Nurs 220 Exam 1-4 Review

A young adolescent client is in the hospital preparıng for major surgery for the removal of a tumor on the kidney. The client's mother tells the nurse that she doesn't want her child to receive narcotics for postoperative pain. What is the nurse's best response?

​"Your child's pain will be severe after the surgery. Can you tell me why you feel this​ way?"

Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family?

- Same sex Rationale: This family would be considered a same -sex family . Cohabiting refers to a couple who live together with no legal bond Nuclear refers to the traditional male and female core family with one or more children . Single parent refers to a family with one adult and one or more children

Which of the following best describes stress?

-stress is a condition in which the human system responds to Change in its normal balance state. Stress results from a change in the environment that is perceived as a challenge, a threat, or a danger, and can have both positive and negative affects.

The nurse has been asked to review a hospital's written policies for the pediatric care unit. Hospital management is concerned that the current materials express an authoritarian attitude that is off-putting to families. The goal of the nurse's review is to recommend changes that promote openness and communicate appreciation for the role of families in the care of children. Which of the following statements meets this goal?

- "Parents are welcome to remain in their child's room overnight if they wish." Rationale: Words like policies , allowed , and not permitted imply that hospital personnel have authority over families in matters concerning their children . Words like guidelines , working together , and welcome communicate openness and appreciation for families in the care of their children.

A novice nurse is working in a busy emergency department of a hospital situated in a culturally diverse area of the city. Which should the nurse do when providing competent care?

- Acquire the underlying background knowledge necessary that will provide these clients with the best care possible Rationale: As healthcare providers, it is imperative to recognize common prejudices. Prejudices are prejudgments about cultural groups or vulnerable populations that are unfavorable or false because they have been formed without the background knowledge and context upon which to form an accurate opinion. Healthcare providers must acquire this background knowledge to develop their cultural competence. The nurse cannot treat every client as having the same needs, assume that the emergency department does not present a unique context that must be understood on its own terms, or base his standard of care on what best serves a single cultural group, dominant or not.

The nurse is providing care to a client diagnosed with type 2 diabetes mellitus. The client wishes to take Communion but must fast for 1 hour prior to receiving it. Which action by the nurse is most appropriate?

- Find out when the hospital clergy will be distributing Communion and adjust the client's medications and breakfast accordingly Rationale: The nurse should follow the client's expressed wishes regarding spiritual care and should not pressure them to relinquish any of their beliefs or practices. To support the client's spiritual needs, the nurse should find out when Communion will be distributed and adjust the medications and breakfast accordingly The nurse should not suggest that eating and drinking will not affect Communion. The nurse should not ignore the client's needs by providing medication and breakfast. The nurse should also not contact the healthcare provider to suggest alternetive forms of nutrition. because the client is not refusing to eat or drink but wants to delay eating and drinking until after Communion

Which of the following questions would best help the nurse assess a client's self-esteem?

- Global self-esteem is the degree to which an individual likes himself or herself overall, as a whole being. "how satisfied are you with yourself and your life so far?" Rationale: Would help the nurse assess the clients global self-esteem. The remaining questions would be the nurse garage the clients specific self-esteem, or his or her positive regard for certain aspects of himself or herself.

A general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the type of definitions a female or male is

- Intersex Rationale: Intersex is a general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the typical definition of female or male. Homosexuality is a sexual preference for members of the same sex. Transgender individuals do not identify with the gender assigned to their bodies. Gender queer individuals don't identify with male or female exclusively but with both categories.

The nurse is caring for an older adult client with advanced dementia. The family often mentions that the client was very spiritual earlier in life and loved to sing. Look at the nurse suggest to the family to help support the clients religious needs?

- One way that clients with dementia can worship is through various art forms, including music. Rationale: this is an especially appropriate option for this client, given his history of spirituality and the love of singing. Letting the client listen to some favorite of his spiritual songs will give him an opportunity to enjoy an enriching spiritual experience without being pressured to participate, generate new ideas, or remember events from the past.

Which term best describes individuals self-concept?

- self image Rationale: One's self-concept is synonymous with one's self image. Self-esteem and self actualization are components of self concept.

The nurse planning to assess the structure of a family should ask which question?

-"Who lives with you in this home?" Rationale: The structure of the family includes who is in the family and what their relationship is. "Who does the shopping?" would provide information about family functioning. "Who provides support?" would provide information about family functioning. "How old are the members?" would provide information about family development.

-A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a client advocate and through the moral principle of autonomy, Clients, not their families, should make decisions about their own healthcare and treatment. The physician may or may not be involved, but would not disregard the client's refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.

-A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. Rationale: This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a client advocate and through the moral principle of autonomy, Clients, not their families, should make decisions about their own healthcare and treatment. The physician may or may not be involved, but would not disregard the client's refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.

While reviewing the chart for an assigned client before beginning care, a nursing student notes that the client does not belong to a specific religion. Based on this information, what should the nursing student interpret about the client? A) A person may be deeply spiritual but not profess a religion. B) Belonging to an organized religion is essential to spirituality. C) The student will not have to consider the spiritual dimension. D) The client should be referred for spiritual counseling.

-A) A person may be deeply spiritual but not profess a religion. religion refers to an organized system of beliefs about a higher power. A nurse should not interpret the fact that a client does not belong to an organized religion to mean the client has no spiritual needs; a person may be deeply spiritual yet not profess a religion. The nursing students are still assess the spiritual dimension in the plan of care. The client does not need to be referred for spiritual counseling.

A nurse is admitting a client to the oncology unit. During the admission assessment, when the nurse asks the client about religious preference, the client states, "I am an atheist." The nurse should recognize that the client holds which belief?

-An atheist is an individual who does not believe in any god. Rationale: monotheism is the belief in the existence of one God. Polytheism is the belief of more than one god. An agnostic is an individual who doubts the existence of God or a supreme being or who believes that the existence of God has not been proven.

The nurse is assessing a patient's spirituality and observes the patient meditating before any treatments. What is the nurse's best action?

-Arrange for quiet time for the patient as needed Rationale: The nurse can best promote the patient's spirituality practices by arranging for the patient to be left alone when possible meditate. Meditation is an exemplar of spirituality, not necessarily of the Christian faith. The Bible is most often read by believers in the Christian faith. Meditation does not imply that the patient is not religious. Time for meditation should not be limited, whenever possible

A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. Which is the priority nursing action? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

-B) Complete a thorough cardiopulmonary assessment. The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. Rationale: The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.

Which action demonstrates correct reporting of suspected child abuse? A) The nurse includes the entirety of the client's medical record. B) The nurse compiles a report with all pertinent information that is factually true. C) The nurse recommends that the organization report the abuse to state authorities. D) The nurse reports only information the client has authorized for release.

-B) The nurse compiles a report with all pertinent information that is factually true. Reports should be complete and accurate and should be made according to the policy of the organization for which the nurse works. In addition to reporting the abuse within the organizational framework, the nurse should personally report the abuse to the proper authorities. Rationale: When abuse is reported, all pertinent information in the client's medical record (not simply the entire record) is required by law to be disclosed to the reporting agency. As such, reporting abuse or suspected abuse represents an exception to client confidentiality rules.

A couple recently married. Both the husband and the wife have previously been married and had two children. What is given to this type of family?

-The blended family is one that is formed when parents bring unrelated children from previous relationships together to form a new family. Rationale: An extended family includes relatives; a nuclear family is the traditional father/mother/children; a cohabiting family is composed of member who live together but are not married.

