HESI practice questions

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s) A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bed sores also indicates client abuse. Unexplained bruises on the wrist(s) may also be an indication of abuse in older adults. The presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding in older adult abuse.

A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do?

The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.

Which activity by the community nurse can be considered an illness prevention strategy? Encouraging the client to exercise daily Arranging an immunization program for chicken pox Teaching the community about stress management Teaching the client about maintaining a nutritious diet

Arranging an immunization program for chicken pox An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain the present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child?

Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames.

What type of interview is most appropriate when a nurse admits a client to a clinic? Directive Exploratory Problem solving Information giving

Directive The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad, because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

Which nursing process involves delegation and verbal discussion with the healthcare team? Planning Evaluation Assessment Implementation

Implementation The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? Highly active Irritable and irregular in habits Negative reaction to new stimuli A positive mild-to-moderately intense mood

Negative reaction to new stimuli A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved?

The pre-auricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? Analysis Inference Explanation Interpretation

explanation Explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?

prone position Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

A client requests information about the prescribed medication regimen. What is the best response by the nurse? Give a computer printout about the medication to the client. Ask the client to state what is already known about the medication. Advise talking to the primary healthcare provider to seek information about the medication. Delegate the task of sharing information about the medication to the licensed practical nurse.

Ask the client to state what is already known about the medication. Assessing the client's knowledge to delineate baseline information should be done before planning appropriate health teaching. Providing written material without knowing the client's ability to read is inappropriate; also, it limits the nurse's personal involvement in the teaching process. Having the client talk with the healthcare provider avoids carrying out the nurse's responsibility to provide teaching about a prescribed medication regimen. Health teaching about medication is the responsibility of the registered professional nurse.

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? A. Bending and then straightening their knees B. Bending at the waist and then straightening the back C. Placing one foot in front of the other and then leaning back D. Placing pressure against the client's axillae and then raising their arms.

Bending and then straightening their knees. The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs, the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomic structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.

What should a nurse recommend to best help a client during the period immediately after a spouse's death? Crisis counseling Family counseling Marital counseling Bereavement counseling

Bereavement counseling Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

In one of the sections of an evidence-based article a researcher is writing, the researcher explains how the research study was organized and conducted to answer the research question. What does the next section of the article include? A brief summary of the article Details on the results of the study Information about the purpose of the article An explanation if the findings from the study have implications

Details on the results of the study An explanation on how the research study was organized and conducted to answer the research question is given in the methods or design section of the evidence-based article. The next section after methods and design is results or conclusions, where details regarding the results of the study are provided. A brief summary of the article is provided in the abstract, which is the first element of the evidence-based article. Information about the purpose of the article is provided in the introduction, which comes after the abstract section. An explanation of whether the findings from the study have implications is given in the clinical implications section, which is the last element of the evidence-based practice article. This section is included after the results or conclusions.

Which nursing interventions indicate client care that supports physical functioning? . A. Interventions to facilitate client's learning B. Interventions to alter client's undesirable behavior C. Interventions to maintain client's nutritional status D. Interventions to maintain client's regular bowel patterns E. Interventions to prevent complications in the client related to electrolyte imbalance

Interventions to maintain client's nutritional status Interventions to maintain client's regular bowel patterns Providing interventions to maintain the client's nutritional status and providing interventions to maintain the client's regular bowel patterns indicates interventions that support physical functioning [1] [2]. Providing interventions to facilitate a client's learning and providing interventions to alter the client's undesirable behavior indicates interventions to support psychosocial functioning and facilitates lifestyle changes. Providing interventions to prevent complications related to electrolyte imbalance indicates the nursing care that supports homeostatic regulation.

A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief but the client is still reporting pain. Which actions of the nurse would help the client to get relief? . Learning more about the client Looking for different distraction techniques Using known scientific and practice-based criteria Involving the client's family in creating a new plan for pain relief Bringing co-workers together to find a solution

Looking for a different distraction technique can help the client in pain relief. The nurse should also involve the client's family in adapting new approaches to pain relief. Learning more about the client will not help the nurse provide effective pain relief to the client. Scientific and practice-based criteria are used to perform assessments and evaluations. When some facts about the client are missing, then the nurse brings all the co-workers together to find the solution of the problem.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Fainting Headache Weakness Lightheadedness Shortness of breath

fainting, weakness, and lightheadedness Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.

