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Practice Questions Care Final

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A client is experiencing nausea and abdominal distention postoperatively. The nurse initiates the interventions listed below. Which of the interventions is an example of an independent intervention? (Select all that apply.) A) Provides frequent mouth care B) Maintains intravenous infusion at 100 ml/hr C) Administers prochlorperazine (Compazine) via rectal suppository D) Consults with the dietitian on initial foods to offer the client E) Controls aversive odors and unpleasant visual stimulation that trigger nausea

A and E Providing frequent mouth care and controlling aversive odors and unpleasant visual stimulation that trigger nausea are examples of independent intervention. The other options are dependent interventions.

7. Which steps do you follow when you are asked to perform a procedure about which you are unfamiliar? Select all that apply. A) Seek necessary knowledge B) Reassess the client's condition C) Collect all equipment necessary D) Have an experienced nurse available to assist E) Consider all possible consequences of the procedure

A, B, C, D, and E Each of the five options is important in performing a new procedure. Be sure to seek all necessary knowledge, consider the possible consequences of the procedure, reassess the patient, collect the appropriate supplies, and ask a nurse experienced in the procedure to help out

A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.) A) Pain intensity B) Location of pain C) Character of pain D) Radiation of pain E) Meaning of pain to the client F) Family history of myocardial infarctions

A, B, C, D, and E The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation.

What techniques encourage a client to tell his or her full story? (Select all that apply.) A) Active listening B) Back channeling C) Use of open-ended questions D) Use of closed-ended questions

A, B, and C Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story. The other options give clients the opportunity to tell their stories and feel supported. Active listening helps them feel that they, and their stories, are important.

Which of the following are nurse-provided indirect care activities? (Select all that apply.) A) Delegating B) Documenting C) Evaluating new products D) Administering medications E) Providing client counseling

A, B, and C The correct options do not involve direct interaction with the client or family. The other options do require such direct interaction.

The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that apply.) A) Client is restless. B) Respirations are 24/min and irregular. C) Client states feeling short of breath. D) Fluid intake for 8 hours is 800 ml. E) Client has drainage from surgical wound. F) Client reports loss of appetite for over 2 weeks.

A, B, and C The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia.

Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.) A) Nocturia B) Frequency C) Urinary retention D) Inadequate urinary output E) Receipt of intravenous fluids F) Sensation of bladder fullness

A, B, and C The defining characteristics for Impaired urinary elimination according to NANDA include nocturia, frequency, and urinary retention. The other options are not defining characteristics from NANDA.

When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? (Select all that apply.) A) Ability to cook meals B) Ability to feed oneself C) Ability to write checks D) Ability to bathe oneself E) Ability to take medications

A, C, and E The correct options are skills that allow the client to live independently in society. They may or may not be performed on a daily basis. The other options are activities of daily living.

Leininger's theory of cultural care diversity and universality specifically addresses: A) Caring for clients from unique cultures B) Understanding the humanistic aspects of life C) Identifying variables affecting a client's response to a stressor D) Caring for clients who cannot adapt to internal and external environmental demands

A. Caring for clietns from unique cultures The goal of Leininger's theory is to provide the client with culturally specific nursing care, in which the nurse integrates the client's cultural traditions, values, and beliefs into the plan of care.

The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. What skill is the nurse demonstrating? A) Cognitive skill B) Behavioral skill C) Interpersonal skill D) Psychomotor skill

A. Cognitive skill The nurse is using sound judgment and clinical decisions to provide individualization of care. A decision is made without direct interaction with the client but is based on knowledge about the client. No psychomotor skill is involved in this decision-making process. There is no such thing as a behavioral skill.

A client tells the nurse, "I'm not happy with the way the patient care technician did my bath. He just seemed to be in a hurry and did not wash my back like I asked." The nurse decides to go talk with the technician to learn his side of the story as well. This is an example of: A) Fairness B) Curiosity C) Risk taking D) Responsibility

A. Fairness Fairness involves analyzing all viewpoints to understand the situation completely before making a decision. Curiosity gives the critical thinker the motivation to continue to ask questions and learn more. Risk taking involves trying different ways to solve problems.

The nursing assessment is which phase of the nursing process? A) First B) Second C) Third D) Fourth

A. First The nursing process cannot proceed unless the nurse first conducts a client assessment. The other phases of the nursing process occur after assessment.

Theories that are broad and complex are: A) Grand theories B) Descriptive theories C) Middle-range theories D) Prescriptive theories

A. Grand theories Grand theories are described as broad and complex. Middle-range theories are limited in scope, less abstract, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Prescriptive theories address nursing interventions and predict the consequence of a specific intervention.

The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to: A) Have the client void. B) Place the client in Sims' position. C) Premedicate the client with analgesics. D) Insert a peripheral intravenous (IV) catheter.

A. Have the client void The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters are not required for this procedure.