A client is receiving care in the hospital for life-threatening injuries sustained in a motor vehicle crash and is taken immediately into surgery. There is no family available to provide consent, however, the client's medical record is available and reviewed by the nurse. Which treatments are appropriate in this situation? Select all that apply. A) Emergency surgery B) Treatment that was previously refused C) Treatment that violates religious beliefs D) Medications to treat the injury E) Experimental medications for a research study

-B) Treatment that was previously refused C) Treatment that violates religious beliefs E) Experimental medications for a research study In most states, the law assumes an individual's consent to medical treatment when the person is in imminent danger of loss of life or limb and unable to give informed consent. Rationale: In other words, the emergency doctorine able to do so.

Occupation-specific stressors that are ongoing and unmanaged can lead to what extreme form of​ stress?

-Burnout Rationale: Eustress is good stress that leads to accomplishment and victory. Distress is bad stress that is associated with inadequacy, insecurity, and loss. Although occupation-specific stressors can be a type of distress, distress is not the specific term for the extreme form of stress caused by ongoing and unmanaged stress. The term used for that form of extreme stress us burnout. Burnout in nurses can lead to reduced quality of care and decreased patient satisfaction. Allostasis refers to changes necessary to achieve homeostasis

A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that it is showing signs and symptoms of infection. The client's spouse asks for the new nurse how the wound looks. The new nurse responds by stating "it looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse, the preceptor should note a need to work on which aspect of communication?

-Congruence Rationale: Congruence is adjusting​ one's tone of speech and facial expression to match​ one's spoken message. If a​ nurse's facial expression and words are not​ congruent, the client and family will often suspect that something is wrong. Credibility is the quality of being​ truthful, trustworthy, and reliable. Although the​ nurse's words in this situation may not be completely​ true, they do not necessarily reflect a larger problem with credibility. Timing means that a message is delivered when the client and family are capable of processing it fully and correctly. Clarity and brevity are characteristics involving preciseness and use of few words.

It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests a minister to see him. Family is at the bedside. What action would the nurse take to address the client's spiritual distress on this day?

-Contact the chaplain to request to see the client today. Rationale: Even on a holy day, there is usually a spiritual caregiver on call for the hospital. Encouraging the family to talk to the client ignores the client's request. The other options may bring some relief to the client, but they still ignore his request for a spiritual caregiver.

Despite the presence of a large number of older adult residents of Asian heritage, a long term care facility has not integrate the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of:

-Cultural blindness. Rationale: Not taking into consideration the importance of cultural practices either aware or unaware of the actions.

A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain.

-D) Evaluate the client's level of pain. Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Rationale: Most clients are not going to want to get up after surgery, and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath

-D) The client experiencing shortness of breath

During a care conference, the nursing student differentiates between the different theories of caring when discussing client care. Which type of knowledge is the student demonstrating?

-Empirical knowledge is systematic and helps to describe, explain, and predict phenomena. This student is exhibiting empirical knowing as the student is able to analyze the different theories of caring. Rationale: Aesthetic knowing is the art of nursing and is expressed in creativity and style in meeting the needs of the client. Personal knowing is concerned with knowing, encountering, and actualizing the concrete, individual self. Ethical knowing focuses on matters of obligation or what ought to be done, and goes beyond simply following the ethical codes of the discipline.

The nurse is caring for a woman who was involved in a car accident. The client's husband was killed in the accident. The couple has two teenage children. Which statement explains how this tragedy will be approached by the family?

-Family disorganization may occur. Rationale: The death of a family member often has a profound effect on the whole family-especially if the deceased, as in this situation, was the head of the family. Family disorganization would be common, but as the family begins to recover, a new sense of normalcy develops and the family reintegrates its roles and functions. Families need support from extended family members, their community, and spiritual advisers. The other options are not considered normal patterns of family grieving, and the nurse should be alert for problems that may develop if these are present.

A nursing instructor has assigned to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preference are important for the students to consider when caring for this client?

-Individuals of Asian descent are more comfortable with some distance between themselves and others. Direct eye contact may be considered impolite or aggressive within the Asian culture, and they may tend to avoid direct eye contact and revert their eyes while speaking with others.

The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client?

-Involving children in their own care increases cooperation and decreases anxiety. The nurse would ask the dietary worker to come back later to increase the child's involvement in his own care and to avoid disturbing the client or choosing a meal the client won't eat. Rationale: If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.

Which statement accurately reflects the distinction between nursing diagnoses and medical diagnoses?

-Nursing diagnoses consider physical, psychosocial, and spiritual responses to illnesses or conditions, whereas medical diagnoses are concerned primarily with disease processes. Rationale: Nursing diagnoses change as the client's response to the illness or situation changes, whereas medical diagnoses remain in place as long as the disease process persists. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Both consider etiology (e.g.. "Viral Pneumonia" and "Disturbed Sleep Pattern related to frequent coughing") Both nursing and medical diagnoses are not only based on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources.

Which regulatory agency ensures the health and safety of Americans in the workplace?

-OSHA works to ensure the health and safety of Americans in the workplace. The DHHS is the federal government's principal agency for the protection of the health of all Americans and the provision of essential human services for those least able to care for themselves. Rationale: The NIH is a branch of the DHHS that is responsible for health research and the provision of health-related information. The CMS is responsible for healthcare financing.

Which organization promotes excellence in all levels of nursing education?

-Part of the mission of the NLN (national league of nursing) is to promote excellence in nursing education to build a strong and diverse nursing workforce. Rationale: The NSNA is a nonprofit organization that mentors nursing students who are preparing for initial licensing as a registered nurse

To evaluate a client's personal identity, the nurse should consider what three aspects of the client's self?

-Personal identity can be evaluated from the standpoint of three aspects of self; the ideal self, the real self, and the public self. Rationale: The ideal self reflects the qualities an individual believes he or she should possess, as well as those he or she aspires to develop. The real self represents an individual's perceived true self; it may include observations about self or self perceived qualities that the individual hides from others or does not readily share. The public self is formed on the basis of how the individual wishes to be perceived by others.

During an assessment, a client tells the nurse that she "can't stand her mother" and does "whatever she wants me to do" because the client "can't do anything right anyway." This information is helpful for the nurse in determining the client's

-Self Esteem Rationale: The client is critical of her mother, verbalizes feelings of helplessness by saying that she does whatever her mother wants her to do, and is critical of self by saying she cannot do anything right. These findings help the nurse assess the client's self-esteem. Role performance would be assessed by asking the client about the different roles held and the satisfaction with each of the roles. Body image would be assessed by asking the client how she feels about her appearance. Personal identity would be assessed by asking the client to describe personal characteristics and self-concept.

What is the name given to the evaluative and affective component of the self-concept?

-Self esteem is the evaluative and affective component of the self-concept. Sometimes termed self-respect, self-approval, or self-worth.

What is the major effect of a health crisis on family structure?

-Serious illness or injury may result in changes in family roles, responsibilities, and functions. Rationale: Illness may precipitate a health crisis in a family. Regardless of how the family adapts to an illness, members of the family must constantly adjust roles and responsibilities to manage the need of the ill family member.

A nursing student would like to learn more about developing professional behavior. Which action should the student take in order to access information that may be useful in developing professional demeanor?

-The NSNA is an organization specifically for student nurses with a goal of assisting the student to foster their professional development. Nurse practice acts do need to be read by students, but they denote laws, not professionalism. Rationale: The ANA is for members practicing nursing, not students, although students may join. The NSNA focuses on students and is a better resource. The Internet is good for obtaining information and for networking but is not necessarily a help to the student who wishes to increase professionalism.

What is the purpose of the affective and coping function of the family?

