Final - fundamental

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate? "It involves working primarily with computers and programming codes." "It refers to the use of the electronic health record." "It combines nursing science with information management and analytical sciences." "It is a specialty that deals with online client educational programs."

"It combines nursing science with information management and analytical sciences." Explanation: The ANA defines nursing informatics (NI) as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice." It is more than just working with computers or the electronic health record (although this is the core of informatics practice). Client education can be one component of a clinical information system with which nursing informatics may be involved.

A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accord with which of the following, a principle of bioethics? A) Nonmaleficence B) Advocacy C) Morals D) Values

A) Nonmaleficence Ans: A Feedback: Nonmaleficence is a principle of bioethics and is defined as the obligation to prevent harm. Advocacy, morals, and values are not principles of bioethics.

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering

Ans: D Feedback: Cue clustering brings together cues that if viewed separately would not convey the same meaning.

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief? Depression Bargaining Anger Denial

Depression Depression is a commonly accepted form of grief and it represents the emptiness when the client realizes the person or situation is gone or over. Signs and symptoms may be withdrawn, sadness, crying, and flat affect. Denial is the stage where client may disregard that the news of diagnosis or death is not true. Anger is the stage where the client may think "why me?" and "life's not fair!" Bargaining is the stage of false hope. The client might falsely make themselves believe that they can avoid the grief through a type of negotiation.

What is Evidence-based Practice What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered? Nursing care now uses EBP as a means of ensuring quality care. Nurses now have to take part in research. Nursing care now incorporates research studies into client care. Nurses now spend time looking up the best way to give nursing care. explanation:

Nursing care now uses EBP as a means of ensuring quality care. The facilitation of EBP involves identifying and evaluating current literature and research, as well as incorporating the findings into client care as a means of ensuring quality care. The other answers are incorrect; they were used even before EBP became a major force in the delivery of nursing care.

Which nursing role is the nurse exhibiting when collecting data about the number of urinary tract infections on the nursing unit? Avocate Leader Counselor Reseacher

Reseacher

Source of Knowledge for Objective Data Which of the following sources of knowledge is based on objective data? authoritative traditional -scientific -applied

-scientific

Chapter 36- Nutrition Folic acid significance for pregnant women · The nurse is preparing to educate a pregnant client who is in the clinic for the first prenatal appointment. Which vitamins or minerals will the nurse include in the teaching to prevent neural tube defects in the fetus? 1. folic acid 2. ascorbic acid 3. vitamin E 4. vitamin D

1. folic acid Folic acid has significantly decreased the number of children born with neural tube defects. Vitamin C, or ascorbic acid, helps with wound healing. Vitamin E helps maintain strong immunity, healthy eyes, and skin. Vitamin D helps prevent osteoporosis by keeping bones strong.

Nutritional assessment for older adult A nurse performing a nutritional assessment determines that the BMI of a 5'11" (1.8 meters) male client who weighs 81 kilograms is which of the following? A) 25.1 B) 18.5 C) 20.3 D) 28.6 The formula for calculating BMI is (body weight in kilograms) divided by (body height in meters squared). (weight in kg) (height in meters) * (height in meters)

A) 25.1

A woman complains of pain with intercourse. What client medications should the nurse check for that contribute to dyspareunia? A) Antihistamines B) Calcium supplements C) Antibiotics D) Antihypertensives

A) Antihistamines Common causes of dyspareunia are organic problems, including inadequate lubrication at the vaginal opening or within the vaginal walls. Medications that cause dyspareunia include antihistamines, certain tranquilizers, marijuana, and alcohol.

When the nurse inserts an ordered urinary catheter into the client's urethra after the client has refused the procedure, then the client suffers an injury, the client may sue the nurse for which type of tort? A) Battery B) Assault C) Invasion of privacy D) Dereliction of duty

A) Battery Ans: A Feedback: Battery is the actual carrying out of such threat (unlawful touching of a person's body). A nurse may be sued for battery if he or she fails to obtain consent for a procedure.

Nursing diagnosis for urinary elimination problems A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A) Urinary incontinence B) Urinary incompetence C) Normal micturition D) Uncontrolled voiding

A) Urinary incontinence The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence.

An informatics nurse specialist has conducted the initial testing of an update to the clinical information system and is preparing to conduct further testing. Which area would the nurse test next?

Ability of the system to work for a specific function

Knowledge gained from someone with a great deal of perceived experience is which type of knowledge? Authoritative knowledge Traditional knowledge Philosophy knowledge Scientific knowledge

Authoritative knowledge

Patient teaching on lung congestion ⇒A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and 23. expectorated. What would be one self-care measure to teach? A) Limit oral intake of fluids to less than 500 mL per day. B) Increase oral intake of fluids to two to three quarts per day. C) Maintain bed rest for at least three days. D) Take warm baths every night for a week.

B) Increase oral intake of fluids to two to three quarts per day.

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client? Disturbed Body Image Impaired Comfort Disturbed Sleep Pattern Activity Intolerance

impaired comfort

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? A) It can cause the nasal mucosa to dry in case of high flow. B) It can cause anxiety in clients who are claustrophobic. C) It can create a risk of suffocation. D) It can result in an inconsistent amount of oxygen

A) It can cause the nasal mucosa to dry in case of high flow.

The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed 3. assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A) The registered nurse B) The American Nurses Association C) The nurse manager D) The unit's medical director

A) The registered nurse Ans: A Feedback: It is the registered nurse who is responsible and accountable for nursing practice.

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client? A) Administer oxygen. B) Call for help. C) Discontinue the IV promptly. D) Elevate the affected arm.

C) Discontinue the IV promptly. When there is phlebitis, the nurse should discontinue the IV promptly and apply warm compresses to the affected site to provide immediate relief to the client. The nurse elevates the client's affected arm when there is infiltration. When there is pulmonary embolus, the nurse should call for help and administer oxygen. phlờ báidis

A home care client has both visual and hearing deficits. Although all of the following are important, what would be a high priority concern when planning and implementing care? A) Nutrition B) Comfort C) Safety D) Communication

C) Safety

A patient is having liquid fecal seepage. He has not had a bowel movement for 6 days. Based on the data, what would the nurse assess? A) amount of intake and output B) color and amount of urine C) color of the feces D) consistency of the feces

D) consistency of the feces

An informatics nurse is part of a team working on developing a clinical information system for a facility. The team is working on ensuring that the system supports usability. During which phase of the system development lifecycle would the team integrate the principles of usability as a priority?

Design

A nurse studies the culture of Native Alaskans to determine how their diet affects their overall state of health. Which method of qualitative research is the nurse using? Historical Ethnography Grounded theory Phenomenology

Ethnography Ethnographic research was developed by the discipline of anthropology and is used to examine issues of culture of interest to nursing. dan toc hoc

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? Nurses formulate nursing diagnoses to identify diseases. Nursing diagnoses remain the same for as long as the disease is present. Nurses write nursing diagnoses to describe client problems that nurses can treat. Nursing diagnoses focus on identifying healthy responses to health and illness.

Nurses write nursing diagnoses to describe client problems that nurses can treat. Explanation: Data collection leads the nurse to identifying client problems that the nurse is able to treat with planned nursing interventions, which is the focus of nursing diagnoses. Nursing diagnoses change as client goals are met or as new problems develop. Medical diagnoses identify disease processes.'

Nursing intervention for a patient with spiritual distress diagnosis A bedridden hospitalized client expresses a belief that missing weekly church service is a failure to live by the church's rules. The notes not missing a service in the past 50 years. Which is an appropriate nursing diagnosis for this client? Dysfunctional Grieving related to inability to attend church services as a result of his medical condition Spiritual Need as evidenced by verbalizations and distress at missing Methodist church services Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt Potential for Enhanced Spiritual Well-Being related to distress at missing Methodist church services

Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt Persons suffering spiritual dysfunction or distress may verbalize such distress or express a need for help.

A nursing instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? "Any information that can identify a person is considered a breach of client privacy." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." "You may continue to post about a client you cared for during clinicals, as long as you do not use the client's name." "All aspects of the clinical experience are confidential and should not be discussed."

"Any information that can identify a person is considered a breach of client privacy."

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend? "Have the Norplant system implanted in your arm." "If your male partner doesn't have genital warts, you will not get them." "Douching will help to prevent them." "Get the human papillomavirus vaccine."

"Get the human papillomavirus vaccine." Human papillomavirus (HPV) is a DNA virus also called genital warts and is a sexually transmitted infection (STI). A vaccine is now available to prevent this disease. Male partners with HPV may or may not have lesions. Women should avoid douching to prevent STIs, as they remove normal protective bacteria in the vagina and increases the risk of getting some STIs. The Norplant system is a contraceptive method and does not prevent STIs

A nursing instructor is discussing burnout with a group of graduating nursing students. Which statement might lead the instructor to believe that the particular student has not developed needed coping mechanisms for nursing practice? "I know that I am not prepared to take on a leadership role right now since I am new and need to learn." "There's so much to learn. I have to find a way to balance these new challenges with settling back into my regular life." "I can handle absolutely any situation now. You teachers have trained us well." "I hope I get a good preceptor. I know that will help me get used to this

"I can handle absolutely any situation now. You teachers have trained us well." Anxiety over the uncertainty of succeeding in a new life role is to be expected. Recognizing that this will be a stressor is an important step in positive coping and adaptation. Erroneously thinking that this will not be a challenge is a form of denial, may lead to role conflict and disillusionment, and later can become a burnout situation.

Characteristics of hospice care A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education? "Palliative care provides relief from pain and other distressing symptoms." "Hospice care programs focus on quality rather than length of life." "Palliative care affirms life and regards dying as a normal process." "In hospice care, the nurses make most of the care decisions for the clients."

"In hospice care, the nurses make most of the care decisions for the clients." The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life.

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate? "You should try to make things right with your family." "There's no need for anger." "I can't imagine how awful this is for you." "It must be very difficult for you."

"It must be very difficult for you." Use statements with broad openings such as "It must be difficult for you" and "Do you want to talk about it?" Such language encourages communication and allows the client to choose the topic or manner of response. Accept the client's behavior. Anger is part of the grieving process. Indicating that this is "awful" is not an appropriate way to promote coping. It is not the nurse's role to tell the client to make things right with the family. While this may be desired, the client should initiate it.

The nursing student is describing moral values to another student. Which statement is correct? "Moral values give individuals some sense of what is right and wrong." "Moral values are assigned by one's religion." "Moral values place an emphasis on emotional attitudes." "Moral values determine one's beliefs about others."

"Moral values give individuals some sense of what is right and wrong." Moral values give individuals the ability to identify correct behaviors and the ability to discern right from wrong.

A nurse reads in a client's chart that he or she has gender dysphoria. The nurse determines that the client understands the diagnosis when making what statement? "People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria." "Gender dysphoria is a condition in which there are contradictions among chromosomal sex, internal organs, and external genital appearance." "People who find pleasure with both opposite-sex and same-sex partners have gender dysphoria." "People who experience sexual fulfillment with a person of the opposite sex have gender dysphoria."

"People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria." People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria. Heterosexuals experience sexual fulfillment with a person of the opposite sex. People who find pleasure with both opposite-sex and same-sex partners are bisexual.An intersex condition occurs in about 1 in every 2000 babies in which there are contradictions among chromosomal sex, internal organs, and external genital appearance, resulting in ambiguous gender.

STI education/teaching The nurse has provided information to a client about oral contraceptives. Which statement by the client would indicate a need for further education? "Oral contraceptives need to be taken on a daily basis." "Some hormonal contraceptives do not contain estrogen and rely instead on a progestin only." "Hormonal oral contraceptives reduce the risk of ovarian cancer." "Some oral contraceptives protect against STIs."

"Some oral contraceptives protect against STIs." Oral contraceptives need to be taken on a daily basis to prevent breakthrough ovulation. Oral contraceptives do not protect against STIs and clients still need to use STI protection such as condoms. In addition to preventing pregnancy, hormonal contraceptives have many health benefits, including reducing the risk for ovarian cancer and endometrial cancer, reducing symptoms of premenstrual discomforts, decreasing blood loss and anemia, reducing symptoms of endometriosis, and many other benefits.

⇒When preparing for palliative care with the dying client, the nurse should provide the family with which explanation? "The client will have to go to an inpatient hospice unit in order to receive palliative care." "Palliative care is the gradual withdrawal of mechanical ventilation from a client with terminal illness and poor prognosis." "In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops." "The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."

"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." Palliative care involves taking care of the body, mind, spirit, heart, and soul. It views dying as something natural and personal. The goal of palliative care is to give clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. A do-not-resuscitate order means that no attempts are to be made to resuscitate a client whose breathing or heart stops. Gradual withdrawal of mechanical ventilation from a client with a terminal illness and poor prognosis is called terminal weaning. Clients do not have to be in an inpatient hospice unit to receive palliative care.

The nurse is performing the intake assessment for a 16-year-old adolescent in the emergency department. Which question by the nurse will assist in understanding the adolescent's spirituality? "How many times per week do you attend religious services?" "What are your spiritual beliefs?" "What religion do you practice?" "What religion do you want me to write down in your medical record?"