A nursing student is learning about Erikson's theory of psychosocial development. Which statement made by the client indicates the Identity versus Role Confusion stage?

"I like to dress like a boy even though my parents want me to dress like a girl." "I want to get a clear skin like my best friend, so I am visiting the skin specialist today." "I do not want to become an engineer like my parents want me to be; I dream of becoming a pilot." According to Erikson's theory of psychosocial development, in the Identity versus Role Confusion stage, an individual may pass through dramatic physiological changes. A client who says that she likes to dress like a boy but her parents want her to dress like a girl is in the Identity versus Role Confusion stage. A client who wants clear skin like his or her best friend is also in this stage. A client who wants to become a pilot instead of an engineer is also in the Identity versus Role Confusion stage. A client who fears that his or her relationship will not last like his or her previous one is in the Intimacy versus Isolation stage. An older adult who feels that she has not been able to be a good mother is in the Integrity versus Despair stage.

A nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching? "I will increase my meat consumption." "I will perform a self-breast examination every week." "I will schedule routine mammograms." "I will reduce my caffeine and theophylline intake."

"I will increase my meat consumption." Meat consumption should be reduced to prevent breast cancer; a high meat consumption may lead to obesity, which is a risk factor for breast cancer. Performing self-breast examinations is an effective way to feel changes or any abnormal growth in the breast. The client should undergo mammograms regularly to check for early signs and abnormalities of the breast. Although the approach of reduced intake of caffeine and theophylline is controversial, these actions may reduce the symptoms of benign breast disease.

A nurse prioritizes client care using Maslow's hierarchy of needs. Which situation should the nurse address first according to Maslow's hierarchy? A. A client has a history of getting injured due to sudden falls B. A client complains of sleeplessness due to pain post-surgery D A client complains that he/she feels lonely and socially isolated from others E. A client conveys to the nurse that he/she wants to become the manager of the company

A client complains of sleeplessness due to pain post-surgery According to Maslow's hierarchy of needs, the nurse should address the physiological needs of the client first. In the given scenarios, the nurse should ideally attend to the client who complains of sleeplessness due to pain post-surgery on priority basis. Then, the nurse should attend to the client who has a history of getting injured due to sudden falls as it comes under safety and security needs. After this, the nurse should attend to the client who complains that he/she feels lonely and socially isolated from others as this falls under self-esteem needs. When a client conveys to the nurse that he/she wants to become the manager of the company, the nurse understands this to be a self-actualization need. This is the highest level need and therefore should be addressed last.

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning?

A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in two years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in two months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in one month. If a client's BP is greater than 180/110 mm Hg, then he or she should be treated immediately or within 1 week.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Apical Carotid Brachial Femoral Popliteal

Carotid and femoral Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. Because the client is diagnosed with a hand fracture and is receiving intravenous fluids through the antecubital fossa, the brachial artery cannot be accessed to measure the pulse rate. The popliteal site is used to assess the status of the circulation in the lower leg.

A client is ambivalent about making a change in health behavior. Which stage of health behavior does the nurse suspect? Preparation Maintenance Contemplation Precontemplation

Contemplation The nurse suspects that the client is in the stage of contemplation. This stage of health behavior is characterized by the client's attitude toward a change and the client is most likely to accept that change over the next 6 months. In the preparation stage, the client believes that a change in behavior will be advantageous. The client may need assistance to bring about the change in behavior. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to receive any information about changes in behavior and may become defensive and confrontational.

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Encouraging regular dental checkups Facilitating smoking cessation programs Administering influenza vaccines to older adults Teaching the procedure for breast self-examination Referring clients with a chronic illness to a support group

Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

What is the difference between evidence-based practice and quality improvement? Evidence-based practice is a part of a regular clinical practice. Evidence-based practice aims to improve client care and outcomes. Evidence-based practice focuses on the implementation of evidence already known into practice. Evidence-based practice consists of internal funding and can be conducted by practicing nurses.