-The affective and coping function of the family is necessary to provide emotional comfort to family members and to help members establish an identity to be maintained in times of stress. Rationale: The physical function provides a safe environment for growth and development, the economic function ensures financial assistance, and the socialization function transmits values, attitudes, and beliefs.

A patient is the primary caregiver for a disabled family member at home, and has not been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient?

-The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. Rationale: A long absence from the home on the rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide care by another, appropriate method of transfer, and distance of transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person.

What is the term for the change that takes place in response to a stressor?

-The change that takes place in response to a stressor is adaptation Rationale: When a person is in a threatening situation, immediate and often involuntary responses occur.

A cohesive nuclear family has one kindergarten age child. Her mother works from home and is the primary caregiver for the child. The father is required to travel a lot for work. Currently, the father is on an out of town project that will last for six months. He is home on the weekends, but gone the rest of the week. The nurse understands that family cohesion in this family is likely to become:

-The family relationship is already cohesive and will likely remain so. Become dyadic. Rationale: however, with the father absent, the dynamics will likely become dyadic (two-person) between the mother and child as they come to depend on each other more. The mother and child will become less dependent on the father, making triadic (three-person) Dynamics less likely. Similarly, the mother is less likely to have a strong dyadic relationship with the father during this time.

A client begins to vomit blood. The nurse immediately measures the blood pressure and prepares to insert a Asiatic tube while directing others to notify the Healthcare provider. Which of the features of the Tanner Clinical Judgment Model did this nurse demonstrate?

-The four features of the Tanner model include noticing, interpreting, responding, and reflecting. Rationale: The nurse noticed that something was wrong with the client, interpreted the cues to gain understanding of the situation, and responded by choosing the best course of action.

The nurse is caring for two clients on the same unit. One client states that cold temperatures and loud noises or stressors. The other client says the temperature is fine and the noises do not bother him. What is the difference between the two clients related to the stressors?

-The perception and effects of stressors are highly individualized. A stressor is anything that is perceived as challenging, threatening, or demanding. Stressors may be internal or external. The perception and effects of those stressors are highly individualized.

Which hormone is one of the primary mediators of stress?

-The two primary stress mediators are glucocorticoids (e.g. cortisol) and catecholamines (e.g. epinephrine). Rationale: Serotonin is a neurotransmitter that is involved in some mood and anxiety disorders, but it is not a primary mediator of stress. Somatostatin is a hormone released by the pituitary gland. It is not involved in the stress response. Glucagon is secreted by the pancreas to increase blood glucose levels.

A nurse is caring for preschool age client who was admitted for dehydration. The child lives with the parents and maternal grandparents. In which of the following types of family does this child reside?

-in some cultures and as people live longer, more than two generations May live together in an extended setting. Rationale: A two-career family is one where both partners are employed. A blended family occurs when existing family units join together to form new families. A nuclear family is viewed as an autonomous unit in which both parents reside in the home.

In which way can nurses develop cultural self awareness?

-nurses can develop cultural self-awareness by becoming aware of the role of the cultural influences in their own lives; objectively examining their own beliefs, values, and practices; and identifying and reflecting on personal biases.

Which action by the nurse will help a client meet self-esteem needs? A) Verbally negate the client's negative self-perceptionsB) Freely give compliments to increase positive self-regardC) Independently establish goals to improve self-esteemD) Respect the client's values and belief systems

-self-esteem needs include the need to feel good about oneself, to feel pride and a sense of accomplishment, and to believe others respect and appreciate those accomplishments. Answer is D Rationale: by respecting the clients values and beliefs, the nurse can meet self-esteem needs. Actions suggest negating the clients negative self perceptions, establishing goals without input from the client, and providing compliments for any action, though well meaning, will not meet the clients self-esteem needs.

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function?

-the sympathetic nervous response. when the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved When the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Rationale: modifying electronics signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more stressful to less stressful reflects the cognitive approach to stress management. Reducing Catecholamine Production is the basis for guided imagery's effectiveness.

The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client?

Assessment

Which practices support promotion of health safety? Select all that apply. 1. Physical 2. Interpersonal 3. Spiritual 4. Mental 5. Employment

1. Physical 3. Spiritual 4. Mental

An individual's work ethic reflects his or her

A person's work ethic reflects his or her belief in the importance and moral worth of work. Rationale: An individual does not need to be part of a specific profession in order to have a strong work ethic. Although an optimistic attitude is often associated with a strong work ethic, optimism itself does not determine an individual's work ethic.

A researcher is investigating the effect of bed angle of hospitalized patients (15°, 30°, 45°) on the patients' heart rate. This is an example of what type of study?

A quantitative study

Which of the following is a licensure examination developed by the National Council of State Boards of Nursing (NCSBN) for state and territory boards of nursing (BONS) to implement as part of their requirements for licensure? A) National Council Licensure Examination for Registered Nurses (NCLEX-RN) B) National Nurse Aide Assessment Program (NNAAP) C) Medication Aide Certification Examination (MACE) D) Nursing Workforce Diversity (NWD) program

A) National Council Licensure Examination for Registered Nurses (NCLEX-RN)

"Male" is which variable? A) Not a variable B) An independent variable C) A dependent variable D) An outcome variable

A) Not a variable

While making rounds on the night shift, a nursing supervisor notes that a 73-year-old client under observation following a myocardial infarction has multiple visible bruises on the arms and legs. The supervisor suspects abuse because nothing in the client's chart suggests this client should have sustained these injuries. This state's good faith immunity applies in cases of suspected abuse not only of children but also of older adults or adults with disabilities. Which action has the highest priority for the nursing supervisor in this situation? A) Notify authorities regarding the suspected abuse. B) Do nothing about the situation. C) Notify the security department. D) Ask a shift nurse about the source of the injuries.

A) Notify authorities regarding the suspected abuse.

The nurse is documenting in the electronic medical record (EMR) after providing care in the client's room. The client asks the nurse why a computer is being used. Which response by the nurse is appropriate? A) "The information that is uploaded is available for anyone to view." B) "Computers improve client care because information is readily available." C) "The computer decreases documentation time for nurses." D) "Computers allow you access to your medical record."

B) "Computers improve client care because information is readily available."

A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statement exemplifies correct documentation on the report? 1. "Patient fell out of bed onto the floor." 2. "Heard patient fall from the bed to the floor." 3. "Patient accidentally fell out of bed onto the floor." 4. "Found patient lying facedown on the floor beside the bed."

4. "Found patient lying facedown on the floor beside the bed."

A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

A) "I do not know, but I will find out."

The nurse must start an IV for a toddler in the emergency department. The toddler is accompanied by a parent. The parent asks the nurse, "Can I stay with my child and comfort him?" Which response by the nurse is best? A) "Yes, it would be helpful for you to stay and comfort your child." B) "We do this all the time, so don't worry. I will come get you when we are done starting the IV." C) "Be ready to hold your child down when I tell you to." D) "It doesn't take long to start an IV, so there's no need for you to stay for the procedure."

A) "Yes, it would be helpful for you to stay and comfort your child." An important part of nurse competency is knowing what procedures to follow when performing skills. For example, when initiating an IV on a pediatric client, procedure dictates that the nurse should always seek assistance from the client's parent if the parent is willing and capable of offering assistance. If the parent agrees to offer assistance, the nurse can then provide appropriate teaching. Instructing the parents to hold down the child without giving them a choice is inappropriate; many parents do not want to participate in activities that cause pain to their child. Telling the parent not to worry is both pointless and dismissive of the parent's concerns. It is also inappropriate for the nurse to say that the procedure won't take long, because the nurse does not know how much time the procedure will actually require.

The urgent care clinic nurse is treating a client who is experiencing abdominal pain. The client states, "I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the healthcare provider does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.

