exam 5 questions

A nurse newly highly at a community hospital learns about intentional hourly rounding during orientation. Which of the following are known evidence based outcomes from intentional rounding? (select all that apply) 1:reduction of nurse staffing requirements 2:improved patient satisfaction 3:reduction in patient falls 4:reduction in patient call light use

2,3,5 rationale: intentional rounding is an evidence based practice used in an increasing number of hospitals today. Studies have shown that intentional rounding can reduce patient falls and call light use and improve patient satisfaction scores. Proactive problem solving can occur when using intentional rounding. Education for patients helps them understand the importance of this practice

Which information would the RN provide a nursing student about assault? 1:assault refers to any action of intentional touching without consent 2:a procedure performed without the consent of the client is considered assault 3:assault refers to any action that places a client in apprehension of harmful contact without consent 4:threatening a client before performing a medical procedure is not considered assault

3

which point requires correction regarding the characteristics of an ethical issue? 1:the situation is perplexing, and it is not easy to think logically or make a decision 2:it is not possible to resolve solely though a review of scientific data 3:the problem aims at the greatest good for the greatest number of people 4:the answer to the problem has a profound relevance for areas of human concern

3 rationale: a situation can be called an ethical dilemma if it fulfills one of three conditions: challenging and generally cannot be solved through logical decision making, cannot be solved solely through review of scientific data, and the answer to the problem has a profound relevance for areas of human concerns

An informed consent has not yet been obtained for an unconscious client scheduled for surgery. Which course of action does the nurse expect to be taken to deal with this situation? 1:the clients spouse will give informed consent for the surgery 2:the procedure will be postponed until the client is able to give consent 3:the surrogate decision maker designated by the client will give consent 4:the primary HCP will perform the procedure without consent

3 rationale: if the client has legally designated a surrogate decision maker through a special power of attorney, the consent for surgery would be obtained from them. The clients spouse may give informed consent only if authorized to do so on the clients behalf -the HCP can perform the procedure without consent only if there is a medical emergency

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

3,4,1,2

a middle aged client states that he feels he was unsuccessful in raising his children. According to Eriksons theory, at which stage of psychosocial development would the nurse conclude the client has arrived? 1:integrity VS despair stage 2:intimacy VS isolation 3:identity VS role confusion stage 4:generativity VS self absorption and stagnations

4

which mental process would be recognized by the nurse as associated with deterioration that accompanies aging? 1:judgement 2:intelligence 3:creative thinking 4:short term memory

4

which opposing conflict would a middle aged adult face according to eriksons theory of psychosocial development ? 1:integrity VS despair 2:intimacy VS isolation 3:identity VS role confusion 4: generativity VS self absorption and stagnation

4

Which physical change seen in a 70 year old would cause a nurse to instruct the client to dress warmly in cold weather? (select all that apply) 1:reduced sebum production 2:degeneration of elastic fibers 3:decreased dermal blood flow 4:thinning of the subcutaneous layer 5:decreased vasomotor responsiveness

4,5 rationale: these two cause risk of hypothermia -reduced sebum production can increase the size of pores, producing comedones -degeneration of elastin will decrease the skin turgor of the client but does not produce hypothermia -decreased dermal blood flow will increase the risk of dry skin which does not require warm clothing

Initiative vs. Guilt

third stage in which the preschooler has the desire to explore and imagine but can also lead to feelings of guilt if the child is punish for showing initiative -3 to 5 years

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?1. Justice 2. Fidelity 3. Beneficence 4. Nonmaleficence

1

At which stage of Eriksons theory of psychosocial development would parents need to teach their child impulse control and cooperative behaviors? 1:initiative VS guilt 2:intimacy VS isolation 3:autonomy VS sense of shame and doubt 4:generativity VS self absorption and stagnation

1 rationale: initiative VS guilt stage is when parent teaches the child these certain behaviors, which helps avoid risks of altered growth and development

Which problems would the nurse plan to address when dealing with ethical issues specifically related to end of life care? (select all that apply) 1:clients may be unable to communicate effectively 2:all interventions for helping the clients seem futile 3:clients are often unfamiliar with the concept of autonomy 4:multiple medications affect the cognitive ability of clients 5:predictions regarding health outcomes are not always accurate

1,2,5

according to Eriksons theory of psychosocial development, which opposing conflict is an older adult likely to face? 1:trust VS mistrust 2:integrity VS despair 3:intimacy VS Isolation 4:industry VS inferiority

2 rationale: -birth-1 year olds are to face conflict of trust vs mistrust -young adult is to fave conflict of intimacy VS isolation -school aged is likely to face conflict of industry VS inferiority

The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept? 1. Older-adult patient who requires dialysis 2. Teenager in labor who requests epidural anesthesia 3. Middle-aged father of three with an advance directive declining life support 4. Family elder who is making the decisions for a young-adult female member

4 rationale: Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care.

A man who is homeless enter the emergency department seeking health care. The HCP indicates that the patient needs to be transferred to the city hospital for care before assessing the patient. The action is most likely a violation of which of the following laws? 1:health insurance portability and accountability act 2:americans with disabilities act 3:patient self determination act 4:emergency medical treatment and active labor act

4 rationale: The EMTALA requires that an emergency situation needs to be establish and the the patient needs to be stabilized before a transfer is appropriate

A nurse is teaching the parents of a school-aged child about accidents most common in this age group. Which topic should the nurse address? a. Falls b. Fires c. Drownings d. Poisonings

B rationale: Because accidents such as fires and car and bicycle crashes are the leading cause of death and injury in the school-age period, safety is a priority health teaching consideration. -Falls, drownings, and poisonings are priority for toddlers.

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.

B rationale: 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.

A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act? a. A family can choose whether to have health insurance with no consequences. b. Primary care physician payments from Medicaid services can equal Medicare. c. Adult children up to age 26 are allowed coverage on the parent's plan. d. Private insurance companies can deny coverage for any reason.

C rationale: Adult children up to the age of 26, regardless of student status, are allowed to be covered under their parents' health insurance plan.

The nurse is preparing to teach a group of parents with infants about growth and development. Which information should the nurse include in the teaching session? a. 3-month-old infants will be able to bang objects together. b. 4-month-old infants will be able to sit alone with support. c. 5-month-old infants will be able to creep on hands and knees d. 6-month-old infants will be able to turn from back to abdomen.

D rationale: 6-month-old infants will be able to turn from back to abdomen. 6 to 8 month olds can sit alone without support and bang objects together. 8 to 10 month olds can creep on hands and knees.

A staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking? a. Authority b. Autonomy c. Responsibility d. Accountability

D rationale: Accountability refers to individuals being answerable for their actions. The nurse in this situation is not taking ownership of the inappropriate delegation of a task

A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. Which question is the priority for the nurse to ask the family before beginning postmortem care? 1. "Is an autopsy going to be done?" 2. "Which funeral home do you want to use?" 3. "Would you like to assist in bathing your loved one?" 4. "Do you want me to remove the lines and tubes before you see your loved one?"

1 rationale: An autopsy or postmortem examination may be requested by the patient or the patient's family, as part of an institutional policy, or if required by law. Because the patient's death occurred as a result of long-term illness and not under suspicious circumstances, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. -The nurse needs to know if the lines can be removed or not depending upon the family's response to the question. Asking about bathing the deceased patient is a valid question but is not a priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. -Finding out which funeral home the deceased patient is to be transported to is valid but is not a priority, because other actions must be taken before the deceased patient is transported from the hospital. -Asking about removing the lines may not be an option depending on the response of the family to an autopsy.

The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? 1. Advocacy 2. Responsibility 3. Confidentiality 4. Accountability

1 rationale: Nurses advocate for patients when they support the patient's cause. A nurse's ability to adequately advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient's point of view.

Which finding indicates the best quality improvement process? 1. Staff identifies the wait time in the emergency department is too long. 2. Administration identifies the design of the facility's lobby increases patient stress. 3. Director of the hospital identifies the payment schedule does not pay enough for overtime. 4. Health care providers identify the inconsistencies of some of the facility's policy and procedures.

