NUR 2101 Exam 3

Which patient situations require the completion of an incident report? (Select all that apply.) a. A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy. b. A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold. c. A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist. d. The nurse accidentally enters the wrong vital signs into the patient's medical record and corrects the error shortly afterward. e. The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.

a. A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy. c. A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist. Near misses such as medication errors that almost occurred should be documented with an incident report to help prevent the same problem from recurring in the future. Mishaps by visitors, vendors, or staff should always be documented in incident reports as well. Patient preferences for nursing care and food do not require incident reports. An incident report should not be completed if the nurse corrected the computer entry appropriately and there was no adverse impact on patient care.

Which technique by the nurse will facilitate communication with an older adult? a. Allow reminiscing. b. Use long sentences. c. Ask several questions in a row. d. Play soft music in the background.

a. Allow reminiscing. Allow older adults the opportunity to reminisce. Reminiscing has therapeutic properties that increase the sense of well-being. During conversation maintain a quiet environment that is free from background noise (turn off the TV). Allow time for conversation; do not ask several questions in a row. Avoid long sentences to explain the subject. Try to keep it short, simple, and to the point.

Which preoperative task may be delegated to the nursing assistant? a. Apply the patient's thromboembolism deterrent (TED) stockings. b. Teach the patient how to perform incentive spirometry exercises. c. Witness the patient's signature on the informed consent document. d. Make sure that the patient swallowed the prescribed preoperative medication.

a. Apply the patient's thromboembolism deterrent (TED) stockings. The nursing assistant may apply the patient's thromboembolism deterrent (TED) stockings. The nursing assistant may not teach the patient, witness the patient's signature, or make sure that medication was swallowed.

A nurse is caring for a patient who cannot speak clearly. Which technique should the nurse use to enhance conversation with this patient? a. Ask questions that require "yes" or "no" answers. b. Avoid communication aids to prevent embarrassment. c. Speak loudly and slowly to facilitate patient understanding. d. Finish the patient's sentences when the patient is unable to.

a. Ask questions that require "yes" or "no" answers. For patients who are mute, unable to speak, or cannot speak clearly, ask simple questions that require "yes" or "no" answers. Use normal volume and do not shout or speak too loudly. Do not finish the patient's sentences. Use communication aids as needed; do not avoid them.

Which interventions are appropriate to assist the patient who is exhausted and depressed from providing care to the spouse with advanced dementia? (Select all that apply.) a. Assist the patient to identify and utilize support systems. b. Teach the patient how to maintain a sleep and activity log. c. Arrange for intervals of respite care for the patient's spouse. d. Help the patient to find personal time to rest and recuperate. e. Educate the patient about advanced directive and living will options.

a. Assist the patient to identify and utilize support systems. c. Arrange for intervals of respite care for the patient's spouse. d. Help the patient to find personal time to rest and recuperate. The nurse should assist the patient to identify and utilize support systems for assistance with caring for the spouse. This will reduce feelings of abandonment and loneliness when caring for the spouse. Helping the patient to find personal time to rest and recuperate will allow self-care and increase patient coping skills. Arranging for intervals of respite care for the spouse will provide breaks from the constant caregiving duties of the patient. Maintaining a sleep/activity log and learning about advanced directives will not reduce caregiver role strain.

Which key elements are included in decentralized decision making? (Select all that apply.) a. Authority b. Autonomy c. Prioritization d. Responsibility e. Accountability

a. Authority b. Autonomy d. Responsibility e. Accountability Decentralized decision making includes responsibility, autonomy, authority, and accountability. Prioritization is not a key element but does help with organizing care.

Which action indicates the new nurse is fulfilling entry-level competencies? a. Communicating concerns to the patient's physician b. Developing a theoretical framework for practice c. Creating a quality improvement plan for the unit d. Monitoring staff compliance with unit policies

a. Communicating concerns to the patient's physician The entry-level nurse is expected to effectively communicate concerns to the patient's physician. Developing a theoretical framework, creating a quality improvement plan, and monitoring staff compliance are not responsibilities of the entry-level nurse.

Which educational topic is the highest priority for a patient who has received a new prescription for sildenafil? a. Condoms must be used to prevent spread of STIs even though contraception is not needed. b. The sildenafil tablet may be split into two pieces if the patient has difficulty swallowing the tablet whole. c. Sildenafil is most effective when the tablet is taken approximately 1 hour before sexual activity. d. Eating a high-fat meal before taking sildenafil may reduce effectiveness of the medication.

a. Condoms must be used to prevent spread of STIs even though contraception is not needed. Sexual activity due to medications like sildenafil has caused an increase in sexually transmitted infections in the elderly. Condoms must be used to prevent spread of STIs even though contraception is not needed. Teaching about splitting the pill, timing of the dosage, and dietary considerations are not as important as STI prevention.

A registered nurse works as a case manager on an orthopedic unit. What primary role is fulfilled by the nurse? a. Coordinating care for patients following joint replacement surgery b. Obtaining insurance preauthorization for joint replacement surgeries c. Providing bedside care to patients who have had joint replacement surgery d. Tracking infection rates and outcomes for patients after joint replacement surgery

a. Coordinating care for patients following joint replacement surgery The case manager coordinates care for patients with various departments such as physical therapists, dietitians, social workers, and such. Case managers do not provide direct care. Instead they collaborate with and supervise the care that other staff members deliver. The case manager does not obtain insurance preauthorization or track infection rates.

Which hormone is the most important factor for the physiological response to stress? a. Cortisol b. Glucagon c. Histamine d. Vasopressin

a. Cortisol Corticotropin stimulates the adrenal gland to increase the production of corticosteroids, including cortisol, the primary hormone impacting the stress response. Cortisol increases blood glucose, enhances the brain's use of glucose, and increases the availability of substances for tissue repair. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. Glucagon raises blood sugar levels. Histamine causes allergic reactions.

A patient telephones a crisis intervention hotline. The nurse assigned to this center assesses that the patient is experiencing a crisis. What is the most appropriate action for the nurse to take? a. Define the problem at hand and ensure that the patient is safe. b. Take control of the situation and tell the patient what needs to be done. c. Ask the patient how he would like to handle the crisis and follow through. d. Ask the patient to list all of his problems and prioritize which to deal with first.

a. Define the problem at hand and ensure that the patient is safe. Crisis intervention begins with defining the problem, ensuring patient safety, and providing support. First determine that a patient is safe and is not at risk for injury to self or others, and then use crisis intervention to examine alternatives, make plans, and obtain a commitment to positive action from the patient. Ideally these last three steps are completed collaboratively with a patient, but a patient in crisis may be unable to participate actively and may need a very directive approach or a crisis interventionist. Emphasize focusing on the specific problem, and help a patient to avoid all-encompassing, catastrophic interpretations.

The patient refuses to believe the physician's diagnosis and insists on a second opinion from a specialist. Which ego-defense mechanism is used by the patient? a. Denial b. Dissociation c. Deterioration d. Displacement

a. Denial Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one's surroundings. Deterioration is the worsening of a situation or patient condition.

The nurse informs the patient that a code pink is paged overhead when an infant is abducted from the hospital. What is the best description of the use of the term code pink in this situation? a. Denotative meaning b. Perceptual stereotype c. Emotional inflection d. Sender territoriality

a. Denotative meaning Code pink in this instance is a denotative meaning in that the term refers to infant abduction to providers within the agency. Individuals who use a common language share the denotative meaning of a word or phrase. Perceptual stereotyping prevents accurate interpretation of messages from others. Inflection refers to the tone and pitch of the voice during verbal communication. Territoriality refers to the physical space between the sender and the receiver.

An elderly patient with Alzheimer's disease tells the nurse that she will be baking cookies with her mommy when she gets home from school later that afternoon. Which nursing diagnosis is most appropriate for this patient? a. Disturbed personal identity related to delusional description of self b. Readiness for enhanced power related to desire for freedom of choices c. Risk for loneliness related to hospitalization and separation from family d. Chronic low self-esteem related to negative feelings about self-capabilities

a. Disturbed personal identity related to delusional description of self Disturbed personal identity reflects the patient's inability to distinguish between self and non-self. The patient believes that she is a young girl rather than an elderly woman so the diagnosis of disturbed personal identity is appropriate. The patient does not demonstrate a desire for freedom of choices, risk for loneliness or negative feelings about self-capabilities.

The nurse is caring for a patient who climbed out of bed and fell on the floor. What will the nurse do in regard to the incident report? (Select all that apply.) a. Document how the patient was found and a description of the injuries. b. Include recommendations for future fall prevention interventions. c. Note in the patient's chart that an incident report was completed. d. Indicate that the nursing assistant wasn't doing her job correctly. e. Document fall prevention steps that were in place before the patient fell.

a. Document how the patient was found and a description of the injuries. e. Document fall prevention steps that were in place before the patient fell. The nurse should document exactly how the patient was found and a description of the injuries using clear, objective terms. Subjective or judgmental statements about other staff members are never included. Any fall prevention steps that were in place before the patient fell should be included as well. Recommendations for future fall prevention interventions are not included in the incident report. No mention of the incident report is included in the patient's medical record.

The patient is severely injured in an accident but does not feel the pain until several hours afterward. Which type of hormone reduced the patient's sense of pain as part of the stress response? a. Endorphins b. Mineralocorticoids c. Prostaglandins d. Bradykinins

a. Endorphins Endorphins are hormones that interact with the opiate receptors in the brain to reduce the perception of pain and produce a sense of well-being. Mineralocorticoids control salt and water balance within the body. Prostaglandins cause vasodilation and inhibit platelet function. Bradykinins play a role in inflammation causing vasodilation and pain.