A) Ask the client open-ended questions to further assess the situation.

A female client, from a male-dominated culture, is being discharged after a lengthy hospitalization. Which action by the nurse prior to providing discharge instructions is appropriate? A) Assess who the decision maker is in the family. B) Ensure that the healthcare provider gives the instructions. C) Make sure instructions are understood by the client. D) Ask the client when the best time for teaching would be.

A) Assess who the decision maker is in the family. The nurse needs to identify who has the "authority" to make decisions in a client's family. If the decisionmaker is someone other than the client, the nurse needs to include the individual in healthcare discussion. Nurses need awareness of cultural variations of gender because they will be caring for diverse client needs. What might be considered sexism by one culture may not be in another. Regardless of who is present during the teaching, it is always necessary to make sure that the instructions are understood, but it is difficult to do that before instructions are given. Asking the client when the best time for teaching would be does not Address the need for the decision maker of the family to be present. The nurse should not simply leave giving instructions to the healthcare provider.

The nurse is assessing his client's self concept. The client is status post-myocardial infarction and is due to be discharged tomorrow. Which of the following focuses will give the nurse the most information about the client's self concept? select all that apply. A) Body image B) Gender identity C) Self-esteem D) Role performance E) Sexual orientation

A) Body image C) Self-esteem E) Sexual orientation The nurse assessing self-concept focuses on the client's personal identity, body image, self-esteem, and role performance. Sexual orientation and gender identity do not always provide information about self-concept.

The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, "I do not want to be put on a ventilator because I had to watch my mother die on a ventilator. I want information on making out a living will." When planning care for this client, which intervention is the most appropriate? A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. B) Encourage the client to allow for mechanical ventilation. C) Educate the client on the purpose of mechanical ventilation. D) Refer the client to a therapist to deal with the death of her mother.

A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so.

Which of the following most accurately describes the family burden associated with mental illness? A) It is the overall level of distress experienced as a result of the mental illness. B) It is the pattern of negative attitudes that lead people to fear individuals with mental illness. C) It is the measurable or quantifiable impacts of mental illness on the family. D) It is the assessment that visualizes the way the family interacts with the community.

A) It is the overall level of distress experienced as a result of the mental illness Family burden is the overall level of distress experienced as a result of the mental illness. Stigma is the pattern of negative attitudes that lead people to fear in discriminate against individuals with mental illness and their families. Objective burdens are a type of family burden that is measurable or quantifiable. An echo map is an assessment tool that helps nurses visualize how the family can interacts with the external community environment.

After discussing advance directives during a home visit, an older adult client decides to prepare documents for future care needs. Which actions by the nurse are Appropriate in this situation? Select all that apply. A) Telling the client that changes to the advance directive can be made at any time B) Telling the client that it is not necessary to make decisions about healthcare needs in the future C) Giving a copy of the advance directives to the client's adult children D) Educating the client about the purpose and types of life-sustaining measures E) Having the client name an individual to be responsible for care decisions

A) Telling the client that changes to the advance directive can be made at any time C) Giving a copy of the advance directives to the client's adult children D) Educating the client about the purpose and types of life-sustaining measures The nurse should explain that if a decision is made on an advance directive, the decision can be changed. Rationale: Clients should be instructed to provide a copy of their advance directives to their next of kin. The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures and provide teaching on these measures if necessary. An advance directive does not mean that the client does not need to make any future decisions about healthcare. An individual to be responsible for care decisions is a durable power of attorney for healthcare and may or may not be included when creating an advance directive.

The nurse is caring for a client who is hospitalized with pneumonia. Which of the following will the nurse assess when determining the impact of the illness on the family? Select all that apply A) The duration of the illness B) The effect of the illness on future family functioning C) The cause of the illness D) The meaning of the illness to the family E) The financial impact of the illness

A) The duration of the illness B) The effect of the illness on future family functioning D) The meaning of the illness to the family E) The financial impact of the illness The impact on the family is assessed by the duration of the illness as well as its effect on the family finances and functioning. Other factors include residual effects of the illness, meaning of the illness to the family, and its significance to family systems. The cause of the illness is not a factor that determines the impact on the family.

A nurse who reports suspected child abuse, honestly believing it to have occurred, is not subject to civil or criminal liabilities when the subsequent Investigation does not make a determination of abuse. This is called A) good faith immunity. B) protection of privacy. C) breach of confidentiality. D) criminal malfeasance.

A) good faith immunity. In every state, healthcare workers are protected from civil or criminal liabilities when they report suspected child abuse in good faith, even if the subsequent investigation does not make a determination of abuse. This is called good faith immunity. This is not protection of privacy, breach of confidentiality, or criminal malfeasance

In the following clinical question, what is the Outcome (O component)? "What is the effect of relaxation therapy versus biofeedback on the functional ability of patients with rheumatoid arthritis?" A)Functional ability B)Rheumatoid arthritis C)Biofeedback D)Relaxation therapy

A)Functional ability In the PIO acronym, P stands for the population or patients (rheumatoid arthritis); I stands for the intervention, influence, or exposure (biofeedback or relaxation therapy); and O stands for the outcomes (functional ability).

The nurse working in a healthcare setting is charged with inappropriate delegation after asking an unlicensed assistive personnel (UAP) to change the IV bag for a client. To which agency should this action be reported? A. Board of nursing B. Occupational Health Safety Network C. Health Hazard Evaluation Program D. Occupational Health and Safety Administration

A. Board of nursing The state board of nursing has established procedures for reporting errors and violations made by licensed nurses and acts to investigate those reports. Complaints can include unsafe nursing​ practices, such as inappropriate delegation. The other agencies do not investigate nursing errors.

A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating. scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A. Responding to a change in the client's condition B. Time management skills C. Prioritizing the client's care D. Meeting a client's goal

A. Responding to a change in the client's condition Each client has a plan of care, but it is the nurses who constantly evaluate the client for changes that the nurse responds to, if needed.

An older adult client experiences an extended hospitalization due to a chronic illness. The client states to the nurse, "I don't know how I can pay for this hospital stay and afford all of the new medication that I have been prescribed." Which response by the nurse is the most appropriate? A. ​"Much of your care will be covered by​ Medicare." B. ​"Don't worry.​ I'm sure everything will work out​ okay." C. ​"I'll have someone from the business office come and talk to you about your​ bill." D. ​"You need to focus on recovering and stop worrying about​ money."

A. ​"Much of your care will be covered by​ Medicare." Medicare is a federally funded health insurance program for individuals age 65 and older. Coverage can include both hospital, medical, and pharmacy costs. However, it does not cover all medical costs. Rationale: Ignoring the client's concerns by telling him not to worry is not therapeutic communication and does little, if anything, to confront the client's concerns. Giving the concern to the business office is merely "passing the buck."

A group of staff nurses is discussing the importance of uniform language within healthcare documentation. Which statement made by the one of the nurses indicates an understanding of uniform language in healthcare documentation? A) "Uniform language is useful only when communicating with other staff nurses." B) "Uniform language is the consistent use of the same terminology among all providers." C) "Uniform language decreases the value of nursing interventions in the eyes of other providers." D) "HIPAA and HITECH are examples of uniform languages used by nurses."

B) "Uniform language is the consistent use of the same terminology among all providers."

The nurse in an inpatient hospice realizes that part of hospice care is aggressive pain management, including the administration of high doses of pain medications to patients. The nurse is not morally opposed to this practice, believing that it gives comfort in a patient's final days. Which process does the nurse apply to reach this decision?

