Wellness Exam 2 practice questions

Which questions are appropriate to ask during a transcultural assessment? (Select all that apply.) a. How do you act when you are angry? b. What is your role in your extended family? c. Why do you continue to speak German at home? d. When communicating with friends, how close do you stand? e. What is the purpose of not preparing beef with milk products?

A B D How a person acts when angry, the person's role in the family, and comfort with proximity all are relevant aspects of the patient's cultural norms, according to Giger and Davidhizar, and should be assessed to raise the nurse's awareness of patient needs. Asking a patient why they use their native language in the home is unnecessary. If primary language information is needed, the nurse should simply ask what language is spoken in the home. The nurse should not try to seek information about the reason a person maintains dietary traditions during the assessment process.

Which statements reflect the practice of transcultural nursing? (Select all that apply.) a. May be considered a general and specialty practice area b. Focuses on the worldview rather than patient needs c. Challenges traditional ethnocentric nursing practice d. Aims to identify individual patient care preferences e. Focuses patient care on the nurse's cultural norms

A C D Transcultural nursing is a general and specialty practice that focuses on both world view and individual patient and family needs for planning and providing care. It challenges nurses to investigate other cultures in order to reject ethnocentric care and respond to individual needs.

What aspect of culture is a full-time employed granddaughter of an elderly Asian woman exhibiting if she asks the social worker to place her grandmother in an extended-care facility against the wishes of her parents? a. System change b. Gender role c. Cultural norms d. Shared attributes

A As one aspect of a society changes, the systems within that society change. The granddaughter in this case is employed full time and unable to adequately care for her grandmother at home. Therefore, her request to have the grandmother placed in an extended-care facility is a reflection of societal changes that affect traditional culture expectations of one generation's providing care in the home. Shared attributes, cultural norms, and gender role all are challenged by the granddaughter's actions.

Culturally competent care would encourage which action by a patient's family? a. Asking the family's spiritual advisor to visit the patient b. Speaking English to everyone involved in patient care c. Adhering to highly publicized restrictive unit visiting hours d. Limiting food consumption to items provided by the cafeteria

A Culturally competent care allows for flexibility within safety guidelines and patient care limitations. Allowing a patient to meet with a spiritual advisor recognizes the importance of a patient's spiritual needs. Limiting language use, food consumption, and visiting hours in a strict manner without sensitivity to a patient's preference do not reflect culturally competent nursing care.

a nurse is reviewing the effect of culture on nutrition during a staff in service which of the following groups precribes eating specific foods to balance forces in the body durign illness (select all that apply) a. asian culture b. african culture c. roman catholicism d. hispanic/latinx culture e. buddhism

A. correct: Asian traditions can include balancing yin and yang forces within the body, and foods are grouped into those categories B.African culture has influenced development of the soul food diet, but individual preferences vary widely C. Roman catholicism includes few laws related to fasting on holidays or from certain foods D. correct: hispanic/latinx cultural traditions can include balancing hot or cold within the body, and foods are grouped into those categories E. buddhism has recommendations for eating foods in a manner that do not cause harm

Because of Mr. Smith's progressing dementia, he has difficulty feeding himself. When Margaret prompts him to eat his oatmeal at breakfast, he just stares at his spoon. Margaret picks up his spoon and wraps his hand around the handle. For which psychomotor learning skill is Margaret trying to retrain Mr. Smith? A. Set B. Mechanism C. Perception D. Guided response

Answer: C Rationale: Perception is the simplest behavior, which requires being aware of objects or qualities through the use of sense organs. Margaret tries to retrain Mr. Smith's perceptions by having him hold his spoon.

Chris reviews Erikson's Stages of Growth and Development to determine which state Mr. Moats is in. This is an example of what type of theory? A. Interdisciplinary Theory B. System Theory C. Mid-Range Theory D. Prescriptive Theory

Answer: A Rationale: Nurses must use a strong scientific knowledge base. Erikson's Stages of Growth and Development is an interdisciplinary theory.

Which of the following of Mr. Hannigan's assessment findings can Nigel group together to formulate a data cluster? (Select all that apply.) A. Respirations 32 breaths/min B. Crackles in right and left lung bases C. Pain at incision site D. Shortness of breath with ambulation E. Hematuria

Answer: A, B, D Rationale: A data cluster is a set of signs or symptoms gathered during assessment that are grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Pain at the incision site and hematuria aren't directly related to respiratory issues.