Which is the most appropriate nursing diagnosis to use for a patient with expressive aphasia following a stroke? a. Impaired verbal communication related to inability to speak and reply b. Readiness for enhanced comfort related to drooling and facial droop c. Deficient diversional activity related to lack of stimuli in hospital room d. Noncompliance related to inability to verbally answer questions

a. Impaired verbal communication related to inability to speak and reply Impaired verbal communication is the nursing diagnostic label used for a patient who has limited or no ability to communicate verbally. This diagnosis is useful for a wide variety of patients with special problems and needs related to communication. It is defined as difficulty or inability to use or understand language in interpersonal reactions. Readiness for enhanced comfort, deficient diversional activity, and noncompliance do not directly relate to the patient's inability to speak.

Which type of program is appropriate to educate staff about new fall prevention protocols that are to be implemented on the nursing unit? a. In-service education b. Advanced education c. Continuing education d. Certification education

a. In-service education In-service education programs are instruction or training provided by a health care agency or institution designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Some roles for RNs in nursing require advanced graduate degrees, such as a clinical nurse specialist or nurse practitioner. Continuing education is required for professionals in many states. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses' associations, professional nursing organizations, and educational and health care institutions.

Which sexual education concept is appropriate for a 3-year-old child? a. Little boys have a penis while little girls do not. b. Sometimes white liquid comes out of the penis. c. The penis gets bigger when it is ready to make a baby. d. The penis goes into the woman's body to make a baby.

a. Little boys have a penis while little girls do not. The 3-year-old child is just beginning to identify with a gender and realize that boys are different from girls. The 3-year-old child will be satisfied with a simple explanation that little boys have a penis while little girls do not. The 3-year-old child is not ready to learn how the penis is used to make a baby or that white liquid sometimes comes out of the penis.

The patient is frustrated after being treated poorly by providers due to lack of health insurance. Which type of factor is causing the stress for the patient? a. Rational b. Situational c. Maturational d. Sociocultural

d. Sociocultural Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Situational factors include work-related stress. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Rational factors are not a cause of stress.

The patient was not able to continue along the migraine headache critical pathway after suffering a stroke. Which terminology describes this deviation from the prescribed pathway? a. Negative variance b. Noncompliance with the treatment plan c. Risk-prone health behavior d. Care plan intolerance

a. Negative variance Any deviation from a critical pathway is termed a variance. A negative variance occurs when the patient develops a complication or new condition that leads to cessation or modification of the pathway. The patient did not demonstrate noncompliance with the treatment plan, risk-prone health behavior, or care plan intolerance.

The young child cries and tries to run away when after being told that a flu shot is to be administered. Which term best describes the psychological reaction of the child? a. Primary appraisal b. Ineffective denial c. Adventitious crisis d. Developmental crisis

a. Primary appraisal When a person encounters an event, there is an immediate process of primary appraisal or rating of the event. If this appraisal results in the event being identified as a potential harm, loss, threat, or challenge, the person has stress. Ineffective denial is not indicated as the child realized the injection would be administered shortly and became upset. An adventitious crisis is a major disaster such as an earthquake or fire. A developmental crisis is when new coping strategies are needed to deal with stages of maturation such as getting married or having a child.

Which leadership skills will the nursing student use when caring for patients? (Select all that apply.) a. Priority setting b. Time management c. Case management d. Careful delegation e. Team communication

a. Priority setting b. Time management d. Careful delegation e. Team communication Priority setting, time management, delegation, and team communication are all leadership skills. Student nurses do not perform case management and case management is not a leadership skill but an approach to delivery of patient care.

Which specifics of care will be included in a patient's critical pathway? a. Refer the patient to the outpatient cardiac rehabilitation program. b. Elevate the head of the patient's bed to ease shortness of breath. c. Provide small meals throughout the day and encourage fluid intake. d. Teach the patient how to use relaxation techniques to ease shortness of breath.

a. Refer the patient to the outpatient cardiac rehabilitation program. Critical pathways are usually organized according to categories such as activity, diet, treatments, protocols, and discharge planning. The case-management plan incorporates critical pathways, which standardize practice and improve interdisciplinary coordination. Referral of the patient to the outpatient cardiac rehabilitation program would be included in the critical pathway. Elevating the head of the patient's bed, providing small meals, and teaching relaxation techniques would be considered independent nursing interventions that fall outside the realm of the critical pathway.

A young child begins wetting the bed again after the parents bring home a new baby sister. Which ego-defense mechanism is used by the child? a. Regression b. Conversion c. Identification d. Compensation

a. Regression Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Identification is the adoption of another person's behaviors or mannerisms.

At the nursing station, the nurse receives a verbal order from the physician for a routine medication. What is the best action of the nurse? a. Request that the doctor enter the order into the computer. b. Repeat the order to the doctor and enter it into the computer. c. Direct the unit secretary to enter the order into the computer. d. Call the pharmacy to determine that the drug dosage is appropriate.

a. Request that the doctor enter the order into the computer. Verbal orders should only be used when absolutely necessary such as patient emergencies. They should never be used for the physician's convenience. The nurse should direct the physician to enter the order into the computer to minimize the risk of an error. The nurse should not enter the order into the computer or direct the unit secretary to do it. Calling the pharmacy to determine the drug dosage may be done after the physician has entered the order into the computer.

The nurse is caring for a young adult patient who frequently participates in sexual activities after abusing alcohol. Which is the priority nursing diagnosis for this patient? a. Risk for sexually transmitted infection related to participation in unprotected sexual activity b. Risk for compromised human dignity related to exposure on social media c. Ineffective sexuality patterns related to alcohol-induced promiscuous behavior d. Impaired social interaction related to inability to maintain satisfying relationships

a. Risk for sexually transmitted infection related to participation in unprotected sexual activity Risk for sexually transmitted infection (STI) is the highest priority nursing diagnosis for this patient. Risk for compromised human dignity, ineffective sexuality patterns, and impaired social interaction are all less important than the development of a potentially fatal infection.

Which therapeutic communication techniques should the nurse use while communicating with a small child? (Select all that apply.) a. Sit at the child's eye level. b. Use simple, direct language. c. Use drawings and toys as needed. d. Tell the child exactly what they can do. e. Avoid sudden movements or gestures.

a. Sit at the child's eye level. b. Use simple, direct language. c. Use drawings and toys as needed. e. Avoid sudden movements or gestures. Sudden movements or gestures can be frightening so they need to be avoided. When giving explanations or directions, use simple, direct language and be honest. Meet a child at eye level. Drawing and playing with young children allows them to communicate nonverbally (making the drawing) and verbally (explaining the picture). Telling the child exactly what they can do is inappropriate. Remain calm and gentle and, if possible, let a child make the first move.

The nurse manager is overwhelmed as the unit prepares for an accreditation inspection. Which type of factor is causing the stress for the nurse manager? a. Situational b. Maturational c. Sociocultural d. Conventional

a. Situational Situational factors include work stress that happens with work overload (patient load, distractions, conflicting priorities), heavy physical work, long hour work shifts, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care professionals and staff. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Conventional factors are not a cause of stress.

The nurse is caring for a patient who no longer feels like a real woman after hysterectomy surgery. Which nursing diagnosis is most appropriate for this patient? a. Situational low self-esteem related to negative perception of self after removal of reproductive organs b. Risk for self-directed violence related to emotional distress and hormonal fluctuations c. Anticipatory anxiety related to concerns about feelings of inadequacy during recovery from surgery d. Deficient diversional activity related to boredom from hospitalization and need for increased rest after surgery

a. Situational low self-esteem related to negative perception of self after removal of reproductive organs Situational low self-esteem is a negative perception of a person's self-worth in response to a particular situation or event. In this case, the patient has a low self-esteem after removal of her reproductive organs. The patient does not demonstrate any risk for self-directed violence, anticipatory anxiety, or deficient diversional activity.

Which program is appropriate for a nurse who wishes to become an expert in ostomy and wound care? a. Specialty certification b. Master of Science program c. Doctoral degree program d. Continuing education program

a. Specialty certification Specialty certification programs are appropriate for nurses who wish to become experts in certain areas of nursing care such as perioperative care, wound care, or occupational health. Master of Science programs prepare nurses for advanced practice roles as educators, administrators, or clinical nurse leaders. Doctoral programs prepare nurses for advanced clinical practice and research. Continuing education is required for professionals in many states. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses' associations, professional nursing organizations, and educational and health care institutions.

Which health care professional will be of most assistance to help the patient with aphasia following a stroke? a. Speech therapist b. Medical interpreter c. Physical therapist d. Mental health nurse specialist

a. Speech therapist Speech therapists help patients with aphasia. The nurse should collaborate with other health care providers who have expertise in communication strategies. Medical interpreters are invaluable when a patient speaks a foreign language. Mental health advanced practice nurses help in communicating with angry or highly anxious patients. Physical therapists help with mobility issues.

The new mother experiences insomnia, irritability, and lack of appetite after several weeks in the neonatal care unit with her critically ill infant. Which nursing diagnosis is most appropriate for the new mother? a. Stress overload related to ongoing stress and worry about her critically ill infant b. Chronic low self-esteem related to lack of success at beginning of motherhood c. Disturbed sensory perception related to change in problem-solving abilities d. Disturbed personal identity related to inability to distinguish day shift from night

a. Stress overload related to ongoing stress and worry about her critically ill infant Stress overload related to ongoing stress and worry about her critically ill infant is the appropriate nursing diagnosis for the new mother. The new mother is at the exhaustion stage of the GAS due to the excessive demands of caring for her critically ill infant. The new mother does not demonstrate chronic low self-esteem, disturbed sensory perceptions, or disturbed personal identity.