Values clarification

The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care? Select all that apply. A) Apply physical restraints if the client gets out of bed. B) Assess the client's vision and make sure he is utilizing any prescribed eyewear. C) Utilize side rails on client beds. D) Keep frequently used items within easy reach.

Answer: B) Assess the client's vision and make sure he is utilizing any prescribed eyewear. C) Utilize side rails on client beds. D) Keep frequently used items within easy reach. Explanation: Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of bed. The nurse could include in the plan of care to apply physical restraints only when absolutely necessary for the client's safety and only by physician's order.

Which behaviors by a new nurse are likely to reduce stress and burnout? Select all that apply A) Meditate or take a long soak in a tub. B) Join a local aerobics class. C) Participate in a professional organization. D) Refuse to acknowledge personal limitations. E) Don't accept failure; try, try, and try again.

Answer: ABC A) Meditate or take a long soak in a tub. B) Join a local aerobics class. C) Participate in a professional organization.

A client, learning that her baby has died in utero, is planning to carry the baby until natural delivery because abortion is against her religion. Which in the client demonstrating based on this data? A) Fear of retribution B) Morals C) A healthy decision D) Sound judgment

Answer: B B) Morals

A nurse forgets to return a client's bed to the low position after performing a bed bath. When a colleague points this out, the nurse states, "I should have returned the bed to the low position. Thank you for pointing out my error." With which characteristic is the nurse's response most consistent? A) Compassion B) Integrity C) Fidelity D) Justice

Answer: B- Integrity Integrity involves adherence to a strict moral or ethical code. Nurses demonstrate integrity in various ways, such as by accepting feedback as a tool for improving their delivery of client care and by maintaining accountability for their actions and freely admitting when they make mistakes. By admitting to an error, this nurse is demonstrating integrity. Justice has to do with being fair. Fidelity means to be faithful to agreements and promises. Compassion is an awareness of and concern for the suffering of others.

The nurse is caring for a 230-lb client who needs to be repositioned every 2 hours. While positioning the client, the nurse injured a muscle in her back To prevent the injury and ensure safety for both the nurse and client, what should the nurse have done differently in this situation?

Ask for additional help

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient?

Ask if there is another family member who can help at home while the patient is in the hospital. Rationale: The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person.

A nurse is caring for an older adult client with terminal cancer. The client's family wants to continue treatment, but the client would like to discontinue treatment and go home. The nurse agrees to be present while the client tells the family. Which principle is the nurse supporting?

Autonomy refers to the right to make one's own decisions. The nurse is supporting this principle by supporting the client in his decision. Rationale: Nonmaleficence is the duty to "do no harm." Justice is often referred to as fairness. Beneficence means "doing good."

A rural home health nurse is caring for a client recovering from a myocardial infarction. The client is concerned that the community clinic does not have the ability to provide the necessary monitoring for the health problem. Which response by the nurse supports the use of informatics to meet client needs? A) "It is not necessary for you to be monitored after a myocardial infarction." B) "We can send your information to the cardiologist using telehealth." C) "You are right. We will be sending you to the city every month." D) "We use an intranet in this facility."

B) "We can send your information to the cardiologist using telehealth."

A client on a medical-surgical unit experiences a code blue situation unexpectedly. The emergency situation has ended and the client survived. The nurses are breaking for lunch and plan to process their feelings about the emergency. Which action by the nurses will facilitate this? A) Discussing the event outside the hospital B) Asking management for the use of a private room to debrief C) Talking while riding in the staff elevator D) Debriefing about the situation at home

B) Asking management for the use of a private room to debrief

A nurse educator is talking to a student about how to regarding actions during an ethical dilemma? deal with an ethical dilemma in practice. Which does the nurse educator explain to the student as important? A) Examining all conflicts in the situation. B) Investigating all aspects of the situation. C) Relying on nursing judgment. D) Making a decision based on the policy of the agency.

B) Investigating all aspects of the situation.

The home healthcare nurse is conducting a home risk assessment for a family with one-year-old and three-year-old children. Which should the nurse identify as the priority safety hazard? A) Safety plugs in electrical outlets B) Medications on the kitchen counter C) Lack of helmets next to bicycles D) Deadbolt locks on the doors

B) Medications on the kitchen counter Rationale: The nurse would instruct the parents to keep medications out of the children's reach. Medication poisoning happens easily with young toddlers and preschool-age children who think the medication is candy. Safety plugs are appropriate for this age group. Deadbolt locks are appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike does not mean there are no helmets in the house. This finding would cause the nurse to ask more questions but is not considered a definite safety risk.

An adolescent client with a sexually transmitted infection (STI) says to the nurse, "Promise you won't tell my parents about my condition." The agency policy is that all STIs must be reported in accordance with state and federal law, Which action by the nurse is appropriate? A) Disclosing information to the parents B) Reporting the STI to the proper authorities C) Respecting the client's privacy and confidentiality by not mentioning or reporting the STI D) Telling other nurses in the clinic that the client has an STI

B) Reporting the STI to the proper authorities

The nurse is assessing a client's spirituality. Which of the following findings would suggest that the client experiences of spirituality as a source of strength? A) The client uses the telephone to inform family members of an unwanted diagnosis. B) The client reads spiritual material every morning. C) The client asks to watch a religious service on television. D) The client says she has no desire to meet with a chaplain. E) The client tells the nurse she is convinced she will be punished in the afterlife.

B) The client reads spiritual material every morning. E) The client tells the nurse she is convinced she will be punished in the afterlife. Regularly reading spiritual material and asking to watch a religious service on Television are actions that suggest the client views spirituality as a source of strength in contrast, focusing on possible punishment in the after life would suggest that the client is experiencing spiritual distress. Lack of interest in meeting with a chaplain might indicate spiritual distress, or it might indicate that the diagnosis on the phone is unrelated to spirituality.

What is the meaning of the statement, "This finding was statistically significant"? A) A significant number of people participated in the study. B) The finding is probably true and replicable in a new sample. C) A significant theme was identified. D) The finding is clinically important.

B) The finding is probably true and replicable in a new sample.

Which group is best served by the development of a rigorous base of evidence for nursing practice? A) health care policymakers B) nurses' clients C) nursing administrators D) practicing nurses

B) nurses' clients

A nurse enters the client's room to evaluate the response to IV pain medication administer per patient request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered the client states "I do not want to move." The nurse asks the client to rate the current level of pain Which step of the nursing process does this action represent? A. Planning B. Assessment C. Implementation D. Evaluation E. Diagnosis

B. Assessment C. Implementation D. Evaluation

Which is a likely trend for the future of nursing research? A. Improving the methods for conducting research B. Improving nurses attitudes toward evidence based practice C. Enhancing the focus on the clinical significance of research findings D. Enhancing nursing students interest in conducting their own research

C. Enhancing the focus on the clinical significance of research findings

In holistic nursing, the nurse should emphasize the client's personal responsibility in maintaining health. This idea is most closely related to which concept in caring interventions? A. Nursing presence B. Empowerment C. Compassion D. Competence

B. Empowerment Empowerment is the process whereby the client develops the autonomy to identify her own health needs in lieu of being instructed how to do so. This helps the client take personal responsibility in maintaining health. Nursing​ presence, compassion, and competence are less likely to help clients take personal responsibility for their own health.

The nurse is working for a healthcare organization that is going through the reaccreditation process. What action can the nurse take to help the organization be successful in the reaccreditation process? A. Influence change by working with public officials at the​ local, community,​ state, and national levels. B. Facilitate the use of nursing procedures that are current and​ evidence-based. C. Understand how healthcare policy affects​ patients, their own​ practice, and their organization. D. Write position statements related to current events that affect the nursing profession.