Mr. Smith tells Margaret that he doesn't think he can hold the spoon on his own and feed himself. Mr. Smith lacks self-efficacy. Self-efficacy comes from which of the following sources? (Select all that apply.) A. Enactive mastery experiences B. Vicarious experiences C. Auditory persuasion D. Physiological states

Answer: A, B, D Rationale: Self-efficacy, which is the person's perceived ability to successfully complete a task, comes from four sources: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states.

For Jeffrey to deliver acceptable care to Mrs. Lasky, he must exhibit cultural competence. Which of the following are the interlocking components of cultural competence? (Select all that apply.) A. Cultural awareness B. Cultural imposition C. Cultural knowledge D. Cultural skills E. Cultural encounters

Answer: A, C, D, E Rationale: The interlocking components of cultural competence are cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire.

Chris is planning care based on use of nursing theory in caring for Mr. Moats. Using nursing theory to define a phenomenon uses which of the following components? Select all that apply. A. Concepts B. Nursing process C. Definitions D. Assumptions E. Systems F. Propositions

Answer: A, C, D, F Rationale: A theory is a set of concepts, definitions, assumptions, and propositions that define a phenomenon. The theory explains how these components are uniquely related in the phenomenon.

Mr. Smith becomes agitated as Margaret tries to retrain him in his use of eating utensils. Margaret knows that, as his anxiety increases, his ability to pay attention also increases. A. True B. False

Answer: B Rationale: As anxiety increases, the patient's ability to pay attention often decreases, not increases.

Lucy asks Mrs. Shirer, "Why do you think it's difficult for you to manage your colostomy and colostomy bag as indicated?" Lucy is expressing integrity by asking Mrs. Shirer this question. A. True B. False

Answer: B Rationale: Curiosity involves asking patients why they do the things they do. Curiosity motivates the nurse to investigate a clinical situation.

When discontinuing a portion of Mr. Tate's care plan, it is not necessary for Aiyana to document the discontinued care plan since it is no longer effective. A. True B. False

Answer: B Rationale: Once the nurse and patient agree to discontinue a portion of the care plan, documenting the discontinued portion ensures that other nurses will not unnecessarily continue interventions.

Aiyana is modifying Mr. Tate's care plan. Rank in order the steps she must take. A. Review goals and expected outcomes B. Reassess patient factors C. Evaluate interventions D. Redefine diagnoses

Answer: B, D, A, C Rationale: To modify a patient's care plan, the nurse: reassesses patient factors; redefines diagnoses; reviews goals and expected outcomes; and evaluates interventions.

Lalani needs to call the county hospital free clinic to arrange an interpreter for Ms. Lam for her mammogram. Rank in order the steps Lalani should take for ensuring a successful phone consultation. A. Summarize the problem. B. Have all of the necessary information available. C. Think through possible solutions to the problem. D. Assess the patient.

Answer: B, D, C, A Rationale: To ensure a successful phone consultation, perform the following: have all of the necessary information available before making the call; assess the patient yourself before making the call; think through some of the possible solutions to the problem; and summarize the problem.

Chris is basing his nursing care on helping Mr. Moats perform activities that he normally would do for himself to contribute to his recovery from the stroke. Which theory is Chris applying? A. Nightingale's Theory B. Roger's Theory C. Henderson's Theory D. Orem's Theory

Answer: C Rationale: Henderson's Theory defines nursing as assisting the individual, sick or well, in the performance of activities that will contribute to health, recovery, or peaceful death that the individual would perform unaided if he or she had the necessary strength, will, or knowledge.

Lalani updates Ms. Lam's care plan. Care plans for community-based settings require a thorough assessment of ___________, _______, and _______.

Answer: Community, home, and family Rationale: Planning care for patients in community-based settings involves using the same principles of nursing practice. However, in these settings a more comprehensive assessment of the patient's community, home, and family is required.