1 rationale: The quality improvement process begins at the staff level, where problems are defined by the staff. It is not identified by administration, the hospital director, or health care providers.

Which health care system focuses on palliative care? 1:hospice 2:rehab 3: assisted living 4:extended care facilities

1 rationale: a hospice is a system of family centered care that allows clients to continue living at home with comfort, independence, and dignity while easing the pain of terminal illness. The focus of hospice care is palliative care

Which would the nurse consider to be the center of decision making when providing client care? 1:ethics 2:nursing skills 3:analytical skills 4:research based practice

1 rationale: a nurse always follows the ethics of care and considers caring to be the center of decision making. The nurse must know what behavior is ethically appropriate while caring for a client.

According to Erikson, which need would nurses focus care on for the middle aged adult? 1:encouraging productivity 2:maintaining control 3:assuring independence 4:gaining autonomy

1 rationale: a psychosocial task for middle adulthood is concerned with the sense of productivity and accomplishment.

According to erikson, which need would nurses focus care on for the middle aged adult? 1:encouraging productivity 2:maintaining control 3:assuring independence 4:gaining autonomy

1 rationale: a psychosocial tasks for middle adulthood is generativity; this task is concerned with the sense of productivity and accomplishment

Which opposing conflict does a young adult face according to Eriksons theory of psychosocial development? 1:intimacy VS isolation 2:identity VS role confusion 3:autonomy VS sense of shame and doubt 4:generativity VS self absorption and stagnation

1 rationale: a young adult is likely to face intimacy VS isolation -identity VS role confusion (adolescent) -autonomy VS sense of shame and doubt (toddler of 1-3 years) -generativity VS self absorption and stagnation (middle aged adult)

which ability can be inferred when a professional is said to have ethical sensitivity? 1:recognizes ethical dilemmas 2:takes a morally correct action 3:justifies a well reasoned action 4:thinks critically to rank ethical obligations

1 rationale: having ethical sensitivity helps the nurse recognize if there is an ethical dilemma or issue

The ostomy nurse floated to the obstetric unit lacks expertise to care for clients in the unit. which course of action should the nurse take to deal with this situation? 1:notify the nursing supervisor 2:refrain from taking the assignment 3:learn the policies of the institution regarding floating 4:perform necessary interventions using self-knowledge

1 rationale: if the nurse who floats lacks the required expertise to care for the client, they would immediately call their supervisor. -nurse would not refuse the assignment because it can be seen as insubordination

Which example indicates that the child is in the autonomy VS sense of shame and doubt stage of Eriksons theory of psychosocial development? 1:a child began walking on her toes with her legs wide apart 2:a client reports not wanting to consume meat even though this family owns a slaughterhouse 3:the client states "I want to go to the club with my friends, but my dad wont let me go" 4:A client reveals that he has been in a romantic relationship for 3 years but that his partner now wants to end

1 rationale: in the autonomy VS sense of shame and doubt stage, the child develops basic self care activities and develops personal autonomy by making choices. -identity VS role confusion: client does not want to consume meat even though family owns slaughterhouse -identity VS role confusion: client wants to go to club but dad wont let them -intimacy VS isolation: client wants to break up with 3 year relationship

Which nursing intervention fosters the hospitalized infants development of trust? 1:follow the parents directions while providing care when parents are away 2:ask parents to name objects in the infants surrounding 3:encourage different caregivers to interact with the infant 4:instruct caregivers to talk to the infant while providing care

1 rationale: parents would provide the majority of the care when an infant is hospitalized. If the parents are away, the nurse would follow the parents directions in order to foster the infants trust.

A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care? 1:patient will be able to walk 200 feet without shortness of breath 2:wound will heal without signs of infection 3:patient will express concerns related to return to home 4:patient will identify strategies to improve sleep habits

1 rationale: restorative interventions focus on returning patients to their previous level of function or on reaching a new level of function limited by their illness or disability. The goal of restorative care is to help individual regain maximal functional status and to enhance quality of life through promotion of independence

Which of the following are common barriers to effective discharge planning? (select all that apply) 1:ineffective communication among providers 2:lack of role clarity among health care team members 3:sufficient number of hospital beds to manage patient volume 4:patients long term disabilities 5:the patients cultural background

1,2 rationale: barriers to effect discharge planning include ineffective communication, lack of role clarity among HC members, and lack of resources.

Which information would the nurse provide a client about tertiary prevention? (select all that apply) 1:focuses on preventing complications of illness 2:helps clients achieve as high a level of functioning as possible 3:aims at minimizing the effects of long term disease or disability 4:applied when the client is physically and emotionally healthy 5:activities are aimed at diagnosis and treatment instead of rehabilitation

1,2,3

which intervention would the nurse follow to prevent future falls in an older adult experiencing delirium who sustained a leg fracture caused by a fall? (select all that apply) 1:minimizing sedating medications 2:modifying the home environment 3:teaching clients about the safe use of the internet 4:manage foot and footwear problems 5:providing information about the effects of using alcohol

1,2,4

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? 1. Advocacy 2. Responsibility 3. Confidentiality 4. Accountability

2 rationale: Responsibility refers to one's willingness to respect and adhere to one's professional obligations. It is the nurse's responsibility to report missing narcotics. -Accountability refers to the ability to answer for one's actions. -Advocacy refers to the support of a particular cause. -The concept of confidentiality is very important in health care and involves protecting patients' personal health information.

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? 1. Consequentialism 2. Autonomy 3. Fidelity 4. Justice

2 rationale: 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.

Which genitourinary factor contributes to urinary incontinence in older adult clients and needs to be considered by the nurse when planning the care for these clients? 1:sensory deprivation 2:UTI 3:frequent use of diuretics 4:inaccessibility of a bathroom

2 rationale: UTI affects the genitourinary tract and interfere with voluntary control of micturition -inaccessibility of a bathroom is an environmental problem not genitourinary

Which conflict according to erikson is exhibited by a 68 year old client with a new ileostomy who remarks to the nurse, "it will be difficult for my wife to care for a helpless old man"? 1:initiative vs guilt 2:integrity vs despair 3:industry vs inferiority 4:generativity vs stagnation

2 rationale: poor self conflict and feelings of despair are conflicts manifested in those who are older than 65 years of age. -initiative vs guilt= conflict in 3-6 years -industry vs inferiority= conflict in 6-11 years -generativity vs stagnation= conflict in 45-65 years

A nurse is planning care for a Pt going to surgery. Who is responsible for informing the Pt about the surgery along with possible risks, complications, and benefits? 1:family member 2:surgeon 3:nurse 4:nurse manager

2 rationale: the person performing the procedure is responsible

arrange the stages of life in eriksons theory in the correct order 1:initiative VS guilt 2:trust VS mistrust 3:intimacy VS isolation 4:identity VS role confusion 5:industry VS inferiority 6:autonomy VS a sense of shame and doubt

2,6,1,5,4,3 2: trust vs mistrust 6: autonomy vs shame and doubt 1: initiative vs guilt 5:industry VS inferiority 4: identity VS role confusion 3: intimacy VS isolation

The nurse is caring for a dying patient. Which intervention is considered futile? 1. Giving pain medication for pain 2. Providing oral care every 5 hours 3. Administering the influenza vaccine 4. Supporting lower extremities with pillows

3 rationale: Administering the influenza 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.

which stage of psychosocial development would the nurse expect in a 4 year old child? 1:trust 2:industry 3:initiative 4:autonomy

3 rationale: initiative vs guilt happens during 3-6 years old.

a family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. which action would the nurse take to handle the situation ? 1:wait for the courts order to give blood to the client 2:proceed with the transfusion to save their life 3:inform the primary HCP and not give blood to the client 4:explain to the family member that the client needs this transfusion

3 rationale: the client and family have the right to refuse treatment

which of these is an ethical issue related to the long term care setting? (select all that apply) 1:guardianship 2:power of attorney 3:advance directives 4:responsible party designation 5:do not resuscitate orders 6:adherence to a patients bill of rights

all of these are correct rationale: residents rights are a universal priority in all long term care settings

