IPN exam 2

Which is an open-ended question? "Do you take this medication daily?" "Why did the health care provider prescribe this medication for you?" "When was the last time you had your prescription refilled?" "How many tablets do you take at one time?"

"why did the health care provider prescribe this medication for you?"

Which is the proper way to document midnight in a client's record?

0000

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? - 8:00: Pt is resting in bed and appears to be comfortable. - 0800: Resting in bed, eating some breakfast. Complains of headache. - 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. - 0800: Side rails up, call light in reach. Bed in high position.

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

Which activity generally occurs during the orientation phase of the helping relationship? A. An agreement or contract about the relationship is established B. The nurse provides any assistance needed to achieve patient goals C. The nurse provides patient counseling and teaching D. The patient and nurse examine the goals of the helping relationship for indications of attainment

A. An agreement or contract about the relationship is established.

A nurse reassuring oneself of being prepared to speak in front of a peer group is using which of the following types of communication? A. Intrapersonal B. Interpersonal C. Group D. Organizational

A. intrapersonal

What is the term for the heat that is lost when a person goes out in the cold without a hat? A. Convection B. Radiation C. Evaporation D. Conduction

B. Radiation

A nurse is handing off a patient to a nurse in an extended-care facility using the ISBARQ framework of communication. Which step is performed correctly? A. The nurse introduces the patient to the new nurse B. The nurse discusses the patient's background C. The nurse assesses the patient's vital signs D. The nurse questions the patient about comfort level

B. The nurse discusses the patient's background

A nurse stretches out a patient's leg and moves it in a circle. This is an example of what type of body movement? A. Abduction B. Flexion C. Circumduction D. Dorsiflexion

C. Circumduction

Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes? A. Source-oriented records B. Problem-oriented records C. PIE (problem, intervention, evaluation) D. Focus charting

C. PIE (problem, intervention, evaluation)

Characteristics of the therapeutic nurse-patient relationship

Caring, person-centered relationship Dynamics; both people involved are active participants Purposeful and time limited The person providing the assistance is professionally accountable for the outcomes Goals are determined cooperatively and defined in terms of the patient's needs

Which pulse site is located on the inside of the elbow? A. Temporal B. Radial C. Femoral D. Brachial

D. Brachial

Which statement accurately describes part of the process involved when a patient leaves AMA? A. The patient is not legally free to leave without being discharged B. The patient leaving AMA must sign a form releasing the nurse from legal responsibility for health status C. After signing the form, the patient should be informed of any possible risks involved with leaving AMA D. The patient's signature must be witnessed, and the form becomes part of the patient's record

D. The patient's signature must be witnessed, and the form becomes part of the patient's record

What factors influence communication?

Developmental level Sociocultural differences Roles and responsibilities Space and territoriality Physical, mental, and emotional state Values Environment

The nurse is working with a client's family and social worker to select a home health care agency. Which question does the nurse state should be the family's priority when interviewing potential home health agencies? - Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? - Is the facility listed as a government-approved facility with no infractions? - Does the agency provide care to facilitate transition to a hospital? - How does the agency train employees for accountability and do they require a background check?

Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs?

In a helping relationship, the nurse would most likely perform what action?

Establish communication that is continuous and reciprocal.

True or false: An open-ended question or comment serves to validate what the nurse believes is heard or observed.

False, A validating question or comment serves to validate what the nurse believes is heard or observed.

True or false: In same-day surgery clinics, screening tests and teaching take place upon admission to the clinic

False, In same-day surgery clinics, screening tests and teaching take place prior to admission to the clinic.

True or false: Planning for discharge begins when the patient receives discharge orders from the physician in charge of care.

False, Planning for discharge begins on admission when information about the patient is collected and documented

True or false: Touch is a personal behavior that means the same thing to all persons

False, Touch is a personal behavior that means different things to different people.

True of false: a patient has the right to obtain, review, and revise the patient information in his or her health record

False, a patient cannot revise their own patient information in their health record.

True or false: Jogging is an example of isometric exercise.

False, jogging is an example of isotonic exercise

A new client arrived on the unit while the nurse was obtaining the end-of-shift report from the night nurse. This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. The unlicensed assistive personnel has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. Which is the nurse's priority action?

Gather information and complete the admission database

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

What are the characteristics of effective and ineffective groups?

Group identity Cohesiveness Patterns of interaction Decision making Responsibility Leadership Power

Which statement is not true regarding a medication administration record (MAR)? - If the client declines the dose, the nurse does not have to document this on the MAR. - The MAR distinguishes between routine and "as needed" medications. - The MAR identifies routine times for medication administration. - After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR.

What are the 3 phases of therapeutic relationship?

Orientation phase Working phase Termination phase

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client? - Notifying all departments of the room change. - Discussing the move with both client and the family. - Asking family members to meet with the social worker at the receiving facility prior to the client's arrival. - Providing accurate and complete communication to the new facility.

Providing accurate and complete communication to the new facility.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? - Dialogue - Documentation - Reporting - Verification

Reporting

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? - Shift their weight back and forth from the legs to the back muscles. - Rock the client back and forth to raise the client up in bed. - Turn the client from side to side while pushing upward. - Shift their weight back and forth, from back leg to front leg.

Shift their weight back and forth, from back leg to front leg.

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client?

The heart rate is within normal limits due to the exercise regimen the client is following.

A nurse is caring for a client who decides to leave the hospital against medical advice (AMA). The nurse knows that the client must sign a form before leaving. What is the purpose of the AMA form?

To release the health care provider and the institution from any legal responsibility

True or false: Changes in the rate and depth of inhalation and exhalation are brought about by the inhibition or stimulation of the respiratory muscles by respiratory centers in the medulla and pons

True

True or false: The oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter region.

True

True or false: a nurse who fails to log off a computer after documenting patient care has breached patient confidentiality

True

True or false: one of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing care

True

True or false: the normal pulse rate for adolescents and adults ranges from 60 to 100 beats/min

True

care transition

a continuous process in which a patient's care shifts from being provided in one setting of care to another. Central responsibility of all health care professionals, especially nurses.

Which classification describes the bones located in the wrist? A. Long bones B. Short bones C. Flat bones D. Irregular bones

b. short bones

Each facilitates a therapeutic nurse-client relationship except: - closed-ended questions - rephrasing - active listening - reflection

closed-ended questions

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to: - communicate these feelings to family and friends. - allow a religious leader in the client's life to visit. - be certain that the client's educational needs are being met. - increase the client's activity to assist in coping.

communicate these feelings to family and friends.

The nurse is educating a client about ways to increase their cardiac output. Which topic does the nurse include in the teaching? - exercise - sleep - decrease in blood pressure - dehydration

exercise

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

facial expressions

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client?

orthostatic hypotension

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

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

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? - pulse is strong, and light pressure causes it to disappear. - Pulse is felt with difficulty and disappears with slight pressure. - Pulse is felt easily, and moderate pressure causes it to disappear. - Pulse is strong and remains strong despite moderate pressure.

pulse is felt with difficulty and disappears with slight pressure.

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity?

safety

Clients demonstrating apnea have what?

temporary cessation of breathing

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? - the 24-month-old child who is unable to walk unassisted - the 3-month-old child who is unable to raise the head when prone - the 6-month-old child who is unable to roll over - the 18-month-old child who is unable to stack blocks

the 24-month-old child who is unable to walk unassisted

The nurse is preparing to assess the client's vital signs. The client just had morning coffee. What explanation and action does the nurse take in this situation?

wait 30 minutes, then assess the oral temperature because the client had a beverage