Jeffrey asks Mrs. Lasky about her transition to American culture. Mrs. Lasky assures Jeffrey that she is now bicultural. Which of the following statements clarifies the term biculturalism? A. Mrs. Lasky does not identify with America or Poland. B. Mrs. Lasky identifies with America more than Poland. C. Mrs. Lasky identifies with Poland more than America. D. Mrs. Lasky identifies with both America and Poland equally

Answer: D Rationale: Biculturalism, also known as multiculturalism, occurs when an individual identifies equally with two or more cultures.

Lucy tries several different teaching methods to try to improve Mrs. Shirer's compliance to her medical regimen. She keeps at the process, hoping to find an approach that works with Mrs. Shirer. Lucy is demonstrating which attitude for critical thinking? A. Discipline B. Risk taking C. Responsibility D. Perseverance E. Accountability

Answer: D Rationale: To persevere means to keep looking for resources until a successful approach is found. It leads the nurse to try different communication approaches.

Mr. Smith constantly denies that he has dementia by stating, "I'm old. A little forgetfulness is normal." Mr. Smith is in the _________ or _________ stage of grieving.

Answer: Denial or disbelief Rationale: Patients in the denial or disbelief stage of grieving do not acknowledge that their health has changed, and they are not prepared to deal with the problem.

Lucy uses an analytical process to determine the cause of Mrs. Shirer's noncompliance. Lucy is using the process of __________ _____________.

Answer: Diagnostic reasoning Rationale: Diagnostic reasoning is the analytical process for determining a patient's health problems. Accurate recognition of a patient's problems is necessary before determining a course of action.

Lucy does not approve of Mrs. Shirer's lack of compliance with her medical regimen. However, Lucy always treats Mrs. Shirer with ____________ and deals with situations justly.

Answer: Fairness Rationale: Regardless of how the nurse feels about a patient, he or she must always treat the patient with fairness and justice to promote positive outcomes for him or her.

Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. The acronym PES stands for _________ ______________ ___________________.

Answer: Problem, etiology, symptoms Rationale: The acronym PES stands for problem, etiology or related factor, and symptoms or defining characteristics.

Nigel develops nursing diagnoses for Mr. Hannigan's care plan. Impaired gas exchange is a ______ nursing diagnosis for pneumonia.

Answer: Risk Rationale: A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Impaired gas exchange is a risk nursing diagnosis for pneumonia.

Aiyana knows that she must deliver the minimum level of care accepted to ensure high quality of care to Mr. Tate. This minimum level of care is referred to as __________________.

Answer: Standard of care Rationale: A standard of care is the minimum level of care accepted to ensure high quality of care to patients.

Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Readiness for Enhanced Knowledge b. Knowledge Deficit c. Information Processing d. Health-Seeking Behaviors

Answer: a A patient's expression of an interest in learning is one of the defining characteristics of the nursing diagnosis, Readiness for Enhanced Knowledge. Knowledge Deficit would indicate that the patient has a deficiency of knowledge on a particular subject. Information Processing is an outcome rather than a nursing diagnosis and is the patient's ability to acquire use information. Health-Seeking Behaviors is active seeking by a person in stable health of ways to alter habits to enhance health.

What is the most significant problem that may result from improperly written nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs

Answer: a Accurate nursing diagnostic statements provide direction for the development of individualized plans of care. Orders are part of the patient's assessment data. Combining unrelated patient problems is a function of diagnostic development, not a result of an improperly written statement. Poorly written nursing diagnostic statements may or may not result in increased team collaboration.

A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. What should the nurse do before placing the tube? a. Assess the presence of any family members who may speak English and the patient's native language. b. Take two additional staff members into the room when placing the tube so the patient can be restrained if needed. c. Request an interpreter by leaving a voicemail on his or her office extension. d. Do not place the NG tube because the physician would not want to frighten the patient.

Answer: a Although an interpreter employed by the hospital would be the best choice, eliciting the help of family members that speak both the patient's primary language as well as English may be the best option because the procedure is needed now. This will provide comfort and familiarity for the patient. Taking additional staff into the room may increase the patient's anxiety, thereby decreasing his ability to comprehend the instructions. Leaving a message on a voicemail for an interpreter is also incorrect because the intervention has a level of urgency that may have a detrimental effect if the message is not retrieved in a relatively short amount of time because it is late on Saturday. Although the physician would not want to frighten the patient, he or she ordered the NG tube for the benefit of the patient; therefore, it needs to be carried out.