The nurse asks the client whether the client has any allergies. This is an example of: A) Health history data B) Biographical information C) History of present illness D) Environmental history data

A. Health history data Known allergies are a part of historical data. Biographical data include age, address, occupation, work status, marital status, course of health care, and insurance. The history of the present illness includes when the symptoms began, whether they began suddenly or gradually, whether they come and go, and other information about the illness. The environmental history includes data about the client's home and working environments.

nurse routinely asks clients if they take any vitamins or herbal medications, encourages family members to bring in music that clients like to help them relax, and frequently prays with clients if that is important to them. The nurse is using which model of care? A) Holistic B) Health belief C) Transtheoretical D) Health promotion

A. Holistic The holistic model attempts to create conditions that promote optimal health. The holistic model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions. The health belief model addresses the relationship between a person's beliefs and behaviors. The transtheoretical model of change discusses a series of changes through which clients move, starting with precontemplation and ending maintenance. The health promotion model defines health as a positive, dynamic state and not merely the absence of disease.

A postsurgical client calls for a nurse and asks to be repositioned. The nurse finds that the client's drainage tube is disconnected and the intravenous (IV) line has 100 ml of fluid remaining. Which of the following should be performed first? A) Reconnect the drainage tube. B) Inspect the condition of the IV dressing. C) Improve the client's comfort and turn her to her side. D) Go to the medication room and obtain the next IV fluid bag.

A. Reconnect the drainage tube The nurse should reconnect the drainage tube first to ensure that the wound is properly draining. The client should then be turned (with care taken to ensure that the tubing remains connected), followed by replacing the IV fluid bag, checking the IV site, and restarting the IV fluid. With 100 ml left, the nurse has a bit of time to replace the IV bag before it runs dry, so caring for the client's wound and comfort should come first.

Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following? A) Safety B) Nurse staffing C) Confidentiality D) Adequate pain relief

A. Safety Client safety is an environmental factor and is always the first concern. Pain relief, staffing, and confidentiality are important but are not environmental factors.

A 72-year-old man diagnosed with chronic obstructive pulmonary disease 5 years ago has been participating for the last 2 years in a pulmonary rehabilitation exercise class offered by the local hospital at a fitness facility. This is what level of prevention? A) Tertiary prevention B) Primary prevention C) Secondary prevention D) Quaternary prevention

A. Tertiary prevention Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Primary prevention is true prevention that precedes disease and involves clients considered physically and emotionally healthy. Secondary prevention is aimed at individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Quaternary prevention is not a recognized term.

In the examples given below, which nurse is acting to avoid a data collection error? A) The nurse asks her colleague to chart her assessment data. B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis. C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her. D) After performing an assessment the nurse critically reviews his level of comfort and competence with interviewing and physical assessment skills.

A. The nurse asks her colleague to chart her assessment data A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error. The nurse reviewing his level of comfort and competence is being complete but can miss his own errors. Considering conflicting clues does not help avoid data collection errors. Asking a colleague to chart data is incorrect.

A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client's pain rating stayed the same (8 out of 10). What should the nurse recognize? A) The pain plan needs changing. B) The client is overrating the pain. C) Complications from surgery are occurring. D) Nonpharmacological pain-relieving strategies are now appropriate.

A. The pain plan needs changing The current pain medications are not effectively relieving the pain. The nurse needs to call the physician and discuss changing the medication is some way (type, dose, frequency, formulation). Pain is what the client says it is. There is no objective way to measure pain. The clinician must accept the client's report of pain. Nonpharmacological strategies are adjuncts to the pain plan. They are not to be used in place of pain medications. Pain following surgery is an expectation.

Nursing theories focus on the phenomena of nursing and nursing care. Which of the following is true of phenomena? A) They are aspects of reality that can be consciously sensed or experienced. B) They convey the general meaning of concepts in a manner that fits the theory. C) They are statements that describe concepts or connect two concepts that are factual. D) They are mental formulations of an object or event that come from individual perceptual experience.

A. They are aspects of reality that can be consciously sensed or experienced. Phenomena are defined as aspects of reality that can be consciously sensed or experienced.

The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a client interview? A) Working B) Orientation C) Termination

A. Working The nurse's questions exemplify the working phase of the interview.

A client says, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the client through the stages of change toward regular exercise? A) "Walking is OK. I really think running is better." B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?" C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start eating more fruits and vegetables, too." D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes walking if you are going to do any good."

B. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?" This option supports the preparation stage in which the client is beginning to consider making small changes. The other options are not good ones for this client.

The nursing theory that emphasizes the delivery of nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family is: A) Rogers' theory B) Abdellah's theory C) Henderson's theory D) Nightingale's theory

B. Abdellah's theory The question describes the nursing theory developed by Fay Abdellah and others. Rogers' theory considered the individual as an energy field existing within the universe. Henderson's theory defines nursing as "assisting the individual, sick, or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death." Nightingale viewed nursing as providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition.