The nurse is caring for a patient with the nursing diagnosis self-mutilation related to inability to cope with ongoing sexual abuse. Which interventions will the nurse include in the patient's plan of care? (Select all that apply.) a. Teach the patient appropriate alternative outlets for anger and pain. b. Assess and treat injuries using careful aseptic technique for wounds. c. Report the patient's situation to the state protective services department. d. Encourage the patient to forgive and forget in order to move on with life. e. Perform a physical examination to check for sexually transmitted infection.

a. Teach the patient appropriate alternative outlets for anger and pain. b. Assess and treat injuries using careful aseptic technique for wounds. c. Report the patient's situation to the state protective services department. e. Perform a physical examination to check for sexually transmitted infection. The patient's injuries must be carefully treated and the patient's situation must be reported to the appropriate state agency. A physical examination must be done to check for sexually transmitted infection. The nurse should teach the patient about appropriate alternative outlets for anger and pain instead of self-mutilation. The nurse should not encourage the patient to forgive and forget as that will not help the patient to cope with the pain of the abuse. The patient is not at a point of forgiveness if self-mutilation is needed to help cope with the pain.

Which patient assignment demonstrates the concept of team nursing? a. The RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift. b. The RN cares for the same five patients every day during their stay following joint replacement surgery. c. The hospice RN works closely with the patient's daughter to ensure that the patient's dying requests are met. d. The RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed.

a. The RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift. Team nursing is demonstrated when the RN, the LPN, and the nursing assistant work together to provide care needed by the patients. Primary care nursing is demonstrated when the RN cares for the same patients every day. Family-centered care is demonstrated when the RN works with the patient's daughter. Interprofessional collaboration is demonstrated when the RN coordinates care with the physician assistant.

Which action by the nurse demonstrates the concept of nurse autonomy? a. The nurse braids the patient's long hair to prevent tangles. b. The nurse directs the nursing assistant to obtain the patient's weight. c. The nurse counts the patient's pulse before administering digoxin. d. The nurse checks the policy manual before changing the central line dressing.

a. The nurse braids the patient's long hair to prevent tangles. Autonomy is the nurse's freedom to choose an appropriate action of care for the patient. The nurse demonstrates this by braiding the patient's long hair to prevent tangles. Delegation is demonstrated by directing the assistant to obtain the patient's weight. It is standard policy for nurses to check the patient's pulse for a full minute before administering digoxin. Checking the policy manual before performing a procedure demonstrates accountability.

Which actions of the nurse demonstrate the nursing role of leader? (Select all that apply.) a. The nurse implements a new skin-care protocol to reduce decubitus ulcers. b. The nurse develops a therapeutic relationship with the patient's family members. c. The nurse ensures that the patient assignments are created fairly for each shift. d. The nurse works to meet the patient's cultural preferences for personal care. e. The nurse clearly communicates expected standards of care for the patients.

a. The nurse implements a new skin-care protocol to reduce decubitus ulcers. c. The nurse ensures that the patient assignments are created fairly for each shift. e. The nurse clearly communicates expected standards of care for the patients. The nurse functions as a leader by implementing new protocols, ensuring that patient assignments are made fairly and clearly communicating the expected standards of care. Developing a therapeutic relationship and meeting the cultural preferences of patients are both caring behaviors of the nurse.

Which actions of the nurse demonstrate the nursing role of educator? (Select all that apply.) a. The nurse teaches the patient's family how to perform sterile dressing changes. b. The nurse includes the patient in clinical decision making whenever possible. c. The nurse provides written teaching materials in the patient's preferred language. d. The nurse speaks about diabetes management at a professional conference. e. The nurse assesses for adequate protein intake for a patient on a vegetarian diet.

a. The nurse teaches the patient's family how to perform sterile dressing changes. c. The nurse provides written teaching materials in the patient's preferred language. d. The nurse speaks about diabetes management at a professional conference. The nurse acts as an educator by teaching the patient's family about care and speaking at professional conferences. Written teaching materials should be provided in the patient's preferred language to maximize learning and retention of information. Determining protein intake is part of the assessment process. Including the patient in clinical decision making demonstrates the role of nurse as advocate.

The nurse is caring for a patient who has just been diagnosed with amyotrophic lateral sclerosis (ALS). Which assessment findings justify the diagnosis of ineffective denial related to fear of loss of body function and death for the patient? (Select all that apply.) a. The patient attempts to hide shortness of breath from the nurse. b. The patient has fallen twice after insisting that a walker is not needed. c. The patient uses a gastrostomy tube for nutrition when unable to swallow. d. The patient attends support group meetings for families and patients with ALS. e. The patient insists that an uneven sidewalk caused a fall rather than leg weakness.

a. The patient attempts to hide shortness of breath from the nurse. b. The patient has fallen twice after insisting that a walker is not needed. e. The patient insists that an uneven sidewalk caused a fall rather than leg weakness. Ineffective denial occurs when the patient continues to deny the presence of an illness to the point where the patient's health is endangered. The patient demonstrates ineffective denial by trying to hide shortness of breath, refusing to use a walker, and insisting an uneven sidewalk caused a fall. Use of the gastrostomy tube and attendance at support group meetings do not demonstrate ineffective denial.

The nurse has just completed teaching the patient how to self-administer insulin injections. Which entry in the patient's chart demonstrates that the teaching was successful? a. The patient correctly self-administered his next scheduled dose of insulin. b. The patient denied having any questions or concerns about the procedure. c. Additional written instructions about how to perform the injection was provided. d. The patient identified the steps and equipment used for the injection.

a. The patient correctly self-administered his next scheduled dose of insulin. Having the patient self-administer the next dose of insulin in front of the nurse will demonstrate competence and any areas that require reinforcement or correction. Asking the patient if there are any questions will not demonstrate competency as the patient may not be truthful about concerns. Providing additional written materials or identifying pieces of equipment will not demonstrate patient competency in the skill.

A nurse is using SBAR. Which information will the nurse report for the "B"? a. The patient has a fractured right leg with a cast that was applied 2 days ago. b. The patient's toes are cool and pale and the patient reports that the foot feels numb. c. The patient is reporting severe pain 1 hour after pain medication was given. d. The nurse requests that the primary health care provider examines the patient.

a. The patient has a fractured right leg with a cast that was applied 2 days ago. "B" stands for background. The information for the patient's background is the following: the patient had a broken right leg with a cast applied 2 days ago. Structured communication techniques used by health care teams that improve communication include briefings or short discussions among team member; group rounds on patients; and use of Situation-Background-Assessment-Recommendation (SBAR) when sharing information. "S" is the situation. The patient is reporting severe pain—10 out of 10—even after pain medication was given. "A" is assessment. The patient's toes are cool and pale. "R" is the recommendation. The nurse requests that the primary health care provider examines the patient.

Which action by the nurse demonstrates implementation of Florence Nightingale's original theories about nursing care? a. The patient is gently bathed and given fresh linens after giving birth. b. The nurse forms a close therapeutic relationship with the patient. c. The nurse helps the patient conserve energy for healing processes. d. The nurse views the patient as a unique, ever-changing energy field.

a. The patient is gently bathed and given fresh linens after giving birth. Florence Nightingale worked to improve sanitation and healing environments for patients. Gently bathing and providing fresh linens to patients is an example of Nightingale's theory in practice. Formation of a close therapeutic relationship with the patient, energy conservation, and viewing patients as energy fields were not concepts included in Nightingale's theory of nursing practice.

Which assessment findings will the nurse communicate to the physician using the SBAR tool? a. The patient is having difficulty breathing and the pulse oximetry is 75%. b. The patient has not had a bowel movement since surgery eight hours ago. c. The patient's family member initially refused to learn how to perform the dressing changes. d. The patient sent the breakfast tray back to the kitchen because the food was cold.

a. The patient is having difficulty breathing and the pulse oximetry is 75%. SBAR stands for situation, background, assessment, and recommendation. Use of common language when communicating critical information helps prevent misunderstandings. SBAR has become a best practice for standardizing communication between health care providers. SBAR is not used to communicate low-priority assessment findings such as constipation, initial refusal to learn, or cold breakfast trays.

Which information must be shared during the hand-off report to the oncoming nurse? a. The patient is nauseated and complaining of moderate generalized pain. b. The patient has six children and fourteen grandchildren. c. The patient will drink chicken broth but prefers to have lime gelatin. d. The patient sent back the dinner tray twice because the food was cold.

a. The patient is nauseated and complaining of moderate generalized pain. The hand-off information must communicate priority patient assessment data, changes in the patient's condition, and any recent or anticipated changes to the treatment plan. The number of children and grandchildren in the patient's family, clear liquid preferences, and returned dinner trays may be shared with the oncoming nurse but are not priorities.

Which information must be included in the patient's discharge summary? (Select all that apply.) a. The patient is to follow up with the primary care physician in 14 days. b. The patient arrived at the hospital by ambulance with acute shortness of breath. c. Supplemental oxygen was administered to the patient in the emergency room. d. The patient is to have a protime (PT) level drawn daily for the next 7 days. e. The patient is to take the prescribed antibiotic daily even after symptoms subside

a. The patient is to follow up with the primary care physician in 14 days. d. The patient is to have a protime (PT) level drawn daily for the next 7 days. e. The patient is to take the prescribed antibiotic daily even after symptoms subside The discharge summary should include directions for medications, follow-up appointments with physicians, and ongoing laboratory testing. The patient's condition on arrival to the hospital and emergency treatment do not need to be included.

