Prof Nursing and Health 1 Exam

Therapeutic nurse-patient relationships

- Orientation/ introductory phase - Working phase - Termination Phase

What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem?

Change slowly from sitting to standing

What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion?

Maintain eye contact when talking with the client.

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented?

Mongolian spots

The school nurse is conducting a teacher's in-service on signs that may indicate that a child is a victim of bullying. Which sign should the nurse include in the teaching session?

The child asks to go to the nurse's office frequently with vague complaints

The newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?

This reflexive response is an expected part of development

What is the function of the Professional Standards Review Organizations (PSROs) set up by the federal government?

To review the quality, quantity, and cost of hospital care

4 identity statuses

identity diffusion, foreclosure, moratorium, identity achievement

foreclosure

in which the person keeps talking about changing those around him or her and conspicuously not about making change him- or herself.

Working phase

longest part of the relationship. Data collection, identifying problems, setting goals

The nurse is caring for a client with severe menstrual bleeding and abdominal cramps. Which task is appropriate to be delegated to the licensed practical nurse (LPN)?

Administration of oral analgesics

A nurse manager determines which nurses on the unit will care for particular patients for the upcoming shift. Which element of the health care system is the manager practicing?

Assignment

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what?

Be aware of any personal bias about sexual assault

After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice?

Being licensed by the state Board of Nursing

A client with myasthenia gravis has been receiving neostigmine and asks about its action. What information about its action should the nurse consider when formulating a response?

Blocks the action of cholinesterase

A preschool child with a spinal cord injury will be on prolonged bed rest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan?

Cheese - Cheese contains calcium, which is excreted by the kidneys and may contribute to the formation of kidney stones; it adds to the child's risk because immobility causes bone decalcification.

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse?

Clinical nurse specialist

A client with asthma and depression is admitted to the hospital. Which tasks delegated by the delegator would indicate the task is applicable for the registered nurse?

Teach the client how to use a meter dose inhaler

A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?

Wear a particulate respirator mask

A nurse teaches a client about side effects that will necessitate discontinuation of an oral contraceptive. Which statement made by the client indicates that the teaching is understood?

"I'll stop taking the pills if I have chest pain."

The parents of a 2-year-old child are watching the nurse administer the Denver II Developmental Screening Test to their child. They ask, "Why did you make our child draw on paper? We don't let our child draw at home." What is the best response by the nurse?

"It lets us test the child's ability to perform tasks requiring the hands."

Neomycin 1 gram is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond?

"It will kill the bacteria in your bowel and decrease the risk for infection after surgery."

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this?

"It would be helpful to understand; let's talk."

After an incomplete abortion, a client tells the nurse that although her primary healthcare provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse?

"It's when the fetus is expelled but other parts of the pregnancy remain in the uterus."

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?

"There are some tetrahydrocannabinol (THC)-based medications that contain marijuana that control chemotherapy-induced nausea and vomiting in some people."

Which questions should the delegator assess to determine the right task? Select all that apply.

- "Is the task legally appropriate to delegate?" - "Is the task appropriate to delegate based on institutional policies and procedures?"

What qualities does the professional nurse require to lead, manage, and follow in a team? Select all that apply.

- Exercising self-awareness - Motivating self and others - Managing emotions in self and others

Which is the critical factor among healthcare professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster?

Communication

The registered nurse is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for being delegated the task of administering vaccinations?

Licensed practical nurse

During a health symposium a nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood?

Meats and cream-based foods need to be refrigerated

To improve client care, the registered nurse (RN) has delegated tasks involved in assisting the client with activities of daily life (ADLs) to a certified nursing aide, and the administration of oral medications to the licensed practical nurse. Which member of the health care team would be accountable for the final client care?

Registered nurse

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse?

Sit down quietly next to the bed and allow her to cry.

A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage?

The nurse is able to identify the basic principles of nursing care through careful observation - A nurse in the novice stage learns about the profession through a specific set of rules and procedures - After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients - A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. The nurse's best response is:

The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

A 1-week-old infant has been in the pediatric unit for 18 hours after placement of a spica cast. The nurse obtains a respiratory rate slower than 24 breaths/min; no other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later the infant experiences severe respiratory distress, and emergency care is necessary. What should be considered if legal action is taken?

Vital signs that are outside the expected parameters are significant and should be documented

What is holistic nursing

all nursing practice that has healing the whole person as its goal

five attributes of professional identity

doing, being, acting ethically, flourishing, changing identities

Orientation phase

introductions, building trust, establishing rapport, explaining things

A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure?

"Tell me what you know about this procedure."

3 categories of communication

Linguistic, paralinguistic, meta-communication

A nurse is measuring the blood pressure of toddlers during a community health camp. What blood pressure finding is the nurse most often to find in the toddlers?

Toddler: 95/65 mm Hg Infant: 85/54 mm Hg Children above 6 years: 105/65 mm Hg Ages 10-13: 110/65 mm Hg

A nurse is reviewing discharge instructions with the parent of an infant with cystic fibrosis. What statement indicates that the parent knows how to administer the pancreatic enzyme replacement?