The nursing diagnosis Hypothermia is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis

B. Actual nursing diagnosis An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. The term readiness is present in a wellness nursing diagnosis. A potential nursing diagnosis is a risk for diagnosis.

A client's wound is not healing and appears to be worsening with the current treatment. What is the first option the nurse should consider? A) Notifying the physician B) Calling the wound care nurse C) Consulting with another nurse D) Changing the wound care treatment

B. Calling the wound care nurse Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. Notifying the physician may be appropriate after the nurse decides on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Unless the nurse is knowledgeable in wound management, changing the wound care treatment could delay wound healing. Also, the current wound management plan might have been ordered by the physician. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.

Which of the following is the most accurate information to give a nurse during change-of-shift reporting? A) Client refuses to take medications. B) Client reports sharp pain in left anterior knee. C) Client encouraged to consume more fluids. D) Client expressed concern about pending surgery.

B. Client reports sharp pain in elft anterior knee The information in option 2 represents objective data that the nurse can use as part of baseline information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact concern would be more accurate. Option 1 may be true, but accurate data would also report why the client refused medication.

Interdisciplinary care plans represent: A) All nursing personnel having input in the care plan. B) Contributions of all disciplines in caring for the client. C) The client's express wishes and advance directives. D) Physicians and nurses working together to develop a plan of care.

B. Contributions of all disciplines in caring for the client Interdisciplinary care plans include the contributions of all disciplines involved in the patient's care. The client's advance directives and express wishes may be included, as well as nursing and physician input, but other involved disciplines also contribute their plans.

7. When discussing the client's care with a nurse's aide, the nurse instructs the aide to report any coughing during meals in the client, who recently experienced a stroke and requires feeding. In this situation the nurse is acting as which of the following? A) Educator B) Delegator C) Client advocate D) On-the-job trainer

B. Delegator The nurse is delegating the task of feeding to the aide but is also providing directions.

6. Which theories describe an orderly process beginning with conception and continuing through death? A) Systems theories B) Developmental theories C) Interdisciplinary theories D) Stress and adaptation theories

B. Developmental theories Developmental theories discuss human growth from conception to death. The other options are incorrect

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to do which of the following? A) Implement the specialist's recommendations. B) Discuss and review advised strategies with the CNS. C) Report the recommendations to the primary physician. D) Clarify the suggestions with the client and family members.

B. Discuss and review advised strategies wtih the CNS Because the primary nurse requested the consultation, it is important that the primary nurse and the CNS communicate and discuss recommendations. The primary nurse can then accept or reject the CNS's recommendations. A consultation requires review of the recommendations but not immediate implementation. Reporting the recommendations to the physician would be appropriate after the nurse first talks with the CNS about recommended changes in the plan of care and the rationale. Only then should the primary nurse call the physician. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. It is better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including which of the following? A) Apply a cold pack to the tibia. B) Elevate the leg 5 inches above the heart. C) Perform range-of-motion movement with right leg every 4 hours. D) Administer aspirin 325 mg every 4 hours as needed.

B. Elevate the leg 5 inches above the heart Elevation of the leg does not need a physician's order. Applying a cold pack and administering medication do require a physician's order. Range-of-motion movement of the fractured tibia is inappropriate.

A theory is a set of concepts, definitions, relationships, and assumptions that: A) Formulates legislation B) Explains a phenomenon C) Measures nursing functions D) Reflects the domain of nursing practice

B. Explains a phenomenon A theory is a set of concepts, definitions, relationships, and assumptions that explains a phenomenon. Theories do not formulate legislation, measure nursing functions, or reflect any domain of nursing practice.

11. A person's ideas, convictions, and attitudes about health and illness can be described as: A) Moral beliefs B) Health beliefs C) Holistic views D) Negative health behaviors

B. Health beliefs Health beliefs are an individual's perceptions of health or illness, which may be based on factual information or misinformation, common sense or myths, or reality or false expectations. Moral beliefs are learned behaviors that are in accordance with the principles of right or wrong. Holistic views consider the emotional and spiritual well-being of the individual. Negative health behaviors include behaviors that are typically harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take appropriate medications.

Clients maintain health or enhance their health by routine exercise and proper nutrition. This is known as: A) Illness B) Health promotion C) Control of external variables D) Wellness education

B. Health promotion Health promotion activities help clients maintain and enhance their present level of health. Wellness education instructs persons on how to care for themselves in healthy ways and includes topics such as physical awareness, stress management, and self-responsibility. Illness is defined as poor condition or disease. External variables are outside factors that influence a person's health beliefs and practices. They include family practices, socioeconomic factors, and cultural background.