The patient's daughter requests to see the patient's medical record. What is the nurse's appropriate response? a. "Come with me and we will look at it together." b. "I'm sorry but that information is confidential." c. "Let me ask my supervisor if it is okay." d. "The doctor will have to give permission first."

b. "I'm sorry but that information is confidential." Nurses may not disclose information about patients' status to other patients, family members unless specifically granted in writing by the patient. Looking at the medical record together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. The doctor does not give permission for the daughter to look at the patient's medical records.

The patient requests that her chart be destroyed as soon as she is discharged. What is the best response of the nurse? a. "The hospital can give you the chart after you are discharged." b. "Your chart will be kept secure and confidential." c. "The information must be reported to the health department first." d. "Your chart can be shredded if you give consent."

b. "Your chart will be kept secure and confidential." The patient's hospital record may not be destroyed after the patient is discharged. The patient should be reassured that all of the information in the record will be kept secure and confidential.

The nurse is caring for a patient who suddenly becomes acutely short of breath. The nurse elevates the head of the patient's bed, checks the patient's pulse oximetry, and administers 2 L of oxygen before notifying the patient's physician. Which term best describes the actions of the nurse? a. Accountability b. Autonomy c. Licensure d. Certification

b. Autonomy Autonomy is essential to professional nursing and involves the initiation of independent nursing interventions without medical orders. Accountability means that you are professionally and legally responsible for the type and quality of nursing care provided. To obtain licensure in the United States, RN candidates must pass the NCLEX-RN® examination administered by the individual State Boards of Nursing to obtain a nursing license. Beyond the NCLEX-RN®, some nurses choose to work toward certification in a specific area of nursing practice.

Which assessment finding is expected for a patient who was just chased by an attacker? a. Blood sugar 45 mg/dL b. Blood pressure 180/94 c. Pulse rate 55 beats/minute d. Hyperactive bowel sounds

b. Blood pressure 180/94 In the early part of the twentieth century, the fight-or-flight response was described. This arousal of the sympathetic nervous system prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, heart rate, respiratory rate, and blood glucose levels.

The patient reports using history of ibuprofen for arthritis pain after telling the nurse about a severe allergy to NSAID medications. The nurse asks the patient to further explain the allergy and use of ibuprofen. Which action is demonstrated by the nurse? a. Focusing b. Clarifying c. Summarizing d. Sharing observations

b. Clarifying The nurse's request for more information is used to clarify the patient's conflicting statements. Clarifying validates whether the person interpreted the message correctly. Focusing directs conversation to a specific topic or issues when a discussion becomes unclear. Summarizing provides a concise review of main ideas. Sharing observations is commenting on a patient's appearance and how he or she sounds and acts such as, "I see you didn't eat any breakfast."

The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which ego-defense mechanism is used by the patient? a. Conversion b. Dissociation c. Compensation d. Reimbursement

b. Dissociation Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one's surroundings. The patient is demonstrating dissociation by immersion in the mind-numbing details of funeral planning. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Reimbursement is not an ego-defense mechanism.

The patient verbalized frustration to the nurse about the lengthy recovery time after surgery. The nurse's response was "I understand how you want to be feeling better already." Which communication technique was used by the nurse? a. Sympathy b. Empathy c. Focusing d. Self-disclosure

b. Empathy Empathy is the ability to understand and accept another person's perspective. Although no one can ever totally know another's experiences, a nurse can try to understand what the person is experiencing. Focusing directs conversation to a specific topic or issue when a discussion becomes unclear. Self-disclosures are personal statements intentionally revealed to the other person. Sympathy is the concern, sorrow, or pity that you feel for a patient when you personally identify with his or her needs. Unlike empathy, which tries to understand a patient's experience, sympathy takes a subjective look at the patient's world.

The nurse is caring for a patient who feels useless after chronic illness has left the patient unable to work. Which intervention will be most beneficial for this patient? a. Tell the patient that a fulfilling life is about more than just a career. b. Encourage the patient to participate in activities that support and help others. c. Use reminiscence therapy to help the patient remember enjoyable activities. d. Help the patient to start a daily journal to record and express emotions.

b. Encourage the patient to participate in activities that support and help others. The patient needs to feel useful again in order to relieve feelings of uselessness. The patient can do this by participating in activities that support and help others. The patient can use skills and abilities that remain after chronic illness. Remembering enjoyable activities and recording emotions will not help the patient to feel useful. Telling the patient that a fulfilling life is about more than just a career is condescending and not helpful.

Which is the priority intervention for an elderly patient with the nursing diagnosis ineffective sexuality pattern related to vaginal dryness? a. Help the patient to communicate the need for privacy for sexual activity. b. Encourage the patient to utilize a water-based vaginal lubricant for comfort. c. Let the patient know that vaginal dryness is a normal finding in older women. d. Instruct the patient to void immediately after intercourse to prevent irritation.

b. Encourage the patient to utilize a water-based vaginal lubricant for comfort. The patient should be encouraged to use a water-based vaginal lubricant for comfort as vaginal dryness is the cause of the sexual difficulty. Ensuring privacy and voiding after intercourse will not reduce vaginal dryness. Letting the patient know that vaginal dryness is a normal finding in older women does not help to solve the problem.

The patient is overwhelmed by the stresses of being a spouse, new parent, and full-time employee. The nurse encourages the patient to use a housekeeper, babysitter, friends, or relatives to help reduce personal responsibilities and obligations. Which stress-relieving technique was recommended for the patient? a. Assertiveness training b. Engaging support systems c. Mindfulness stress reduction d. Progressive muscle relaxation

b. Engaging support systems The nurse encourages engagement of support systems to relieve the patient's overwhelming duties. The patient will be better able to cope if a support system can assist with some of the patient's personal responsibilities and obligations. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress. When a group leader teaches assertiveness, the effects of interacting with other people increase the benefits of the experience. Progressive muscle relaxation diminishes physiological tension through a systematic approach to releasing tension in major muscle groups. Mindfulness stress reduction is a form of meditation to reduce symptoms of stress.

A nurse is caring for a patient who is visually impaired. Which technique will the nurse use to facilitate communication? a. Touch the patient before speaking. b. Identify self when entering the room. c. Quietly leave the room when finished. d. Keep the room dimly lit for calmness.

b. Identify self when entering the room. For a visually impaired patient, identify yourself when entering the room. The nurse should communicate verbally before touching the patient who is visually impaired. Notify the patient when leaving the room; do not quietly leave the room when finished as the patient will think you are still in the room. Ensure that lighting is adequate for the patient to see the speaker; do not keep it dimly lit.

Which technique should the nurse use when providing information to a patient with a health literacy level of fifth grade? a. Use the passive voice of language. b. Present the most important information first. c. Use medical terminology to explain the concepts. d. Shift from subject to subject until the patient responds.

b. Present the most important information first. To promote understanding in a patient with a health literacy level of fifth grade is to present the most important information first. Use the active voice instead of passive. Break complex information into understandable chunks; do not shift from subject to subject. Use simple language, avoid medical jargon.

The nurse educates the patient about what to expect during suctioning of the tracheostomy tube. Which term best describes the patient's communication role? a. Channel b. Receiver c. Message d. Sender

b. Receiver The patient is the receiver in this scenario, as they have received the message. The nurse is the sender in this scenario. The sender is the person who delivers the message. The message is the content of the conversation; in this scenario explaining what will happen is the message. The channel is the means of conveying and receiving messages through visual, auditory, and tactile senses, the nurse's spoken words in this scenario.

After a patient fall, the supervisor asks the nurse to rewrite the entry in the patient's chart to show that the patient's bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Remind the supervisor that it is against regulations to alter or falsify the patient's chart. c. Ask the nurse assistant to chart that the patient's bed was lowered to the floor at the time of the fall. d. Rewrite the entry as requested but note that the patient's bed was not lowered to the floor in the incident report.

b. Remind the supervisor that it is against regulations to alter or falsify the patient's chart. It is against regulations to alter or falsify the patient's medical record regardless of the intent or desire to avoid a malpractice lawsuit. The nurse should never ask the nurse assistant to falsify information. The information in the incident report and patient chart should be factual and consistent.

Which nursing diagnosis has the highest priority for the patient following a stroke? a. Unilateral neglect related to disturbed perception about left side of body b. Risk for aspiration related to impaired swallowing and absence of gag reflex c. Constipation related to decreased physical activity and medication side effects d. Adult failure to thrive related to apathy and depression about physical disability

b. Risk for aspiration related to impaired swallowing and absence of gag reflex Risk for aspiration is the highest priority diagnosis as aspiration pneumonia may be life-threatening. Unilateral neglect, constipation, and adult failure to thrive may be addressed after risk for aspiration.

Which action by the nurse will help to reduce the fears of a hospitalized young child? a. Stand over the bed when talking to the patient. b. Sit in a chair next to the bed when talking to the patient. c. Maintain constant eye contact with the patient at all times. d. Stay within 12 inches of the patient when talking to the patient.

b. Sit in a chair next to the bed when talking to the patient. The nurse should sit in a chair next to the bed. A nurse appears less dominant and less threatening when interacting at the patient's eye level. Looking down on a person (standing by the bed) establishes authority, but interacting at the same eye level indicates equality in the relationship. Constant eye contact can be intrusive or threatening to some people. Twelve inches is within the intimate zone and can be threatening.