Evidence-based practice focuses on the implementation of evidence already known into practice. Evidence-based practice focuses on the implementation of evidence already known into practice whereas quality improvement measures the effect of changing practices on a specific population. Both evidence-based practice and quality improvement are a part of regular clinical practice. Both aim at to improve client care and outcomes. Both evidence-based practice and quality improvement consist of internal funding and can be conducted by practicing nurses and other healthcare professionals.

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? A. Evaluation B. Explanation C. Interpretation D. Self-regulation

Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? False imprisonment Malpractice Breach of duty False imprisonment

False imprisonment False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

The nurse is caring for an infant at the healthcare facility. Which nursing intervention fosters the infant's development of trust? Follow the parents' directions while providing care. Ask parents to name objects in the infant's surroundings. Encourage different caregivers to interact with the infant. Encourage caregivers to talk to the infant while providing care.

Follow the parents' directions while providing care Parents should provide the majority of the care when an infant is hospitalized. If the parents are away, the nurse should follow the parents' directions. This helps to foster the infant's continuing development of trust. The nurse asks parents to name objects in the infant's surroundings to enable the infant to recognize sounds and differentiate objects. This intervention promotes language development. The nurse should limit the number of caregivers interacting with the hospitalized infant. The nurse encourages caregivers to talk to the infant while providing care to provide sensory stimulation and enhance language development.

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? NANDA-I label, related factor, and etiologies NANDA-I label, risk factor, and nursing interventions NANDA-I label, related factor, and nursing interventions NANDA-I label, related factor, and defining characteristics

NANDA-I label, related factor, and defining characteristics The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? Orient the client to the unit environment Have a copy of hospital regulations available Explain that there is no reason to be concerned Reassure the client that the staff is available if the client has questions

Orient the client to the unit environment Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. Explaining that there is no reason to be concerned may be false reassurance because no one can guarantee that there is no reason to be concerned. Reassuring the client that the staff is available to answer questions implies that staff members are available only if the client has specific questions.

Which nursing action would be considered a part of self-regulation in the decision-making process? A. Reflecting on one's own experiences B. Looking at all the situations objectively C. Supporting findings and conclusions D. Making careful assumptions about a client's information

Reflecting on one's own experiences Self-regulation requires the nurse to reflect on his or her own experiences. Explanation requires looking at all situations objectively. Findings and conclusions are supported by explanation. Analysis requires the nurse to not make any careless assumptions.

A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario? Spiritual factors Emotional factors Developmental stage factors Intellectual background factor

Spiritual factor Religious practices are one way that people exercise spirituality. In the given scenario, the client asks the nurse to refrain from cutting the religious thread. This is an example of a spiritual factor. Emotional factors involve the client's degree of stress, depression, or fear. The nurse considers the client's developmental stage when using the client's health beliefs and practices as a basis for planning care. Intellectual background factors are a person's beliefs about health that are shaped by their knowledge, lack of knowledge, or incorrect information about body functions and illnesses.

Which questions should the nurse ask the client when obtaining the health history? Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you sustained any personal loss recently?" "Have you ever experienced any allergic reactions?" "Does any family member have a long-term illness?"

Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you ever experienced any allergic reactions?" The health history of a client includes the client's food habits so that the nurse can obtain an assessment of the client's nutrition status. The nurse also assesses the client's habits and lifestyle patterns. The use of alcohol and tobacco helps to determine the client's risk for diseases involving the liver or lungs. The health history includes descriptions of allergies and reactions to food, latex, drugs, or contact agents such as soap. While assessing the family history, the nurse assesses the client for stress-related problems by asking about recent personal losses. The family history provides information about family members to determine the risk for illnesses of a genetic or familial nature.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. What is it important for the nurse to inform the client of?

That the client must accept full responsibility for possible undesirable outcomes The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for the illness and possible injury or undesirable outcomes. Healthcare professionals have a responsibility to inform the client and, if possible, have the client sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current primary healthcare provider will refuse to provide care to the client in the future.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? Maligning a person's character while threatening to do bodily harm A legal wrong committed by one person against property of another The application of force to another person without lawful justification Behaving in a way that a reasonable person with the same education would not

The application of force to another person without lawful justification Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons, not property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

The nurse assessing an adult understands that the client is experiencing a midlife crisis. Which factor should the nurse attribute to this condition?