The RN assesses and older couple: the husband is alert/forgetful and has an enlarged prostate with infrequent urinary incontinence,; the wife has diabetes mellitus, rheumatoid arthritis, and difficulty walking. The couple lives alone and has children who do not live nearby. After identifying their need for assistance with bathing, dressing, and meal preparation, what would the nurse suggest?

keep the couple in their home and schedule assistance with a home health aid

A nurse is teaching parents about the fine motor skills of infants to help parents understand development growth and needs. Match the information to the correct age that the nurse should include in the teaching session. a. Can place objects into containers b. Pulls a string to obtain an object c. Can hold a baby bottle d. Holds rattle for short periods e. Uses pincer grasp well 1. 2-4 months 2. 4-6 months 3. 6-8 months 4. 8-10 months 5. 10-12 months

1. D 2. C 3. B 4. E 5. A

A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse's primary objective? 1. Screening 2. Education 3. Dependence 4. Counseling

2 rationale: Health promotion and education are traditionally the primary objectives of home care, yet at present most patients receive home care because they need nursing care. -screening is preventive -counseling is through psychiatric care

when teaching about Eriksons theory of psychosocial development, to which age group would the nurse apply industry VS inferiority? 1:3-6 years 2:1-3 years 3:6-11 years 4:birth-1 year

3 rationale: -initiative vs guilt applies to 3-6 -autonomy vs sense of shame and doubt applies to 1-3 -trust vs mistrust applies to birth-1

A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? 1. Teleology 2. Deontology 3. Utilitarianism 4. Feminist ethics

4 rationale: 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.

Which consideration would the nurse make when obtaining an informed consent from a 17 year old? 1:determine whether the client is legally allowed to give consent 2:recognize that the client cannot make informed decisions about health care 3:know that 17 year olds are able to give consent in most states 4:acknowledge that the client probably will be unable to choose between alternatives when asked to consent

1 rationale: a person is legally unable to sign a consent until the age of 18 or 19 years depending on the states, unless the client is an emancipated minor or married. The nurse must first determine the legal status of the adolescent

to meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take? 1:initiate an agency incident report 2: report the fall to the state health department 3:write a brief description of the incident to be kept by the nurse manager 4:determine that no document is need because the visitor is not a client in the hospital

1 rationale: health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor

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 the award winner? (Select all that apply.) 1. The nurse manager regularly rounds on staff to gather input on unit decisions. 2. The nurse manager sends thank-you notes to staff in recognition of a job well done. 3. The nurse manager sends memos to staff about decisions that the manager has made regarding unit policies. 4. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvements. 5. The nurse manager develops a philosophy of care for the staff.

1,2,4 rationale: 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. The manager shares the philosophy of care developed by the nurse executive of the organization.

In which instances can an adult give consent for a minors medical treatment? (select all that apply) 1:as the guardian for a ward 2:as the parent of an emancipated minor 3:as the parent of an unemancipated minor 4:as an adult for the treatment of their minor brother or sister (if an emergency and parents are not present) 5:as a grandparent for a minor grandchild under normal circumstances

1,3,4

which age related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1:atrophy of the sweat glands 2: decreased subcutaneous fat 3:stiffening of the collagen fibers 4:degeneration of the elastic fibers

2 rationale: in older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers.

Which client statement indicates placement in the identity VS role confusion stage of Eriksons theory of psychosocial development? (Select all that apply) 1:I fear this current relationship will not last, just like my previous one did not last 2:I like to dress like a boy even though my parents want me to dress like a girl 3:when I look back at my life, I feel like i have not been able to be a good mother 4:i want to have clear skin like my friend, so I am visiting a specialist today 5: i

2,4,5 rationale: identity VS role confusion stage, an individual may pass through dramatic changes

Which of the following nursing actions is provided in a secondary health care environment? 1:conducting BP screenings for older adults at the senior center 2:teaching a patient with COPD purse-lipped breathing techniques at an outpatient clinic 3:changing the postoperative dressing for a patient on a medical surgical unit 4:doing endotracheal suctioning for a patient on a ventilator in the medical ICU

3 rationale: In secondary care the diagnosis and illnesses are traditionally the most common services. Secondary services are usually provided in an acute care setting. Inpatient medical surgical units provide secondary care. Critical care units provide tertiary care

A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? 1. Taking a bath 2. Getting dressed 3. Making a phone call 4. Going to the bathroom

3 rationale: 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.

Which point regarding ethics and value requires further education? 1:the nurses point of view offers a unique voice in the resolution of ethical dilemmas 2:professional nursing promotes accountability, responsibility, advocacy, and confidentiality 3: The ANAs code of ethics ensure that the code remains constant 4:standards ethics in health care consist of autonomy, beneficence, nonmaleficence, justice, fidelity

3 rationale: The ANA code of ethics reviews and revises the code regularly to reflect changes in practice.

According to erikson, which developmental stage will an 85 year old client who is alert and able to participate in care need to adjust to? 1:industry vs inferiority 2:identity vs role confusion 3:generativity vs stagnation 4:autonomy vs shame/doubt

3 rationale: generativity vs stagnation stage is before the integrity vs despair stage; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage.

Which nursing intervention would a nurse implement to help a late middle age individual cope with emotional aspects of aging? 1:focusing on the individuals past experiences 2:scheduling them to attend lectures on aging 3:assisting them with plans for the future 4:encouraging them to focus on their career

3 rationale: helping them maintain an interest in the future is therapeutic. It is forward looking and fosters a positive attitude -focusing on their past experiences is appropriate for an older adult, not middle age adults

A woman has severe life threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The HCP ordered two units of packed red blood cells to treat the womans anemia. The womans husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurses responsibility? 1:obtain a court order to give the blood 2:convince the husband to allow the nurse to give it 3:call security and have the husband removed from the hospital 4:gather more information about the wifes preferences and determine whether the husband is her power attorney for health care

4

Which legal defense is important for the nurse to develop? 1:dedication 2:certification 3:assertiveness 4:accountability

4 rationale: accountability is the highest priority which means the nurse is liable and answers for actions

Which nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom? 1:instructing the client to be quiet 2:allowing the client to act out until fatigue sets in 3:immediately guiding the client from the room by gently holding the clients arms 4:giving the client one simple direction at a time in a firm, low pitched voice

4 rationale: clients with delirium response to simple directions stated one at a time in a firm low pitched voice

which stage describes the will of an adolescent to achieve a goal according to the eriksons theory? 1:initiative VS guilt 2:integrity vs despair 3:intimacy vs isolation 4:identity vs role confusion

4 rationale: identity vs role confusion is the 5th stage of development. Identity deelopment begins with the goal of achieving some perspective or direction

Which action should the nurse take when teaching a 5-year-old patient about a scheduled surgery? a. Do not discuss the procedure with the child to decrease anxiety. b. Let the child know the surgery will be at 9:00 AM in the morning. c. Insist that the parents wait outside the room to ensure privacy of the child. d. Allow the child to touch and hold medical equipment such as thermometers.

D rationale: Nursing interventions during the preoperational period (ages 2 to 7 years) should recognize the use of play (such as handling equipment) to help the child understand the events taking place. The nurse should talk to the child about the procedure in terms the child can understand. Children at this stage have difficulty conceptualizing time; telling the child surgery is at 9:00 AM in the morning is inappropriate. Parents should be allowed in the room.