Which behavior best demonstrates active listening by the nurse? a. Keeping arms crossed b. Sitting facing the patient c. Standing facing the patient d. Leaning away from the patient

b. Sitting facing the patient The best behavior is sitting facing the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient. Several nonverbal skills facilitate attentive listening, which are identified by the acronym SOLER: Sit facing the patient. Observe an open posture. Lean toward the patient. Establish and maintain eye contact. Relax. Keeping arms crossed is a closed posture. Leaning toward, not away, from the patient is active listening. Sitting, not standing, is best.

The nurse feels that an assigned duty is outside the scope of nursing practice. Which document is the best source to answer the nurse's concern? a. ANA Code of Ethics b. State Nurse Practice Act c. QSEN Initiative Act d. Nurse's Bill of Rights

b. State Nurse Practice Act In the United States each State Board of Nursing oversees its Nurse Practice Act (NPA), which regulates the scope of nursing practice for the state and protects public health, safety, and welfare. The ANA's Code of Ethics for Nurses: Interpretation and Application (2010) provides a guide (not a law) for carrying out nursing responsibilities to ensure high-quality nursing care and provide for the ethical obligations of the profession. The Quality and Safety Education for Nurses (QSEN) initiative responds to reports about safety and quality patient care by the National Academy, Health and Medicine Division. The Nurses' Bill of Rights is a statement about the professional rights of nurses and does not dictate the scope of practice for nurses.

Which characteristic qualifies the hospital for Magnet Recognition status? a. The hospital is affiliated with a nationally recognized medical school. b. The hospital participates in nursing research and implements the findings. c. The hospital is owned by a religious order that offers daily prayer services. d. The hospital receives federal grant funding for advanced medical research.

b. The hospital participates in nursing research and implements the findings. Magnet Recognition status is awarded by the American Nurses Credentialing Center to recognize hospitals that deliver high-quality nursing care. Magnet status does not reflect federal grant funding for medical research, religious order ownership, or affiliation with a medical school.

Which action of the nurse demonstrates patient-centered care? (Select all that apply.) a. The nurse elevates the head of the bed when the patient becomes short of breath. b. The nurse and patient work together to determine the patient's health goals. c. The nurse checks the patient's name and birthdate before giving medications. d. The nurse maintains privacy when conversing with the patient and providing care. e. The nurse respects the patient's choice to refuse transfusion of blood products.

b. The nurse and patient work together to determine the patient's health goals. d. The nurse maintains privacy when conversing with the patient and providing care. e. The nurse respects the patient's choice to refuse transfusion of blood products. Patient-centered care is demonstrated by maintaining privacy, respecting the patient's choices and working together to determine the patient's health goals. Checking the patient's identifiers and elevating the head of the bed are routine nursing interventions that do not demonstrate patient-centered care.

Which action by the nurse manager facilitates empowerment of the nursing staff? a. The nurse manager sets the policies for the nursing staff to follow. b. The nurse manager works with the staff to set annual goals for the unit. c. The nurse manager advocates for patients when care difficulties develop. d. The nurse manager prioritizes patient care needs when creating assignments.

b. The nurse manager works with the staff to set annual goals for the unit. The nurse manager facilitates empowerment of the nursing staff by using their input to set annual goals and provide the best possible care for patients. Empowerment is not facilitated by advocating for patients, prioritizing patient needs, or setting policies for the nursing staff to follow.

Which nursing actions incorporate informatics into nursing practice? (Select all that apply.) a. The nurse uses written materials to teach a patient who is hard of hearing. b. The nurse uses an online database to learn more about the patient's disease. c. The nurse uses a bar-code scanner to prevent medication administration errors. d. The nurse teaches the patient's family how to perform range of motion. e. The nurse checks the electronic record to review the patient's medical history.

b. The nurse uses an online database to learn more about the patient's disease. c. The nurse uses a bar-code scanner to prevent medication administration errors. e. The nurse checks the electronic record to review the patient's medical history. Informatics is the use of technology such as electronic medical records, online databases for research and bar-code scanning to prevent medication errors. Informatics does not apply to patient teaching through written materials or demonstration of range of motion.

Which action by the nurse demonstrates appropriate timing for effective communication? a. The nurse sits in a chair next to the patient's bed to maintain eye contact. b. The nurse waits to begin teaching until the patient's nausea has subsided. c. The nurse speaks slowly and loudly for a patient who is hard of hearing. d. The nurse maintains privacy during all conversations with the patient.

b. The nurse waits to begin teaching until the patient's nausea has subsided. The nurse demonstrates appropriate timing by waiting to begin teaching until the patient's nausea has subsided. Timing must be appropriate in order for the receiver to understand the message. The nurse demonstrates pacing by speaking slowly for a patient who is hard of hearing. Timing does not refer to ensuring privacy or maintaining eye contact.

Which action of the nurse demonstrates coordination of care for the patient? a. The nurse creates a warm, therapeutic relationship with the patient by actively listening to what the patient has to say. b. The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair. c. The nurse educates the patient about energy conservation techniques to increase activity tolerance. d. The nurse uses clear and objective language when documenting assessment findings in the patient's medical record.

b. The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair. Coordination of care involves working with other health care professionals to meet the needs of the individual patient. The nurse can do this by working with the physical therapist to determine how to best transfer the patient from the bed to the chair. Developing a warm therapeutic relationship demonstrates caring and effective communication. Educating the patient about energy conservation and charting clearly are not examples of coordination of care.

The patient developed a large hematoma where the laboratory technician drew blood earlier in the shift. Which statement is appropriate to enter in the patient's chart? a. The laboratory technician did not know what he was doing and traumatized the patient's arm. b. The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture. c. The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised. d. The patient must have moved during the blood draw because there is a huge bruise on his left arm.

b. The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture. Charting must be clear and factual without guesses or opinions. The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture reflects objective documentation of the patient's hematoma.

When the nurse takes the patient's hand, the patient quickly pulls it back. How will the nurse interpret this patient's behavior? a. The patient is unable to express feelings. b. The patient is uncomfortable with being touched. c. The patient has impaired social skills with others. d. The patient has difficulty with nonverbal communication.

b. The patient is uncomfortable with being touched. Nurses need to remain sensitive to their actions as well as the patient's feelings. If a patient refuses to hold a nurse's hand while in pain or pulls away from physical contact, this signals that the patient is uncomfortable with being touched by the nurse. It does not imply impaired social skills, inability to express feelings, or difficulty with nonverbal communication.

Which statement exemplifies important patient information in the change-of-shift report? a. The patient sent his dinner tray back to the kitchen twice because the food was cold. b. The patient keeps taking his nasal cannula off and threading it around the side rails of the bed. c. The patient prefers to drink coffee that has cooled to room temperature with two sugars and two creamers. d. The patient took all of the prescribed morning medications with a big glass of apple juice.

b. The patient keeps taking his nasal cannula off and threading it around the side rails of the bed. A change-of-shift report is a hand-off and provides information to ensure continuity and individualized care for patients. Important information should be communicated to make the most efficient use of the nurses' time. The oncoming nurse must be told that the patient frequently takes off the nasal cannula as the patient may become hypoxemic. The other pieces of information are less important.

Which chart entry reflects appropriate documentation of patient data? a. The patient voided a moderate amount of urine. b. The patient voided 220 mL of clear yellow urine. c. The patient was incontinent. d. The patient voided an adequate amount of urine for the shift.

b. The patient voided 220 mL of clear yellow urine. The use of precise measurements makes documentation more accurate. For example, documenting "Voided 450 mL clear urine" is more accurate than "Voided an adequate amount." Small and moderate are not as accurate as precise measurement. Patient incontinent of urine does not tell how much and although accurate is not as accurate as a precise measurement.

Which patient's needs must be addressed first by the registered nurse? a. The patient who is waiting for discharge teaching in order to go home b. The patient with chest pain after two doses of sublingual nitroglycerin c. The constipated patient who needs to use the toilet after receiving a laxative d. The patient who is nauseated and vomiting after receiving narcotic pain medication

b. The patient with chest pain after two doses of sublingual nitroglycerin The patient with chest pain that continues despite two doses of sublingual nitroglycerin should be addressed first by the registered nurse. The other patient needs can be addressed after the chest pain is resolved.

Which nursing leadership approach demonstrates decentralized management? a. The nurse manager sets unit policies, conducts annual reviews, and disciplines the staff as needed. b. The staff nurses work with the manager to review care options to prevent surgical site infections. c. The nurse manager conducts regular staff meetings to provide updates about new equipment and agency policies. d. The nurse manager makes rounds on the unit every day to monitor for problems with patient care.

b. The staff nurses work with the manager to review care options to prevent surgical site infections. Decentralized management is demonstrated when the staff nurses take on leadership roles alongside the nurse manager so that decisions may be made at the staff level. Daily patient rounds, regular staff meetings, and manager-set policies do not demonstrate decentralized management.

Which approaches will the nurse use in order to effectively participate in interprofessional collaboration? (Select all that apply.) a. Utilize a top-down communication strategy. b. Work to maintain a climate of mutual respect. c. Support a team approach to the maintenance of health. d. Use role-specific knowledge to address health care needs. e. Apply relationship-building values and principles of team dynamics.

b. Work to maintain a climate of mutual respect. c. Support a team approach to the maintenance of health. d. Use role-specific knowledge to address health care needs. e. Apply relationship-building values and principles of team dynamics. Competencies needed for effective interprofessional collaboration include: 1. Work with individuals of other professions to maintain a climate of mutual respect and shared values. 2. Use the knowledge of one's own role and those of other professions to appropriately assess and address the health care needs of patients and populations served. 3. Communicate with patients, families, communities, and other health care professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and treatment of disease. 4. Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient- and population-centered care that is safe, timely, efficient, effective, and equitable. Using a top-down communication strategy does not apply as a team approach, but is needed for interprofessional collaboration.

Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system? a. "I am thankful that I won't have to keep changing my passwords all the time." b. "I'll be able to see my son's medical record using my password and user ID." c. "I won't have to worry about reading the doctor's messy handwriting anymore." d. "It will take me so much less time than writing everything out on paper."

c. "I won't have to worry about reading the doctor's messy handwriting anymore." One of the main benefits of electronic medical record systems is that nurses and ancillary staff do not have to decipher illegibly written orders from providers. Electronic charting has not been shown to decrease documentation time. It will still be against HIPAA policy for the nurse to view family members' medical records. Passwords must be changed regularly for all new electronic medical record system in order to maintain security of the documents.

A nurse must give feedback to a nursing assistant that did not take vital signs. How will the nurse give feedback? a. "Did you miss the class about how to take vital signs?" b. "I refuse to work with you again if you cannot do your job." c. "The patient's vital signs were not taken. What happened?" d. "I cannot trust you to complete tasks that you are assigned."

c. "The patient's vital signs were not taken. What happened?" The best approach is to determine why the vital signs were not taken. Feedback given should be specific regarding any mistakes that staff members make, explaining how to avoid the mistake or a better way to handle the situation.

Which is the correct military time entry for a medication that was administered at 8:30 p.m.? a. 0830 b. 140 c. 2030 d. 2230

c. 2030 12 + 8 = 20 so... 8:30 + 12 = 20:30

Which nursing care concept is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient? a. Delegation b. Empowerment c. Accountability d. Responsibility

c. Accountability Accountability refers to liability or individuals being answerable for their actions. It involves follow-up and a reflective analysis of your decisions to evaluate their effectiveness. Delegation is the assignment of tasks to assistive personnel. Empowerment is the provision of self-esteem and confidence by management. Responsibility is the duty that the nurse is expected to perform.

The patient's spouse is overwhelmed and exhausted trying to provide the ongoing care required by the patient. Which nursing diagnosis is most appropriate for the patient's spouse? a. Activity intolerance related to fatigue and generalized weakness b. Readiness for enhanced comfort related to change in personal health status c. Caregiver role strain related to amount and complexity of patient health needs d. Risk for compromised human dignity related to loss of control of bodily functions

c. Caregiver role strain related to amount and complexity of patient health needs The patient's spouse is demonstrating caregiver role strain by feeling overwhelmed and exhausted trying to meet the patient's needs. The patient's spouse is not experiencing activity intolerance and is not at risk for compromised human dignity. The patient's spouse is exhausted and overwhelmed so readiness for enhanced comfort is not appropriate.

Which is the best strategy for the nurse to use when communicating with a patient from different culture? a. Using a cultural joke to break the ice b. Stereotyping the patient within his or her culture c. Considering the context of the patient's background d. Assuming the patient or the family member speaks English

c. Considering the context of the patient's background When a patient is from another culture, the nurse should consider the context of the patient's background. Accept patients' rights to adhere to cultural customs and norms. People of different cultures use different types of verbal and nonverbal cues to convey meaning. A nurse should make a conscious effort not to interpret messages through his or her own cultural perspective; instead, a nurse considers the context of the other individual's background. Avoid stereotyping people from other cultures or making jokes about them. With patients from another culture, the nurse cannot assume the patient or family members can speak English.

The nurse is mandated by the state to complete 25 contact hours of nursing education before the nursing license may be renewed. Which term best describes this requirement? a. In-service education b. Advanced education c. Continuing education d. Certification education

c. Continuing education Continuing education is required for professionals in many states. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses' associations, professional nursing organizations, and educational and health care institutions. In-service education programs are instruction or training provided by a health care agency or institution designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Some roles for RNs in nursing require advanced graduate degrees, such as a clinical nurse specialist or nurse practitioner.

The nurse is caring for an adolescent patient who dips snuff because all of his friends do it. Which self-concept need led the patient to do this? a. Body image b. Sexual identity c. Cultural identity d. Role performance

c. Cultural identity Cultural identity develops from identifying and socializing within an established group and through incorporating the responses of individuals who do not belong to that group into one's self-concept. Body image involves attitudes related to the perception of the body, including physical appearance, femininity and masculinity, youthfulness, health, and strength. Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband. Sexual identity refers to the patient's preference for sexual partners (i.e., homosexual, heterosexual).

The nurse is caring for an adolescent who feels overweight with a BMI of 16. Which nursing diagnosis is most appropriate for this patient? a. Risk-prone health behavior related to inadequate self-efficacy b. Noncompliance related to failure to adhere to healthy dietary plan c. Disturbed body image related to distorted view of ideal body weight d. Self-mutilation related to depersonalization and self-destructive behaviors

c. Disturbed body image related to distorted view of ideal body weight The patient has a distorted view of ideal body weight so disturbed body image is the most appropriate nursing diagnosis. There is no information to indicate risk-prone health behaviors, self-mutilation, or noncompliance.

The nurse realizes that the wrong patient's name was written on several important paperwork forms that were already signed by the attending physician. How will the nurse correct this error? a. Black out the error with a thick marker and enter the correct information. b. Use correction tape to write over the incorrect information. c. Draw one line through the error, make the correction and initial it. d. Shred the forms with the incorrect information and write on new ones.

c. Draw one line through the error, make the correction and initial it. The nurse should make draw one line through the error, make the correction, and initial it so there is no attempt to cover up the mistake. The error should not be blacked out or covered with correction tape as it will hide the information. The forms should not be shredded as they were already signed by the physician. Agency policy may indicate the physician should initial each change as well.

Which position is best suited for a nurse who preferred to study until the early hours of the morning during nursing school? a. Full-time 8-hour day/evening rotation b. Part-time 12-hour day/night rotation position c. Full-time 12-hour night position d. Full-time 8-hour day position

c. Full-time 12-hour night position In general, people doing shift work need to maintain as consistent a sleep and mealtime schedule as possible. Some nurses often ease their coping with shift work by knowing their own circadian rhythms. A nurse who typically thinks well at night and tends to sleep late in the morning will adapt better to night shift than to day shift. Rotating shifts prevent establishment of a consistent sleep and mealtime schedule.

The nurse is entering a note in the patient's medical record using the SOAP format. Which statement belongs in the Assessment section? a. The patient stated "I started feeling short of breath after smelling strong perfume." b. The patient is using accessory muscles and has wheezes in all lung fields. c. Ineffective airway clearance related to exposure to environmental allergen. d. Monitor pulse oximetry and administer nebulized bronchodilators.

c. Ineffective airway clearance related to exposure to environmental allergen. The Assessment section of the SOAP note describes the nurse's assessment of the situation, usually in the form of a nursing diagnosis such as ineffective airway clearance. The patient's feelings of dyspnea belong in the Subjective information section of the note. The patient's wheezes and use of accessory muscles belongs in the Objective section of the note. Monitoring pulse oximetry and administering bronchodilators belongs in the Plan section of the note.

The nurse manager rehearses what to say to a nurse who made a serious medication error. Which form of communication is being used by the nurse manager? a. Intonation b. Nonverbal c. Intrapersonal d. Orientation

c. Intrapersonal Intrapersonal communication, also called self-talk, is a powerful form of communication that occurs within an individual. People "talk to themselves" by forming thoughts internally that strongly influence perceptions, feelings, behavior, self-concept, and performance. Self-talk is a mental rehearsal for difficult tasks or situations so that individuals deal with them more effectively. Nonverbal communication uses body language, gestures, and eye contact to convey messages rather than spoken phrases. Intonation is inflection and pitch of the voice used to help convey a message. Orientation is the interview phase when the patient and nurse meet and get to know each other.

Which professional nursing organization ensures that nursing programs adequately prepare students to enter the nursing profession? a. Federal Nurses Association (FNA) b. International Council of Nurses (ICN) c. National League for Nursing (NLN) d. National Student Nurses Association (NSNA)

c. National League for Nursing (NLN) The National League for Nursing (NLN) oversees nursing educational programs to help ensure that students are well prepared to enter the nursing profession. The Federal Nurses Association (FNA) is for nurses who are on active duty within the American Armed Forces. The National Student Nurses Association (NSNA) provides a voice for nursing students and does not oversee nursing programs. The International Council of Nurses (ICN) is a global organization that promotes quality nursing care for all people.

Which is the first action of the nurse when starting care for the patient at the beginning of the shift? a. Administer prescribed medications. b. Conduct the patient's health history. c. Perform a focused patient assessment. d. Create the nursing care plan for the patient.

c. Perform a focused patient assessment. Assessment is the first step of the nursing process. The focused patient assessment should be completed first. The patient's health history may be completed after the focused assessment is done. Medications should not be administered without a focused patient assessment. The nursing care plan is created after the assessment is complete.

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician? a. Withhold the medication until the physician signs the order. b. Authorize the physician's order with the pharmacy. c. Read back the order to the physician for confirmation. d. Double-check the order with another registered nurse.

c. Read back the order to the physician for confirmation. The nurse receiving a verbal order or telephone order writes down the complete order or enters it into the computer as it is being given. Then the nurse reads it back, called read-back, and receives confirmation from the person who gave the order. The medication will still be given because in most institutions the health care provider has 24 hours to sign the order. Verification is in the read-back with the person who ordered the medication, not with pharmacy or another nurse.