The client is examining life goals and relationships Individuals between the age of 35 and 43 are vigorously examining their life goals and relationships. These individuals often experience stress or a midlife crisis during this reexamination, which may lead to changes in personal, social, and occupational areas. A young adult who is aware of his or her skills seeks to pursue a degree suitable to his or her desired occupation. A young adult between the ages of 29 to 34 directs enormous energy toward achievement and mastery of the surrounding world. A young adult must share all responsibilities in a two-career family to avoid stress.

When assessing a client, the nurse notices that he or she has reached the action stage of health behavior change. What should the nurse expect to be the client's reaction after providing suggestions for change? The client's previous habits may prevent taking action related to new behaviors. The client believes that the advantages outweigh the disadvantages of behavior change. The client accepts information as he or she is developing stronger beliefs in the value of change. The client is not interested in information about the behavior and may be defensive when confronted with it.

The client's previous habits may prevent taking action related to new behaviors. In the action stage, the client's previous habits may prevent him or her from taking action to form new behaviors. In the preparation stage, the client believes that the advantages outweigh the disadvantages of behavior changes. In the contemplation stage, the client will probably accept information as he or she is developing stronger beliefs in the value of change. In the precontemplation stage, the client is not interested in information about the behavior and may be defensive when confronted with it.

Which nursing actions may help in effective assessment of older clients? Select all that apply A.The nurse makes eye contact with the client. B. The nurse leans backward during the interaction C. The nurse smiles at the clients during the interaction D. The nurse shrugs her shoulders in response to a client's question E. The nurse asks the clients to express details as quickly as possible

The nurse makes eye contact with the client. The nurse smiles at the clients during the interaction The nurse should make eye contact while interacting with the client. It shows that the nurse is interested to hear client issues. The nurse shows positivity and of good humor with a smile during an interaction. The nurse should lean forward while interacting with the client; this shows attention and interest. The nurse should answer questions verbally, not simply with body language. Older adults may need time to think and answer; therefore, the nurse should allow pauses and time while asking client to explain anything.

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis?

The nurse must gather more information to clarify interpretations of assessment data. Correct interpretation of information allows the nurse to select the right diagnosis that applies to the client. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse should identify related factors to individualize a nursing diagnosis for the client. The nurse should review all the defining characteristics, eliminate irrelevant ones, and confirm the relevant ones. The nurse must interpret the data to form data clusters only after reassessing and validating it. At this stage, the nurse should have only validated assessment data in the database. The nurse need not reject all diagnoses. The nurse should review all the defining characteristics to support or eliminate the irrelevant ones.

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion? The nurse shares constructive criticism with his or her team members. The nurse meets with colleagues regularly to discuss work experience. The nurse recalls, thinks, analyzes and learns from day-to-day work situations. The nurse organizes or connects information in a way so the diverse information about a client forms meaningful patterns.

The nurse recalls, thinks, analyzes and learns from day-to-day work situations. Reflective practice is a conscious process of recalling, thinking, analyzing, and learning from work situations. This practice may also include journaling work experiences for self-evaluation. Meeting with colleagues to share constructive criticism and discuss work experiences is an important part of critical skill development. The use of concept mapping requires the nurse to organize and collect the client's information in a way that forms meaningful patterns.

What points should the nurse remember when caring for a client who has a history of suicide attempts? The nurse should document the measures taken to prevent suicides. If the client makes a suicide attempt in the hospital, this action may lead to a lawsuit. The client may be detained for 21 days if a judge grants an involuntary detention. The primary health care facility will be responsible for failing to provide adequate supervision. The nurse should file paperwork with the court within 96 hours of the client's admission to the facility.