"What are your spiritual beliefs?" The purpose of a spiritual assessment is to determine the beliefs and practices of the client to provide high-quality, individualized care. Spirituality is an important aspect of providing holistic health care. Asking the adolescent about spiritual beliefs and what things have meaning to the client is the best way to determine the adolescent's spirituality. Asking what religion is practiced is limiting the client's choices and the client's spirituality may not be practiced in a traditional fashion. Assuming the client goes to religious services may result in a poor nurse-client relationship, as the client may see the nurse as judgmental based on church attendance. Asking what religion to list in the medical record is not demonstrating the importance of this information in the overall health and well-being of the client.

Which of the following accurately describes Florence Nightingales influence on nursing knowledge? -She defined nursing practice as the continuation of medical practice. -She differentiated between health nursing and illness nursing. -She established training for nurses under the direction of the medical profession. -She established a theoretical base for nursing that originated outside the profession.

-She differentiated between health nursing and illness nursing.

Chapter 42- Stress & Adaptation Social adjustment The nurse is caring for four clients. Which client does the nurse identify as the highest risk for social readjustment concerns? 32-year-old who has recently been incarcerated 40-year-old who was fired from work last month 54-year-old who is undergoing marital separation 77-year-old whose spouse just died

77-year-old whose spouse just died Death of a spouse ranks as the most stressful life event on The Social Readjustment Rating Scale. The client whose spouse just died is at highest risk for social readjustment concerns.

Which example best supports the diagnosis of Sexual Dysfunction: Dyspareunia? A 50-year-old woman with a history of stroke is afraid to have sex with her partner for fear it will elevate her blood pressure. A 50-year-old woman in the process of menopause has pain and burning during intercourse. A client with a colostomy believes she cannot have a sexual relationship with her husband because he will be repulsed by her stoma. A 39-year-old alcoholic woman is no longer interested in having sex with her partner.

A 50-year-old woman in the process of menopause has pain and burning during intercourse. Dyspareunia refers to pain and burning during intercourse. This is a common cause of sexual dysfunction, especially during menopause. A colostomy, fear of blood pressure elevation, and lack of interest in sex may lead to the nursing diagnosis of Sexual Dysfunction, but not related to dyspareunia.

Which client is experiencing the panic level of anxiety? A client loses control and expresses irrational thinking. A client focuses narrowly on specific detail. A client displays a narrow perception field. A client experiences increased alertness and motivated learning.

A client loses control and expresses irrational thinking. Panic causes the person to lose control and experience dread and terror. The resulting disorganized state is characterized by increased physical activity, distorted perception of events, and loss of rational thought. Increased alertness and motivated learning describes mild anxiety. Narrowing the focus on a specific detail describes moderate anxiety. A patient displaying a narrow perception field is a characteristic of severe anxiety

The nursing diagnosis Risk for Sensory Deprivation is best suited for which client? the client who is able to fall asleep even when the television volume is too loud the client who keeps changing the television station the client who keeps talking to the nurse the whole time A client whose room at the end of the hallway has the door closed most of the time

A client whose room at the end of the hallway has the door closed most of the time A nurse should realize that a person who experiences less than the usual stimulation may be at risk for sensory deprivation.The client who is at the end of the hallway and has the door closed may be at risk. The client who is talking to a nurse for a period of time is not exhibiting less than ideal stimulation. The client who manipulates the television and is able to fall asleep even when the television is loud identifies the ability of a client who is used to stimulation and not at risk for sensory deprivation.

Defense mechanisms (Displacement) Which client is handling stress by using the defense mechanism termed displacement? A man with symptoms of prostate cancer refuses to see a doctor. An athlete who doesn't make the team concentrates on body-building instead. A mother who is angry at her husband shouts at the kids to "keep quiet." A man who forgets his medication blames his wife for putting it away.

A mother who is angry at her husband shouts at the kids to "keep quiet." Displacement is described as transferring (displacing) an emotional reaction from one object or person to another object or person, as with the mother who is angry at her husband and shouts at the kids to "keep quiet." The athlete who doesn't make a team and instead concentrates on body-building represents the defense mechanism of compensation. A man with symptoms of prostate cancer refusing to see a doctor is displaying the defense mechanism of denial. A man who forgets his medication and blames his wife for putting it way is demonstrating the defense mechanism of projection.

Upon arrival to the emergency room, the mother of a client involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing? Severe anxiety A panic attack Moderate anxiety Mild anxiety

A panic attack Panic causes the person to lose control and experience dread and terror. Panic is characterized by a disorganized state, increased physical activity, difficulty communicating, agitation, trembling, dyspnea, palpitations, a choking sensation, and sensations of chest pressure or pain. Severe anxiety creates a narrow focus on specific detail; moderate anxiety leads to a focus on immediate concerns; and mild anxiety is often present in day-to-day living. It increases alertness and perceptual fields.

A client tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition? A) Sensory deficit B) Sensory deprivation C) Sensory overload D) Sensory stimulation

A) Sensory deficit Impaired or absent functioning in one or more senses is termed sensory deficit.

Breach in confidentiality examples Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication

A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. D) A nurse updates the employer of a client regarding the client's return to work. Ans: Feedback:Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

A nurse is making a home care visit to a client with a hearing deficit. What can she do to facilitate communication with the client? A) Ask for permission to turn off the television set during the visit. B) Talk in a loud tone of voice at all times during the visit. C) Use written communication rather than verbal communication. D) Reduce the time spent with the client to decrease frustration.

A) Ask for permission to turn off the television set during the visit. One way in which communication with a client with a hearing deficit can be facilitated is to decrease background noises (as from a television).

A client refuses to have a pain medication administered by injection. A nurse says, "If you don't let me give you the shot, I will get help to hold you down and give it." With what crime might the nurse be charged? A) Assault B) Battery C) Negligence D) Defamation

A) Assault Ans: A Feedback: Assault and battery are intentional torts. Assault is a threat or attempt to make bodily contact with another person without that person's consent. Threatening to forcibly administer an injection after the patient has refused it is assault. Battery is an assault that is carried out and includes willful, angry, and violent or negligent touching of another person's body, clothes, or anything attached to or held by that other person. Negligence is defined as performing an act that a reasonably prudent person under similar circumstances would not do or, conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do. Defamation is an intentional tort in which one party makes derogatory remarks about another that diminish the other party's reputation.

The client indicates that he does not believe in a higher power and therefore has no preferred religion. The nurse knows that which of the following terms describes the client's feelings about religion? A) Atheist B) Jehovah's Witness C) Agnostic D) Spiritualist

A) Atheist An atheist is a person who denies the existence of a higher power. An agnostic is one who holds that nothing can be known about the existence of a higher power. Jehovah's Witnesses are an organized religion. A spiritualist is one who believes in spirituality.

The nurse working in research correctly identifies which of the following to be mandatory for the ethical conduction of research in a hospital setting? A) Clients must grant informed consent if they are to participate. B) All interventions must benefit all clients. C) The client must directly and personally benefit from the research. D) Descriptive studies are more ethical than experimental studies.

A) Clients must grant informed consent if they are to participate. Informed consent is an absolute prerequisite for clients who are asked to participate as subjects in a research study. Not all interventions will benefit all (or even any) clients. The risks and benefits of research are considered carefully in light of ethical principles, but this does not necessarily mean that every participant in a study stands to benefit from it. Ethical standards are applicable and achievable in every type of research, and descriptive studies are not necessarily more ethical than experiments.Informed Consent

What term is used to describe painful intercourse? A) Dyspareunia B) Dysmenorrhea C) Impotence D) Vulvodynia

A) Dyspareunia ˌdis-pə-ˈrü-nē-ə, -nyə/

Nursing considerations for clients with a need for nutritional intake The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake? A) Encourage his daughter to prepare food at home and bring it to the client. B) Serve large meals and encourage the client to eat as much as possible. C) Provide distractions while the client is fed so that he will eat more. D) Provide bland meals.

A) Encourage his daughter to prepare food at home and bring it to the client. Feedback:The nurse should solicit food preferences and encourage favorite foods from home, when possible. Be sure the foods look attractive and the eating area is free of odors, clutter, and distractions during mealtime. Provide small, frequent meals to avoid overwhelming the client with large amounts of food.

Which of the following are signs and symptoms of poor nutritional status? A) Flaky facial skin, facial edema, pale skin color B) Tongue is a deep red in color with surface papillae present. C) Firm, pink nailbeds D) Firm hair that is resistant to plucking

A) Flaky facial skin, facial edema, pale skin color Feedback:Healthy skin is uniform in color and not swollen.

Bowel training program and expected outcomes Which is an expected outcome for a client undergoing a bowel training program? A) Have a soft, formed stool at regular intervals without a laxative. B) Continue to use laxatives, but use one less irritating to the rectum. C) Use oil-retention enemas on a regular basis for elimination. D) Have a formed stool at least twice a day for two weeks.

A) Have a soft, formed stool at regular intervals without a laxative. Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client's control (such as exercise or fluid intake) to produce the elimination of a soft, formed stool at regular intervals without a laxative.

A staff development nurse is asking a group of new staff nurses to read and be prepared to discuss a qualitative study that focuses on nursing events of the past. This is done in an attempt to increase understanding of the nursing profession today. What method of qualitative research is used in this article? A) Historical B) Phenomenology C) Grounded theory D) Ethnography

A) Historical Ans: A Feedback: This article uses historical methodology, which examines events of the past to increase understanding of the nursing profession today. Phenomenology is used to describe experiences as they are lived by the subjects being studied. Grounded theory is the discovery of how people describe their own reality and how their beliefs are related to their actions in a social scene. Ethnography is used to examine issues of a culture that are of interest to nursing.

Which of the following laboratory results indicates the presence of malnutrition? A) Serum albumin 2.8 g/dL B) Hemoglobin (Hgb) 11.3 g/dL C) Creatinine 1.9 mg/dL D) Hematocrit (Hct) 56%

A) Serum albumin 2.8 g/dL Feedback:Increased Hct indicates dehydration.

Correctly written nursing diagnosis (NANDA) Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Incorporate subjective and judgmental terminology. B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."

A) Incorporate subjective and judgmental terminology. Defining characteristics should follow the etiology and be linked by the phrase "as evidenced by" when included in the nursing diagnosis. The nursing diagnosis should be phrased as a client problem or alteration in health state, rather than as a client need. The client problem precedes the etiology and is linked by the phrase "related to." Avoid using judgmental language and write in legally advisable terms.

Assessment before, during, and after small-volume cleansing enema ⇒A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? A) Increased bowel sounds B) Abdominal tenderness C) Areas of distention D) Muscular resistance

A) Increased bowel sounds Feedback: The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.

⇒A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What IV complication does this describe? A) Infiltration B) Sepsis C) Thrombus D) Speed shock

A) Infiltration Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site, and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

Which of the following are examples of characteristics of evidence-based practice? Select all that apply. A) It is a problem-solving approach. B) It uses the best evidence available. C) It is generally accepted in clinical practice. D) It is based on current institutional protocols. E) It blends the science and art of nursing.

A) It is a problem-solving approach. B) It uses the best evidence available. E) It blends the science and art of nursing. Ans: A, B, E Evidence-based nursing is a problem-solving approach to making clinical decisions, using the best evidence available. EBP may meet resistance in clinical practice as a result of the nursing shortage, the acuity level of clients, nurse's skill in reading and evaluating published research, and an organizational culture that does not support change. EBP blends both the science and the art of nursing so that the best client outcomes are achieved. EBP takes into consideration client preferences and values as well as the clinical experiences of the nurse.

How can religious, life-affirming influences be compared with basic human needs? A) Life-affirming influences encourage self-actualization. B) Life-affirming influences enhance life. C) Life-affirming influences meet basic physiologic needs. D) Life-affirming influences cultivate wisdom.

A) Life-affirming influences encourage self-actualization. Religious influences may be life affirming or life denying. Life-affirming influences encourage self-actualization, the highest level of basic human needs.

What spiritual need is believed to underlie all religious traditions and is common to all people? A) Love and relatedness B) Physical hygiene C) Religious education D) Church services

A) Love and relatedness

The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs which of the following interventions to assist the client in adapting to this sensory deficit? Choose all that apply. A) Make sure he wears his hearing aid. B) Speak in a lower tone of voice. C) Speak so he can observe your lip movement. D) Keep his environment clear of clutter. E) Orient to person, place, and time frequently

A) Make sure he wears his hearing aid. B) Speak in a lower tone of voice. C) Speak so he can observe your lip movement. Ans: A, B, C Feedback: Speaking in low tones and making sure he can see your lip movement will assist the client in hearing and understanding better, as will wearing his hearing aid. Keeping his room free of clutter is nice, but will not assist his hearing. Reorienting will not help to improve the client's hearing.

Chapter 19- Documenting & Reporting Review Pie charting, flow sheet, and narrative note The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

A) Narrative notes Feedback:One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A nurse is caring for a young adult female client who has a folic acid deficiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A) Neural tube deficits in the fetus B) Inadequate absorption of calcium and phosphorus C) Hemolysis of red blood cells D) Impaired neuromuscular functioning

A) Neural tube deficits in the fetus Ans: A Feedback: Folic acid deficiency in pregnant women can lead to neural tube deficits like spina bifida in the fetus. Because fetal neural development begins so early in pregnancy, women in their childbearing years must have adequate folic acid intake. Deficiency in vitamin D intake leads to inadequate absorption of calcium and phosphorus, and a deficiency of ​​

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client's systolic blood pressure is 170 or greater. B) Let me know if the client's blood pressure becomes elevated. C) If the client's blood pressure falls outside normal limits, come get me. D) I need to know if the client's blood pressure changes from his normal baseline.