Which action communicates to the patient that the nurse wants to leave the patient's room to care for other patients? a. Sitting in a chair next to the patient's bed b. Making sure the door is completely shut for privacy c. Repeatedly checking the clock to see what time it is d. Holding the patient's hand when the patient starts to cry

c. Repeatedly checking the clock to see what time it is Repeatedly checking the clock to see what time it is communicates to the patient that the nurse wishes to leave the room. Sitting next to the patient, ensuring privacy, and holding the patients hand are supportive nonverbal communications.

The patient tells the nurse that the spouse is only interested in sexual activity when inflicting physical pain on the patient. Which is the priority nursing diagnosis for the patient? a. Activity intolerance related to inability to fulfill spouse's sexual needs b. Ineffective sexuality pattern related to differing sexual activity expectations c. Risk for injury related to physical abuse from spouse during sexual activity d. Risk for compromised human dignity related to spouse's demeaning actions

c. Risk for injury related to physical abuse from spouse during sexual activity The highest priority nursing diagnosis is risk for injury as the patient may be physically hurt during sexual activity. The couple should be referred to therapy only after the patient's physical safety is ensured. Activity intolerance does not relate to the patient's inability to fulfill spouse's sexual needs. Ineffective sexuality pattern and risk for compromised human dignity should be addressed only after the patient's physical safety is ensured.

Which is the priority nursing diagnosis for an adolescent who is being bullied by peers? a. Powerlessness related to inability to stop bullying from peers b. Social isolation related to dysfunctional relationships with peers c. Risk for self-directed violence related to feelings of worthlessness d. Risk for loneliness related to inability to make supportive friendships

c. Risk for self-directed violence related to feelings of worthlessness Adolescents who are being bullied are at risk for violence toward themselves or toward others as they attempt to cope. Risk for self-directed violence is the highest priority nursing diagnosis as it can lead to significant injury or death. Powerlessness, social isolation, and risk for loneliness may be addressed once the potential for violence has been resolved.

Which intervention is appropriate for the nurse to reduce compassion fatigue? a. Increase nursing responsibilities at work. b. Hang out with co-workers when not at work. c. Strengthen relationships outside of the hospital. d. Take control over new areas at work to reduce stress.

c. Strengthen relationships outside of the hospital. Compassion fatigue occurs as a result of chronic stress and is often associated with the human service professions. Make a clear separation between work and home life. Strengthening friendships outside of the workplace, socially isolating oneself for personal "recharging" of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Identify the limits and scope of your responsibilities at work. Recognize the areas over which you have control and the ability to change and those for which you do not have responsibility.

Which agency creates standards that require nursing documentation to be accurate, timely, and patient-centered? a. Centers for Disease Control and Prevention b. World Health Organization c. The Joint Commission d. Agency for Healthcare Research and Quality

c. The Joint Commission The Joint Commission standard for record of care, treatment, and services requires that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning. Other standards include those directed by state and federal regulatory agencies such as HIPAA, as enforced through the Department of Justice, and the Centers for Medicare and Medicaid Services. The World Health Organization is concerned with international public health. The Centers for Disease Control and Prevention are concerned with the spread of infections. The Agency for Healthcare Research and Quality performs research to make health care safer for patients and providers.

Which situation demonstrates an allostatic stress load? a. The nursing student uses meditation to cope with mild test anxiety. b. The patient develops anaphylactic shock after being stung by a bee. c. The nurse develops hypertension after working too many double shifts. d. The patient's heart rate returns to normal after a painful procedure is completed.

c. The nurse develops hypertension after working too many double shifts. An allostatic load is the negative physiological effect of long-term extreme stress on the body. An allostatic load is demonstrated by the nurse's development of hypertension after working too many double shifts. Mild test anxiety, recovery after a stressful experience, and anaphylactic shock are not examples of allostatic stress.

A nurse enters a patient's room and sees the patient grimacing with each movement. When the nurse asks how the patient is feeling, the patient states "I feel fine." Which finding will the nurse classify as nonverbal communication? a. The patient states "I feel fine." b. The nurse asks how the patient is feeling. c. The patient grimaces with each movement. d. The nurse is present at the patient's bedside.

c. The patient grimaces with each movement. The patient grimacing with each movement is nonverbal communication. Nonverbal communication includes messages sent through the language of the body, without the use of words. Nonverbal forms of communication include use of facial expressions, eyes, gestures, posture, and physical appearance. Nonverbal communication often reveals physical feelings. Tone of voice, asking questions, and saying that he or she feels fine are examples of verbal communication. Verbal communication involves the use of words or phrases and includes intonation, pacing, denotative and connotative meanings, volume, clarity, brevity, timing, and relevance. The nurse's presence at the patient's bedside is not nonverbal communication.

The nurse is working at a hospital whose electronic medical records system uses charting by exception. Which entry would be appropriate to include in the narrative section of the patient's chart? a. The patient voided 400 mL of clear yellow urine during the last 12 hours. b. The patient denies smoking, alcohol intake, or use of illicit substances. c. The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. d. The patient's lung sounds are clear bilaterally with no cyanosis or dyspnea.

c. The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. Charting by exception allows nurses to enter narrative notes only for assessment findings that are unusual, unexpected, or abnormal. Assessment findings that are expected or within normal limits may simply be checked off as such. The patient's severe knee pain is outside of the normal limits and should be described using a narrative note.

Which is the primary purpose of a patient's medical record? a. To invoice the nursing services for hospital reimbursement b. To protect the patient in case of a malpractice suit c. To facilitate professional communication and safe health care d. To contribute to a worldwide databank for trends in health care

c. To facilitate professional communication and safe health care The medical record helps to ensure that all health team members are working toward a common goal of providing safe and effective care. Documentation can be used for reimbursement but it is not to invoice the nurse, but to invoice patients and/or insurance companies. It protects the clinician in cases of a malpractice suit, not the patient. It does not contribute to a worldwide databank for trends in health care, but it can be used for medical or nursing research.

Which statement by the nurse is an example of an SBAR recommendation? a. "The patient has become increasingly short of breath over the last few hours." b. "The patient has a history of chronic respiratory failure due to emphysema." c. "The patient's pulse oximetry is 84% and crackles are heard over all lung fields." d. "The patient needs oxygen titrated to maintain oximetry between 90% and 92%."

d. "The patient needs oxygen titrated to maintain oximetry between 90% and 92%." The SBAR recommendation statement is what the nurse believes should happen next for the patient to address the crucial situation at hand. The nurse recommends that the patient receive oxygen to maintain pulse oximetry between 90% and 92%. The SBAR situation statement is the increasing shortness of breath. The SBAR background statement is the patient's history of respiratory failure. The SBAR assessment statement is the current pulse oximetry and lung sounds.

The nurse is caring for a patient who has lost all sexual desire due to severe chronic illness. Which term will the nurse use to chart this assessment finding? a. Fluid b. Queer c. Binary d. Aromantic

d. Aromantic The nurse will use the term aromantic to chart the patient's lack of sexual or romantic desire. The term fluid is used to indicate sexual desires that fluctuate between heterosexual, homosexual, and trans-sexual. Queer is a term used to describe individuals who have sexual desires outside of the usual heterosexual preferences. The term binary is used to describe a set of only two options rather than a wide range of options.

The patient develops an inability to swallow after many years of emotional abuse. The physicians can find no medical reason for the patient's dysphagia. Which ego-defense mechanism is used by the patient? a. Displacement b. Dissociation c. Compensation d. Conversion

d. Conversion Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one's surroundings. Displacement is the practice of taking out stressful feelings on someone or something else than the cause.

What is the best method for to The Joint Commission to demonstrate that it is assessing quality patient care? a. Cost of care per patient day b. Number of registered nurses c. Absence of sentinel events d. Documentation audits

d. Documentation audits Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care. Typically, such monitoring and evaluations occur through the auditing of information health care providers document in patient records. It does not include cost of care per patient day, number of RNs, nor absence of sentinel events.

Before leaving at the end of the shift, the nurse realizes that a set of patient assessments were taken earlier in the day but never charted. What is the appropriate action of the nurse? a. Enter the assessments in the chart the next day before receiving report. b. Do nothing because the other patient assessments were obtained during the shift. c. Direct the nursing assistant to enter the assessments into the patient's chart. d. Enter the assessments into the chart as a late entry with a reason for the delay.

d. Enter the assessments into the chart as a late entry with a reason for the delay. The nurse should enter the assessments into the chart as a late entry with a reason for the delay. The nurse should not wait until the next day to enter the assessments or do nothing with the information. The nursing assistant should never be directed to chart the nurse's assessments.

The new mother experiences insomnia, irritability, and lack of appetite after several weeks in the neonatal care unit with her critically ill infant. Which stage of the general adaptation syndrome (GAS) is the new mother experiencing? a. Alarm b. Resistance c. Adaptation d. Exhaustion

d. Exhaustion If the stressor remains and adaptation does not happen, the person enters the third stage of the GAS, exhaustion. The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy. During the alarm reaction, rising hormone levels result in increased blood volume, blood glucose levels, heart rate, blood flow to muscles, and mental alertness. During the resistance stage, the body stabilizes and responds in an opposite manner to the alarm reaction. In the adaptation stage, antiinflammatory adrenocortical hormones are released, and healing occurs.