In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias? a. Collecting the patient's medical history b. Administering IV medications c. Performing oral care d. Completing a bed bath

Answer: a Donning gloves every time the nurse enters the patient's room may reflect bias related to the care of a patient with HIV infection and may interfere with the development of a therapeutic relationship with the patient. The patient with HIV is on standard precautions unless there are complications that put the nurse at risk of blood or body fluid exposure. It would be appropriate for the nurse to wear gloves during the other activities.

Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.

Answer: a Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.

Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview

Answer: a Hospice referral requires collaboration with many health care team members. Physical assessment and completion of a health history interview are independent nursing actions that can be performed by a nurse alone. Activities of daily living can be completed by patients independently or with the help of a nurse or unlicensed assistive personnel (UAP), requiring little collaboration among health care team members.

Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure with pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measurement

Answer: a Inductive reasoning uses specific facts or details to make conclusions and generalizations (i.e., going from specific to general). Using assessment data (specific data) to arrive at a conclusion (diagnosis) is an example of induction. Deductive reasoning involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific). The validation of a disease process (general) by specific assessment parameters (signs and symptoms, diagnostic study results, etc.) is an example of a deduction.

During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance

Answer: a Patient information must first meet the intellectual standard of clarity before it is evaluated for precision, logic, or significance.

What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests

Answer: a Patient needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.

What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis? a. Defining characteristics are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed in a risk diagnosis.

Answer: a Risk diagnoses do not have defining characteristics; actual and health-promotion nursing diagnosis statements have defining characteristics. Risk diagnoses do not establish a cause and effect, because they identify potential rather than existing problems. Risk diagnoses contain related or risk factors rather than defining characteristics, subjective or otherwise. Risk diagnoses, like actual diagnoses, have nursing interventions to address a patient's current or potential problem.

A weight-loss program that combines nutrition instruction with exercise is an example of teaching based on which domain of learning? a. Psychomotor b. Affective c. Psychosocial d. Cognitive

Answer: a Weight management that combines instruction and exercise is an example of psychomotor domain learning. Affective domain learning integrates new knowledge by recognizing an emotional component. Psychosocial is not one of the domains of learning. Cognitive domain learning is based on knowledge and material that is remembered, memorized, and recalled.

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.

Answer: a When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient's problem. Depending on the underlying reason for the patient's inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change

Answer: a, b, c, d Cultural practices, functional status, communication barriers, and scope of practice influence whether an intervention should or may be implemented. Shift change time is not necessary to consider before implementation of most interventions.

What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research e. Convenience to the nursing staff

Answer: a, b, c, d Patient treatment preferences, cultural and ethnic influences, the level of a nurse's professional expertise, and current evidence-based research should all be taken into consideration when planning care. The convenience to nursing staff should not be of concern.

Which actions are a part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining whether the nursing interventions were completed d. Reviewing whether a patient met the short-term goal e. Identifying realistic outcomes with patient input

Answer: a, d Determining whether a goal or outcome is met is part of the evaluation. Making sure interventions are completed and documenting them are part of implementation. Identifying outcome criteria is done during the planning stage of the nursing process.

Jeffrey tells Mrs. Lasky that it sounds as if she has ____________ into American culture since she has American friends and follows many of the American traditions.

Answer: assimilated Rationale: Assimilation occurs when a person is absorbed into a new culture.

Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization. c. Patient's visitors will be instructed in proper handwashing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.

Answer: b A patient's white blood cell count is a laboratory test that is a measureable indicator of infection. The correct answer is also patient-focused and realistic. Encouraging the use of sterile technique by the nurse during each dressing change and instructing the patient's visitors in the proper handwashing technique before direct interaction with the patient are not patient-focused. The patient understanding the importance of cleaning around the incision with a clean cloth during bathing uses a nonmeasurable verb, which should be avoided when formulating patient goals.

If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Knowledge Deficit d. Body Image Disturbance

Answer: b Acute Pain is the most urgent nursing diagnosis to address. Fatigue may be a result of the pain and may be alleviated if the patient's pain level is reduced. Body Image Disturbance and Knowledge Deficit can be treated only after the patient's pain level is at an acceptable level. Both diagnoses require teaching, during which the patient needs to concentrate. A person's ability to concentrate is affected by the pain level.