A) Notify me right away if the client's systolic blood pressure is 170 or greater. Ans: A Feedback: When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement, which includes specific parameters for the systolic blood pressure, clearly identifies what the UAP should be alerted to and the subsequent action to take. The other three options are vague and do not provide adequate direction for the UAP.

Nurse-healthcare team professional relationship Nurse-health care team ⇒A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

A) Nurse-health care team Ans: A Feedback: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary.

A client with dehydration is being administered IV fluids. During her rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible? A) Phlebitis B) Thrombus formation C) Pulmonary embolus D) Air embolism

A) Phlebitis The nurse should record that the client has phlebitis, which is an inflammation of the vein. Thrombus formation is a situation in which there is a stationary blood clot. Pulmonary embolus is a situation in which the blood clot travels to the lung. Air embolism is a bubble of air traveling within the vascular system.

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written? A) Post-trauma syndrome related to being attacked B) Psychological overreaction related to being attacked C) Needs assistance coping with attack D) Mental distress related to being attacked

A) Post-trauma syndrome related to being attacked Ans: A Feedback: Post-trauma syndrome is a NANDA-approved problem statement and being attacked is the correct etiology. Overreaction and mental distress implies a value judgment by the nurse. Needs assistance addresses the need of the client.

Qualitative Research Involves what? A nurse researcher is studying perceptions of vocational rehabilitation for clients after a spinal cord injury. What type of research method will be used to study the perceptions of this group of individuals? A) Qualitative research B) Quantitative research C) Basic research D) Applied research

A) Qualitative research Ans: A Feedback: The nurse researcher will use qualitative research methods to investigate perceptions, and the researcher will analyze words instead of numbers, which are analyzed in quantitative research. Basic and applied research are quantitative research methods.

Chapter 16- Outcome Identification & Planning Follow up on outcomes- How is this done? The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Remove the outcome from the client's care plan. C) Ask the nurse who wrote the plan of care to document this development. D) Reassess the client's psychomotor skills at dinner time.

A) Record an evaluative statement in the client's plan of care. The client has successfully met this outcome, and the nurse should note the time and date that it was achieved in theclient's plan of care. The outcome should not be removed from the plan of care and it is unnecessary to have the originalauthor of the plan update it. Further observation may or may not be necessary at dinner time, but an evaluative statementshould nonetheless be recorded at the present time.

Data collected and organized together is consider? After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used? A) Selecting nursing interventions to meet expected outcomes B) Establishing a database of information for future comparison C) Mutually establishing desired outcomes of the plan of care D) Evaluating the effectiveness of the established plan of care

A) Selecting nursing interventions to meet expected outcomes The nurse formulates, validates, and lists nursing diagnoses for each client. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued client outcomes for which the nurse is responsible.

The nurse is caring for a female age 45 years who discloses during the admission nursing history that she is no longer able to enjoy sex with her husband because it causes too much pain in her vagina. The nurse includes which of the following nursing diagnoses in the client's care plan related to this information? A) Sexual Dysfunction: Dyspareunia B) Altered Sexuality Patterns: Change in sexual expression C) Altered Sexuality Patterns: Loss of desire D) Altered Sexuality Patterns: Change in positioning

A) Sexual Dysfunction: Dyspareunia

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A) Social Isolation B) Impaired Adjustment C) Defensive Coping D) Impaired Memory

A) Social Isolation Urinary incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing him or her to feel like a social outcast.

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) Suprapubic catheter B) Indwelling urethral catheter C) Intermittent urethral catheter D) Straight catheter

A) Suprapubic catheter Feedback:A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.

Correct method to write client outcomes Which of the following is a correctly written client goal? Select all that apply. A) The client will identify five low-sodium foods by October 9. B) The client will know the signs and symptoms of infection. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. D) The client will understand the side effects of digoxin (Lanoxin). E) The client will eat at least 75% of all meals by May 5.

A) The client will identify five low-sodium foods by October 9. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. E) The client will eat at least 75% of all meals by May 5. Ans: A, C, E Feedback: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (eat), how well (75%) under what circumstances (not always included), and by when (May 5). Understand and know are vague and are not action-oriented.

Chapter 18- Evaluating What is meant by physiologic outcomes ?? ⇒Which client outcome is a physiologic outcome? Select all that apply. A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. D) The client self-administers insulin subcutaneously. E) The client describes manifestations of wound infection.

A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. Ans: A, B, C Feedback: Physiologic outcomes are physical changes in the client, such as pain ratings and blood pressure and HA1c measurements. Psychomotor outcomes describe the client's achievement of new skills, such as insulin administration. Cognitive outcomes demonstrate gains in client knowledge, such as manifestations of infection.

Which of the following are characteristics of nursing theories? Select all that apply. A) They provide rational reasons for nursing interventions. B) They are based on descriptions of what nursing should be. C) They provide a knowledge base for appropriate nursing responses. D) They provide a base for discussion of nursing issues. E) They help resolve current nursing issues and establish trends.

A) They provide rational reasons for nursing interventions. C) They provide a knowledge base for appropriate nursing responses. D) They provide a base for discussion of nursing issues. E) They help resolve current nursing issues and establish trends. Nursing theory provides rational and knowledgeable reasons for nursing interventions, based on descriptions of what nursing is and what nurses do. Additionally, nursing theory gives nurses the knowledge base necessary for acting and responding appropriately in various situations. It also provides a base for discussion, and, ideally, helps resolve current nursing issues. Nursing theories should be simple and general; simple terminology and broadly applicable concepts ensure their usefulness in a wide variety of nursing practice situations.

Chapter 6- Values, Ethics, & Advocacy Unprofessional, incompetent, unethical, illegal physician practice A nurse in a physician's office has noted on several occasions that one of the physicians frequently obtains controlled- drug prescription forms for prescription writing. The physician reports that his wife has chronic back pain and requires pain medication. One day the nurse enters the physician's office and sees him take a pill out of a bottle. The doctor mentions that he suffers from migraines and that his wife's pain medication alleviates the pain. What type of nurse- physician ethical situation is illustrated in this scenario? A) Unprofessional, incompetent, unethical, or illegal physician practice B) Disagreements about the proposed medical regimen C) Conflicts regarding the scope of the nurse's role D) Claims of loyalty

A) Unprofessional, incompetent, unethical, or illegal physician practice Ans: A Feedback: The physician is demonstrating unprofessional, incompetent, unethical, or illegal physician practice.

Duty of nursing students to protect patient privacy/confidentiality A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

A) Writing the client's name on the student care plan Feedback:Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medic ations with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

What is the unique focus of nursing implementation? A)patient response to health and illness B)patient response to nursing diagnosis C)patient compliance with treatment regimen D)patient interview and physical assessment

A)patient response to health and illness

A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation? A. communication is the primary purpose of client records. B. nurses should not document progress notes on a pt's record C. pt's should keep the original record at home in a fire proof safe D. physicians will not review nurse's documentation in the pt's record

A. communication is the primary purpose of client records.

Nurse-initiated interventions are A. determined by state Nurse Practice Acts. B. supervised by the entire health care team. C. made in concert with the plan of care initiated by the physician. D. developed after interventions for the recent medical diagnoses are evaluated.

A. determined by state Nurse Practice Acts.

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next? Train Test Implement Analyze and Plan

Analyze and Plan Evaluation may be the last phase of the system development lifecycle, but it represents an essential step for nurses to be involved in before circling back to Analyze and Plan based on the results of the evaluation. This step is important to complete before making updates or improvements to a system already in place. Once this step is completed, the other steps of the system development lifecycle would follow.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross? Anger Denial Acceptance Bargaining

Anger Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fateand make peace spiritually and with those to whom they are close.

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking

Ans: A Feedback: The appropriately written nursing diagnosis is "ineffective airway clearance related to inability to clear secretions." "Ineffective health maintenance related to unhealthy habits" is incorrect because it shows value judgments by the nurse. "Ineffective breathing pattern related to pneumonia" is incorrectly written because it includes a medical diagnosis. "Ineffective therapeutic regimen management due to smoking" is incorrect because the clause "due to" implies a direct cause-and-effect relationship.

In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

B) Source-oriented record Feedback: A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.

The nursing role in prioritizing nursing diagnosis - Caregiver Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise programB) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing

Ans: A, D, E Feedback:The purpose for which the assessment is being performed offers the best guideline about what type and how much data to collect. Assessment priorities are influenced by the client's health orientation, developmental stage, culture, and need for nursing. After the comprehensive nursing assessment has been completed, client health problems dictate assessment priorities for future nurse-client interactions.

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment

Ans: B Feedback: A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.

Toddlers and regressive behavior??? Say "no" ( chap 21 ) ?? A child 2 years of age is hospitalized for a surgical procedure. Although previously all fluids were taken from a cup, the toddler wants a bottle to suck on. The nurse recognizes this behavior as what? A) Totally unacceptable B) Proof that the child is sick C) Normal regression D) Abnormal behavior

Ans: C Feedback: Based on the principles and theories of growth and development, the nurse recognizes possible regression during difficult periods or times of crisis, accepting and supporting a return to a forward progression in development. It is acceptable, normal behavior for the hospitalized toddler.

Positioning self to conduct an interview with a bed confined patient A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed

Ans: D Feedback: If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an easy exchange of information. If the nurse stands at the side or foot of the bed and physically looks down at the client, a superior-inferior relationship is communicated and can negatively affect the interview.

Action of the nurse post death of a client A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) Remove the dentures from the body. make sure the body is lying completely flat. Apply fresh linens and place a clean gown on the body. Remove all equipment from the bedside. Dim the lights in the room.

Apply fresh linens and place a clean gown on the body. Remove all equipment from the bedside. Dim the lights in the room.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply pressure to the insertion site for at least 3 minutes. Instruct client to remain flat for 30 minutes. Apply petroleum-based ointment and sterile occlusive dressing. Ask client to perform Valsalva maneuver.

Apply pressure to the insertion site for at least 3 minutes. The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

The nurse receives a "do not resuscitate" (DNR) order for a dying client. What should the nurse do next? Inform the family that this order does not keep the nurse from doing her job. Avoid talking about suicide and its effects. Inform the client that a priest will be in to see her very soon. Assess the client's spiritual needs

Assess the client's spiritual needs Conducting a spiritual assessment is an essential aspect of maintaining health and providing holistic and sensitive nursing care especially in a DNR. Following the spirituality assessment, if the client has additional questions or concerns related to spirituality, the nurse may suggest follow-up with a chaplain or a priest, but there is no indication the client requested spiritual guidance. A nurse should not discuss suicide and its affects as that is inappropriate. The order may impact the nurse's interventions but this is not the priority at this point.

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. Explain: The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.

Nurses initiated interventions (Examples) Which of the following groups of terms best describes a nurse-initiated intervention? A) Dependent, physician-ordered, recovery B) Autonomous, clinical judgment, client outcomes C) Medical diagnosis, medication administration D) Other health care providers, skill acquisition

B) Autonomous, clinical judgment, client outcomes Feedback: A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed).

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following? A) "I should take frequent bubble baths." B) "I need to void after sexual intercourse." C) "I should wipe from back to front after going to the bathroom." D) "I need to wear pants that are snug fitting."

B) "I need to void after sexual intercourse." Feedback:The client's statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increases the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fittingpants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination.

A client tells the nurse, "I am an atheist. I do not believe in God." What would be an appropriate response by the nurse? A) "Well, I believe in God and you should, too." B) "I respect what you choose to believe in." C) "How can you deny the existence of God?" D) "What makes you think you are an atheist?"

B) "I respect what you choose to believe in." An atheist is a person who denies the existence of God, guided by philosophies of living that do not include a religious faith. The atheist deserves respect for what he or she chooses to believe. While admitting a clilent who is having elective surgery tomorrow, the nurse asks if he has a preferred religion or faith.

Supplies type required for urinary catheterization ⇒A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina

B) A sterile catheterization kit or tray Feedback:The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray.

During the neurological assessment, the nurse asks the client if she has any problems with her sense of smell. The client relates that she lives near a factory that emits an obnoxious odor, but that she no longer notices the smell. The nurse tells Joan that this phenomenon is normal and is called which of the following? A) Tolerance B) Adaptation C) Acceptance D) Adjustment .

B) Adaptation Ans: B Feedback: The body quickly adapts to constant stimuli. In addition, the repeated stimulus of a continuing noise, such as city traffic, or a noxious odor eventually goes unnoticed. This phenomenon is termed "adaptation"

Physician initiated interventions (Examples) The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention? A) Teach client how to transfer from bed to chair and chair to bed. B) Administer oxygen 4 L/min per nasal cannula. C) Assist the client with coughing and deep breathing every hour. D) Monitor intake and output every 2 hours.