Industry vs. Inferiority

fourth stage in which school aged children learn to work and play with peers, thrive on praise and positive reinforcement, and need support for developing new skills (industry= a feeling of productivity) (inferiority= a feeling of inadequacy and low self esteem) -6 to 12 years

Autonomy vs. Shame and Doubt

second stage in which toddlers have new independence, make simple choices, and increased perception of control over physical skills. (autonomy=self government ) (shame/doubt= negative emotions due to failing at new things) -18 months to 3 years

Generativity vs. Stagnation

seven stage in which middle aged adults either feel a sense of productivity, contribution, or fulfill life goals (generativity) or feel unproductive, lack purpose, and have a negative response to aging (stagnation) -40-65 years old

Intimacy vs. Isolation

sixth stage in which the young adult forms meaningful friendships and intimate relationships. It also refers to the challenge of forming these close relationships with other which can lead to a sense of loneliness and isolation -20-35 years old

Which statement needs correction on obtaining informed consent from clients? 1:"obtaining informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty 2:consent would be obtained in all situations except during extraordinary circumstances 3:pt gives consent based on the full disclosure of risks, benefits, alternatives, and consequences of refusal 4:HCP legally has to disclose facts in terms that the pt understands to make an informed choice

1 rationale: informed consent is a vital part of the relationship between the HCP and the client. Nurses are responsible for making sure the HCP explains any surgical procedure to the client, including risks -informed consent from clients would be obtained in all situations except emergencies, because failure to do so may lead to battery -clients provide informed consent after they are made completely aware of the risks, benefits, alternatives, and consequences

Which action would the nurse take to comply with the ethic of nonmaleficence in the health care setting? 1:focus on doing no harm 2:keep promises made to clients 3:respect the autonomy of clients 4:keep the best interests of the client in mind

1 rationale: nonmaleficence refers to the nurse focusing on doing no harm -autonomy refers to the nurse including the patient in decision making -beneficence refers to the nurse keeping the best interests of the client in mind

The RN reviews the record of a PT with terminal cancer and notes a do not resuscitate order. The order was written with the pt admission orders. The RN recalls which factor is relevant to the legal aspects of the order? 1: the policies of the agency establish the status of DNR orders 2:the age of the pt. is a primary factor in the decision not to resuscitate 3:decisions of resuscitation reside with the pt. HCP 4:once a DNR order is signed, it remains in force for the entire hospitalizations

1 rationale: policies relative to DNR orders vary among hospitals, and the nurse must adhere to the policies of the institution. The policies of an institution generally reflect the parameters of DNR orders associated within the state

Which action would the nurse take for a daughter who states that she gives sleeping pills to her live in mother who has dementia to stop her wandering at night? 1:explore hiring a home health aide to stay with the client at night 2:discuss the possibility of having the client placed in a nursing home 3:suggest moving the client among family members on a monthly basis 4:empathize with the daughter but suggest that wrist restraints would be preferable

1 rationale: the daughter is not asking that the client be moved from the home so the nurse needs to focus on helping reduce the confusion the client experiences at night, keeping the client safe, and easing the burden on the daughter

A mother of a 7 month old infant reports that her baby cannot sit without support. Which question would the nurse ask the mother to further assess gross motor skills? 1:can your child hold on to furniture? 2:does your child show hand preference? 3:does your child move on the hands and knees? 4:can your child place objects into containers?

1 rationale: the development of gross motor skills in a 7 month old includes sitting alone without any support, as well as ability to hold on to furniture.

which delivery system was developed to provide care through others as an adaptation to functional nursing? 1:team 2:primary 3:case management 4:differentiated practice

1 rationale: the hallmark of team nursing is "care through others" which was designed as an adaptation to functional nursing. -primary nursing is an adaptation to the case method -case management is the process of coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes -differentiated practice consist of models of care delivery that are differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation

According to Erikson's theory, in which stage would the nurse expect a preschooler to start to pretend? 1:initiative vs guilt stage 2:integrity vs despair stage 3:autonomy vs a sense of shame and doubt stage 4:generativity vs self absorption and stagnation stage

1 rationale: the initiative vs guilt is the third stage of his theory. During this stage, children like to pretend and try out new roles

which information is accurate regarding the role of value clarification in the resolution of ethical dilemmas? 1:tolerating difference of opinion 2:reinforcing or challenging family values 3:accepting strong values by individuals as facts 4:relating values to facts when dealing with ethical issues

1 rationale: the process of value clarification involves tolerating differences of opinion with others. This often helps in the resolution of ethical dilemmas. -value formation involves reinforcing or challenging family values -value clarification is possible if the nurse is able to understand that facts are different from values

which element must be considered in a legal action against a nurse who continued to administer cortisone while evading the clients questions after the client had refused the prescribed cortisone? (select all that apply) 1:clients have a right to refuse treatment 2:nurses are required to answer clients truthfully 3:the HCP should have been notified 4:the client had insufficient knowledge to make such a decision 5:legally prescribed medication are administered despite a clients objections

1,2,3

The nurse signs as a witness to informed consent provided by the client. Which concept does the signature of the nurse imply? (select all that apply) 1:the signature of the client is authentic 2:consent has been given voluntarily 3:the client appears to be competent to give consent 4: treatment cannot be refused after consent is given 5:the nurse has explained all procedures to the client

1,2,3 rationale: when the nurse signs as a witness to informed consent, the signature implies that the clients signature is authentic, has consented to the procedure voluntarily, and appears to be competent enough to give consent. -the client has the right to refuse treatment at any time -the nurse is not the appropriate person to provide explanations regarding procedures

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.) 1. Electrolyte imbalance 2. Sensory deprivation 3. Hypoglycemia 4. Drug effects 5. Dementia

1,2,3,4 rationale: 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 effects, 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 gradual, progressive, and irreversible

A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.) 1: Empirical quality results 2: Structural empowerment 3: Transformational leadership 4: Exemplary professional practice 5: Willingness to recommend the agency

1,2,3,4 rationale: The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. The five components are Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovation, and Improvements; and Empirical Quality Results. -Willingness to recommend the hospital/agency is a component of the Hospital Consumer of Assessment of Healthcare Providers and Systems survey.

A RN ask an AP to help the Pt. in room 418 to the bathroom right now. The RN tells the AP that the Pt. needs the assistance of one person and the use of a walker. The RN also tells the AP that the Pt.s O2 can be removed while he goes to the bathroom but to make sure that when it is put back on the flowmeter is still at 2 L. The RN also instructs the AP to make sure the side rails are up and the bed alarm is reset after the Pt gets back in bed. Which of the following of "Five Rights of Delegation" were used by the RN?(select all that apply) 1:right task 2:right circumstance 3:right person 4:right directions/communication 5:right supervision/evaluation

1,2,3,4 rationale: The nurse provided 4 of the 5 components but did not provide the right supervision and evaluation. The nurse delegated the task of a patient to the bathroom to the AP, which is in the scope of an AP's duties and responsibilities and matched to the AP skill level. The nurse did provide clear directions by describing the task and the time period to complete the task. The nurse did not use "please" and "thank you" in the request. The nurse did not ask whether there were any questions, which would provide the AP an opportunity to get clarification if needed. The nurse did not ask the AP to follow up on how the patient did or whether there were any problems. The nurse did not provide appropriate monitoring, evaluation, intervention as needed, or feedback

When interviewing and assessing a 17 year old client, which finding alerts the nurse to explore substance abuse with the adolescent? (Select all that apply) 1:failing grades 2:blood spots on clothing 3:absenteeism from school 4:long sleeved shirts in warm weather 5:separating emotionally from the family

1,2,3,4 rationale: signs of drug abuse include failing grades and absenteeism because school performance is impacted, as well as blood spots on clothing and long sleeves in warm weather, which is related to IV drug use. -separating emotionally from family is a normal development finding in adolescents

which about restorative care are accurate? (select all that apply) 1:the restorative health team consists of health professionals, the pt, and the caregivers 2:success depends on effective/early collaboration with pt. and their families 3:pt and families follow treatment plans better when they're involved in restorative care 4:pt who are disabled or suffering from terminal diseases need restorative care 5:restorative care is provided through home health care, rehab, or extended facilities

1,2,3,5

Which statements properly apply an ethical principle to justify access to health care? (select all that apply) 1:access to health care reflects the commitment of society to principles of beneficence and justice 2:if low income compromises access to care, respect for autonomy is comprised 3:access to health care is a privilege in the US, not a right 4:poor access to affordable health care causes harm that is ethically troubling because nonmaleficeence is a basic principle of health care ethics

1,2,4 rationale: Access to health care services can be justified through the application of the principles of justice, beneficence, respect for autonomy, and nonmaleficence

Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (select all that apply) 1:community values influence definitions of quality in different ways, and they are subject to change over time 2:individual experiences influence perceptions of quality in different ways, making consensus difficult 3:the value of elements such as cognitive skills, ability to perform meaningful work and relationships to family is difficult to quantify using objective measures 4:statistical analysis is difficult to apply when the outcome cannot be quantified 5:whether a person has a job is an objective measure, but it does not play a role in understanding quality of life

1,2,4 rationale: these statements describe why a single definition for the term quality of life is challenging

Which example might an individual experience in Eriksons initiative VS guilt stage? select all that apply 1:pretends and tries out new roles 2: may develop a superego or a conscience 3:thrives on his/her autonomy by making choices 4:may develop his/her autonomy by making choices 5:fantasizes and imagines discovering the environment

1,2,5 rationale: in the initiative VS guilt stages, a 3-6 year old child likes to pretend and try out new roles. In this stage, a child may develop a superego or conscience. Child may also fantasize and imagine in this stage

Which of the following are examples of nurse participating in primary care activities? select all that apply 1:providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2:assessing the nutritional status of older adults who come to the community center for lunch 3:working with patients in a cardiac rehabilitation program 4:providing home wound care to a patients 5:teaching a class to parents at the local grade school about the importance of immunizations

1,2,5 rationale: primary care activities are focused on health promotion. Health promotion programs contribute to quality health care by helping patients acquire healthier lifestyles. Health promotion activities help keep people healthy through exercise, good nutrition, rest and adopting positive health attitudes and practices

Which is a normal finding during the regular checkup of an older adult? (select all that apply) 1:loss of turgor 2:urinary incontinence 3:decreased night vision 4:decreased mobility of ribs 5:increased sensitivity to odors

1,3,4

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (select all that apply) 1:ethics of care pays attention to the context in which caring occurs 2:ethics of care is used only by nurses because it is part of the nursing code of ethics 3:ethics of care requires understanding the relationships between involved parties 4:ethics of care considers the decision makers relationships with other involved parties

1,3,4 rationale: The ethics of care emphasizes attention to the context in which an ethical problem occurs and the relationships between involved parties, including relationships with the decision maker.

which of the following describes characteristics of an integrated health care systems (select all that apply) 1:the focus is holistic 2:participating models follow the same model of health care delivery 3:the system coordinates a continuum of services 4: the focus of health care providers is finding a cure for patients 5:members of the HC team link electronically to use the EMR to share the patients the patients records

1,3,5 rationale: integrated health care systems are shifting to more holistic approaches to health care. At the core of this shift is provision of a coordinated continuum of services for enhancing the health status of defined populations. Two types of integrated HC delivery systems are organization structure and patient centered medical home care -there is no single model for the integrated HCS

Which clients statement confirms they reached the integrity VS despair stage according to Erikson's theory of psychosocial development? (Select all that apply) 1:looking back at my entire life, I find that I have actually achieved nothing 2:i was in love, but my partner ditched me for someone good looking 3:in the twilight of my life, I regret not fulfilling the promises I made to my wife 4:could you prescribe some good medications that can help me get back to work as soon as possible, because I need money to support my family 5: now that I am at the end of the road, I think i am the luckiest person on the earth because God has given me everything I have asked for

1,3,5 rationale: the integrity VS despair stage occurs in older adults who view their lives with a sense of satisfaction or consider themselves failures

Which of the following actions, if performed by a RN, could result in both criminal and administrative law sanctions against the nurse? (select all that apply) 1:reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit 2:refusing to provide health care info to a patients child 3:reporting suspected abuse and neglect of children 4: applying physical restraints without a written order 5:completing an occurrence report on the unit

1,4 rationale: viewing a family members health record violates the patients rights provided by HIPPA. A physical restraint can be applied only on the written order of a HCP based on the Joint Commission and Medicare guidelines

A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.) 1. Use informatics 2. Use transparency. 3. Apply globalization. 4. Apply quality improvement. 5. Use evidence-based practice

1,4,5 rationale: The Institute of Medicine competencies include: Provide patient-centered care; work in interdisciplinary teams; use evidence-based practice; apply quality improvement; and use informatics. -Transparency is included in the 10 rules of performance in a redesigned health care system, not a competency. -globalization is important in health care, it is not a competency.

Which behavior will the nurse notice in a 13 year old student according to eriksons theory? (select all that apply) 1:such students want to know "who am i " 2:such students exhibit the sense of care for others 3:such students show eagerness to learn social skills 4:such students like to pretend and try out different new roles 5:such students show a marked preoccupation with body appearance

1,5 rationale: during puberty students want to know answers to who they are (identity vs role confusion) and are concerned with their appearance -young adults exhibit a sense of care for others at the stage of intimacy vs isolation -6-11 years shows eagerness to learn social skills (industry vs inferiority) -3-6 years like to pretend (initiative vs guilt)

A nurse is experiencing an ethical dilemma with a patient. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? 1. unequal power 2. Presence of conflicting values 3. Judgmental perceptions of patients 4. Poor communication with the patient

2

Which action is the professional nurses legal responsibility regarding child abuse? 1:honor the request of the parents not to report suspected abuse 2:report any suspected abuse to local law enforcement authorities 3:return the child to the legal parent even if they are suspected of abuse 4:provide the parents with a copy of the childs medical record

2

Which action is the professional nurses legal responsibility regarding child abuse? 1: honor the request of the parts not to report the suspected abuse 2:report any suspected abuse to local law enforcement authorities 3:return the child to the legal parent even if they are suspected of abuse 4:provide the parents with a copy of the childs medical record

2

A nurse works full time on the oncology unit at the hospital and works part time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. How will the hospital's malpractice insurance provide coverage for this nurse? 1. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly. 2. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital. 3. As long as the nurse has never been sued before this incident, the hospital's malpractice insurance will cover the nurse. 4. The hospital's malpractice insurance will provide approximately 50% of the coverage the nurse will need.

2 rationale: Malpractice insurance provided by the employing institution covers nurses only while they are working within the scope of their employment. It is always wise to find out if malpractice insurance is provided by a secondary place of employment, in this case, the pharmacy, or the nurse should carry an individual malpractice policy to cover situations such as this. The hospital policy would not provide coverage even if the nurse followed all procedures and policies or had never been sued. It will not provide 50% of coverage.

A nurse received change-of-shift report on these four patients and starts rounding. Which patient does the nurse need to focus on as a priority? 1. The patient who had abdominal surgery 2 days ago who is requesting pain medication 2. A patient admitted yesterday with atrial fibrillation who now has a decreased level of consciousness 3. A patient with a wound drain who needs teaching before discharge in the early afternoon 4. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

2 rationale: This patient is of high priority. The patient is experiencing the physiological problem of decreased level of consciousness that is an immediate threat to the patient's survival and safety. The nurse must intervene promptly and notify the health care provider of the life-threatening problem.

which age related finding would a nurse expect when performing a male reproductive system assessment of an older adult client? 1:asymmetrical testes 2:reduced size of testes 3:absence of pubic hair 4:foreskin that is difficult to retract

2 rationale: a reduction in the size of testes is a characteristic of aging. -the testes are symmetrical in shape/length and any change denotes an abnormality

which basic health care ethic does the nurse follow when signing the clients consent form as a witness? 1:justice 2:autonomy 3:beneficence 4:nonmaleficence

2 rationale: autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent

While caring for a middle aged adult client after emergent placement of a colostomy as a result of colorectal cancer, the nurse encourages the clients family members to have a colonoscopy done before age 50 years and annually depending on health care provider recommendations. Which concept is the primary basis for the nurses recommendations to the clients family? 1:holism 2:genomics 3: accountability 4:evidence-based practice

2 rationale: genomics describes the study of all the genes in a person and interactions of these genes with one another and with that persons environment. using genomic information allows the nurse to determine how genomic changes contribute to client conditions and influence treatment decisions.