Different attitudes about illness cause people to react in different ways when illness does occur. Medical sociologists call the reaction to illness: A) Health belief B) Illness behavior C) Health promotion D) Illness prevention

B. Illness behavior Illness behavior is the client's reaction to illness. The other three options are models of health

. Indirect care measureA 34-year-old client had a surgical repair of an abdominal hernia in the morning. At 12 noon, the nurse records the client's vital signs on the recovery room flow sheet. What is this an example of? A) Psychomotor skill B) Indirect care measure C) Physical care technique D) Anticipating complications

B. Indirect care measures Recording vital signs is an example of indirect care. Taking vital signs is an example of a psychomotor skill. Anticipating complications is a cognitive skill that is an assessment skill. Recording vital signs is a direct care measure and not a physical care technique.

When calling a nurse consultant about a difficult client-centered problem, which of the following should the primary nurse report? A) Client's concern about the current treatment B) Length of time current treatment has been in place C) Spouse's reaction to the client's current treatment D) Physician's reluctance to change the current treatment plan

B. Length of time current treatment has been in place Reporting the length of time the current treatment has been used gives the consulting nurse facts that will influence formulation of a new plan. The other options are subjective and emotional issues or conclusions about the current treatment plan and may bias the nurse consultant's decision regarding a new treatment plan.

Which of the following characteristics of a goal is missing from the statement "Client will ambulate daily"? A) Observable B) Measurable C) Client centered D) Singular goal or outcome

B. Measurable Goals must be measurable, such as "Client will ambulate 15 feet daily." The other characteristics are met in this goal statement.

Which of the following is subjective information to be entered in the client's medical record? A) Skin warm and dry. B) Pain intensity 8 out of 10. C) Breath sounds clear to auscultation. D) Amber urine in sufficient quantities.

B. Pain intensity 8 out of 10 Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it depends on the client's report. The other options are objective data.

10. A nurse teaches the importance of folic acid intake to a group of pregnant women. This is considered which level of preventive care? A) Illness behavior B) Primary prevention C) Tertiary prevention D) Secondary prevention

B. Primary prevention Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual.Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual.

A parish nurse for a Catholic church provides a free blood pressure screening the first Sunday of every month. This is what level of prevention? A) Tertiary prevention B) Primary prevention C) Secondary prevention D) Quaternary prevention

B. Primary prevention Primary prevention is true prevention that precedes disease and is aimed at clients considered physically and emotionally healthy. Secondary prevention involves individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Quaternary prevention is not a recognized term.

After establishing a nursing diagnosis of Acute pain, the nurse develops which of the following appropriate client-centered goals? A) Determine effect of pain intensity on client function. B) Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay. C) Encourage client to implement guided imagery when pain begins. D) Administer analgesic 30 minutes before physical therapy treatment.

B. Reduce pain intensity to the level of a client rating of 3 or below during the client's hopsital stay

A nurse provides counseling to a family in spiritual distress caused by the recent, but expected, death of a family member when the nurse implements which of the following interventions? A) Praying with the family B) Reminiscing with the family C) Arranging for the chaplain to visit the family D) Obtaining a consult with a psychiatric clinical nurse specialist

B. Reminiscing with the family Reminiscing is an active intervention that allows family members to remember the deceased in a positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and arranging for a chaplain's visit may be appropriate interventions, but they are not counseling.

During the planning phase of the nursing process, the nurse along with the client decides which of the following? (Select all that apply.) A) Interventions B) Nursing diagnosis C) Expected outcomes D) Client-centered goals E) Nurse-centered priorities

C, and D Expected outcomes and goals are the main components of the planning phase of the nursing process. The nurse determines these from the assessment. The client should be the focus of the planning stage. Interventions are initially determined by the nurse.

3. Based on the transtheoretical model of change, what is the most appropriate response to the following client statement: "Me, exercise? I haven't done that since Junior High gym class and I hated it then!" A) "That's fine. Exercise is bad for you anyway." B) "OK. I want you to walk 3 miles four times a week and I'll see you in 1 month." C) "I understand. Can you think of one reason why being more active would be helpful for you?" D) "I'd like you to ride your bike three times this week and eat at least four fruits and vegetables every day."

C. "I understand. Can you think of one reason why being mroe active would be helpful for you?" The transtheoretical model of change describes a series of changes that clients move through, starting with precontemplation and ending with maintenance. The first stage for this client would be to validate the client's opinion and move to the first part of precontemplation. The other options are later steps in the model.

Which of the following is an open-ended question the nurse might use when interviewing a client? A) "Do you have any concerns right now?" B) "Is your family worried about your being in the hospital?" C) "What do you mean when you say, 'I don't feel quite right'?" D) "How many times do you get up to go to the bathroom at night?"

C. "What do you mean when you say, 'I don't feel quite right'?" The way the nurse asks question 3 allows the client to respond completely and with more than a one-word answer. The other options allow the client to respond with one word and make it unlikely that the client will give additional information.

The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask? A) "How many times do you get up at night?" B) "How long have you been getting up at night?" C) "Why do you get up at night?" D) "How easily do you go back to sleep after you get up?"