B) Administer oxygen 4 L/min per nasal cannula. Feedback: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician's order. A physician's order is required for the nurse to administer drugs, such as oxygen. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing- initiated interventions, such as teaching client how to transfer, assisting with coughing and deep breathing, and monitoring intake and output do not require a physician's order.

Which of the following group of terms best defines spiritual distress? A) Spirituality, religion B) Alienation, despair C) Faith, prayer D) Forgiveness, purpose

B) Alienation, despair Terms that define spiritual distress include spiritual pain, alienation, anxiety, guilt, anger, loss, and despair.

⇒While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating? A) The importance of food in meeting a basic human need B) Basic respect for human dignity C) Men do not gossip with women D) A low value on collegiality and friendship Ans: B

B) Basic respect for human dignity Nurses who feel uncomfortable gossiping with other nurses about patients realize that this behavior contradicts a basic respect for human dignity. This respect is a value that allows one to choose freely to believe in the worth and uniqueness of each individual.

Recommended guidelines for implementation Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply. A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. Ans: B, D Feedback: When implementing nursing care, the nurse should act in partnership with the client/family and reassess the client to determine if the nursing action is still needed. The nurse should always question that the nursing intervention selected is the best of all possible alternatives. The nurse should consult colleagues and related nursing literature to see if other approaches might be more successful. The nurse should develop a repertoire of skilled nursing interventions, and check to make sure that the ones selected are consistent with standards of care and within legal/ethical guidelines to practice.

A group of students is reviewing information about evidence-based practice in preparation for an exam. The students demonstrate understanding of the information when they identify which of the following as associated with evidence- based practice? A) It emphasizes personal experience over science. B) Clinical expertise is integrated with external evidence. C) It involves gaining solutions to problems. D) The purpose is to learn about a specific problem.

B) Clinical expertise is integrated with external evidence. Evidence-based practice (EBP) is an approach to health care that realizes that pathophysiologic reasoning and personal experience are necessary, but not sufficient for making decisions. Advocates argue that medical decisions should be based, as much as possible, on a firm foundation of high-grade scientific evidence, rather than on experience or opinion. Its practice involves integrating individual clinical expertise with the best available external evidence from systematic research. Nursing research aims to gain solutions to problems, learn about a specific problem, or to understand a situation.

⇒What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking B) Critical thinking C) Traditional knowing D) Rote memory

B) Critical thinking Ans: B Feedback: Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes.

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse

B) Focused In focused assessments, the nurse determines whether the problem still exists and whether the status of the problem has changed.

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment

B) Focused assessment - The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status ofthe problem has changed. - An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. -Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. -An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.

Then nurse is caring for a hospice client who tells the nurse that she is worried about how she has treated a younger sister. She asks the nurse how to make things right. The nurse recognizes this as which of the following spiritual needs? A) Meaning B) Forgiveness C) Purpose D) Love

B) Forgiveness

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

B) Intervention carried out Feedback: In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only

A nurse has documented that a client has anorexia. What does this term mean? A) Eating more than daily requirements B) Lack of appetite C) Vitamin C deficiency D) Fluid deficit

B) Lack of appetite Feedback:Anorexia is lack of appetite. It may be related to multiple factors, including diseases, psychosocial causes, impaired ability to chew and taste, or inadequate income.

Lactose intolerance client characteristics A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ... A) Allergic to sugar B) Lactose intolerant C) Experiencing infectious diarrhea D) Deficient in fiber

B) Lactose intolerant Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, xglucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after ingestion of milk products.

Role of the nurse in safe medication orders (Questioning physician orders) ⇒ A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? A) Administer the medication based on the order B) Question the order for the medication C) Refuse to administer the medication D) Document concerns about the order

B) Question the order for the medication Ans: B Feedback: The nurse should question any physician order that is ambiguous, contraindicated by normal practice (such as an abnormally high medication dose), or contraindicated by the client's present condition. The nurse should not administer the medication, refuse to administer the medication without contacting the physician, or document concerns about the order without doing anything further.

The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client? A) Risk for activity intolerance B) Risk for impaired skin integrity C) Risk for infection D) Risk for falls

B) Risk for impaired skin integrity A client who is incontinent, utilizes adult diapers, and only changes them daily is at Risk for Impaired Skin Integrity in the genital and perineal area.

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency

B) Urinary retention Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary loss of urine from the bladder. Retention is an accumulation of urine in the bladder. Frequency is voiding more often than usual.

A heterosexual couple enjoys anal intercourse. What may result from this type of intercourse? A)feelings of guilt and shame B)vaginal infections C)damage to the vagina D)penile infections

B)vaginal infections

A woman age 49 years has sought care from her primary care provider because of "intimacy problems." Upon questioning, the woman reveals that she is experiencing sexual desire, but that intercourse causes her significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What would the clinician recognize that this client is most likely experiencing? A. Vaginismus B. Dyspareunia C. A sexually transmitted infection (STI) D. Vulvodynia

B. Dyspareunia Dyspareunia is painful intercourse. Vaginismus is characterized by difficult penetration rather than acute pain during intercourse. Vulvodynia is associated with pain that is not limited to intercourse. hare infections that can be caught or passed on from unprotected sex, or close sexual contact. An STI may or may not be contributing to the woman's problem, though most cases of dyspareunia are unrelated to infections.

Which nursing diagnosis would most likely be considered a high priority? A. Disturbed personal identity B. Impaired gas exchange C. Risk for powerlessness D. Activity intolerance

B. Impaired gas exchange Rationale: Impaired gas exchange poses a threat to the patient's well-being. Disturbed personal identity and risk for powerlessness are non-life-threatening and are ranked as medium priorities. Activity intolerance, if not specifically related to the current health problem, is a low priority.

Which example may illustrate a breach of confidentiality and security of patient information? A. The nurse informs a colleague that she should not be discussing pt information in the hospital cafeteria. B. The nurse provides information over the phone to the patient's family member who lives in a neighboring state. C. The nurse assesses pt information on the computer at the nurse's station, and logs off before answering a call light D. The nurse provides info to a professional caregiver involved in the care of the pt

B. The nurse provides information over the phone to the patient's family member who lives in a neighboring state. Rationale: providing info over the phone without knowing if the pt wants the family member to know the info is a breach of confidentiality

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the bargaining stage? A) "The doctors must have made a mistake." B) "Why did this happen to me? I always exercised." C) "Just let me live to see my grandson born." D) "I've had a good life and I can die in peace."

C) "Just let me live to see my grandson born." Ans: C In the bargaining stage of the psychosocial responses to dying and death, the client tries to bargain for more time to live. It is important to meet wishes for putting personal affairs in order and fulfilling last wishes during this time, if possible, because bargaining helps clients move into later stages of dying.

Which of the following statements by a nurse would nurture spirituality by promoting love and relatedness? A) "I know you are angry about your diagnosis." B) "Tell me about what you do in your job." C) "Tell me about how you get along with others." D) "How often do you read the Bible each day?"

C) "Tell me about how you get along with others." The nurse can help the client nurture his or her own spirituality by promoting meaning and purpose, love and relatedness, and forgiveness. To promote love and relatedness, encourage the client to talk about relationships with others and to identify the origin of negative beliefs about people

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct? A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"

C) "ineffective airway clearance related to thick mucus" Ans: C Feedback: It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use client needs, put defining characteristics before the diagnoses, or judge the willingness of the client to cough.

⇒ A client visits a health care facility with complaints of loss of appetite following a prolonged illness. How should the nurse document the client's condition? A) Emaciation B) Cachexia C) Anorexia D) Nausea

C) Anorexia Feedback:The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.

A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client? A) Oil retention enema B) Carminative enema C) Anthelmintic enema D) Nutritive enema

C) Anthelmintic enema Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve distention. Nutritive enemas are administered to replenish fluids and nutrition rectally.

A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor? A) Adaptation B) Homeostasis C) Coping mechanism D) Defense mechanism

C) Coping mechanism Ans: C When a person is in a threatening situation, immediate responses occur. Those responses, which are often involuntary, are called coping responses. The change that takes place as a result of the response to a stressor is adaptation.

A man has noticed bright red blood in his bowel movements for over a month. He says to himself, "Oh, it's just my hemorrhoids." What defense mechanism is the man using? A) Rationalization B) Repression C) Denial D) Compensation

C) Denial When using denial as a defense mechanism, an individual is refusing to acknowledge the presence of a condition that is disturbing.

Which is a responsibility of the nurse in the nurse-client-family team relationship? A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B) Support the nursing care given by other nursing and non-nursing personnel. C) Educate the family to be informed and assertive consumers of health care. D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

C) Educate the family to be informed and assertive consumers of health care. Ans: C Feedback: Educating the family to be informed and assertive consumers of health care is a role responsibility in the nurse-client- family relationship. Responsibilities of the nurse in the nurse-health care team relationship include coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work, and supports the nursing care given by other nursing personnel.

What independent nursing intervention can be implemented to stimulate appetite? A) Administer prescribed medications. B) Recommend dietary supplements. C) Encourage or provide oral care. D) Assess manifestations of malnutrition.

C) Encourage or provide oral care. Feedback:There are many methods of stimulating appetite in a client to prevent malnutrition. One independent nursing intervention that is useful is to encourage or provide oral care.

Before developing a procedure, a nurse reviews all current research-based literature on insertion of a nasogastric tube. What type of nursing will be practiced based on this review? A) Institutional practice B) Authoritative nursing C) Evidence-based nursing D) Factual-based nursing

C) Evidence-based nursing Evidence-based nursing practice (EBNP) is the conscientious, explicit, and judicious use of research-based information in making decisions about the delivery of care. EBNP does not include institutional practice, authoritative nursing, or factual-based nursing. có lương tâm, rõ ràng và hợp lý

A nurse is educating a student nurse on how STIs affect the health of their clients. Which of the following statements accurately describes an effect of an STI? A) STIs are most common in young to middle adulthood populations. B) The incidence of STIs is decreasing due to health promotion efforts. C) Most of the time STIs cause no symptoms, especially in women. D) Health problems caused by STIs are more severe and frequent in men.

C) Most of the time STIs cause no symptoms, especially in women. Most of the time, STIscause no symptoms, particularly in women.STIs affect men and women of all backgrounds and economic levels; they are most prevalent among teenagers and young adults. The incidence of STIs is rising, in part because in the last few decades, young people have become sexually active earlier yet are marrying later. Health problems caused by STIs tend to be more severe and more frequent for women than for men, in part because the frequency of asymptomatic infection means that many women do not seek care until serious problems have developed.

A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patients daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patients value as an individual? A) Sarah, can you tell me how long your father has been this way? B) Sarah, I have to go and read your fathers old charts before we talk. C) Mr. Koeppe, tell me what you do to take care of yourself. D) Mr. Koeppe, I know you cant answer my questions, but its okay.

C) Mr. Koeppe, tell me what you do to take care of yourself.

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

C) Narrative note Feedback:A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A) Nurse-client B) Nurse-nurse C) Nurse-client-family D) Nurse-health care team

C) Nurse-client-family Ans: C Feedback: The nurse is fulfilling role responsibilities of the nurse-client-family relationship when being present for a discussion of the matter by the client and family.

Which of the following outcomes is correctly written? A) Abdominal incision will show no signs of infection. B) On discharge, client will be free of infection. C) On discharge, client will be able to list five symptoms of infection. D) During home care, nurse will not observe symptoms of infection.

C) On discharge, client will be able to list five symptoms of infection. Feedback: To be measurable, outcomes should have a subject (client or part of the client), verb (action to be performed), conditions (not always included), performance criteria (observable, measurable), and target time (to achieve the outcome).

The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

C) Physiologic outcome Ans: C Feedback: Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Psychomotor outcomes describe the client's achievement of new skills.

A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing? A) Physical B) Psychological C) Sensory deficits D) Sociocultural

C) Sensory deficits Sensory deficits in vision and hearing interfere with one's ability to interact with other people and with the environment.

A nurse is responding to sexual harassment from a client at work. Which of the following is a recommended guideline for dealing with this behavior? A) If confronted by management, deny any feelings about being harassed. B) Do not confront the person harassing you in person. C) Set and enforce limits to the behavior and maintain boundaries. D) Document the incident but do not report it to the supervisor unless harassment continues.

C) Set and enforce limits to the behavior and maintain boundaries. The following assertive response is recommended and supports the nurse in maintaining his or her self-respect; it encourages the client to accept responsibility for his or her behavior. Be self-aware: Do not deny feelings about being harassed. Confront: Provide feedback to the client in a nonthreatening way and clearly state what behavior is or is not acceptable. Set limits: Define clear and reasonable consequences that will be enforced if the behavior continues. Enforce the stated limits: Maintain boundaries. Report: Document the incident and submit to the supervisor.

A client states that his life has meaning and purpose, he feels loved, and has experienced forgiveness in his life. What is the term that describes this state of spirituality? A) Spiritual belief B) Spiritual alienation C) Spiritual health D) Spiritual bliss

C) Spiritual health Defined most simply, spiritual health or well-being is the condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met

When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem? A) Change jobs. B) Avoid people who dump tasks on him. C) Take control of the situation. D) Avoid doing petty jobs.