Which statement indicates that the child is in the initiative vs guilt stage of Eriksons theory of psychosocial development? 1:see, I have got highest marks among all my friends in the class 2:my child likes to fantasize and tries out new characters every day 3: i give healthy finger foods to my baby so that she can pick them up and eat by herself 4:Look, I learned the numbers between 1-1000 and my teacher says i am the best student

2 rationale: in the initiative VS guilt stage, children like to pretend and try out new roles. -(1)child receiving highest test score among her friends is industry VS inferiority stage -(3) baby who can pick up and eat food by their self is autonomy VS sense of shame and doubt -(4) learning numbers 1-1000 and is proud of being congratulated is industry vs inferiority

Which approach would the nurse use for a client with alzheimer disease who expresses fear and anxiety upon admission to a long term care facility? 1:exploring the reasons for the concerns 2:reassuring the client with the presence of 1 or 2 staff members 3:providing the client with a written schedule of planned interactions 4:explaining to the client why the admission to the facility is necessary

2 rationale: the client needs reassurance because forgetfulness blocks previous explanations and the presence of 1-2 staff members serves as a support system. -this client will be unable to explain the reasons for concern because of short term memory loss

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? 1. Deontology 2. Utilitarianism 3. Ethics of care 4. Feminist ethics

2 rationale: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 defines actions as right or wrong based on their "right-making characteristics" such as fidelity to promises, truthfulness, and justice -Feminist ethics looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible -ethics of care: emphasizes roles of feelings

A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What should the oncoming nurse do? (Select all that apply). 1. Add this information to the board hanging at the patient's bedside. 2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. 4. Forward the text to the charge nurse. 5. Thank the nurse for sending the information.

2,3 rationale: the HIPAA and health information technology act provide rules about how and with whom nurses can share patient health information. Sending a text message to another nurse about a Pt is a violation of these acts. Report violations of the privacy of patients health information to your supervisor or manager

Which is an example of an individual in the intimacy versus isolation stage, according to Eriksons theory of development? (Select all that apply) 1: an individual may often engage in a retrospective appraisal of their life 2:An individual develops a sense of identity and deepens their capacity to love others and care for them 3:An individual searches for meaningful friendships and an intimate relationship with another person 4:an individual may develop fears, rejection and disappointment if

2,3,4 rationale: in the intimacy VS isolation stage, an individual develops a sense of identity and deepens their capacity to love other and care for them. A young adult also searches for meaningful friendships and an intimate relationship with another person. They may also develop fears, rejection, and disappointment

Which activities would the nurse participate in while providing a primary level of preventive care? (select all that apply) 1:individual and mass screening activities 2:education about adequate housing an recreation 3:education about attention to personality development 4:instructions about good standard of nutrition adjusted to developmental phases of life 5:providing hospital and community facilities for retraining and education to maximize use of remaining capacities

2,3,4 rationale: while providing a primary level of preventive care, the nurse would educate the client about the need for adequate house and recreation, provide education for personality development, and help clients maintain a good standard of nutrition. -secondary level: nurse would participate in individual and mass screening -tertiary level: nurse would help ensure that clients can access hospital and community facilities for retraining

A nurse is calling a patient's health care provider about a problem the patient is having following surgery. The health care organization uses the SBAR system in reporting patient problems. Put the statements in order according to the SBAR system. 1:Is it possible to give the Pt. an antiemetic to help with nausea and comfort? 2:The Pt. is experiencing nausea right now. The nausea has worsened over the past hour. He says he is going to be sick 3:The pt has surgery earlier today to remove a tumor in the colon. He was admitted to surgical unit 4 hours ago. He has an NG tube and there is no order for an antiemetic 4:The Pt. denies pain and vitals are stable. BP: 114/68, dressing is dry and intact, NG tube is intact and draining light brown fluid. It flushes well and right placement is confirmed. Pt is nausea when on his side

2,3,4,5 rationale: SBAR provides a consistent way to communicate patient problems. In this example, the Situation (S) is that the patient is experiencing nausea. Next the nurse provides the Background (B) about the patient's surgery and current orders. Then the nurse provides Assessment (A) data about the patient's current status. Finally, the nurse provides a Recommendation (R) to administer an antiemetic medication.

At 1200 the registered nurse (RN) says to the assistive personnel (AP), "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 AP? (Select all that apply.) 1. Feedback is given immediately. 2. Feedback focuses on one issue. 3. Feedback offers concrete details. 4. Feedback identifies ways to improve. 5. Feedback focuses on changeable things. 6:Feedback is specific about what is done incorrectly only

2,3,4,5 rationale: These are characteristics of good feedback. The nurse gives feedback on the process of the AP monitoring and ambulating a patient. -The other options are not appropriate because the RN did not provide feedback immediately (the AP performed the task in the morning, but the feedback was not given until the afternoon), and you should give both positive feedback as well as feedback to improve the incorrectly done tasks.

the nurse reviews the medical record of a client who is eligible to receive hospice care. Which are the criteria for a client to receive this type of care? (select all that apply) 1: when the death of the client is imminent 2:when the expected death of the client is within 6 month 3:when the client seeks no aggressive disease management 4:when a family member has signed an informed consent form 5:when the client has been issued a "do not resuscitate" order

2,3,5 rationale: hospice care (end of life care) includes: -patients have a prognosis of 6 months or less to live -when curative treatment such as chemotherapy has been stopped -do not resuscitate orders -client seeks no aggressive disease management

Which strategies are the best ways for the nurse to be protected legally? (select all that apply) 1:ensure that a therapeutic relationship with all clients has been established 2:Provide care within the parameters of the standards for nursing practice set by the state or province 3:carry at least 100,000 worth liability insurance 4: document consistently and objectively 5:clearly document a clients nonadherence to the medical regimen

2,4,5 rationale: -It is unrealistic that the nurse will have a therapeutic relationship with all clients -liability insurance protects the nurse if found guilty and a monetary award is made but does not reduce the possibility of litigation

When conducting a health assessment for a school age child who is a new client to the pediatric practice, which question would the nurse ask the child and parents related to growth? (Select all that apply) 1: which grade are you currently attending? 2:at which age did your child cut their first tooth? 3:do you have a best friend at your new school? 4:what was your childs approximate length at 1 year of age? 5:what was your childs approximate weight at 6 months, and 1,2, and 5 years of age?

2,4,5 rationale: asking questions 1,3 are appropriate when collecting data about the childs development, not growth

which objective would the nurse understand about the secondary level of prevention? 1:aimed at helping clients achieve the highest function possible 2:focused on minimizing effects of long term disease or disability 3:focused on individuals who are in the early stage of their illness 4:aimed at attaining health promotion through wellness development activities

3

While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient's health care provider. Which of the following is the nurse exercising? 1. Authority 2. Responsibility 3. Accountability 4. Decision making

3 rationale: Accountability is nurses being answerable for their actions. It means nurses accept the commitment to provide excellent patient care and the responsibility for the outcomes of the actions in providing that. Following institutional policy for reporting medication errors demonstrates the nurse's commitment to safe patient care

A nurse is measuring an infant's head circumference and height. Which area is the nurse assessing? 1: Moral development 2. Cognitive development 3. Biophysical development 4. Psychosocial development

3 rationale: Biophysical development is how our physical bodies grow and change. Moral development is the difference between right and wrong. Cognitive development comprises changes in intelligence, use of language, and development of thinking. Psychosocial development consists of variations in emotions and relationships with others.

two pts in a med. facility receive different care due to lack of financial resources. The RN tries to resolve the dilemma at hand. The RN collects info about the issue from many sources. What action would RN take next? 1:verbalize the issue by agreeing to a clear statement of the problem 2:analyze the situation to determine if it is an ethical dilemma 3:examine own values about the issue based on the info gathered 4:negotiate outcomes of possible course of action through group discussions

3 rationale: after gathering relevant info regarding an ethical dilemma, the nurse would proceed by clarifying values. The nurse may examine their own values regarding the issue and segregate the info obtained into facts, opinions, and values. -the nurse would verbalize the issue after the clarification of values -the first step would be to analyze the situation. In this scenerio, it ask what the nurse should do after gathering information so the assessment has already been done

which principle did the researcher apply when calculating the risk benefit ratio and concluding there were no harmful effects associated with a survey of diabetic clients? 1:human dignity 2:human rights 3:beneficience 4:utilitarianism

3 rationale: beneficience is defined as the promotion of well being and abstaining from the injuring of others as well as doing good and being kind and charitable

which variables are recognized by the nurse as being a common conflict experienced by older adults? 1:youth and old age 2:retirement and work 3:independence and dependence 4: wishing to die and wishing to live

3 rationale: common conflict with older adults is between the desire to be taken care of by others (dependence) and the desire to be in charge of their own destiny (independence)

The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology? 1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action. 2. The single focus on power imbalances does not apply to all situations in which ethical problems occur. 3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. 4. The focus on consequences rather than on the "goodness" of an action makes decision makers uncomfortable.

