A1C is wrong, "my blood sugar levels have been excellent for the last 6 months". which defense mechanism is the patient using? A. Denial. B. Conversion. C. Dissociation. D. Displacement.
denial A. Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars.
IN CLASS: A patient comes from a close-knit family. The patient's family functions as context. You will need to evaluate: A. attainment of patient needs. B. family attainment of developmental tasks. C. individual family members caring about one another. D. family satisfaction with its new level of functioning.
•Answer: A •Rationale: When you look at the family as context, you will want to remember that the primary focus is on the health and development of the individual members. ----------- uFamily as Context Health and development of individual members uFamily as Patient Family patterns and processes uFamily as System Both family members and family unit
IN CLASS: 3. You are about to administer an oral medication and you question the dosage. You should: A. administer the medication. B. notify the physician. C. withhold the medication. D. document that the dosage appears incorrect.
•Answer: B •Rationale: If you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor.
♕You are about to administer an oral medication and you question the dosage. You should: A. administer the medication. B. notify the physician. C. withhold the medication. D. document that the dosage appears incorrect.
•Answer: B •Rationale: If you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor.
IN CLASS:You are caring for a patient. Visitors at the bedside include the patient's life partner, widowed father, brother, and niece. The nurse acknowledges that current trends in American families include: A. couples without children. B. more singles choosing to live alone. C. a very different look from 15 years ago. D. a mother, father, and more than one child.
•Answer: C •Rationale: Although the institution of the family remains strong, the family itself is changing.
IN CLASS: A student nurse employed as a nursing assistant may perform care: A. as learned in school. B. expected of a nurse at that level. C. identified in the hospital's job description. D. requiring technical rather than professional skills.
•Answer: C •Rationale: Student nurses should never perform a task that is not in the job description of the facility with which they work.
♕A student nurse employed as a nursing assistant may perform care: A. as learned in school. B. expected of a nurse at that level. C. identified in the hospital's job description. D. requiring technical rather than professional skills.
•Answer: C •Rationale: Student nurses should never perform a task that is not in the job description of the facility with which they work.
IN CLASS: A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: A. living wills. B. assisted suicide. C. passive euthanasia. D. advance directives.
•Answer: D •Rationale: Advance directives are written documents that outlay the patient's wishes, should he or she become incapacitated.
♕A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: A. living wills. B. assisted suicide. C. passive euthanasia. D. advance directives.
•Answer: D •Rationale: Advance directives are written documents that outlay the patient's wishes, should he or she become incapacitated.
CLASS: A nurse who has recently graduated has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes for the older adult include: A.a transition from young adulthood. B. the ability of the older adult to achieve sexual arousal. C. a time when cognitive performance begins to peak. D. adjusting to decreasing health and physical strength.
•Answer: D •Rationale: Older adults have many physiological and psychological changes. It is important for the nurse to know these changes, and to be able to distinguish whether changes are normal or abnormal for the older adult.
o **FIVE RIGHTS OF DELEGATION***
•Right Task •Right Circumstance •Right Person •Right Direction •Right Supervision