The nurse should document the measures taken to prevent suicides. If the client makes a suicide attempt in the hospital, this action may lead to a lawsuit. The primary health care facility will be responsible for failing to provide adequate supervision. If a client has a history of suicide attempts, the nurse should document all suicide prevention measures within the health care facility. The documentation may be helpful if a lawsuit is filed. If the client attempts suicide in the hospital, this action may lead to a lawsuit. In the event of a lawsuit, the likely allegations against the primary healthcare provider are that he or she failed to supervise the client adequately and safeguard the facilities. If a client is admitted to a health care facility involuntarily, the judge may determine that the client is a danger to himself or herself or others and grant an involuntary detention for 21 days. This is not applicable for all suicide-risk clients. The nurse should file with the court within 96 hours of admission to the health care facility only if the client is admitted involuntarily.

Which principles are appropriate for promoting older adult learning?

The nurse should use past experiences while teaching an older client, keep environmental distractions to a minimal and use audio, visual, and tactile cues to enhance learning. This helps the client to remember all the information. The nurse should emphasize concrete material. The nurse should teach clients by using one example at a time.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs? Low in fat and vitamin D High in calories and fiber Low in residue and bland High in protein and vitamin C

high in protein and vitamin c Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

For what clinical indicator should a nurse assess a client who is having a gastric lavage? A. decreased serum pH B. increased serum oxygen level C. increased serum bicarbonate level. D. decreased serum osmotic pressure

increased serum bicarbonate level Gastric lavage causes an excessive loss of gastric fluid, resulting in excessive loss of hydrochloric acid (HCl), which can lead to alkalosis; the HCl is not available to neutralize the sodium bicarbonate (NaHCO 3) secreted into the duodenum by the pancreas. The intestinal tract absorbs the excess bicarbonate, and alkalosis results. Gastric lavage will lead to alkalosis, which is associated with increased pH. Gastric lavage will not affect oxygen levels. Gastric lavage may lead to dehydration, which will increase osmotic pressure.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine

respiratory and urinary Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

Which assessment finding of the skin refers to elasticity? Turgor Edema Texture Vascularity

turgor Turgor refers to the elasticity of the skin. Edema indicates fluid buildup in the tissues. Texture refers to the character of the skin. Vascularity refers to the circulation of the skin.

An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 36.0ºC 36.8ºC 37.2ºC 38.5ºC

38.5 In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.

Which client body temperatures are indicative of moderate hypothermia? 80° F (26.7° C) 84° F (28.9° C) 88° F (31.1° C) 92° F (33.3° C) 96° F (35.6° C)

88 Fand 92 F Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.

A visitor comes to the nursing station and tells the nurse that a client and a relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? Ask the client if he or she is okay. Call security from the room. Find out if there is anyone else in the room. Ask security to make sure the room is safe.

Ask security to make sure the room is safe Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and ensured that any other people in the room are safe.

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? Wait until a family member is also present. Assess the client's barriers to learning self-injection techniques. Begin with simple written instructions describing the technique. Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

Assess the client's barriers to learning self-injection techniques. Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 39ºC. What is this temperature in Fahrenheit? Record your answer using one decimal place.

Celsius is converted to Fahrenheit by multiplying the Celsius reading by 9/5 and adding the product to 32. In this case, the calculation is: (9/5)(39) + 32 = 102.2.

A registered nurse is educating the nursing student regarding the importance of consensus building in the resolution of bioethical dilemmas. Which statements by the student nurse indicate effective learning? "Consensus building is an act of discovery." "Consensus building promotes respect and agreement." "Consensus building inspires respect for unusual points of view." "Consensus building is based on choosing a particular philosophy." "Consensus building is based on the greatest good for the greatest number of people."

Consensus building is an act of discovery." "Consensus building promotes respect and agreement." "Consensus building inspires respect for unusual points of view." Consensus building is considered to be an act of discovery, as the best possible decision is reached on the basis of collective wisdom, which refer to harmonizing different points of view. When solving ethical dilemmas, consensus building focuses on promoting respect and agreement toward multiple philosophies instead of fixating on a particular moral system. Consensus building aims at bringing about an agreement among all participants in the decision-making process by encouraging respect for unusual points of view. Consensus building does not focus on a particular philosophy or moral system. Utilitarianism is based on the greatest good for the greatest number of people.