C) Take control of the situation. A behavioral technique for modifying stress is to take control rather than become immobilized. This is also known as alternative behavior. Another behavioral approach to reduce stress is to sometimes say "no," in order to avoid becoming overwhelmed and more stressed. Changing jobs, avoiding the person, or avoiding the petty jobs would not help.

A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply. A) Ensure that UAPs closely follow the nursing process when providing care. B) Audit the client documentation that UAPs record after they perform interventions. C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients.

C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients. Ans: C, D, E Feedback: The nurse must take careful action to ensure that delegation results in safe and competent client care. This necessitates such measures as taking frequent mini-reports, identifying the clinical cues that UAPs should be aware of, and performing rounds often. UAPs are not normally educated to follow the nursing process nor to perform documentation.

Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool. B) The client understands what foods are low in sodium. C) The client will ambulate 10 feet with a walker by October 12. D) The client correctly self-administers the morning dose of insulin.

C) The client will ambulate 10 feet with a walker by October 12. Ans: C Feedback: Outcomes are client-centered, use action verbs, identify measureable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (ambulate), how well (10 feet), under what circumstances (with a walker), and by when (October 12). Understand is vague and not action-oriented. The outcomes regarding eliminating a stool and self-administering insulin are missing the time frame.

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

C) The nurse transfers responsibility but is accountable for the outcome. Ans: C Feedback: UAPs are trained to function in an assistive role to the RN in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome.

A nurse providing palliative care for a dying man and his family knows that the goal of palliative care is what? A) To aggressively treat the disease. B) To provide care for the dying in the home. C) To aggressively treat the symptoms of the disease. D) To support the family of the dying client.

C) To aggressively treat the symptoms of the disease. Ans: C Feedback: Palliative care means taking care of the whole person—body, mind, and spirit, heart and soul. It views dying as something natural and personal. The goal of palliative care is to give clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. Hospice care is care provided for people with limited life expectancy, often in the home. While hospice care focuses on the needs of the dying, palliative care is appropriate across the spectrum of disease and illness.

A client is taking diuretics. What should the nurse teach the client about his urine? A) Urinary output will be decreased. B) Urinary output will be increased. C) Urine will be a pale yellow color. D) Urine may be brown or black.

C) Urine will be a pale yellow color. Feedback:Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The nurse should inform the client about this side effect of the medication.

Based on knowledge of the physiology of the gastrointestinal tract, what type of stools would the nurse assess in a patient with an illness that causes the stool to pass through the large intestine quickly? A) hard, formed B) black, tarry C) soft, watery D) dry, odorous

C) soft, watery

Chapter 14- Assessing Approach to interviewing a patient with dementia A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) carrying out a physicians order to intubate a patient B) teaching a novice nurse the principles of triage C) using the nursing process to diagnose a blocked airway D) interviewing a patient suspected of being a victim of abuse privately E) checking the data supplied by a patient with dementia with the family F) teaching a diabetic patient about the importance of proper foot care

C) using the nursing process to diagnose a blocked airway D) interviewing a patient suspected of being a victim of abuse privately E) checking the data supplied by a patient with dementia with the family

What activity is carried out during the implementing step of the nursing process? A)Assessments are made to identify human responses to health problems. B)Mutual goals are established and desired patient outcomes are determined. C)Planned nursing actions (interventions) are carried out. D)Desired outcomes are evaluated and, if necessary, the plan is modified.

C)Planned nursing actions (interventions) are carried out. during the implementing step of the nursing process, nursing action (interventions) planed during the planning step are carried out.

A nurse is caring for a client who has stage Iv lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kübler‐Ross model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance

C. Bargaining

Which of the following flow sheets provides the health care provider with information on an ongoing record of fluid loss? A. Vital signs graphic sheet B. Critical care flow sheet C. Intake and output graphic sheet D. Health assessment flow sheet

C. Intake and output graphic sheet Flow sheets document where vitals are recorded (INO, RR, BP, HR, temp)

hich of the following is a potential complication of O2 therapy via nasal cannula for patients? A. A cold sensation B. Feelings of suffocation C. Mucosal dryness D. Aspiration

C. Mucosal dryness

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action? Discontinue the administration of the enema Clamp the tube for a brief period and resume at a slower rate. Continue infusing at a faster rate to finish the enema quicker. Remove the tubing.

Clamp the tube for a brief period and resume at a slower rate. Cramping can occur with the administration of a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion, possibly at a slower rate. Other choices are incorrect, as these do not facilitate administration of the enema while providing comfort measures.

Types of informatic nurses An informatics nurse is preparing a training program for staff nurses in the facility. The facility will be implementing a new electronic health record. To ensure the best results, which type of training would the informatics nurse most likely use?

Classroom education

2. A client is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than four hours. What should the nurse do next? A) Continue with the transfusion and document the drip rate. B) Report to the next shift the amount of blood left to infuse. C) Take and record vital signs more often. D) Discontinue the blood transfusion.

D) Discontinue the blood transfusion. Blood that has been transfusing for more than four hours must be discontinued to prevent the risk of bacterial contamination.

A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information? A) "I understand these will help me control stress incontinence." B) "I know this is also called pelvic floor muscle training." C) "I will do these 30 to 80 times a day for two months." D) "I will contract the muscles in my abdomen and thighs."

D) "I will contract the muscles in my abdomen and thighs." Feedback:Kegel exercises, or pelvic floor muscle training, are used to tone and strengthen the muscles that support the bladder. They can improve voluntary control of urination and thus improve or eliminate stress incontinence. The muscles to contract are the same ones used to stop urination midstream or control defecation. The client should not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel exercises.

Teaching information related to Urinary system health A school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A) "I will take showers rather than baths." B) "I will wear underpants with cotton crotches." C) "I will tell my parents if I have burning or pain." D) "I will wipe back to front after going to the toilet."

D) "I will wipe back to front after going to the toilet." Feedback:Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum).

Significance of Nursing Theory: ⇒A staff nurse asks a student, "Why in the world are you studying nursing theory?" How would the student best respond? A) "Our school requires we take it before we can graduate." B) "We do it so we know more than your generation did." C) "I think it explains how we should collaborate with others." D) "It helps explain how nursing is different from medicine."

D) "It helps explain how nursing is different from medicine." Nursing theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting, and controlling desired outcomes of nursing care practices.

The nurse as a defendant means ⇒ A nurse has been named as a defendant in a lawsuit. With whom should the nurse discuss the case? A) Colleagues B) Reporters C) Plaintiff D) Attorney

D) Attorney Ans: D Feedback: The nurse should only discuss the case with the attorney representing him or her and/or the institution. Recommendations for the nurse as defendant include not discussing the case with anyone at the employing agency (except the risk manager), the plaintiff, the plaintiff's lawyer, anyone testifying for the plaintiff, or reporters.

A nurse is caring for a hospitalized child. What would the nurse consider to meet the spiritual needs of the child? A) Nothing; children do not have a spiritual self. B) Complete information from the child's parents. C) Only terminally ill children believe in God. D) Children have definite perceptions of God.

D) Children have definite perceptions of God. Heller studied spirituality in children. In his study of 40 children between the ages of 4 and 12 years, he found that the children had definite perceptions of God.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Psychomotor B) Affective C) Physiologic D) Cognitive

D) Cognitive Ans: D Feedback: Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

What factor is necessary to express and experience spirituality? A) Quiet time in isolation from others B) Membership in an organized religion C) Long-term suffering and pain D) Connectedness with other people

D) Connectedness with other people Peopleexpress and experience spirituality throughlove and connectedness with other people. Lovedevelops from the basic human needto love and be loved and is necessary to spiritual wholeness.

Normal Healthy Stoma Characteristics ⇒ A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma? A) Pallor B) Purple-blue C) Irritation and bleeding D) Dark red and moist

D) Dark red and moist The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purpleblue color (possible ischemia), or bleeding.

If a nurse assessed the vital signs of a person who was in the initial alarm reaction stage (shock phase) of the GAS, what would be the expected findings? A) Slow, deep breathing B) Fatigue and lethargy C) Hypotension D) Hypertension

D) Hypertension The alarm reaction is initiated when a person perceives a specific stressor and various defense mechanisms are activated. The initial or shock phase is characterized by increased energy, oxygen intake, cardiac output, blood pressure, and mental alertness.

Successful implementation of each step of the nursing processrequires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process? A) Trust clinical judgment and experience over asking for help. B) Respect clinical intuition, but never allow it to determine a diagnosis. C) Recognize personal biases as a strength in formulating diagnoses. D) Keep an open mind and trust your intuition when formulating diagnoses.

D) Keep an open mind and trust your intuition when formulating diagnoses. Ans: D To correctly diagnose health problems, the nurse must be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy; trust clinical experience and judgment but be willing to ask for help when the situation demands more than his or her qualifications and experience can provide; respect clinical intuitions, but before writing a diagnosis without evidence, increase the frequency of observations and continue to search for clues to verify intuition. The nurse must also recognize personal biases and keep an open mind.

A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made? A) Observe skin color and texture. B) Auscultate bowel sounds. C) Percuss lung density. D) Monitor for GI symptoms.

D) Monitor for GI symptoms. Hyponatremia is an ECF sodium deficit, resulting in osmotic pressure changes as ECF moves into the cells. When this occurs, anorexia, nausea, and vomiting may occur; the nurse should monitor for these symptoms. Skin color and texture, bowel sounds, and lung density are not affected with hypernatremia.

Chapter 7- Legal Dimensions of Nursing Practice Assault, Defamation, Negligence, Battery (Intentional Torts) A nurse does not assist with ambulation for a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? A) Assault B) Battery C) Fraud D) Negligence

D) Negligence Ans: D Feedback: A tort is a civil wrong committed by a person against another person or his or her property. Negligence, an unintentional tort, occurs when a person fails to exercise reasonable care in the performance of his or her duties. In this situation, the nurse did not initiate proper precautions to prevent patient harm and is subject to the charge of negligence.

Negligence/duty to patient for safe care A nurse does not assist with ambulation for a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? A) Assault B) Battery C) Fraud D) Negligence

D) Negligence Ans: D Feedback: A tort is a civil wrong committed by a person against another person or his or her property. Negligence, an unintentional tort, occurs when a person fails to exercise reasonable care in the performance of his or her duties. In this situation, the nurse did not initiate proper precautions to prevent patient harm and is subject to the charge of negligence.

Type of communication that would meet the spiritual needs of a client to provide spiritual nursing care Nurses provide care to meet needs in all the human dimensions. What is one intervention nurses can implement to meet spiritual needs? A) Refer all questions to a spiritual advisor. B) Remind clients that nurses are not ministers. C) Avoid any discussion of religion or spirituality. D) Offer a compassionate presence.

D) Offer a compassionate presence. Although nurses may differ in their beliefs about how involved they should become in meeting spiritual needs, it is impossible to ignore the spiritual dimensions of health. Nurses can assist clients to meet spiritual needs through a variety of interventions, including offering a compassionate presence.

⇒ A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? A) Back rubs B) Chewing gum C) Hair care D) Oral hygiene

D) Oral hygiene Clients with restrictions on fluid intake often complain of thirst or a dry mouth. Provide oral hygiene at regular intervals. Offering hard candy or gum is no longer recommended.

⇒ A woman who was assaulted in the street is brought to the emergency room for observation. A nurse documents that the woman has difficulty communicating verbally, is agitated, and complains of chest pain and a sense of impending doom. What type of anxiety is this client experiencing? A) Mild anxiety B) Moderate anxiety C) Severe anxiety D) Panic

D) Panic Panic causes the person to lose control and experience dread and terror. The resulting disorganized state is characterized by increased physical activity, distorted perception of events, and loss of rational thought. Panic is manifested by difficulty communicating verbally, agitation, trembling, poor motor control, sensory changes, sweating, tachycardia, hyperventilation, dyspnea, palpitations, a choking sensation, and sensations of chest pain or pressure.

Severe, moderate, mild, & panic anxiety (Manifestation) A nurse is preparing to educate a client about care at home. On entering the room, she finds the client pacing around the room, hyperventilating, and complaining of nausea. Based on these manifestations of severe anxiety, what would the nurse do? A) Provide both verbal and written information to the client. B) Ignore the client and teach the family the information. C) Modify the education plan to the client's anxiety level. D) Postpone implementation of the education plan.

D) Postpone implementation of the education plan. Severe anxiety creates a very narrow focus on specific detail, causing all behavior to be geared toward getting relief. Manifestations include increased motor activity, nausea, and hyperventilation. The person has impaired learning ability. Education should be postponed and help to reduce the anxiety should be provided.

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this Procedure? ` A) Using upper chest muscles more effectively B) Replacing the use of incentive spirometry C) Reducing the need for p.r.n. pain medications D) Prolonging expiration to reduce airway resistance

D) Prolonging expiration to reduce airway resistance Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance

A nurse researcher decides to conduct a qualitative research study. With which of the following would the researcher be involved? A) Collection of numerical data B) Determination of cause and effect C) Controlling personal biases D) Real world data collection

D) Real world data collection Qualitative research strives for an understanding of the whole and requires the researcher to become the instrument as data is collected in the real-world, naturalistic setting. Numerical data, cause and effect and control of personal bias are key aspects of quantitative research.