C. "Why do you get up at night?" Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate problem, and this is why she is awakened. The nurse should not assume nocturia without further assessment questions.

nursing diagnosis is: A) The diagnosis and treatment of human responses to health and illness B) The advancement of the development, testing, and refinement of a common nursing language C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests

C. A clinical judgment about individual, family, or community responses toa ctual and potential health problems or life processes A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is not a disease condition or medical diagnosis, or the diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a development or refinement in nursing language.

Maslow's hierarchy of needs is useful to nurses, who must continually prioritize a client's nursing care needs. The most basic or first-level needs include: A) Self-actualization B) Love and belonging C) Air, water, and food D) Esteem and self-esteem

C. Air, water, and food The first level of Maslow's hierarchy of needs includes the need for air, food, and water—basic elements of survival. Love and belonging are on the second level, esteem and self-esteem are on the fourth level, and self-actualization is the final level.

A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of: A) Planning B) Evaluation C) Assessment D) Intervention

C. Assessment Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan.

A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using is: A) Commitment B) Scientific method C) Basic critical thinking D) Complex critical thinking

C. Basic critical thinking At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step. Complex critical thinkers separate themselves from authorities and analyze and examine choices more independently. Commitment is the third level of critical thinking in which the person anticipates the need to make choices without assistance from others. The scientific method is a process of problem solving.

What type of interview technique is the nurse using when the nurse asks the question, "Do you have pain or cramping?" A) Active listening B) Open-ended questioning C) Closed-ended questioning D) Problem-oriented questioning

C. Closed-ended question The example is a closed-ended question which the client can answer with a one-word reply. Open-ended questions allow the client to answer with more information. The other options are not correct.

The client is a 65-year-old overweight woman with multiple medical diagnoses, including diabetes mellitus type 2, hypertension, and residual right-sided weakness resulting from a previous cerebrovascular accident. What tool should be used to plan her care? A) Care plan B) Care map C) Concept map D) Critical thinking

C. Concept map A concept map is a visual representation of client problems and interventions that shows their relationships to each other and allows easy synthesis of data about the client.

Each science has a domain, which is the perspective of the discipline. This domain: A) Represents the recipients of the benefits of the science or discipline B) Is a model that explains the linkage of science, philosophy, and theory that is accepted and applied by the discipline C) Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline D) Is a dynamic state of being in which the developmental and behavioral potential of the individual is realized to the fullest

C. Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline The domain contains the subject, central concepts, values and beliefs, phenomena of interest, and the central problems of the discipline. A paradigm is a model that explains the linkage of science, philosophy and theory that is accepted and applied by the discipline.

"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to error in: A) Data collection B) Date clustering C) Diagnostic label D) Medical diagnosis

C. Diagnostic label The diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association (NANDA) International. The question does not discuss data collection, medical diagnosis, or data clustering.

Which of the following nursing interventions is written correctly? A) Change dressing once a shift. B) Perform neurovascular checks. C) Elevate head of bed 30 degrees before meals. D) Apply continuous passive motion machine during day.

C. Elevate head of bed 30 degrees before meals Option 3 is specific—it indicates what to do and when

17. The nursing process is an example of an open system. An open system: A) Is universal and dynamic B) Represents a relationship between two concepts C) Interacts with the environment by exchanging information D) Is a process through which information is returned to the system

C. Interacts with the environment by exchanging information An open system is defined as a system that interacts with the environment, exchanging information between the system and the environment.

The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the discussion the nurse reviewed information about loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is: A) Experience B) Problem solving C) Knowledge application D) Clinical decision making

C. Knowledge application The nurse sought appropriate information to be able to communicate more knowledgeably with the client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for problem resolution.

Which of the following models of health or illness defines health as a positive, dynamic state, not merely the absence of disease? A) Maslow's hierarchy of needs B) Rosenstoch's health belief model C) Pender's health promotion model D) The holistic health model of nursing

C. Pender's health promotion model Pender's health promotion model was developed to be a "complementary counterpart to models of health protection." This model defines health as a positive, dynamic state, not merely the absence of disease. Maslow's hierarchy of needs defines what is necessary for human survival and health, such as food, water, safety, and love. Rosenstoch's health belief model addresses the relationship between a person's belief and behaviors. It predicts how clients will behave in relation to their health and how they will comply with their health regimen. The holistic health model creates conditions that promote optimal health.

During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the client makes two attempts it is clear that the client does not understand how to prepare the correct dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an example of: A) Reflection B) Risk taking C) Problem solving D) Client assessment

C. Problem Solving This is an example of problem solving because the nurse is taking a problem to a supervisor for help in finding a different approach. Reflection is the process of purposefully thinking back and recalling a situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client assessment is the first step in the process of instruction.

8. Before performing a procedure for the first time at a new agency, the travel nurse: A) Refuses to perform the procedure B) Asks the charge nurse how to perform the procedure C) Reads about the procedure in the policy and procedure manual D) Performs the procedure as at the agency where the nurse previously worked

C. Reads about the procedure in the policy and procedure manual Every agency has its own policies and way of performing procedures. The charge nurse may not know how the procedure should be performed or may explain it incorrectly. The procedure may be performed differently than in the previous agency. If the nurse refuses to perform procedures that are covered by the Nurse Practice Act, the nurse could be fired.