B. Facilitate the use of nursing procedures that are current and​ evidence-based.

The family members of a recently deceased client wrote a letter to the unit manager, expressing their appreciation for the way the client was treated while dying in the hospital. The family mentioned characteristics that indicate the nurses were caring. What behaviors did the family most likely use to explain the caring actions of the nurses? Select all that apply. A .Established limits with the client B. Maintained client confidentiality C. Delivered care with style D. Respected the client E. Treated the client as a human being

B. Maintained client confidentiality C. Delivered care with style D. Respected the client E. Treated the client as a human being Caring has been described as encompassing various intentions and actions. There are 10 behaviors within​ caring, which include appreciating the client as a human​ being, showing respect for the​ client, and treating client information confidentially. Delivering care with style describes aesthetic​ knowing, which includes the concepts of​ empathy, holistic​ thinking, compassion, and sensitivity. Establishing or setting limits is an action that a nurse would perform as part of​ self-care actions.

Which type of commitment involves a feeling of obligation to continue in a profession, usually as a result of having received benefits or having had positive experiences through engagement in the profession?

Normative Commitment

The nurse administers blood to a patient without verifying the patient's identity. As a result, the patient receives the wrong type of blood and has a severe reaction. Which principle of ethical decision making is demonstrated by the nurse's failure to verify the correct blood? A.) Justice B.) Non maleficence C.) Veracity D.) Beneficence

B.) Non maleficence

The nurse is preparing to triage victims of a train derailment who are being transported to the emergency department. Which victim would need immediate care? Select all that apply.

Bleeding from fractured limb with a blood pressure of​ 78/40 mmHg Respiratory rate of 8 and irregular

What is the term for the strategy of withholding information from participants, interventionists, or other research staff, to enhance objectivity?

Blinding

Which action protects the client's confidentiality?

Not revealing what they say during sessions without their consent

Although the positivist and constructivist paradigms differ in many ways, the two paradigms have which feature in common?

Both rely on the cooperation of human beings to participate in a study.

The nurse is caring for a client on a medical-surgical unit that has just implemented the electronic medical record for client documentation. The client asks the nurse about the facility's computerized system for keeping client information, especially in regard to confidentiality. Which is the best response by the nurse? A) "I can see why you're worried, with all the computer hackers out there these days." B) "Our system was designed with a lot of input from nursing staff." C) "Information in the electronic medical record requires a password to retrieve." D) "Don't worry; your information is always safe."

C) "Information in the electronic medical record requires a password to retrieve."

A student nurse administers a medication to the wrong client while the instructor is with another student. Which statement by the instructor is most appropriate in this situation? A) "You have placed the nursing student program in danger." B) "You may be sued by the hospital for the extra care cost to the client." C) "You are expected to practice like a licensed nurse." D) "You have set a bad example for the other students."

C) "You are expected to practice like a licensed nurse."

A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, because my mother has the same illness."

C) "You seem to be frightened by the procedure. Tell me how you are feeling."

A nurse is volunteering time in a local free clinic that provides care to the underinsured population. By volunteering time to work in the clinic, this Nurse is demonstrating which professional value? A) Altruism B) Human dignity C) Social justice D). Integrity

C) Social justice Social justice is upholding fairness on a social scale. This value is demonstrated in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality healthcare. Human dignity is respect for the worth and uniqueness of individuals and populations. Autonomy is respecting the client's right to make decisions about their healthcare. Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice.

The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge, and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching.

C) The client with pneumonia may be experiencing respiratory distress.

A nurse overhears two colleagues belittling a client on a public elevator. Which action by the nurse is most appropriate? A) Immediately ask the nurses to stop talking about clients in public. B) Report the nurses' behavior to the unit manager. C) Wait and speak to the nurses about their behavior in a private place. D) Report the nurses' behavior to the hospital's risk manager.

C) Wait and speak to the nurses about their behavior in a private place.

The nurse is providing home care for a client who traditionally drinks herbal tea to treat an illness. How should the nurse respond to a request for the herbal tea? A)We do not allow our clients to drink herbal tea. B)Why in the world would you want to drink that stuff? C)Let me check with the doctor to make sure it is okay to drink the tea with your medicines. D)I have to fill out a lot of forms that you will have to sign before I can do that. E) Let me check with the doctor to make sure it is okay to drink the tea with your medicines. The client was diagnosed with

C)Let me check with the doctor to make sure it is okay to drink the tea with your medicines. herbs are a common method of treatment in many cultures. If a client traditionally drinks an herbal tea to alleviate symptoms of an illness, there is no reason why both the herbal tea and the prescribed medication cannot be used as long as the tea is safe to drink and does not interfere with, or exaggerate, the action of the medications. telling the client that we do not allow that or asking why the client will want to drink "that stuff" is demeaning. No paperwork is necessary to allow the client to drink herbal tea.

How can a healthcare facility's management best take advantage of the multigenerational nursing staff?

Celebrating the unique strengths of each generation of nurse can decrease interpersonal tension and facilitate personal growth. Rationale: Nurses who learn to acknowledge and appreciate their colleagues from different backgrounds, including generational backgrounds, have a distinct advantage. The best teams use the contributions of each generation's skill set and strenghts.

Several nurses are discussing the Joint Commission's 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients correctly?

Consistently using two methods to identify the client

A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is best? A) "The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than usual." B) "You don't need to worry about posters on the wall. Our primary concern is getting you well." C) "We never make mistakes here. We want the public to know that we have client safety goals here." D) "There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them."

D) "There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them."

Under which circumstance would the use of a geographic information system (GIS) be benelicial for healthcare workers? A) When sharing a traveling client's electronic health record (EHR) with an out-of-state provider B) During a mass casualty incident C) When tracking the sleep pattern of a client D) During an influenza outbreak

D) During an influenza outbreak Answer: D Rationale: A GIS is used to map where infectious diseases are most likely to spread next so that adequate care can be provided. Although sleep patterns can be tracked using GIS, GIS is more beneficial when comparing sleep patterns in different geographic regions rather than tracking sleep patterns of one individual client. GIS is not typically used when sharing a traveling client's EHR with an out-of-state provider or during a mass casualty incident

While reviewing safety precautions with the staff in a long-term care facility, which step should the nurse emphasize that helps to promote a safe environment for the clients? A) Keep clutter out of the hallway and inside the client's room. B) Provide dim lighting. C) Turn off alarms to reduce noise. D) Have the client wear rubber skid-resistant slippers.

D) Have the client wear rubber skid-resistant slippers. Explanation: Having the client wear rubber skid-resistant slippers is the most appropriate intervention to decrease the risk of client falls, which will promote a safe environment. Dim lighting will increase the risk of client falls. The environment should be clutter-free, because any clutter can cause the client to fall. Noise should be kept to a minimum, but turning off alarms would endanger a client.

What is one of the primary reasons that it is important for nurses to prioritize care? A) Nurses need to plan how to accomplish all activities within one shift. B) Nurses can accomplish more if they perform the easiest or fastest interventions first. C) Nurses should perform interventions related to client preferences early in the shift. D) Nurses only have a limited amount of time to perform nursing interventions.

D) Nurses only have a limited amount of time to perform nursing interventions. Rationale: By prioritizing care, nurses can ensure that high-priority interventions are completed first, followed by medium-priority and then low-priority interventions as time allows. It will likely not be possible for a nurse to plan how to accomplish all activities within one shift. Nurses often accomplish less and are more stressed if they perform the easiest or fastest interventions first. Nurses should consider client preferences for all interventions regardless of the time the intervention is completed.