Nursing actions for a dislodged PICC line A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? A) Swab the line with sterile saline and gently reinsert the line. B) Sedate the client, remove the PICC line, and then notify the physician. C) Set up a sonogram for the client to determine the end point of the line. D) Reapply the dressing and notify the physician for further instructions.

D) Reapply the dressing and notify the physician for further instructions. When a PICC line is not all the way out, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied before the chest x-ray, to prevent further dislodgement.

Priority nursing diagnosis (High, medium, low) According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance

D) Risk for body image disturbance Ans: D Feedback:Risk for disturbed body image is the least priority among all the nursing diagnoses mentioned, according to the Maslow's hierarchy. Body image disturbance is not vital for life. Secondly, it is a potential diagnosis, not an actual diagnosis. The other options could be an actual diagnosis present in the client. Ineffective airway clearance is the most important diagnosis because it is vital to life. Impaired urinary elimination is the next most important diagnosis because it is a physiological need. Ineffective coping is a social need, followed by the least important diagnosis of disturbed body image.

3. A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Prescribing the kind of IV solution. Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution. Determining the amount of IV solution.

Deciding the location of the IV catheter. Administering the IV solution. Deciding the size of the IV catheter. The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.

You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5.

D. The patient will identify the need to increase dietary intake of fiber by June 5.

A nursing student is attending a clinical rotation in a labor/deliver/postpartum unit and is able to see a vaginal delivery for the first time. The student takes a picture of the newborn and posts it on a social media website. What action may occur related to this privacy violation? A. no action will be taken as long as the parents don't find out B. there will be no repercussions if the student takes the picture down from the social media page C. the student will never be eligible for entry into a nursing program or be able to take the NCLEX D. The student may be dismissed from the nursing program as well as fined for a HIPAA violation.

D. The student may be dismissed from the nursing program as well as fined for a HIPAA violation.

Information is collected for analysis in both quantitative and qualitative research. What is the information called? Answers. Surveys. Interviews. Data.

Data. data refer to information that the researcher collects from subjects in the study ( expressed in numbers)

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply. Increased appetite Increased interest in interactions with others Depression Sleeplessness Decreased interest in activities

Depression Sleeplessness Decreased interest in activities Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.

Informatics stages (analyze/plan, Design, test, Train) The nurse is using SDLC to implement the placement of new computers in the workplace . In what stage of this process would the nurse most likely consult with coworker for their input in creating the new work station. Analyze and Plan Design Test Implement

Design Explain: Design and build: The nurse help to design a new work area that corporates the use of new computers to create and access electronic health records.

Informatics System Development Cycle (Design & Build, Train, Analyze & Plan, Test) An informatics nurse specialist is working as part of a team that will be developing and implementing a new client assessment tool. During which phase of the system development lifecycle would the team be integrating information about workflow patterns, standard terminology, and recommendations for screen layout from supportive research? Design and build Train Analyze and plan Test

Design and build Mapping out workflow patterns, using standard terminology, and integrating evidence-based research findings for screen layouts would be accomplished during the design and build phase of the system development lifecycle. During the analyze and plan phase, the team would determine the purpose of the technology and the problem to be solved to establish the need. Testing is done once the technology is designed and built. Training of the end-users occurs after the system is tested but before it is implemented.

An informatics nurse specialist is working on a team that is considering a new technological system for the facility. Which aspect would be most important for the team to do as the first step? Determine the need or problem to be solved Identify the use of standard terminology Conduct testing of the system Train those who will be using the system

Determine the need or problem to be solved Explanation: Before considering the use of any new technology or an update to the system, analysis and planning must occur. This involves determining the need for the technology or update or identifying the problem to be solved. Once that step is completed, then design (such as using standard terminology), testing and training would occur.

IV site complications Know infiltration and inflammation) A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Call the primary care provider to see whether anti-inflammatory drugs should be administered. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Discontinue the IV and relocate it to another site. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.

Discontinue the IV and relocate it to another site. The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs is noted. Cleansing will not resolve this common complication of therapy.

A group of nurses along with an informatics nurse specialist are conducting user acceptance testing of an update to a clinical information system. During this testing, which question is the group looking to answer

Does the update function and work as intended?

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. Organizing data Identifying patterns Analyzing data Collecting subjective and objective data Identifying indicators of potential dysfunction

Identifying patterns Analyzing data Identifying indicators of potential dysfunction During the diagnosis phase, the nurse analyzes collected data; identifies client strengths; identifies the client's normal functional level and indicators of actual or potential dysfunction; identifies patterns; validates the diagnosis; and formulates a diagnostic statement in relation to this synthesis. Collecting and organizing data are assessment activities.

A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. What type of assessment will the nurse perform? • time-lapsed assessment • emergency assessment • focused assessment • funtional assessment

Explanation: The nurse will perform a focused assessment. This type of assessment allows the nurse to gather data about a specific problem that has already been identified, such as this client's cancer and subsequent colostomy. The nurse would perform a emergency assessment when a client presents with a physiologic or psychological crisis. This type of assessment allows the nurse to identify life-threatening problems. The nurse would perform a time-lapsed assessment to compare a client's current status to the baseline data obtained earlier. This type of assessment is used most often in residential settings and for those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses. The functional assessment is a comprehensive evaluation of a client's physical strengths and weaknesses in areas such as the performance of activities of daily living, cognitive abilities, and social functioning.

Focused assessment- what is meant by this A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? • Focused • Initial • Emergency • Time-lapse

Focused Explanation: The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.

Characteristics of premenstruation A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase? Calmness Blurred vision Headache Water loss

Headache Premenstruation is characterized by the appearance of one or more of the following symptoms several days before the onset of menstruation: (1) emotional symptoms such as depression, irritability, anxiety, changes in sleep habits, changes in sexual desire, poor concentration, crying, anger, and social withdrawal; and (2) physical symptoms such as appetite changes, breast tenderness, bloating and weight gain, aches and pains, swelling, acne, gastrointestinal issues, and fatigue. Blurred vision may be an ominous sign that is unrelated to premenstrual syndrome.

Which nurse-client positioning facilitates an easy exchange of information? If the client is in bed, the nurse stands at the side of the bed. If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. If the client is in bed, the nurse stands at the foot of the bed.

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client,which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.

Chapter 20- Nursing Informatics Qualifications for nurse informatics A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply. Reduced health of populations Increased health disparities Improvement in health care quality Greater client engagement Reduction in privacy breaches of client information

Improvement in health care quality Greater client engagement Reduction in privacy breaches of client information Meaningful use would be reflected by improved quality, safety, efficiency, and reduced health disparities; engagement of clients and family; improved care coordination and population and public health; and maintenance of privacy and security of client health information.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client? Risk for Impaired Parenting Readiness for Enhanced Parenting Disturbed Sleep Pattern Impaired Comfort Ineffective Breastfeeding

Ineffective Breastfeeding The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a newborn. Although the infant does demonstrate an impaired sleep pattern and impaired comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the mother is at risk for impaired parenting.

Purse lip breathing The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." "Take in a small amount of air very quickly and then exhale as quickly as possible." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD.

Chapter 38- Bowel Elimination Data cluster for bowel elimination (assessment data) The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order.

Inspection Auscultation Percussion Palpation When assessing a client's abdomen, the correct order for assessment is inspection, auscultation, percussion, and palpation.

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating? Altruism Integrity Autonomy Social justice

Integrity The principle of integrity is based on the honesty of a nurse according to professional standards. In this instance, the nurse reported the occurrence of the missed medication to the charge nurse. The definition of altruism is concern for others; it can best be explained by a nurse concerned about how a client will care for self after discharge. Social justice is a concept of fair and just relations between the individual and society and is related to wealth and distribution of goods in a society. Autonomy is the right to self-determination or acting independently and making decisions.

Standard of care for nursing students?? In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value? Altruism. Integrity. Social Justice. Human dignity.

Integrity. The nurse is demonstrating integrity, which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It prescribes oxygen concentration. It determines whether you are getting enough oxygen. It regulates the amount of oxygen received. It decreases dry mucous membranes by delivering small water droplets.

It decreases dry mucous membranes by delivering small water droplets. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flow meter is a gauge used to regulate the amount of oxygen that a client receives. The health care provider prescribes concentration.

Basic human needs (Maslow Hierarchy of needs) A client who is admitted for a debilitating disease is talking to the nurse. The client relates that family is the only thing that matters, stating that family helps fulfill all the spiritual needs by first fulfilling the most basic of all needs. What is this basic need? Self-reliance Autonomy Belonging Love

Love Love develops from the basic human need to love and be loved, and we cannot be spiritually whole, spiritually healthy, unless this need is met. Autonomy is freedom from external control or influence. Self reliance is reliance on one's own powers and resources rather than those of others. Autonomy and self reliance are higher level of needs. A sense of belonging is a human need, just like the need for food and shelter but love is more important.

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. Performing the initial patient assessments Making patient beds Giving patients bed baths Administering patient medications Ambulating patients Assisting patients with meals

Making patient beds Giving patients bed baths Ambulating patients Assisting patients with meals Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

Underlying needs of all religious traditions According to Shelly and Fish (1988), which of the following are spiritual needs underlying all religious traditions that are common to all people? Select all that apply. Formal religion Power Meaning and purpose Love and relatedness Forgiveness

Meaning and purpose Love and relatedness Forgiveness According to Shelly and Fish (1988), there are three spiritual needs underlying all religious traditions and common to all people: need for meaning and purpose, need for love and relatedness, and need for forgiveness.

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? Use written communication whenever possible in order to minimize the client's frustration. Use vocabulary and concepts that are as simple and unambiguous as possible. Repeat each direction or question in different terms in order to maximize understanding. Minimize background noises and ensure that lighting is adequate to see the nurse's face.

Minimize background noises and ensure that lighting is adequate to see the nurse's face. When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading. It would be unnecessary and inappropriate to exclusively use written communication with a client who has moderate hearing loss, or to repeat all questions and instructions in different terms. A hearing deficit is not synonymous with a cognitive deficit; consequently, it is not usually necessary to simplify concepts or vocabulary.

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? Partial rebreather mask Nasal cannula Nonrebreather mask Simple mask

Nasal cannula A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.

A nurse knows that the expression "Do not cause harm" refers to which ethical principle? Beneficence Nonmaleficence Fidelity Justice

Nonmaleficence Nonmaleficence is conducting procedures and interventions in a safe manner so that no harm is caused to the client. Justice is the idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society. Fidelity is demonstrated by continuing loyalty and support to a client. Beneficence requires that the procedure be provided with the intent of doing good for the client involved.

Chapter 15- Diagnosing Role of the nursing in determining data collected The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? Nurses formulate nursing diagnoses to identify diseases. Nursing diagnoses remain the same for as long as the disease is present. Nurses write nursing diagnoses to describe client problems that nurses can treat. Nursing diagnoses focus on identifying healthy responses to health and illness.

Nurses write nursing diagnoses to describe client problems that nurses can treat. Explanation: Data collection leads the nurse to identifying client problems that the nurse is able to treat with planned nursing interventions, which is the focus of nursing diagnoses. Nursing diagnoses change as client goals are met or as new problems develop. Medical diagnoses identify disease processes.'

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? PC: Fear related to new diagnosis of myocardial infarction PC: Decreased Cardiac Output related to cardiac tissue damage PC: Activity Intolerance related to decreased oxygenation capacity PC: Disturbed Body Image related to decreased activity tolerance

PC: Decreased Cardiac Output related to cardiac tissue damage Explanation: All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life-threatening issues. Decreased cardiac output is the only life-thr

Signs of death A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply. Regular deep respirations Strong, bounding pulse Pale, cool skin Irregular heart rate Decreased urine output

Pale, cool skin Irregular heart rate Decreased urine output Signs of dying include extremely pale, cyanotic, jaundiced, mottled or cool skin; irregular heart rate; weak, rapid, irregular pulse; shallow, labored, faster, slower, or irregular respirations; and decreased urine output.

A nurse is testing a new computer program designed to store patient data. In what phase of testing would the nurse determine if the system can handle high volumes of end-users or care providers using the system at the same time? Unit Function Integration Performance

Performance Explain: d. Performance testing is more technical and ensures proper functioning of the system when there are high volumes of end-users or care providers using the system at the same time, ensuring it can handle the load. Unit testing is basic testing that occurs initially. Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Air embolism Sepsis Infiltration Phlebitis

Phlebitis Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems?

Plan and coordinate a multidisciplinary team conference including the chaplain. The nurse should facilitate a care-planning conference involving the social support network including family and friends. Initiating a multidisciplinary social network of conferences facilitates a sense of acceptance, love, and belonging. The nurse should work with the client to explore and build on past positive coping mechanisms, which helps enhance a sense of self-control and self-esteem. Encouraging the client to watch movies when alone does not allow the client to interact and find positive elements of his or her life. Although spiritual review can be helpful, the nurse should not "scare" the client

A client comes to the health care provider's office for a follow up. The client was recently hospitalized for heart failure. The nurse reviews the client's discharge plan, which included the client being supplied with telecommunications technology for monitoring daily weights and blood pressure. Then each day, after completing those tasks, the client would receive a phone call from the nurse practitioner about the results and adjust the client's medication schedule. The nurse identifies this specifically as reflecting which type of care?

