Prep U
Which client growth needs are included in the love and belonging level of Maslow's hierarchy? (Select all that apply.)
Family Intimacy Friendships
A client with an altered self-concept would most likely exhibit which emotional responses? Select all that apply.
Feelings of worthlessness Helplessness Guilt
A nurse is reviewing the different types of health care delivery services available in the community. Which method would the nurse identify as having the primary care goal of reducing costs by preventing illness?
Health maintenance organization (HMO)
A nurse encourages residents of a long-term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure healthy aging. This intervention is based on which aging theory?
Identity-continuity theory
The nurse researcher is aware that the type of variable that can be manipulated in a study is which type of variable?
Independent
A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?
Knowledge Deficit: Medications related to new medical diagnosis
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds.
The nurse practitioner is examining a 55-year-old female client. Which of the following findings would be uncommon for this age group?
Lower extremity pulses are weak
Which nursing action would be most effective in helping a client learn self-care behaviors?
Model self-care behaviors for the client.
What was the focus of nursing research during the first half of the twentieth century,?
Nursing education
If a nurse describes a study of people and the nursing profession including studies of education, policy development, ethics, and nursing history, then what is the nurse defining?
Nursing research
After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?
Objective
As a nursing student is visiting a day care to observe growth and development in action. The nursing student completes assessments on infants and toddlers who are learning to walk, talk, and control elimination. According to Freud, in what developmental stage are they?
Oral; anal
A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?
PC: Decreased Cardiac Output related to cardiac tissue damage
A mother, 13 years of age, delivers a low-birth-weight neonate. The neonate is transferred to the neonatal intensive care unit. The mother reports receiving occasional prenatal care and has a history of excessive alcohol consumption. The growth and development of this neonate has been influenced by which of the following?
Prenatal factors
A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?
Prioritize the nursing diagnoses.
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
A nurse researcher is collecting nominal data. What type of research is being conducted?
Quantitative research
A nurse is preparing to assess a newborn immediately after birth using the Apgar score. Which area would the nurse include in this assessment? Select all that apply.
Respiratory effort Color Heart rate Muscle tone heart rate, respiratory effort, muscle tone, reflex irritability, and color
During the time a client is on a hypothermia blanket, the nurse turns and positions the client every 30 to 60 minutes. What assessments will the nurse complete on each turn? Select all that apply.
Skin color change Lip and nail bed changes Sensory impairment
The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary-level prevention?
Teaching about adhering to a low-sodium diet
A nurse is caring for a toddler in a pediatric clinic. Based on the age of the child, the nurse understands the child should be in Piaget's Preoperational stage. Which of the following activities should the nurse anticipate observing in this stage?
The child rides a broom like a horse.
A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?
The client's most recent temperature
The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply.
The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark.
A nurse is teaching parents of preschoolers about growth and development of their children. Which teaching point would the nurse include?
The pace of growth and development is specific for each person.
The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?
Time-lapsed assessment
What is the purpose of establishing a nursing diagnosis?
To describe a functional health problem
The nurse has established client outcomes and outcome criteria. What should the nurse do next?
Write a client plan of care
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?
a client sitting in a chair who slides down
In contrast to anxiety, fear is characterized by:
a cognitive response to a known threat.
A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider?
alginate
The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually
does not contain documented scientific rationales.
The recognition of health as an ongoing process toward a person's highest potential of functioning is defined as:
high-level wellness.
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity
A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress?
sympathetic nervous system
Which are considered vital signs? Select all that apply.
temperature pulse respiratory rate blood pressure
Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?
"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."
A nurse is taking care of a client who has a new, permanent colostomy. The nurse is talking with the client about the new appliance and asking how the client feels about managing it. Which client response indicates understanding of the relationship between self-concept and health?
"I am developing a set of realistic expectations to help me manage my overall health and quality of life."
The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?
"Reinforced adhesive skin closures will hold my wound together until it heals."
Which statement made by the nurse indicates data that would be documented as part of an objective assessment?
"The client's right leg is cold to the touch, from the knee to the foot."
An 8-year-old girl is brought to the health care provider's office for a well-child visit. During the visit, the child's mother asks the nurse, "When should she get the human papillomavirus (HPV) vaccine? Which response by the nurse would be best?
"The first dose should be given at about 9 or 10 years of age."
The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?
"Will you prescribe a complete blood count to check the white blood cell count and a culture?"
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
1700 Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to 1900.
Which statement is true regarding addressing a priority problem?
A priority problem requires a nursing intervention before another problem is addressed.
Which client would most benefit from the nurse including in the plan of care interventions addressing emotional health?
A stressed client who is experiencing paranoid delusions
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?
Activity and rest
"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?
Actual nursing diagnosis
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
Agent
A nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks how the baby develops soon after conception. Which is an accurate statement from the nurse about the embryonic stage?