All of the following are considered internal variables that influence a client's health beliefs and practices except: A) Emotional factors B) Developmental stage C) Socioeconomic factors D) Perception of functioning

C. Socioeconomic factors Socioeconomic factors are considered external variables. A person seeks approval and support from neighbors, peers, and co-workers; this affects health beliefs and practices. Economic variables may affect a client's level of health. For example, a client with a fixed income who needs long-term medications may determine that food and shelter are more important than the medication; therefore, the client's health suffers. Perception of functioning is an internal variable. It is defined as the way an individual perceives his or her physical functioning and how it affects health beliefs and practices. Emotional factors are internal variables. These include a client's degree of stress, depression, or fear, which can influence health beliefs and practices. An individual's developmental stage is considered an internal variable. A client's thinking about health is dependent on his or her level of development.

A client comes into the clinic for a complete physical examination. The nurse obtains a health history and determines that the client is at risk for heart disease. Which of the following would lead the nurse to conclude this? A) The client is 25 years old. B) The client lives near a chemical plant. C) The client's father died of a heart attack at age 40. D) The client works as a carpet salesman.

C. The client's father died of a heart attack at age 40 Genetic predisposition to specific illnesses is considered a major physical risk factor. The client's father died of a heart attack at the age of 40, which increases the client's risk of heart disease and heart attack. Age may increase or decrease a client's susceptibility to certain illnesses. Age risk factors are often closely associated with other risk factors, such as family history and personal habits. The client is 25 years old; therefore, based on age alone, risk is low for heart disease at this time. The client lives near a chemical plant; this constant exposure to chemicals may lead to health problems. The physical environment in which a person works and lives can increase the likelihood that certain illnesses will occur, but without further information the nurse cannot assess the heart disease risk related to the client's possible chemical exposure.

A nurse is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment, the nurse anticipates the need to monitor the client's abdominal dressing, intravenous infusion, and drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which of the following situations? A) The family comes to visit the client. B) The client expresses concern about pain control. C) The client's vital signs change showing a drop in blood pressure. D) The charge nurse approaches the assigned nurse and requests a report at the end of the shift.

C. The client's vital signs change showing a drop in blood pressure A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site. Concern about pain control, including a thorough assessment focusing the client's pain, would be the second priority. The end-of-shift report and the family's visit are lesser priorities.

4. There is a contemporary move toward addressing nursing as a science or as evidenced-based practice. This suggests that: A) One theory will guide nursing practice. B) Scientists will make nursing decisions. C) Theories will be tested to describe or predict client outcomes. D) Nursing will base client care on the practice of other sciences.

C. Theories will be testing to describe or predict client outcomes Theories will be tested to describe or predict client outcomes as nursing is addressed as a science and an art. Scientists will not make nursing decisions, and nursing will base client care on the practice of nursing science, which will be guided by multiple theories.

Which of the following statements about prescriptive theories is accurate? A) They describe phenomena. B) They have the ability to explain nursing phenomena. C) They reflect practice and address specific phenomena. D) They provide a structural framework for broad abstract ideas.

C. They reflect paractice and address specific phenomena Prescriptive theories address nursing interventions for a phenomenon and predict the consequence of a specific nursing intervention. Descriptive theories describe the phenomena, speculate on the reason the phenomena occur, and predict nursing phenomena. Grand theories are broad and complex and provide a structural framework for broad, abstract ideas about nursing.

Mishel's theory of uncertainty in illness focuses on the experience of clients with cancer who live with continual uncertainty. The theory provides a basis for nurses to assist clients in appraising and adapting to the uncertainty and illness response and can be described as: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory

D. A middle-range theory Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Grand theories are described as broad and complex. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena

The type of theory that tests the validity and predictability of nursing interventions is: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory

D. A middle-range theory Prescriptive theory addresses nursing interventions and predicts the consequence of a specific nursing intervention. Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Grand theories are broad and complex.

On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse have their backs turned to each other, and both have their arms folded across their chests. The best action for the nurse to take at this time is to: A) Introduce himself or herself and begin discharge teaching. B) Proceed with the tasks the nurse was intending to perform. C) Say nothing and leave quickly, closing the door behind. D) Ask the client and spouse if they need some time alone right now.

D. Ask the client and spouse if they need smoe time alone right now. The situation suggests that the nurse entered during a stressful time. Offering privacy would be appropriate. Because the situation indicates tension between the couple, this is not the time to initiate teaching.

Which of the following is an example of an expected outcome statement in measurable terms? A) Client will be pain free. B) Client will have less pain. C) Client will take pain medication every 4 hours. D) Client will report pain intensity of less than 4 on a scale of 0 to 10.