Telemedicine

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process? "This does not seem real to me." "Please go away; I just want to be left alone." "What am I going to do now that my parent "What am I going to do now that my parent is gone?" "It is all my fault! I did not see the signs."

Please go away; I just want to be left alone." The clinical definition of depression is anxiety and hostility turned inward. The statement asking the nurse to go away and a desire to be "left alone" indicates withdrawal, which is a characteristic of depression. "This does not seem real to me" indicates the client is in denial. Blaming oneself for the loss is an expression of guilt that may occur in the anger phase of grieving. Feeling uncertain about the future may occur as the grieving person accepts that the loved one is deceased and life will be different.

A famous actor with bipolar disorder has been admitted in the mental health unit for treatment. A well known news outlet has offered the nurse several thousand dollars to provide information or a picture of the client. The nurse knows that it is their professional duty and legal responsibility to uphold privacy and confidentiality.

Privacy keeping the door closed while conducting physical assessment obtaining the client's permission before allowing a student nurse to assist with care Confidentiality Privacy Confidentiality sharing client information only to the caregivers directly assigned to client care logging off the electronic health record after documenting assessment information asking the client to sign a medical release form before providing information to the health insurance company

The nurse researcher would like to gather data about the attitudes of young adults on spirituality and health care. What is the most effective form of research on this topic? Delphi study Methodologic survey Qualitative research Quantitative research

Qualitative research Explanation: Attitudes on spirituality and health care require the nurse to interview clients or informants to obtain qualitative research. Qualitative research involves the systematic collection and analysis of more subjective, narrative materials using procedures in which there tends to be minimal researcher-imposed control. Quantitative research is based more on collecting numerical data and would not be suitable for this type of study. Delphi is a type of quantitative research that would also not produce the desired data. Methodologic surveys focus on method and not on the subjects' experience.

Quid Pro Quo harassment, environmental harassment, hostile environment harassment, Fetishism During hospitalization for a suicide attempt, the client informs the nurse that she does not want to return to work because her boss expects sexual favors each week before he gives her a paycheck. The client informs the nurse that she needs the job but is embarrassed that she performs these favors. The nurse informs the client that this is illegal behavior and is called what? Fetishism. Hostile environment harassment. Quid pro quo harassment. Environmental harassment.

Quid pro quo harassment. Quid pro quo means that something is given or withheld in exchange for something else. It generally occurs when a person in a position of authority offers either direct or indirect reward or punishment based on the granting of sexual favors. Environmental harassment and hostile environment harassment are identical situations and occur when workplace behaviors of a sexual nature create a hostile, intimidating environment that interferes with a person's work performance. Fetishism is sexual arousal with the aid of an inanimate object not generally associated with sexual activity.

Differentiate the different knowledge applicable to nursing A nurse working in a long-established hospital learned a specific approach to administering intravenous injections from the previous generation of nurses at the hospital. This is an example of which type of knowledge? Traditional knowledge Philosophy knowledge Scientific knowledge Authoritative knowledge differentiate / di fờ rén shi ây t/ (v) to mark or show a difference in

Traditional knowledge Traditional knowledge is passed from one generation to another. Authoritative knowledge is passed from an expert, and scientific knowledge is provided by way of the scientific method. Philosophy is a specific type of knowledge, not a source.

Nursing assessment of an IV site/catheter 1) The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next? Decrease the rate of the intravenous fluids. Remove the peripheral intravenous catheter. Elevate the swollen extremity on a pillow. Place a warm compress over the swollen site.

Remove the peripheral intravenous catheter. The assessment findings of a swollen IV site with surrounding tissue swelling and cool to touch indicate infiltration. The correct action for an infiltrated IV is to remove the IV. Decreasing the rate of fluids requires the health care provider's prescription and is not indicated for infiltration. Placing a warm compress is not indicated for infiltration. Elevating the swollen extremity is for peripheral edema, not infiltration.

A school nurse is providing a class on sexually transmitted infections (STIs).Which statement is correct regarding STIs? The signs and symptoms of an STI are obvious. STIs disproportionately affect people with a lower socioeconomic status and education. The incidence of STIs is decreasing due to limited sex partners. STIs are most prevalent among adolescents and young adults.

STIs are most prevalent among adolescents and young adults. STIs are most prevalent among adolescents and young adults, and nearly two- thirds of all STIs occur in people younger than 25 years of age. The incidence of STIs is increasing due to multiple sex partners and sexual activity at a younger age. STIs affect men and women of all backgrounds and economic levels. Not all signs and symptoms of STI's are obvious such as HIV/AIDS.

An intensive care unit (ICU) nurse does not notice the noise within the environment. However, a client's family member states, "How can you stand it here? The lights, sounds, and activity would drive me crazy and I could not take it." How might noise in the ICU affect the client's well-being? Clients would be put in a state of sensoristasis. Sensory adaptation occurs in the intensive care unit. Increased noise levels depress the reticular activating system. Sensory overload can cause anxiety and irritability.

Sensory overload can cause anxiety and irritability. Sensory stimulation in the environment affects sensory perception. The lights, sounds, and action in the ICU may put the client in a state of sensory overload, which results in irritability, anxiety, and difficulty concentrating. Sensoristasis is the state of optimal arousal. Sensory adaptation occurs when the brain stops perceiving constant stimuli. The RAS, or reticular activating system, brings together information from the brain with information from the sense organs.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Allow nothing by mouth. Give the client a glass of orange juice with added sugar. Start an IV of normal saline as prescribed. Encourage fluid intake.

Start an IV of normal saline as prescribed. To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin.The nurse would implement which priority action? Stop the procedure, monitor heart rate and blood pressure. Slow the infusion rate, withdraw the tubing slightly, then resume the enema. Slow the infusion rate, have the client take deep breaths, then resume the enema. Stop the procedure and reposition the client.

Stop the procedure, monitor heart rate and blood pressure. When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response.

Which is an example of a nurse-initiated intervention? Teach the client how to splint an abdominal incision when coughing and deep breathing. Administer a 1000-mL soap suds enema. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. Administer oxygen at 4 L/min per nasal cannula.

Teach the client how to splint an abdominal incision when coughing and deep breathing. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology Explanation: Telemedicine and mobile health technology facilitate client engagement, while helping providers deliver more cost-effective care. Telemedicine embraces applications and services that include two-way video communications, e-mail, and wireless phones. Mobile health features multiple technologies integrated into the increasingly wireless and mobile health care delivery system. Client engagement technology would include the concept of client portals (where clients can access an electronic medical record system and personal health information); online appointments scheduling; and personalized, condition-focused alerts/reminders in the form of e-mails, automated telephone calls, or text messages. Data aggregation is a process that involves data collection, analysis, use, reporting, and delivery of feedback throughout the organization. Organizations will use process and outcomes data to measure what they achieve for clients and population-based communities. Population health management technology performs data mining, risk stratification, and analysis. Searches can be conducted for disease trends, diagnoses, procedures, and missed appointments.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? Allow the UAPs to do the admission assessment and report the findings to the RN. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. Contact his or her labor representative to report this practice to the state board of nursing.

Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

Which outcome for a client with a new colostomy is written correctly? The client will know how to care for the stoma by 3/29/20. The client will be able to care for stoma and cope with psychological loss by 3/29/20. Explain to the client the proper care of the stoma by 3/29/20. The client will demonstrate proper care of the stoma by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20. Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who is pleasantly confused and requires assistance to the bathroom

The client with continuous pulse oximetry who requires pharyngeal suctioning. Explanation: The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

Which types of knowledge are subjective? (Select all that apply.) Evidence-based practice Scientific knowledge Scientific method Traditional knowledge Authoritative knowledge

Traditional knowledge Authoritative knowledge Traditional and authoritative knowledge are practical but may be subjective. Scientific knowledge, the scientific method, and evidence based practice are all rooted in research

Which aspect of the nursing research process addresses a client's understanding of the potential risks and benefits of the study? Undergoing the informed consent process with the client Obtaining the client's signature on a permission document Giving the client the opportunity to ask questions about the study Meeting with the hospital's institutional review board (IRB)how to

Undergoing the informed consent process with the client

An informatics nurse specialist is involved with testing an update to a facility's clinical information system. The specialist is in the integration testing phase. Which phase has the informatics nurse specialist already completed? Select all that apply.

Unit testing Function testing

Review user acceptance testing, performance testing, integration testing, and function testing for new technology An informatics nurse specialist is working with a group of nurses who are tasked to test a new electronic health record system. Which phase would the group be involved with as the last phase of testing?

User acceptance

Nurses test new technology in phases. In which phase would the nurse "test drive" the new system? Unit Function User acceptance Integration

User acceptance explain: During the phase "user acceptance," the nurse would "test drive" the new system to ensure it's working as designed. Unit testing is basic testing that occurs initially. Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system.

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? Client will verbalize side effects of antipsychotic medications within 24 hours. Within 2 days, client will perform personal hygiene without reminders. Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. Client will understand that the hallucinations aren't real in therapy sessions before discharge.

Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. Outcomes should be specific, measurable, attainable, realistic, and timebound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, and using verbs that are not observable. Safety is a priority for all clients. Clients with thought and mood disorders may present a risk of harm to self or others because of distorted thinking. Therefore, the ability of the client to mingle with others without violence is the highest priority.

An infant is identified as intersex at birth. Which education provided by the nurse is accurate? Your child has variations in the reproductive anatomy. Your child has male and female reproductive organs. You need to choose if you want a girl or a boy. Your child was born without genitalia.

Your child has variations in the reproductive anatomy. Intersex infants are born with variations of sexual characteristics including chromosomes, gonads, sex hormones, or genitals that do not fit the typical features of male or female anatomy.Explaining that the infant has variations in the reproductive anatomy is the most accurate explanation for the parents. Being born without genitals externally is possible; however, the genitalia may be internally located. Intersex cannot be simply explained as "having male and female reproductive organs," as there are many variation complexes that can occur. After testing and collaboration with health care professionals a decision is made to assign gender to the infant. It is not based on if the parents want a girl or boy.

A nurse is developing a plan for a qualitative research study. Which elements would be most important for the nurse to incorporate into the plan? Select all that apply. a) holistic viewpoint of the problem b) control of outside characteristics c) application of intuition for analysis d) use of reliable measurement instruments e) use of subjective interaction

a) holistic viewpoint of the problem c) application of intuition for analysis e) use of subjective interaction Qualitative research involves the systematic collection and analysis of more subjective narrative materials (also known as data), using procedures in which there tends to be a minimum of researcher-imposed control. The focus is holistic. Quantitative research involves the use of reliable measurment instruments and control of confounding subject characteristics.

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?

analyze and plan

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as: sensoristasis. adaptation. cortical arousal. sensory overload.

adaptation. The body quickly adapts to constant stimuli. The repeated stimulus of a continuing noise, such as a low-level cardiac alarm, eventually goes unnoticed. A stimulus must be variable or irregular to evoke a response. This phenomenon is termed adaptation. Sensoristasis is the optimal arousal state of the reticular activating system. Cortical arousal refers to the different states of arousal or awareness. Sensory overload is the condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli

The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as: holistic. theist. agnostic. atheist.

agnostic. Beliefs may range from atheism (denial of God's existence) to agnosticism (belief that God's reality is unknown and unknowable) to theism (belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe).

Chapter 46- Spirituality Atheist, Agnostic, Theist, holistic The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as: holistic. theist. agnostic. atheist.

agnostic. Beliefs may range from atheism (denial of God's existence) to agnosticism (belief that God's reality is unknown and unknowable) to theism (belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe).

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: deep palpation. light palpation. auscultation. percussion.

auscultation. When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.

Coping mechanisms for dealing with anxiety A client informs the nurse that they have a well-paying job but that it is demanding and causes a great deal of anxiety. What statement made by the client indicates that the client has a coping mechanism to deal with anxiety produced by this situation? a. " Everyone feels sorry for me, and I find comfort in that." b. "I am actively seeking job opportunities in a less stressful environment." c. "I am going to have to start taking medication for this anxiety." d. "I am going to tell my manager that I just can't deal with the stress."

b. "I am actively seeking job opportunities in a less stressful environment."

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario? reaction formation sublimation compensation projection

compensation

Review Descriptive Rule-based knowledge All sources of knowledge are useful in the collective body of knowledge that constitutes the nursing profession. Although these three sources provide nursing with important contributions, each has inherent strengths and limitations. A student nurse learns how to give injections from the nurse manager, who dictates a list of steps to follow. This is an example of the acquisition of what type of knowledge? a) Traditional b) Applied c) Descriptive rule-based d) Scientific

c) Descriptive rule-based Descriptive rule-based knowledge comes from an expert and is accepted as truth, based on the person's perceived expertise. This type of knowledge is not necessarily rooted in tradition or science. This category of knowledge can include both applied and theoretical types.

The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is:

condoms. Condoms provide effective (though imperfect) protection against STIs. Spermicides, diaphragms, and cervical caps do not provide effective protection against STIs.

Family conflict around the care of a recently hospitalized woman has escalated to the point that crisis intervention may be required. This process should begin with: presentation of clear, achievable, and evidence-based solutions. careful and objective analysis of different proposed options. clear identification of the relevant problem. comparison of the family's situation to other similar situations.

clear identification of the relevant problem. Crisis intervention is a problem-solving technique that begins with the identification of the problem.This precedes the identification of options and assessment of proposed solutions. Once the problem is identified by the client and the crisis team is way, interventions should be then be developed by the team members. The crisis intervention is very individualized and should not be compared to other families. Analysis is the last step of the process.