3 rationale: deontology is an approach to ethics that identifies the correct action that is supported by fundamental principles and duties. The disadvantage of this approach is that its application relies on consensus around what the primary duties and principles are. -Option 1 describes limitation of the ethics of care -option 2 describes limitations of feminist ethics -option 4 describes limitations of utilitarianism

for which milestone would the nurse assess to determine whether a 75 year old individual is meeting the developmental tasks associated with aging? 1:achievement of a personal philosophy 2:adaptation of the children leaving home 3:attainment of a sense of worth as a person 4:adjustment to life in an assisted living facility

3 rationale: developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self worth

what info about palliative care(PC) as opposed to hospice would the RN provide during a home visit to a pt w/ heart failure? 1:to get PC, a HCP must certify that you have 6 mth or less to live 2:the goal of PC is to humanize the end of life experience, allowing you to die w/ dignity 3:the focus of PC is to enhance you and your familys quality of life despite your heart failure 4:by making the choice to begin palliative care, you must no longer pursue life extending/curative treatment

3 rationale: hospice care requires 6 months or less to live and humanize the end of life

A nurse performs the following four steps in delegating a task to an AP. Place the steps in the order of appropriate delegation. 1. Do you have any questions about walking Mr. Malone? 2. Before you take him for his walk to the end of the hallway and back, please take and record his pulse rate. 3. In the next 30 minutes please assist Mr. Malone in Room 418 with his afternoon walk. 4. I will make sure that I check with you in about 40 minutes to see how the patient did.

3,2,4,1 rationale: -This is the sequence of effective delegation. The nurse delegated the task of walking a patient to the AP, which is in the scope of the AP's duties and responsibilities and matched to the AP's skill level. -The nurse provided clear directions by describing the task (the walk, taking and recording the pulse), the desired outcome (walk to the end of the hallway and back), and the time period (within the next 30 minutes). -The nurse explains the process of follow-up with the AP to check how the patient did. -The nurse asks whether the AP has any questions to provide the AP the opportunity to ask questions for clarification.

according to Eriksons theory, which psychosocial developmental change is observed in middle childhood?(select all that apply) 1:the child is highly imaginative 2:the child is able to trust others 3:the child is engaged in tasks and activities 4:the child can differentiate between industry and inferiority 5:the child develops self control and independence

3,4 rationale: -preschool is highly imaginative -infants begin to trust others -toddlers develop self control and independence

According to Eriksons theory, which psychosocial developmental change is observed in middle childhood? (Select all that apply) 1: the child is highly imaginative 2:the child is able to trust others 3:the child is engages in tasks and activities 4: the child can differentiate between industry and inferiority 5: the child develops self-control and independence

3,4 rationale: according to Eriksons theory, psychosocial developmental changes observed in middle childhood are that the child is engaged in tasks and activities and that the child can differentiate between industry and inferiority. -preschoolers are highly imaginative -a child is able to trust others at infancy stage -a child develops self-control and independence at the toddler stage

which situation does the RN consider most appropriate for obtaining informed consent? 1:consent is given by the pt for a procedure after the RN has explained risks/ benefits in detail 2:a pt provides consent for surgery after the HCP gives the details of the benefits 3:Consent is signed for a procedure after details of the procedure have been told using medical terminology 4:a pt gives consent after the HCP gives a detailed explanation of risks, benefits, and alternatives to the procedure

4

According to Eriksons theory of psychosocial development, which client statement confirms achievement of the intimacy VS isolation stage? 1:I donate a large sum of money to the local school every year 2:i want to enjoy my motherhood and thats why I am leaving this job 3:in the winter of my life, I feel that I do not have anyone to take care of me 4:i did so much for my partner, but i was dumped for someone more attractive

4 rationale: -generativity VS self-absorption and stagnation applies to the client that says they donate a large sum of money to a school every year -integrity VS despair applies to an older adult saying they feel that they have no one to take care of them

A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? 1. Continuing care 2. Restorative care 3. Preventive care 4. Tertiary care

4 rationale: Hospital emergency departments, urgent care centers, critical care units, and inpatient medical surgical units provide secondary and tertiary levels of care. -pts recovering from an acute or chronic illness/disability often require additional services (restorative care) to return to previous level of function -continuing care is available within institutional settings (nursing centers or homes, group homes, retirements communities) -preventive care is more disease oriented

Which of the following statements is true regarding Magnet status recognition for a hospital? 1:nursing is run by a Magnet manager who makes decisions for the nursing units 2:nurses in the Magnet hospitals make all of the decisions on the clinical units 3:Magnet is a term that is used to describe hospitals that are able to hire the nurses they need 4:Magnet is a special designation for hospitals that achieve excellence

4 rationale: Magnet status is a process and review that hospitals go through that shows achievement of excellence in nursing practice. The designation is given by the American Nurses Credentialing Center and focuses on demonstration of quality patient care, nursing excellence, and innovations in professional practice

The RN is caring for a child whose parents refuse a life saving surgery for the child, stating that surgeries are against their belief. What should the nurse take first to resolve this? 1:evaluate the outcome of the plan of action over time 2:verbalize the problem and agree to a statement as a group 3:examine the nurses own values critically to formulate an opinion about the issue 4:obtain info from the child, parents, HC workers, and other sources

4 rationale: after determining that an ethical dilemma exists in a situation, the nurse would focus on gathering info from multiple sources

Which activity performed by a nurse is related to maintaining competency in nursing practice? 1:asking another nurse about how to change the settings on a medication pump 2:regularly attending unit staff meetings 3:participating as a member of the professional nursing council 4:attending a review course in preparation for a certification exam

4 rationale: maintaining ongoing competency is a nurses responsibility. Earning certification in a speciality area is one mechanism that demonstrates competency. Speciality certification has been shown to be positively related to patient safety

the nurse working in a catholic hospital discourages clients from using contraceptives per hospital policy. Which category of ethic is the nurse following? 1: societal ethics 2: research ethics 3: professional ethics 4: organizational ethics

4 rationale: organizational ethics help ensure smooth ethical operation of an organization. These ethical codes include sets of rules and regulations to guide the actions and behaviors of the members of the organization -societal ethics are norms that serve a large community and involve legal and regulatory mechanisms -research ethics are applicable to those conducting research involving human and animal subjects -professional ethics involves a set of ethical standards and expectations for members of that profession that apply to many different companies

A child has not attained which stage of cognitive development when unable to identify which plate has the greater number chocolates? 1:sensorimotor 2:preoperational 3: formal operations 4:concrete operations

4 rationale: the ability to mentally classify objects according to their quantitative dimensions is known as seriation, which is achieved during the concrete operations stage of cognitive development (7-11 years) -if a child (birth-2 years) does not develop object permanence, it indicates that the infant failed to attain the sensorimotor stage -if a child (2-7 years) is unable to think using symbols and mental images, it indicates that the child failed to attain the preoperational stage -if an adolescent is unable to demonstrate feelings and behaviors characterized by self-consciousness, it indicates a failure to attain the formal operations stage

according to eriksons theory of psychosocial development, to which stage of life does the child who dresses and feeds herself belong? 1:initiative VS guilt 2:trust VS mistrust 3:industry VS inferiority 4:autonomy VS sense of shame and doubt

4 rationale: this stage is seen in children ages 1-3 years. By this age, the child is more accomplished in some basic self care activities such as walking, feeding, toileting.