D. Client will report pain intensity of less than 4 on a scale of 0 to 10 Reporting the level of pain on a numbered scale is a measurable, objective goal. The other options do not specify measurable outcomes.

The surgical unit has initiated the use of a pain rating scale to assess the severity of clients' pain during their postoperative recovery. The nurse assigned to a client can look at the pain flow sheet to see the client's pain scores over the last 24 hours. Use of the pain scale is an example of adherence to which intellectual standard?

D. Consistency Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same measurement scale to compare assessments. Relevance refers to how applicable the assessment is. An assessment has depth when it deals with less obvious issues. Specificity refers to the ability of the assessment to provide information about the particular problem of interest.

The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is the nurse demonstrating? A) Concern for safety B) Promotion of client health C) Colleague health education D) Control of adverse reactions

D. Control of adverse reactions The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not an issue. Requesting a laxative does not provide education.

A theory is a set of concepts, definitions, relationships, and assumptions or propositions to explain a phenomenon. The purposes of the components of a theory are to: A) Describe concepts or connect two concepts that are factual B) Formulate a perceptual experience to describe or label a phenomenon C) Express the global view about the individual, situations, or factors of interest to a specific discipline D) Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon

D. Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon Describing, explaining, predicting, and/or prescribing interrelationships among concepts are stated purposes of research.

During the change-of-shift report the night nurse states that a client mentioned having a bad experience with surgery in the past. The nurse was called away and was unable to continue the conversation with the client. The nurse tells the day shift nurse about the comment and notes that the client appears anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking? A) Integrity B) Discipline C) Confidence D) Perseverance

D. Discipline Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved.

The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis. This is an example of avoiding which type of error? A) Error in data clustering B) Error in data collection C) Error in data interpretation D) Error in making a diagnostic statement

D. Error in making a diagnostic statement When a nurse compares collected assessment data with defining characteristics for two diagnoses, the selection of the correct diagnosis is an example of avoiding an error in making a diagnostic statement. There is no indication the data clustering or interpretation were incorrect.

The purpose of assessment is to: A) Make a diagnostic conclusion. B) Delegate nursing responsibility. C) Teach the client about his or her health. D) Establish a database concerning the client.

D. Establish a database concerning the client The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related experiences, health practices, goals, values, and expectations. The other options are not purposes of assessment.

Which of the following is objective information to be recorded in the client's medical record? A) Anxious over upcoming test. B) Increasing stress over past 2 months. C) Performs breast self-examination monthly. D) Expelled 1 tablespoon of yellow sputum.

D. Expelled 1 tablespoon of yellow sputum Objective data are measurable data. Options 1, 2, and 3 describe data that cannot be measured by the nurse but depend on the client's reports; thus they are subjective data.

One of the purposes of the use of standard formal nursing diagnostic statements is to: A) Evaluate nursing care. B) Gather information on client data. C) Help nurses to focus on the role of nursing in client care. D) Facilitate understanding of client problems by different health care providers.

D. Facilitate understanding of client problems by different health care providers. The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the client's needs. The other options are not part of the reason for the development of nursing diagnostic statements.

All of the following are examples of active strategies of health promotion except: A) Exercise training B) Weight reduction C) Smoking cessation D) Fluoridation of drinking water

D. Fluoridation of drinking water Passive strategies of health promotion benefit individuals without any action by the individuals themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. Weight reduction is considered an active strategy of health promotion. With active strategies of health promotion, individuals are motivated to adopt specific health programs. Smoking cessation requires clients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk of disease. Exercise training meets the criteria for active strategies of health promotion because it actively involves the client in his or her own health.

A nurse assessing a client who comes to the pulmonary clinic asks, "Tell me what medications you are taking for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A) Value-belief pattern B) Cognitive-perceptual pattern C) Coping/stress tolerance pattern D) Health perception/health management pattern

D. Health perception/health management patern The health perception/health management pattern involves the client's self-report of health and well-being, how the client manages his or her health, and knowledge of preventative health practices. The cognitive-perceptual pattern involves sensory-perceptual patterns, language adequacy, memory, and decision-making abilities. The coping/stress tolerance pattern involves the client's ability to manage stress, sources of support, and the effectiveness of the patterns in terms of stress tolerance. The value-belief pattern involves the values, beliefs, and goals that guide the client's choices or decisions.

Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not: A) Include subjective data from the client. B) Perform a thorough physical examination. C) Use interpersonal and cognitive skills. D) Include inferences or interpretative statements not supported with data.

D. Include inferences or interpretative statements not supported with data The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.

A nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time frame? A) Indicate which outcome has priority. B) Indicate the time it takes to complete an intervention. C) Indicate how long the nurse is scheduled to care for the client. D) Indicate when the client is expected to respond in the desired manner.

D. Indicate when the client is expected to respond in the dsired manner The time limit sets measurable points to evaluate the client's response and movement toward meeting the outcome goals. The other options are incorrect.

