NURS 3234 Exam #3

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?

"I just don't have time to take a shower."

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?

"Tell me about what signs of infection you will report to the health care provider."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?"

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?

"We reviewed your plans for your new diet and medications. Do you have any other questions?"

A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply.

-Adolescents -Pregnant or lactating women -Strict vegetarians

A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply.

-Available resources -Learning style preferences -Literacy level

As part of a quality improvement initiative nurses are asked to complete a structure evaluation. Which information should the nurse include in this work? Select all that apply.

-Because there is no door on the unit's diet kitchen, client families feel free to walk in and serve themselves coffee. -Newly purchased beds are difficult to move through client room doors.

Which nursing actions follow guidelines for preventing complications with enteral feedings? Select all that apply.

-Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. -Flush the tube before and after feeding. -Clean and moisten the nares every 4 to 8 hours.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

-Insert a swab into the wound. -Press and rotate the swab several times over the wound surfaces. -Place the swab in the culture tube when done.

The health care provider notified the client and the spouse that the client's condition was terminal. The spouse has been crying since the interaction with the health care provider. The nurse is going to talk with the spouse about the spouse's feelings. What action(s) would the nurse do to promote a positive impression with the spouse? Select all that apply.

-Sit at eye level with the spouse. -Maintain eye contact more than half of the time. -Lean forward slightly. -Hold the spouse's hands during the interaction.

The nurse is interviewing a client who is newly admitted to the unit. Which technique(s) used by the nurse will facilitate communication during the interview? Select all that apply.

-Use broad opening statements. -Share observations. -Use silence.

The student nurse is preparing a presentation on bowel elimination. Which potential cause(s) of diarrhea will the student include? Select all that apply.

-antibiotics -acute stress -depression

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

0000

Which statement describes the person who is likely the most motivated to learn?

A 70-year-old female who is the client's spouse and is learning the care so the client can come home

What nursing care behavior by the nurse engenders a client's trust in the nurse?

A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL (28.0 g/L) - albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure injury

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

The nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure?

Clients are better able to handle new experiences.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding?

Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

A nurse manager is preparing for a visit from The Joint Commission. The nurse manager determines that this visit reflects which type of evaluation?

Retrospective evaluation

nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?

Risk for Powerlessness

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill?

The client organizes materials needed and gives return demonstration.

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client?

The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day

A nurse is documenting care in a source-oriented record. What action by the nurse is mostappropriate?

Write a narrative note in the designated nursing section.

A nurse is developing a client's plan of care. As part of planning interventions, the nurse incorporates a set of steps to follow as a means for decision making for care. Which structured methodology is the nurse including in the plan?

algorithm

A nurse is interviewing an asthmatic client who has a high respiratory rate and at times has difficulty breathing. The client is restless and at current can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document?

altered verbal communication related to the breathing problem

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:

fluid and electrolyte levels.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

impaired tissue integrity

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia

A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

niacin

What are specific measurable and realistic statements of goal attainment?

outcomes

A client who hallucinates simply to maintain an optimal level of arousal is experiencing:

sensory deprivation.