The nurse is preparing discharge instructions for a client with a foot wound. How will the clinical information system support this client's learning needs? A) Improves documentation about the client's status B) Summarizes the list of charges that will appear on the client's bill C) Provides a record of all medications received while hospitalized D) Prints discharge instructions to use for teaching

D) Prints discharge instructions to use for teaching The clinical information system provides access to client information and provides data to help the nurse execute the nursing process. Rationale: This includes printing discharge instructions to use in client teaching. Although different information systems can do all of these things, only printing discharge instructions will support the client's learning needs.

The nurse who administered a medication to a patient realizes the wrong dosage was given. Which action by the nurse demonstrates integrity? A) Administering the correct medication B) Monitoring the patient for adverse effects C) Dismissing the error if no adverse effects occur D) Reporting the medication error

D) Reporting the medication error

A nurse conducted a class on fall prevention for a group of older adult clients in the community. Which observation during a client home visit indicates that teaching on fall prevention was effective? A) All meat is placed in the freezer. B) The locks were changed on the doors. C) Scatter rugs are placed in the kitchen. D) Safety strips are installed in the shower.

D) Safety strips are installed in the shower. Explanation: Safety strips in the shower can prevent falls. The client who installs the strips has understood the nurse's teaching. Changing the locks may promote safety if there have been frequent break-ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. The nurse encourages the client to place perishable foods in the refrigerator when arriving home from the store.

During an assessment of a child in the urgent care clinic, the nurse notes that the child has a swollen and split lip. When asking the parent how the child's lip injury occurred, the parent responds, "We are here for my child's ear not my child's lip." Which is the rationale for reporting this incident? A) The child reports that a parent caused the injury. B) The lip injury is unrelated to the ear infection. C) The nurse can be sued if there is no abuse. D) Suspected abuse must be reported.

D) Suspected abuse must be reported.

The nurse is caring for a client on a medical-surgical unit. The client tells the nurse that the healthcare provider has refused to treat the client further if the client continues to be noncompliant with the healthcare provider's recommendations. Which is the priority nursing action in this situation? A) Advise the client to sue the healthcare provider. B) Have the client contact a consumer agency. C) Notify the healthcare provider of the client's complaints. D) Take the issue to the hospital ethics committee.

D) Take the issue to the hospital ethics committee. Acting as a client advocate and protecting the client's rights, the nurse should enlist the help of the hospital ethics committee. The nurse never advises a client to sue but assists the client to find help resolving the issue. A consumer agency is not appropriate because this is an ethical matter. The nurse should act on behalf of the client, and the best way to do that is by taking the issue to the hospital ethics committee, not to the healthcare provider.

A client who sustained a traumatic brain injury several weeks ago is in a chronic vegetative state and is no longer competent to make healthcare decisions. Who should the nurse expect to make care decisions for this client? A) The physician B) The client's spouse C) Social services D) The agent named in the durable power of attorney

D) The agent named in the durable power of attorney

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. What goal will allow the nurse to best evaluate the Mother's ' learning? A) The mothers will be able to set goals for the next class session. B) The mothers will be able to pass a written test on how to bathe a newborn infant. C) The mothers will be able to review the major points of the class. D) The mothers will be able to provide a return demonstration of a bath on a newborn doll.

D) The mothers will be able to provide a return demonstration of a bath on a newborn doll. The nursing process identifies needs, plans, goals, and interventions and then evaluates the effectiveness of the interventions In this case, the evaluation includes having the client demonstrate the ability to care for an infant. Rationale: The nurse would review major points before the end of the class and before evaluating the effectiveness of the teaching. Passing a written test does not allow the nurse to determine if the participants are able to complete the skills taught in the class. Goals for learning are completed after assessing the knowledge level of the class.

A 16-year-old client has requested that she be examined and receive counseling without her parents being present. Which response demonstrates a correct response to this request? A) The nurse asks the client's parents if this is okay with them. B) The nurse agrees but still informs the parents immediately of everything they did not witness. C) The nurse strongly urges the client to reconsider this request to receive the best possible care. D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.

D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved. Adolescent clients may wish to be examined or receive counseling separate from their parents. The nurse should make every effort to honor this request, though doing so may lead to confrontation with the parents. Rationale: Understanding state statutes and organizational policy related to adolescent confidentially is essential when situations such as this arise. When providing confidential care to adolescents, the nurse should encourage adolescents to consider involving parents or guardians in their decision making. The nurse should make it clear that this is a suggestion and not a requirement for receiving care. The nurse should not clear this request with the parents, involve the parents anyway, or make it sound as though competent care depends on the adolescent reconsidering her request.

Which action by the student nurse is most consistent with commitment to the nursing profession? A) The student calls in sick for clinicals in order to study for a class exam. B) The student declines to observe a new procedure for giving a necessary bath. C) The student misses class to attend a political rally. D) The student calls in sick for clinicals because of a respiratory infection.

D) The student calls in sick for clinicals because of a respiratory infection.

In the following clinical question, what is the Population (P component)? "Do stress and depression affect dyspnea in patients with chronic obstructive pulmonary disease (COPD)?" A)Patients who are stressed B)Patients who are depressed C)Patients who experience dyspnea D)Patients with COPD

D)Patients with COPD In the PIO acronym, P stands for the population or patients (patients with chronic obstructive pulmonary disease); I stands for the intervention, influence, or exposure (stress and depression); and O stands for the outcomes (dyspnea).

A novice nurse has accepted a position on a medical-surgical unit at a local university hospital. In order to provide safe care to clients, the nurse should plan to develop which competency? A. Promoting appropriate values that clients should adopt B. Reporting families for bringing food to the​ client's room C. Creating a culture of trust within the hospital D. Functioning as a member of the healthcare team

D. Functioning as a member of the healthcare team New nurses should learn about the healthcare team members and determine whom to collaborate with in certain situations. Rather than reporting​ families, the nurse would work with families to help meet their needs if food is not allowed in the room. The nurse would respect the values of clients and not seek to impose any on the clients. Creating a culture of trust is a system change that is implemented by the administration.

What action can a student nurse take to comply with nurse practice acts and remain accountable for knowing their legal nursing scope of practice in their state? A. Become engaged in organizational quality improvement projects. B. Join the American Nurses Association​ (ANA). C. Become accredited. D. Obtain current licensure.

D. Obtain current licensure. Current licensure is required for practice as a nurse as part of the nurse practice acts. Through licensure, nurses are held accountable for knowing the legal nursing scope of practice in their state and what actions could place their licensure status in jeopardy.

The nurse is assessing a 12-year-old male client. The client is within the normal range for height, weight, and body mass index (BMI) for his age. The client plans to play contact sports at school this year. He lives with his mother and attends after-school events when she is working late. What education should the nurse identify as a priority for this client to promote safety? A. The importance of good hygiene practices and healthy diet B. The importance of maintaining a normal weight and participating in physical activity C. The importance of learning how to feel secure when he is at home alone D. The importance of using safety equipment when playing contact sports

D. The importance of using safety equipment when playing contact sports The​ client's biggest safety risk is a risk of injury from contact sports. The nurse should encourage the client to use proper safety equipment to avoid injury. Promoting a sense of security is important for latchkey​ children, but this client does not appear to be home alone for extended periods based on participation in​ school, sports, and​ after-school activities. The client already has a normal weight and participates in physical​ activity, so education related to these topics is not as important as sports safety. There is no evidence that this client has poor hygiene or an unhealthy diet.

Which is the dependent variable in the research question, "Is the quality of life of nursing home residents affected by their functional ability or hearing acuity?" A) Quality of life B) Functional ability C) Hearing acuity D) Residence in a nursing home

Dependent variable: Quality of life

What is a final step in both quantitative and qualitative research?