"We should give the medication with feedings."

The registered nurse (RN) is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the unlicensed assistive personnel (UAP) to provide quality care to the client? Select all that apply.

- Recording vital signs - Assisting the client with bathing

Meta-communication

- context of the message - is the what is going on in the situation such as environmental stimuli, personal state, and relationship of the people communicating

Paralinguistic

- nonverbal messages, gestures, eye contact, facial expressions - Paralinguistic is how the words are delivered (or not not delivered)

Which of the following statements about a case manager is correct?

A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families

A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care?

Administering mouth wash for oral hygiene

How does a nurse leader effectively implement change in an organization?

By using personal and professional skills

Which activity indicates improper follow-through on the part of the delegatee?

Failure to report results

Which statement is true about the centralization as it relates to organizational structures?

It refers to the location where a decision is made. - Centralization refers to a location where the decision is made - Geographic dispersion refers to the physical location of the units - Formalization refers to the degree to which organization has rules, in terms of policies that define a member's function

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse?

Joining a support group of people who are coping with this problem may be helpful

While organizing a community health care program for polio vaccinations, the registered nurse delegates the task of administering vaccines to the members of the health care team. Who among the health care team is most suitable to carry out the task?

Licensed practical nurse

A nurse is performing a health history and physical assessment of a client with cholelithiasis and obstructive jaundice. Which clinical finding should the nurse expect this client to exhibit?

Pain in the right upper quadrant

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?

Perform an assessment of the client before resuming the change-of-shift report.

Which of these is true about SOAP progress note method?

SOAP progress note includes assessment information.

During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak and ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss?

Speech therapy in addition to hearing aids may be required.

Linguisitc

- Spoken words or written symbols - involves choosing the words. Using non-technical words to describe treatments and medications to patients is a choice

Which psychosocial nursing actions are appropriate when providing client care after a community disaster? Select all that apply.

- Offering choices whenever possible - Requesting assistance from crisis counselors

Pulmonic stenosis is suspected in a 5-week-old infant, and cardiac catheterization is scheduled. When the parents ask what the test involves, how should the nurse reply?

"A catheter will be inserted into a blood vessel in your baby's groin and then threaded to the heart to confirm an anatomic abnormality."

Concept Definition

"A sense of oneself that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting and feeling like a nurse."

The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation?

Advocate

Prednisone is prescribed for a client with an exacerbation of colitis. What does the nurse teach the client before administering the first dose?

Although the medication decreases intestinal inflammation, it will not cure the colitis

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group?

Changing destructive behavior

A nursing student learns to model behavior exemplified by the instructor. What behavior does the nursing student want to emulate?

Ethical Conduct

What does the professional nurse consider to be the center of decision-making when providing client care?

Ethics of Care

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest?

It decreases the potential for further dislodgment of emboli

The count of hydrocodone is incorrect. After several minutes of searching the medication cart and medication records, no explanation is found. Who should the primary nurse notify about the discrepancy?

Nursing unit manager

A 6-year-old child has a fractured arm and multiple old injuries. Child maltreatment is suspected. What parental characteristic supports this suspicion?

Offering inconsistent stories about the injuries

The husband of a young mother who has attempted suicide tells the nurse that he told his wife he would bring their 26-month-old daughter to visit his wife and asks if that would be possible. What is the best response by the nurse?

Tell me what your wife said when you offered to bring your child for a visit

The nurse is an active participant on human resource committees. What does this indicate?

The nurse is staying clear on group outcomes

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain?

Whether an earlier tuberculin test's result was positive

A nurse who promotes freedom of choice for clients in decision-making best supports which principle?

answer: Autonomy - Beneficence relates to the state or act of doing good and being kind and charitable - Justice means to be righteous, equitable, and to act or treat fairly - Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities.

Which characteristic should the nurse use during the nursing process as a guide for delegation?

answer: Critical analysis - Leadership is a role in which a nurse has charge of the personnel as they perform their tasks - Psychomotor tasks are the common characteristics and essential components that a nurse should possess to provide client care - Time management is essential in performing tasks within specified deadlines during delegacy.

Which term refers to the nurse's ability to plan, direct, control, and evaluate others in different situations?

answer: management - Delegation is the transfer of authority to perform some type of task or work - Leadership can be defined as the use of individual traits and abilities in relationship to others and the ability to interpret the context where a situation is emerging - Followership is that each member of a team contributes optimally, but acquiesces to a leader or manager to ensure the best clinical decision-making.

Identity diffusion

is characterized by a lack of interest in commitment, and even in exploration. The catchphrase for this would be "whatever seems good at the moment."

Moratorium

is characterized by overwhelming anxiety that is "hard to sit through" with someone

identity achieved

means that the person is reasonably self-aware, has a sense of self, and can manage overwhelming anxiety should it occur.

Termination phase

summarize and restate findings, clarify data, discuss follow-up plans