The health belief model addresses the relationship between a person's belief and behaviors, therefore: A) A person who smokes does not follow the model. B) This model provides a basis for caring for clients of all ages. C) A person who does not take necessary medications does not follow the model. D) It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens.

D. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens. The health belief model provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens.

A client who is alert and awake is being transferred to another hospital with a copy of his medical records. Before the transfer the nurse must: A) Ask the hospital lawyer if this requires approval from the risk management department. B) Discuss the need to copy the medical records with the client's family. C) Be certain that the physician writes an order for the record to be copied. D) Obtain written permission to copy the medical records for the receiving hospital.

D. Obtain written permissin to copy the medical records for the receiving hospital Obtaining permission to copy the records demonstrates the nurse's understanding of the provisions of the Health Insurance Portability and Accountability Act (HIPAA). Discussing medical records with the client's family is inappropriate because the client's family does not make the decision for a client who is capable of making his own decision. Policies and procedures would already be in place for the nurse with regard to copying medication records. It is not necessary to call the hospital lawyer. Copying a client's medical record does not require a physician's order.

During data clustering, a nurse: A) Provides documentation of nursing care B) Reviews data with other health care providers C) Makes inferences about patterns of information D) Organizes cues into patterns that lead to identification of nursing diagnoses

D. Organizes cues into paterns that lead to identification of nursing diagnoses During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems. The other options are incorrect.

A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day. The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin should be given the morning of surgery. This is an example of: A) Problem solving B) Previous experience C) Clinical practice guideline D) Scientifically based clinical judgment

D. Scientifially based clinical judgment The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level. Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia.

As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, nursing relies on: A) Experimental research B) Nonexperimental research C) Physician-generated research D) Scientifically tested knowledge

D. Scientifically tested knowledge As a science, nursing draws on scientifically tested knowledge applied in the practice setting.

A nurse working in a special care unit for children with severe immunologic problems cares for a 3-year-old boy from Greece. The nurse is having difficulty communicating with the father. What is the appropriate action? A) Care for the boy the same as for any other client. B) Ask the manager to talk with the father and keep him out of the unit. C) Have another nurse care for the boy, because maybe that nurse will communicate better with the father. D) Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community.

D. Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community Acquiring cultural and language assistance will help the nurse understand the needs of both the father and the son. The other three options are not culturally sensitive or helpful to the client and his father.

The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic complications is emphasized. This is considered which level of preventive care? A) Illness prevention B) Tertiary prevention C) Primary prevention D) Secondary prevention

D. Secondary prevention Secondary prevention is prevention geared toward individuals who are already experiencing health problems or illness and who are at risk of experiencing complications or a worsening of their condition

A client-centered goal is a specific and measurable behavior or response that reflects: A) The physician's goal for the specific client B) The client's desire for specified health care interventions C) The client's response compared to that of another client with a similar problem D) The client's highest possible level of wellness and independence in function

D. The client' highest possible level of wellness and independence in function A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. The other options do not meet the definition of a client-centered goal.

Nursing's paradigm includes: A) Health, person, environment, and theory B) Concepts, theory, health, and environment C) Nurses, physicians, models, and client needs D) The person, health, environment/situation, and nursing

D. The person, health, environment/situation, and nursing Nursing's paradigm includes four linkages: the person, health, environment/situation, and nursing.

Evidence-based nursing practice is the end result of: A) Prescriptive theory B) Use of practical knowledge C) Application of theoretical knowledge D) Theory-generating and theory-testing research

D. Theory-generating and theory-testing research The result of theory-generating or theory-testing research is to increase the knowledge base of nursing. As these research activities continue, clients become the recipients of evidence-based nursing care.

The nursing diagnosis Readiness for enhanced communication is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis

D. Wellness nursing diagnosis The term readiness indicates a wellness nursing diagnosis. An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. A potential nursing diagnosis is a risk for diagnosis.

In order to determine whether an intervention was successful, the nurse evaluates the success of attaining a goal. Which of the following is an example of an evaluation? A) Dressing changed every 8 hours using sterile technique. B) Client will ambulate 500 feet 4 times a day with minimal assistance. C) Client performed quadriceps-setting exercises to right leg every 4 hours. D) Wound filling in with granulation tissue is red to pink without signs of infection.

D. Wound filling in with granulation tissue is red to pink without signs of infection Evaluation occurs after an intervention and indicates degree of achievement of goal attainment. The qualifier "will" indicates that this is a future event and does not evaluate current attainment of goal. Doing an intervention is not evaluating whether it was effective or not.

16. A review of systems (ROS) is based on information obtained from the client during the interview. This information is an example of ______________ data.

Subjective

The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?" This is an example of __________________ of assessment data.

Validation

The unit policy and procedure manual states that, for all clients admitted to the cardiac unit, if the client experiences chest pain, 1/150 grain nitroglycerin should be administered sublingually and an electrocardiogram should be obtained immediately. This is an example of a(n) _____________.

protocol