Disseminating research results

The nurse is caring for an older adult client who visits the clinic semiannually to help maintain quality of life. When providing caring interactions to this client, what intervention should the nurse avoid?

Elder speak is a simplified speech characterized by shorter sentences and words. Rationale: This type of speech shows a negative attitude toward older adults, especially adults who are generally healthy and are only seeking care to enhance quality of life. Assessments of older adults should include mental health problems, and older adults may be referred to a geriatrician as needed. Self-care is related to the nurse caring for one's self, not the nurse caring for a client.

The nurse is caring for a female American Indian patient who requires surgery. The patient states, "I want to talk with my tribe's healer before I make my decision, but that surgeon seems like she's in a hurry for me to make up my mind. "In the context of Leininger's theory of culture care diversity and universality, which nursing action represents culture care accommodation and/or negotiation?

Encouraging the patient to tell the surgeon that she wants to speak with her tribal healer before deciding whether to have surgery

A hospital has created a culture of safety by providing organizational support for safety initiatives and by training and encouraging healthcare employees in the area of safety. What other step is needed to promote safety for everyone in the healthcare environment?

Engage clients in their own safety

Advances in technology have made what diagnostic information available to healthcare providers at the client's bedside?

Even before many advances in technology, nurses and other healthcare providers had access to the client's current vital signs, allergy alerts, and dietary restrictions by viewing the client's paper chart at the client's bedside. Rationale: However, they usually could not view radiologic images at the bedside Now, with advances in technology, results from laboratory and radiologic exams can often be viewed at the client's bedside.

What are the two broad classes of quantitative research?

Experimental and nonexperimental

Gaining entrée in a qualitative project usually requires negotiations with whom?

Gatekeeper

A nurse is starting their shift, and enters a client's room to complete their assessment. The client's spouse is sitting in the chair next to the bed reading a book. The client is in bed watching TV. Using A.I.D.E.T. communicate to the client and their spouse why you are in the room

Hi (patient name), my name is (your name) and I will be your nurse today. I will be doing a head to toe assessment and it will take less than 30 minutes to complete. Thank you (after you complete it)

Which is the independent variable in the question, "Do baccalaureate degree-prepared nurses practice more rehabilitative nursing procedures on a client in an ICU than associate degree-prepared nurses?" A. Rehabilitative nursing procedures B. Associate degree-prepared nurses C. Baccalaureate degree-prepared nurses D. Type of educational background of nurse

Independent: D. Type of educational background of nurse

Where are nurses most likely to find research evidence?

Journal articles

A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection. The client states, "T've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift, the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would be the priority for nursing interventions?

Nursing diagnoses of "Ineffective Breathing Pattern," "Disturbed Sleep Pattern," and "Risk for Infection" are diagnoses that need to be considered because of the client's inability to fully expand his lungs because of his rib injury. Of these, "Ineffective Breathing Pattern" would receive the highest priority in the nurse's care planning. Rationale: Addressing the client's disruption in sleep patterns in order to promote quicker healing and taking measures to minimize his risk for infection are also important, but are lower in priority than addressing his current ineffective breathing. In addition, addressing the client's psychosocial needs-his worry about being unable to support his family while he recuperates is also an important aspect of holistic nursing care, but again of lesser priority than his ability to breathe effectively.

The preceptor tells the new nurse, "You are on your own today. You have been on orientation for a week now, so you really should be able to handle these patients by yourself. "Which aspect is most negatively affected by the preceptor's behavior?

Patient safety is most negatively affected by the preceptor's behavior. Rationale: Due to the belittling comments by the preceptor, the new nurse is unlikely to seek help and ask questions, which affects the safety of the patients. Lack of communication, collaboration, and advocacy are all contributing factors to patient safety.

The home healthcare nurse is traveling to a client's home for the first time. What observation would suggest a safety hazard for the nurse?

Porch steps that are broken and rotting

A hospital has had higher than average reports of client handling and movement injuries. What could the nurse advocate for that could most help reduce the number of client handling injuries?

Purchase lifting devices

Which action by a nurse would require immediate intervention by another healthcare team member?

Recapping a needle while holding the cap

A novice nurse who is in orientation is planning care for an older adult client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking?

Request a review of the plan with the nurse's preceptor.

What is a paradigm?

Scientific progress caused by new world views

A nurse in a rural community is employed in a facility that has had a shortage of nurses for several years. As a result, several nurses have left the institution citing burnout. To avoid risking burnout, the nurse regularly works out, practices yoga, socializes with friends once or twice a week, and participates in at least one annual national or state nursing conference. This approach to work-life balance reflects which concept within the framework of Caring Interventions?

Self-care

The nurse who filed a complaint of sexual harassment against a coworker states, "I do not want to work on that unit anymore because I am afraid " Which term best describes the nurse's work environment?

Sexual harassment

The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be Appropriate to calm the client?

Speaking in a soft, calm manner is the first step in attempting to soothe an excited client. The nurse's tone may calm the excited client. Rationale: Using short sentences is a useful-approach, but in the case of an excited client, the nurse would attempt to calm the client first. Isolating the client may be necessary if the client's behavior escalates to violence, but that is not evident here and is not the first choice of action. Giving a sedative is the last resort and is used only if the client is threatening to hurt self or others.

The nurse is caring for a 43-year-old client. What education should the nurse implement to best address the overall health promotion needs of someone in this age group?

Teach the client about​ age-appropriate medical screenings

The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan?

The column plan of care uses columns to categorize data for each phase of the nursing process. Rationale: This type of plan may include four columns. (a) nursing diagnosis, (b) desired outcomes, (c) nursing interventions, (d) evaluation. Medications, medical diagnosis, and diagnostic tests to order are not on the plan of care

The nurse is caring for a client in the intensive care unit (ICU) who was in a motor vehicle crash. The healthcare provider asks the nurse to extubate The client because there is no communication between the brain and body due to a cervical fracture. The family agrees with the decision of the healthcare provider, but the nurse is uncomfortable pulling the tube. Which is the reason the nurse is experiencing difficulty with this task?

The nurse is distressed because of personal values, which are in conflict with causing the client's death. The decision is within ethical principles. Rationale: Cultural values are not in evidence in this instance. Extubating this client would not be a legal decision.

A researcher collects data about a phenomenon by observing people in a naturalistic setting and also by interviewing people in that setting. What strategy did the researcher use?

Triangulation

What is the purpose of an evidence hierarchy?

To rank order evidence according to the strength of evidence provided

A nurse is providing care to a client who is scheduled for a colonoscopy. The client requires a bowel prep prior to the diagnostic test. Which approach should the nurse use to facilitate the client's understanding of the procedure?

Use​ layman's terms to explain the​ procedure, then ask the client to describe the procedure in her own words

Which is a major barrier to evidence-based practice in nursing?

resisting to nursing leadership

What is empirical evidence?

sense experience, is the knowledge or source of knowledge acquired by means of the senses

The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client? a) facilitating and taking action when needed b) maintaining a distance of 25 feet separation when speaking with the client c) leaning towards the client during conversation d) being concrete and inflexible about actions that need to be taken during client care

c) leaning towards the client during conversation The nurse best conveys physical attending by leaning toward the client, which communicates involvement. Facilitating and taking action and maintaining social distance do not convey physical attending. Being concrete is a method of communicating information to the client, not a method of conveying physical attending

A client who is living independently but needs temporary skilled nursing services may take advantage of what type of healthcare?

home healthcare

An experienced nurse has accepted a new position in the mental health unit after working in the medical-surgical floor for the past. years. What training would be beneficial for the nurse to refresh before starting her new position?

how to manage aggressive behaviors