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply . Dry cleaners Dye workers Lathe operators Hospital workers Agricultural workers

Dry cleaners and Dye workers Dry cleaners and dye workers are at high risk of developing dermatitis due to exposure to substances such as solvents and dye stuffs. Lathe operators are at high risk of developing cancer. Hospital workers are at greater risk of latex allergies. Agricultural workers are at high risk of skin cancer.

While assessing an older adult, the nurse observes visual impairment in the client. Which technique should the nurse use to communicate? A. Face the caregiver while speaking B. Provide bright, diffuse, glare lighting C. Stand or sit away from the client while remaining in the client's full view. D. Encourage the older adult to use assistive devices such as glasses

Encourage the older adult to use assistive devices such as glasses. If an older adult has visual impairment, the nurse should encourage the older adult to use assistive devices such as glasses. The nurse should face the older adult while speaking and should not cover his or her mouth. The light should be bright and non-glaring so that the older adult can see properly. The nurse should stand or sit closely in front of the client in full view so that the client is able to identify.

What principle must a nurse consider when caring for a client with a closed wound drainage system? Gravity causes fluids to flow down a pressure gradient. Fluid flow rate is determined by the diameter of the lumen. Siphoning causes fluids to flow from one level to a lower level. Fluids flow from an area of higher pressure to one of lower pressure.

Fluids flow from an area of higher pressure to one of lower pressure. A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Newton's law of gravity is not the physical principle underlying the functioning of a portable wound drainage system. Although fluid flow rate is determined by the diameter of the lumen and siphoning causes fluids to flow from one level to a lower level, they are not what cause the fluid to drain in a portable wound drainage system.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? A. Hypernatremia B. Hyponatremia C. Hyperkalemia D. Hypokalemia

Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? Have the client void every 2 hours. Maintain the client in an isolation room. Spend time with the client to allow verbalization of feelings. Wear two pairs of gloves when touching the client during care.

Maintain the client in an isolation room During radiation therapy with radium implants, the client is placed in isolation so that exposure to radiation by family and staff is decreased. Voiding every 2 hours is unnecessary; a full bladder will not disrupt the seeds. Excess exposure to radiation is hazardous to personnel. Gloves will not protect the nurse from radiation.

How does the World Health Organization (WHO) define "health"?

The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

Which Korotkoff sound represents the diastolic pressure in children? First Second Fourth Fifth

The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.

According to Quality and Safety Education (QSEN), what is patient-centered care? Understanding that the client is the source of control when providing care Functioning effectively within nursing and interprofessional teams to deliver quality care Using data to evaluate outcomes of care processes and designing methods to improve health care Minimizing the risk of harm to clients and health care workers through improved professional performance

Understanding that the client is the source of control when providing care The Quality and Safety Education (QSEN) competency called patient-centered care requires the nurse to understand that the client is the source of control. The nurse should therefore respect the values, beliefs, and preferences of the client to provide quality care. The QSEN competency called teamwork and collaboration states that a nurse should function effectively within nursing and interprofessional teams in order to provide quality care. Quality improvement involves using data to evaluate the outcomes of care processes and design methods to improve the health care delivery system. Safety focuses on minimizing the risk of harm to clients and health care workers through improved professional performance.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? Assess the client's lungs. Assess the client for pain. Obtain details of smoking habits. Ask about the onset of breathlessness.

assess the client's lungs The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

When should the nurse observe the client to assess his or her level of functioning?

during meal time, when preparing medication, when administering insulin injections An observation of the functional level of the client often occurs during a return demonstration. The nurse may also observe the client while eating to determine if the client is able to eat without assistance. The nurse teaches the client how to prepare medications and asks for a return demonstration to assess the client's understanding. The nurse also observes the client administering insulin injections to ensure that the client is able to perform it properly. Observation of functional level differs from the observation during a physical examination. The nurse closely observes the client during the physical assessment when the client talks about pain. During the assessment interview, the nurse observes the client's facial expressions and eye contact to form accurate conclusions about the client's condition. The nurse does not assess the client's functional abilities during the subjective assessment.