A pt. in need of a lung transplant tells the RN, "I wont take the organ of anyone w/ another religion." The RN initiates the process for resolving the dilemma by collabing with other HC team members. Which action would they take after agreeing to a statement of the problem? 1:interview the family of the client 2:negotiate for the appropriate course of action 3:assess if the pt. is satisfied w/ the course of action taken 4:determine all possible courses of action based on available info

4 rationale: when resolving an ethical dilemma, the HC team should weigh all possible options to address the situation. After this stage, the HC team will interview the family

which characteristics is found in an adolescent according to eriksons theory of psychosocial development (select all that apply) 1:the adolescent develops a conscience 2:the adolescent concentrates on work and play 3:the adolescent develops autonomy by making choices 4:the adolescent is concerned about his or her appearance and body image 5:the adolescent acquires a sense of identity by participating in decision-making

4,5 rationale: -3-6 years develops a superego/conscience -3-5 years old concentrate on work and play -a toddler develops his or her autonomy

which nursing activities are examples of primary prevention? (select all that apply) 1:preventing disabilities 2:correcting dietary deficiencies 3:establishing goals for rehab 4:assisting with immunization programs 5:facilitating a program about the dangers of smoking

4,5 rationale: -preventing disabilities and establishing goals for rehab is a tertiary intervention -correcting dietary deficiencies is a secondary intervention

A nurse is caring for a preschooler. Which fear should the nurse most plan to minimize? a. Fear of bodily harm b. Fear of weight gain c. Fear of separation d. Fear of strangers

A rationale: The greatest fear of preschoolers appears to be that of bodily harm; this is evident in children's fear of the dark, animals, thunderstorms, and medical personnel.

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

A rationale: 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.

A nurse is caring for a young adult after surgery. Which action by the nurse will be priority? a. Allow involvement of peers b. Allow involvement of partner c. Allow involvement of volunteer activities d. Allow involvement of consistent schedule

B Rationale: Nurses must understand that during hospitalization, a young adult's need for intimacy remains present; thus young adults benefit from the support of their partner or significant other during this time.

A nurse takes the history of a middle-aged patient in a health clinic. Which information indicates the patient has achieved generativity? a. Married for 30 years b. Teaches preschoolers c. Has no regrets with life choices d. Cares for aging parents after work

B rationale: Teaching preschoolers indicates generativity. Middle-aged adults achieve success (generativity) in this stage by contributing to future generations through parenthood, teaching, mentoring, and community involvement. Married for 30 years indicates achievement of intimacy. Has no regrets is ego integrity. Caring for aging parents is admirable but it does not indicate development of the next generation (generativity).

identity vs. role confusion

fifth stage in which the adolescent focus on appearance, image, peer relationships, and sexual identity. Social isolation may also occur -12-20 years old

Which client would be appropriate for home health care services? (select all that apply) 1:a client with a new ostomy 2:a client requiring wound care 3:a client receiving IV antibiotics 4:a client receiving IV chemo 5:a client recently diagnosed with diabetes requiring insulin 6:a client needing PT after a total knee replacement

all are correct rationale: home health care services enable clients of all ages to remain in the comfort and security of their home while receiving health care includes: wound care, ostomy assistance, setting up oral meds, prefilling insulin syringes, administration of injections, postop assistance, hypertension, heart failure

The nurse is caring for an infant. Which activity is most appropriate for the nurse to offer to the infant? a. Set of cards to organize and separate into groups b. Set of sock puppets with movable eyes c. Set of plastic stacking rings d. Set of paperback book

c rationale: Adults and nurses facilitate infant learning by planning activities that promote the development of milestones and providing toys that are safe for the infant to explore with the mouth and manipulate with the hands such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes.

according to eriksons theory, at which age would a child develop self control and independence? 1: 18 months to 3 years 2:3-6 years 3: 6-12 years 4:12-19 years

1 rationale: 18 months-3 years a child develops self control and independence -3-6 a child is highly imaginative -6-12 years a child is engaged in task and activities -12-19 a child can differentiate between identity and role confusion

The nurse is caring for a Pt who needs a liver transplant to survive. The patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical elements of this case? 1:the HC team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources 2:the patient should enroll in a clinical trial of a new technology that can do the work of the liver, similar to the way dialysis treats kidney disease 3:the social worker should look into enrolling the Pt in medicaid, since many states offer expanded coverage 4:A family meeting should take place in which the details of the Pts poor prognosis are made clear to his family so that they can adopt a palliative approach

1 rationale: the principle of justice as it pertains to the distribution of health care resources is the ethical element present in option 1. Option 2,3,4 are potential strategies for assisting this Pt but they do not address the ethical elements of the case.

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.) 1: libel 2:slander 3:assault 4:battery 5:invasion of privacy

1,2 rationale: 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.

A client with mental illness in the emergency unit needs to undergo an emergency surgery. Which intervention would be the nurses first course of action to prevent any legal complication? 1:wait for a court order to intervene on the clients behalf 2:obtain consent from a person legally authorized to give it on the clients behalf, if available 3:obtain a court order to state that the client is incompetent to make decision for themselves 4: request that the primary health care provider start the procedure without the clients consent

2

Which nursing intervention would the nurse provide to an older client with HTN? (select all that apply) 1:provide skin care 2:advise the client to limit salt intake 3:teach stress management 4:instruct the client to quit smoking 5:advise the client to eat finger foods

2,3,4

The nurse is teaching a parenting class. which suggestion would the nurse make about managing the behavior of a young school age child? 1:avoid answering questions 2:give the child a list of expectations 3:be consistent about establishing rules 4:allow the child to plan the days activities

3 rationale: because of the childs short attention span and distractibility, consistent limit setting by parents is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflict.

Which potential health problem would the nurse include in the young adult's discharge teaching? 1:kidney dysfunction 2:cardiovascular diseases 3:eye problems, such as glaucoma 4:accidents, including their prevention

4 rationale: accidents are common during young adulthood because of immature judgement and impulsivity associated with this stage. -cardiovascular disease is common in middle adulthood -glaucoma is common in older adults

Arrange the actions in the order a nurse should take to resolve an ethical dilemma 1:clarify values 2:verbalize the problem 3:negotiate a plan 4:evaluate the plan over time 5:determine possible courses of action 6:collect relevant case-related information

6,1,2,5,3,4 -collect relevant case related info -clarify values -verbalize the problem -determine all possible courses of action -negotiate a plan -evaluate plan overtime

The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution? 1:list all possible actions that could be taken to resolve the problem 2: articulate a statement of the problem or dilemma that you are trying to resolve 3:develop and implement a plan to address the problem 4:gather all relevant info regarding the clinical, social, and spiritual aspects of the problem 5:take time to clarify values and identify the ethical elements such as principles and key relationships involved 6:recognize that the problem requires ethics

6,4,5,2,1,3

A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter "A"? a. Act b. Alter c. Assess d. Approach

A rationale: PDSA- plan, do, say, act

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.

B rationale: From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world.

A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?a. Primary care b. Preventive care c. Restorative care d. Continuing care

B rationale: Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation. -Primary care is health promotion that includes prenatal and wellbaby care, nutrition counseling, family planning, and exercise classes. -Restorative care includes rehabilitation, sports medicine, spinal cord injury programs, and home care. -Continuing care is assisted living and psychiatric care and older-adult day care

A nurse manager discovers that the readmission rate of hospitalized patients is very high on the hospital unit. The nurse manager desires improved coordination of care and accountability for cost-effective quality care. Which nursing care delivery model is best suited for these needs? a. Team nursing b. Total patient care c. Primary nursing d. Case management

D rationale: Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. 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.

Integrity vs. Despair

eighth stage in which older adults look back over ones life with pride, satisfaction, and fulfillment (integrity) or feel regretful, disappointed, and fear death (despair) -65 years and above

Trust vs. Mistrust

first stage in which the infant's basic sense of trust or mistrust develops as a result of consistent or inconsistent care -newborn to 18 months