The nurse notes that the nursing assistant did not provide oral care to the patient as directed. Where is the best location for the nurse to address this lapse with the nursing assistant? a. In the patient's room b. At the nurse's station c. In the nursing unit hallway d. In a private conference room

d. In a private conference room Give feedback in private to preserve the staff member's dignity. The hallway, nurse's station, and patient's room are too public for effective constructive feedback.

A nurse gives a hand-off report to the oncoming staff nurse. Which type of communication does this illustrate? a. Gossip b. Courtesy c. Validation d. Interpersonal

d. Interpersonal Interpersonal communication is interaction that occurs between two people or within a small group. Gossiping violates confidentiality. The act of validation requires comparing data with another source. Professional courtesy conveys respect between colleagues. The nurse should always utilize professional courtesy when providing report to the oncoming shift.

Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. Which term best describes this patient care action? a. Continuing staff education b. Nursing care delivery model c. Professional shared governance d. Interprofessional communication

d. Interprofessional communication Interprofessional communication is demonstrated when professionals in various disciplines work together to promote quality patient care. Weekly meetings of professionals from various disciplines to discuss patient progress do not demonstrate continuing staff education, a nursing care delivery model, or professional shared governance.

Which patient information may be included in the nursing student's assignment that will be turned in to the instructor after the clinical shift has ended? a. Room number b. Date of birth c. Medical record number d. Nursing diagnosis

d. Nursing diagnosis The nursing diagnosis is acceptable information to give to a nursing instructor. To maintain confidentiality and protect patient privacy, instructors must make sure written materials used in student clinical practice do not have patient identifiers, such as room number, date of birth, medical record number, or other identifiable demographic information.

The emergency room nurse obtains report from the paramedics as the patient is on the way to the hospital. The nurse is in which phase of the therapeutic relationship? a. Working b. Orientation c. Termination d. Preinteraction

d. Preinteraction In the preinteraction stage the nurse gathers information from various sources about the patient such as from the paramedics. The orientation phase when you and the patient meet and get to know one another is the time when the contract is formed. The nurse and patient work together during the working phase to solve problems and accomplish goals. During the termination phase the helping relationship is ended.

The nurse is caring for a patient whose husband is impotent following prostate surgery. Which is the priority intervention of the nurse? a. Stress the importance of condom use to prevent the spread of infection. b. Encourage the patient to exercise in order to be more sexually attractive. c. Educate the patient and spouse about normal sexual anatomy and functioning. d. Present alternative options for sexual expression and mutual sexual gratification.

d. Present alternative options for sexual expression and mutual sexual gratification. Patients who are unable to participate in sexual intercourse due to physical limitations should be encouraged to find alternative options for sexual expression and mutual sexual gratification. Condom use is not relevant as the patient's spouse is impotent. Encouraging the patient to become more sexually attractive does not resolve the spouse's impotence.

Which is the highest priority nursing intervention for a patient with the nursing diagnosis risk for suicide related to recent suicide attempt and desire to die? a. Assist the patient to identify sources of support in the community. b. Assess the patient's readiness to sign a pledge to do no self-harm. c. Question the patient's family members about previous suicide attempts. d. Remove dangerous items such as scissors from the patient's environment.

d. Remove dangerous items such as scissors from the patient's environment. The priority intervention is to maintain the patient's safety by removing dangerous items from the patient's environment. Identification of support sources, assessing readiness to sign a no-harm pledge, and family assessment may be completed once the patient's environment is free of hazards.

The nurse is caring for an adult patient who must quit working due to complications from hypertension. Which self-concept is likely to be put at risk for this patient? a. Identity b. Self-esteem c. Body image d. Role performance

d. Role performance Role performance is the way in which a person views his or her ability to carry out significant roles. This patient is being told that she will have to give up the role of wage earner. Body image involves attitudes related to the perception of the body, including physical appearance, femininity and masculinity, youthfulness, health, and strength. There are no overt bodily changes here. Self-esteem is an individual's overall sense of personal worth or value. Identity involves the sense of individuality and being distinct and separate from others.

The nurse educates the patient about what to expect during insertion of a nasogastric tube. Which term best describes the nurse's communication role? a. Channel b. Receiver c. Message d. Sender

d. Sender The nurse is the sender in this scenario. The sender is the person who delivers the message. The message is sent to a receiver, in this case the patient. The message is the content of the conversation; in this scenario explaining what will happen is the message. The channel is the means of conveying and receiving messages through visual, auditory, and tactile senses, the nurse's spoken words in this scenario.

Which is the priority nursing intervention for a patient who presents to the emergency department after a sexual assault? a. Assist the patient to take a long hot shower to relax and feel clean again. b. Discuss the possibility of pregnancy and sexually transmitted infections. c. Provide personal hygiene items such as shampoo and soap for the patient. d. Stay with the patient and contact the sexual assault response (SART) team.

d. Stay with the patient and contact the sexual assault response (SART) team. The priority action of the nurse is to stay with the patient and contact the sexual assault response (SART) team. The SART team will perform physical examination, provide counseling, and initiate investigation into the incident. Showering or bathing will remove evidence such as hair, semen, or DNA that may be used for prosecution by law enforcement. Providing personal hygiene products is not as important as contacting the SART team. The SART team sexual assault nurse examiner is trained to discuss the possibility of pregnancy and STI with the patient.

The nurse fills out an incident report after a patient fall but makes no mention of the report in the patient's medical record. What is the reason for this? a. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report. b. The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. c. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. d. The incident report is confidential and not intended to be used as evidence in a malpractice suit.

d. The incident report is confidential and not intended to be used as evidence in a malpractice suit. The incident report is never filed with the patient's medical record. The incident report is used to facilitate investigation of the event within the agency. It is not intended to be part of the patient's medical record as the findings of the investigation could potentially be used during a malpractice lawsuit. The incident report information should be factual without guesses or subjective interpretations. The presence of an incident report in the patient's medical record would not lead to a malpractice lawsuit.

Which action by the nurse best demonstrates the concept of right supervision? a. The nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient's weight. b. The nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch. c. The nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task. d. The nurse confirms that the patient's urine output is entered into the medical record by the nursing assistant by the end of the shift.

d. The nurse confirms that the patient's urine output is entered into the medical record by the nursing assistant by the end of the shift. The concept of right supervision includes appropriate evaluation to ensure that the assigned task was completed correctly and on time. The nurse demonstrates this by confirming that the patient's urine output is entered into the medical record by the nursing assistant by the end of the shift. Ensuring the scale is working demonstrates right circumstances. Giving clear directions about how to ambulate the patient demonstrates right communication. Checking hospital policy about the role of the LPN demonstrates right person.

Which chart entry represents appropriate documentation about the patient's pain assessment? a. The patient appears not to be in any pain. b. The patient is sleeping comfortably. c. The patient always complains about being in pain. d. The patient rated the pain at 2 on a 0-to-10 scale.

d. The patient rated the pain at 2 on a 0-to-10 scale. States pain as 2 is factual. To be factual, avoid words such as appears, seems, or apparently because they are vague and lead to conclusions that cannot be supported by objective information.

Which entry in the patient's chart will justify home nursing care reimbursement from Medicare, Medicaid, and private insurance companies? a. The patient's wound is improving slightly each day. b. The patient was receptive to the smoking cessation information. c. The patient's family appreciated the nurse's caring demeanor. d. The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm.

d. The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm. When you provide home care, your documentation must specifically address the category of care and your patient's response to care. Receptive to teaching from the nurse and a gradually improving wound is not factual or objective information. Whether family liked the nurse or not does not affect reimbursement.

A nurse completes an incident/occurrence report after a patient fell. What is the reason for this report? a. To compare patient fall rates between nursing units in the hospital b. To provide justification for the hospital to fire the nurse c. To prevent the patient from filing a malpractice lawsuit d. To aid in the hospital's quality improvement program

d. To aid in the hospital's quality improvement program Incident reports are an important part of quality improvement. The overall goal is to identify changes needed to prevent future reoccurrence. A report is an exchange of information between health care members. Transfer reports involve communication of information about patients from one nurse on the sending unit to the nurse on the receiving unit. Occurrence reports do not prevent lawsuits. The nurse does not complete the incident report to provide cause for the nurse to be fired from the hospital.

Which technique is the best way for the nurse to obtain information from the patient? a. Ask personal questions so as to show interest. b. Use medical vocabulary to appear competent. c. Ask why the patient waited so long to get treatment. d. Use silence while the patient collects his or her thoughts.

d. Use silence while the patient collects his or her thoughts. Most people have a natural tendency to fill empty spaces with words, but sometimes silence is useful when they face decisions that require much thought. Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses or behaviors in others. Asking irrelevant personal questions simply to satisfy your curiosity is inappropriate and invasive and nontherapeutic. Limit questions to health-related information. Health care professionals have their own culture and language. Using technical words in discussions with patients can cause confusion and anxiety. Avoid excessive use of such terms or translate them into lay terms. Sometimes asking "why" implies an accusation and results in resentment, insecurity, and mistrust.

Which action by the nurse minimizes the risk of unauthorized use of computer passwords for the electronic medical record system? a. Using the same password for home and health care agency computers b. Writing each new computer password on the back of the name badge c. Periodically reusing previous computer passwords to prevent forgetting them d. Using passwords of at least eight characters with at least one number and symbol

d. Using passwords of at least eight characters with at least one number and symbol Passwords should have at least eight characters with at least one number and symbol. Nurses should never use the same password for home and health care agency computers. Nurses should have one designated password for work that should be changed every few months. Computer passwords should never be shared with anyone or written where they may be seen by others. Passwords should never be reused or recycled.