An appropriate goal for the client with a nursing diagnosis of Spiritual Distress related to intense pain and suffering as verbalized by the client would be that the client will: express feelings of anger and despair to God. meet with a minister daily. participate in supportive spiritual practices. reflect on past accomplishments in life.

participate in supportive spiritual practices.

Chapter 39- Oxygen & Perfusion Complication of nasal cannula use A patient with hypoxemia cannot tolerate a face mask or a face tent, but needs oxygen at a flow rate of at least 6 L/min. Using a standard nasal cannula for this patient may result in what complication? a. aspiration and vomiting b. high cost to the patient c. suffocation d. mucosal dryness

d. mucosal dryness

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing? bargaining acceptance anger denial

denial By making this statement, the client denies the seriousness of the malignant tumor diagnosis. Denial is often the first emotion the client will experience, as initially it helps in coping with the reality of impending death. There is nothing in the client's statement to indicate anger or acceptance. Bargaining would be indicated by the client negotiating with a higher power to extend life or delay the inevitable.

The client is a single mother of two children who attends college and works full time. She is seeing the college nurse due to a crying outburst in class. The last step of crisis intervention that the nurse employs is: having the client select an acceptable solution to her problem. asking the client, "What would happen if you did this solution?" outlining several solutions to the crisis with the client. determining if the outcome has been achieved.

determining if the outcome has been achieved. Crisis intervention is a five-step problem-solving technique. The last step is to evaluate outcome achievement. The other options precede evaluation.

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to:

eat foods high in folic acid. Folic acid deficiency in pregnant women can lead toneural tube deficits in the fetus. Women during pregnancy may experience constipation. Increased fiber intake is recommended. Saturated fats are to be eaten only in moderation. Milk products are important during the entire pregnancy.

Strategies to lessen feelings of isolation The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population? Continue driving a car to maintain memory skills. Schedule eye examinations every 4 years. good management of illness such as hypertension Avoid places full of people to prevent spread of infection.

good management of illness such as hypertension Client education to promote sensory health and function focuses on ways to prevent sensory loss and to maintain general health. Education topics include the importance of frequent eye examinations (yearly) and close control of chronic illnesses such as hypertension and diabetes. Age related changes in eyesight and motor function may affect the ability to drive. Avoiding places full of people can prevent infection but may cause sensory overload in older adults.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? soap and water tap water hypertonic saline mineral oil

hypertonic saline

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel? tap water mineral oil hypertonic saline water, soap

hypertonic saline The nurse will gather a hypertonic solution to draw water into the bowel by irritating local tissues. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

Chapter 40- Fluid Electrolytes & Acid Base Balance Signs/symptoms of fluid volume deficit (hypovolemia: decrease BP, decrease urine output, increase HR) During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? hypervolemia hypovolemia edema circulatory overload

hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and felevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects: false imprisonment. defamation of character. professional negligence. invasion of privacy.

invasion of privacy. The nurse's action reflects an invasion of the client's privacy. Disclosing confidential information to an unauthorized third party subjects the nurse to liability for invasion of privacy, even if the information is true. Defamation of character includes false communication that results in injury to a person's reputation. Negligence is an act of omission or commission. Prevention of movement or unjustified retention of a person without consent may be false imprisonment.

A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms? herniated lumbar disc obstructive sleep apnea moderate anxiety type 2 diabetes

moderate anxiety This client may have increased anxiety from adjusting to retirement, a significant life stressor. There are not enough data to identify any of the other disorders as being present.

A nurse is educating staff members about the importance of meeting the spiritual needs of clients on the unit. What spiritual needs should be met in the delivery of care? Select all that apply. need for love and relatedness need for complete health and freedom need for forgiveness need for meaning and purpose need for comfort and money

need for love and relatedness need for forgiveness need for meaning and purpose There are three spiritual needs that underlie all religious traditions and are common to all people: need for meaning and purpose, need for love and relatedness, and need for forgiveness. Need for comfort and money, as well as need for complete health and freedom, are nice but are not part of spirituality.

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory: deprivation. adaptation. stimulation. overload.

overload. When the RAS is overwhelmed with input, a person may experience sensory overload and feel confused, anxious, and unable to take constructive action.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? inspection palpation percussion auscultation

palpation The abdominal assessment should be performed in the following sequence: -inspection, auscultation, -percussion, -palpation.

Vulvodynia, Vaginismus, Dyspareunia, STI The nurse is caring for a client diagnosed with vaginismus.When reviewing the client's history, what would the nurse would expect to find? past history of an STI The client is in the first trimester of pregnancy. multiple vaginal births past history of a rape ˌva-jə-ˈniz-məs

past history of a rape Vaginismus usually results from psychological problems, namely fear of penetration due to a negative association such as rape, sexual abuse, or fear of sexual intercourse.

A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility? removing tubes and soiled dressings placing ID tags on the shroud and ankle washing the body to remove blood and excretions placing the body in normal anatomic position

placing ID tags on the shroud and ankle Although the nurse may place the body in a normal anatomic position and remove tubes and soiled dressings, the only legal action is placing ID tags on the shroud and ankle. The body is not usually washed by the nurse, as different cultures and religions have specific guidelines concerning cleansing the body.

Nursing care for the dying and nursing goal ⇒What is the most important goal of care for the dying client who is receiving comfort care? using a feeding tube to provide nutrition ensuring family members are present at the bedside identifying appropriate coping mechanisms providing a comfortable, dignified death

providing a comfortable, dignified death Clients or their surrogates may request a comfort-measures-only order, which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. Using a feeding tube and identifying appropriate coping mechanisms are not characteristics of comfort care. The presence of family members at the bedside is important for any dying client and is not specific to comfort care.

After failing a nursing exam, the nursing student states, "That exam was written terribly." What coping strategy would the nursing instructor identify? denial suppression repression rationalization

rationalization Rationalization is relieving oneself of personal accountability by attributing responsibility to someone or something else. By claiming the exam is written poorly, the student is relieved of the personal responsibility. Denial is simply rejecting information. Repression is forgetting about the stressor. Suppression is purposeful avoidance of the topic or issue causing stress.

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client? increases the volume of the stool, making defecation easier softens and facilitates the removal of intestinal polyps removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit

removes hardened fecal impactions from the rectum Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction; preventing involuntary escape of fecal material during surgical procedures; promoting visualization of the intestinal tract by radiographic or instrument examination; and helping to establish regular bowel function during a bowel training program. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Enemas are not used for diarrhea.

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention? seek assistance from family and friends keep the home environment noise free tense and relax muscle groups systematically perform meditation to relax

seek assistance from family and friends The nurse should suggest that the client seek assistance from family and friends as a crisis intervention. Adequate support during a crisis and its resolution can help clients realistically perceive the problem and reinstitute coping strategies.

A client who is blind is said to be experiencing: sensory overload. sensory deficit. sensory deprivation. sensory overstimulation.

sensory deficit. Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care. Safety is always a special concern for clients with sensory alterations. The nurse must ensure that the client's environment is as free of danger as possible, and assist the client in developing new self-care behaviors to compensate for sensory impairments.

Which behaviors represent effective coping mechanisms? Select all that apply. setting limits with family members who upset you learning relaxation techniques taking a vacation sleeping 14 hours a night sleeping 3 hours a night denying responsibility for a DUI conviction

setting limits with family members who upset you learning relaxation techniques taking a vacation Explanation: Coping mechanisms can have positive or negative effects on a client's well-being. All of these examples represent coping, either effective or ineffective.

The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as: panic. moderate. severe. mild.

severe. Severe anxiety is manifested by difficulty communicating verbally, increased motor activity, tachycardia, and hyperventilating. Mild anxiety is present in everyday living and is manifested by restlessness and increased questioning. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, and slight increases in heart and respiration rates. Panic is manifested by difficulty with verbal communication, agitation, poor motor control, tachycardia, hyperventilation, palpitations, choking sensation, and chest pain or pressure.

The nurse is preparing to provide education to a group of high school students on sexually transmitted infection (STI) prevention. The nurse knows that this age group often uses oral-genital stimulation as a way to prevent pregnancy. Which concept should the nurse make sure to convey to the group? use of public restrooms increases the risk of contracting HIV skin-to-skin contact can spread herpes and genital warts avoid multiple partners to reduce the risk of being infected oral-genital contact is safe with use of a barrier method

skin-to-skin contact can spread herpes and genital warts Some STIs spread through oral-genital sex, anal sex, or even intimate skin-to-skin contact without actual penetration (genital warts and herpes can be spread this way). Therefore, only avoiding all types of intimate genital contact can prevent these STIs. The use of a barrier method reduces the risk of STIs but should not be conveyed as "safe." HIV is contracted through direct contact with infected bodily secretions not through the use of public restrooms. While reducing sexual partners does reduce the risk of infection it only takes one exposure to contract a STI. The concept that should be conveyed is the risk that any skin-to-skin contact can spread herpes and genital warts.

The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider? the client who develops dizziness and diaphoresis during administration the client who has a visual nonbleeding hemorrhoid the client who has an increase in bowel sounds after administration the client who experiences severe abdominal pain

the client who experiences severe abdominal pain Be gentle and lubricate the tip generously before insertion of the enema, but a hemorrhoid is not a reason to stop. When a client experiences dizziness, light-headedness, and sweating, the nurse should slow down the administration of the enema and ask the client to take slow, deep breaths and relax to decrease the symptoms of rapid administration and vagal response. The nurse should stop the enemas with severe abdominal pain, assess bowel sounds, and call the primary care provider because the pain may be a warning sign of trauma to the GI tract or potential perforation of the bowel. It is an expected finding that the enema will stimulate peristalsis.

When the client tells the nurse that she believes God's reality is personal, and that God is the creator of all beings, the nurse determines the client is expressing: deism. atheism. theism. agnosticism.

theism. Theism is the belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.

Types of care provided in Nursing Homes or Long-term care facilities Palliative care is a structured system for care delivery. What is its aim? to give traditional medical care to prevent and relieve suffering to bridge between curative care and hospice care to provide care while there is still hope

to prevent and relieve suffering Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to "...prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies." Palliative care goes beyond giving traditional medical care. Palliative care is considered a "bridge" not exclusively limited to hospice care. "Hope" is something clients and families have even while the client is actively dying.

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? • A client with a high fever receiving intravenous fluids, antibiotics, and oxygen • An older adult with pneumonia who is being discharged to the son's home tomorrow • A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall • An adult client who is being treated for kidney stones

• A client with a high fever receiving intravenous fluids, antibiotics, and oxygen Explanation: For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

The client will verbalize appropriate cast care on discharge" represents which type of outcome? • Psychomotor • Cognitive • Affective • Physical change

• Cognitive

Chapter 17- Implementing Delegating to unlicensed assistive personnel (UAP) Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? • Does this task fall within the scope of a UAP? • What is the client's condition? • How can I supervise the completion of this task? • How can I explain the task to the UAP?

• Does this task fall within the scope of a UAP? Explanation: All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.

Which nursing diagnosis has priority? • Ineffective Airway Clearance related to retention of secretions • Disturbed Sleep Pattern related to abdominal incisional pain • Self-care Deficit: Bathing related to joint inflammation • Constipation related to decreased fluid intake and decreased mobility

• Ineffective Airway Clearance related to retention of secretions

Which statement correctly describes a nurse-initiated intervention? • Nurse-initiated interventions are derived from the nursing diagnosis. • Nurse-initiated interventions require a physician's order. • Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. • Nurse-initiated interventions are actions performed to diagnose a medical problem.

• Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a physician's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? • Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. • The nurse will help the client ambulate the length of the hallway once a day. • Offer to help the client walk the length of the hallway each day. • The client will become mobile within a 24-hour period.

• Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? • Psychomotor • Cognitive • Affective • Physical changes

• Physical changes

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? • Assess an IV site for possible infiltration • Reassess the client's sacrum for redness when doing a bed bath. • Provide the client with assistance in transferring to the bedside commode. • Retrieve a unit of blood from the blood bank.

• Provide the client with assistance in transferring to the bedside commode. Explanation: Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

Cognitive process and critical thinking for nursing ⇒Which are cognitive client outcomes? Select all that apply. • The client lists the side effects of digoxin. • The client describes how to perform progressive muscle relaxation. • The client identifies signs and symptoms of hypoglycemia. • The client correctly ambulates with a walker. • The client reports cycling 30 minutes three times each week.

• The client lists the side effects of digoxin. • The client describes how to perform progressive muscle relaxation. • The client identifies signs and symptoms of hypoglycemia. Cognitive outcomes demonstrate increases in client knowledge, such as listing side effects of medications, identifying signs and symptoms of hypoglycemia, and describing progressive muscle relaxation. Psychomotor outcomes describe the client's achievement of new skills, such as correct ambulation with a walker. An affective outcome involves changes in the client's values, beliefs, and attitude, such as the client's report of cycling.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: • an affective outcome. • a psychomotor outcome. • a physiologic outcome. • a cognitive outcome.

• a cognitive outcome. Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.