All basic organs are established here
During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?
Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.
The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?
Assess the client's ability to stand or sit.
When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?
Assess the client's interactions with the newborn.
Which nursing activity reflects care given on the tertiary level of healthcare delivery?
Assisting with transplant surgery
Knowledge gained from someone with a great deal of perceived experience is which type of knowledge?
Authoritative knowledge
Which statements are true about the implementation phase of the nursing process? Select all that apply.
Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.
The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.
Client states, "I feel so sad all of the time." Client states, "I am in pain."
A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:
Completely unmet
Which example of client care is not the responsibility of the nurse?
Confirming a medical diagnosis
A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client?
Critical reflectivity
The nurse is reading about nursing theorists for a class. The theory reveals the following, "Individuals who use self-care to sustain life and health, to recover from disease or injury, or to cope with its effects." Which individual developed this theory?
Dorothea Orem
A nurse is counseling pregnant women about the detrimental effects of smoking and drinking on a fetus. During what stage of development is the fetus most susceptible to these teratogens?
Embryonic stage
The nurse is caring for an older adult client who has refused a bath for several days and has now developed a rash on the buttocks. What is the priority nursing intervention?
Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.
The pregnant young adult asks the nurse when she will be able to hear the fetal heart beat. Which is the nurse's best response?
"At your 12-week appointment, you will be able to hear the heart beat by Doppler."
A newborn is scheduled for a circumcision and the parent is concerned with the baby feeling pain. What is the best response by the nurse?
"Baby's feel the sensation of touch and pain."
A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client?
"It seems like you are having difficulty with your care regimen."
A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?
progress notes
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?
Modify the plan of care and interventions to meet the client's needs.
How can the nurse best demonstrate being a role model for health promotion?
Avoid smoking and drinking alcohol
A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?
Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth
A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis?
Compromised oxygen transport
Which action is appropriate when evaluating a client's responses to a plan of care?
Continue the plan of care if more time is needed to achieve the goals/outcomes.
Which developmental theorist created the psychosocial theory of development?
Erikson
The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply
Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?
Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?
Health promotion nursing diagnosis
Which are models used in nursing to assist in clustering data? Select all that apply.
Human Needs Functional Health Patterns Human Response Body Systems
A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?
Ineffective Health Maintenance related to client's denial of illness
A nurse manager is attempting to switch the medical records in an orthopedic office to a computerized format. The nurse asks questions about the accuracy and efficiency of the current record keeping system by using the PICO format. Which statements illustrate the components of this process? Select all that apply.
P: The nurse chooses the population involved (orthopedic clients). I: The nurse considers interventions to make the plan work. C: The nurse compares the written records to the computerized records.
The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?
Pain
A healthy 52-year-old client asks the nurse what she can do to maintain her health. Which of the following does the nurse recommend?
Perform self-examination of the skin every month
Which are core concepts in nursing theory? (Select all that apply.)
Person (client) Environment Health Nursing
Before implementing any planned intervention, which action should the nurse take first?
Reassess the client to determine whether the action is needed.
Consultation and diagnostic tests are included in which level of health care?
Secondary Care
The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.
The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past.
The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses?
The client has diminished breath sounds.
The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.
The client is blind. The client denies the need for education.
A nurse is teaching a 2-week pregnant woman what is occurring in the development of her baby. What should the nurse educate the client that normally occurs in this preembryonic stage? Select all that apply.
The zygote implants in the uterine wall. Three distinct layers of cells exist.
The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behaviour indicates the need for additional teaching?
The client sits in the chair with feet flat on the floor and arm below the level of the heart.
A nurse is searching the Cochrane Database of Systematic Reviews for information about evidence-based practice related to pain control measures. The nurse searches this database based on the understanding that these reviews reflect which type of research?
randomized, controlled trials
Which nurse is using criteria to determine expected standards of performance?
The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.
Nurse researchers use both quantitative and qualitative research in their practices. Which actions are examples of the use of qualitative research? Select all that apply.
The nurse examines nursing issues related to Native American/First Nation clients. The nurse investigates past nursing trends to understand the current profession. The nurse discovers how people describe the effect of illness in their lives.
The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. Which precautions should the nurse take?
Use a mask when within 3 ft (1 m) of the client
A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?
Verbally report the finding immediately to the client's physician.
The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:
actual or potential nursing diagnoses.
What does the nurse recognize as purposes of the electronic health record? Select all that apply
documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research
The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize?
impaired concentration
A client, who has limited finances and limited capacity for education, requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, the nurse must first:
implement critical thinking skills.
A nurse is providing care to an older adult who is experiencing delirium. Which risk factors would the nurse identify as being most common? Select all that apply.
pre-existing cognitive impairment advanced age sleep deprivation
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
preventing the client from sliding in bed
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?
use pillows to maintain a side-lying position as needed