The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation d. Evaluating the patient's peripheral circulation

Answer: b Before a nurse can legally administer oxygen to a patient, the method of delivery and amount must be ordered by the primary care provider. Elevating the head of the bed and assessing a patient's oxygen saturation and peripheral circulation are all independent nursing interventions.

What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice

Answer: b Each nursing diagnosis label identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse's scope of practice are not related to the purpose of the nursing diagnostic process.

In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. What do I know about this situation? b. What additional details do I need to gather? c. Does the clinical presentation correlate with the diagnosis? d. Are the treatments appropriate for the diagnosis?

Answer: b Precision relates to providing sufficient detail to lead to an exact understanding of the situation. What do I know about this situation? is focused on self-reflection about what is known about the situation. Does the clinical presentation correlate with the diagnosis? relates to relevance. Are the treatments appropriate for the diagnosis? relates to logic.

Which is true about patient teaching sessions? a. Present all of the information so the patient can learn all that is needed. b. Present the patient with one idea at a time. c. Ensure the presence of a family member at each session. d. End with a written quiz to ensure understanding of the information.

Answer: b Presenting patients with one idea, task, or concept at a time allows them to focus on that item without becoming overwhelmed. For this reason, presenting all of the information is incorrect. Although it may be beneficial to have a family member or friend present in a teaching session, this is sometimes not feasible or appropriate. Providing a written quiz at the end of the session may evoke anxiety if the patient knows he or she is going to be tested on the content.

The nurse receives a change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action? a. Problem solving b. Decision making c. Judgment d. Reasoning

Answer: b The nurse used decision making to guide which patient to see first, based on an analysis of patient data and care needs. Problem solving is used when the nurse is faced with a situation that requires analysis and a solution. Judgment is used in the decision-making process but does not result in the actual decision. Reasoning is logical thinking that may be used in decision making but, again, is not the actual result. Decision making culminates in a definitive action.

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnostic statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.

Answer: b The patient's condition requires immediate performance of the lifesaving steps of the nursing process. All other answers are secondary actions. The nurse later resumes all interventions for previously identified nursing diagnoses and evaluates the success of the acute care plan for management of the cardiac arrest. Nurses do not seek the input of the physician for creation of nursing diagnoses.

The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required.

Answer: b The patient's mother may have limited reading skills or health literacy and should be further assessed. Contacting the physician in this situation would not be appropriate because ensuring that the patient and family understand discharge instructions is the responsibility of the nurse. Assuming that the mother has taken care of casts in the past may be inaccurate. Stating that reading the instructions with the nurse is a requirement does not ensure that the patient or mother comprehends the instructions.

Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration.

Answer: b Verifying patient allergies before administering medication is the most important intervention listed to ensure patient safety. Providing water may or may not be necessary, depending on the type of medication being administered. Although it is okay to ask a patient about having taken a medication previously, it is not routinely done or most important. It is preferable to have patients sit up while taking medication unless contraindicated.

The nurse is completing an assessment of a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference

Answer: b Nurses use interpretation to understand and explain the meaning of data. In this case, the nurse must first interpret the assessment data before reflecting on its meaning, evaluating its reliability or credibility, and making inferences that will have an impact on treatment options.

Which interventions can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages

Answer: b, c, d Auscultating lung sounds and monitoring skin integrity are both important aspects of basic patient assessment that are required independent nursing actions. Ordering and applying heel protectors is done independently by nurses to prevent skin breakdown on patient's confined to the bed. Ordering blood transfusions and adjusting antibiotic dosages are the responsibility of the patient's primary health care provider.

Which of the following nursing diagnoses is appropriately written? (Select all that apply.) a. Risk for Infection related to elevated temperature and white blood count b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to an inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort.

Answer: b, c, d Readiness for Enhanced Relationship is a heath-promotion nursing diagnosis and is written with two sections: the label and the defining characteristics. Noncompliance is a nursing diagnosis that requires a related factor and defining characteristics. Risk for Bleeding requires at least one risk factor, which it has as it is written. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format. The nursing diagnosis of Chronic Pain is incorrectly written because it includes a medical diagnosis and a related factor that is supportive of acute rather than chronic pain.

What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone."

Answer: b, c, e An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are consistent with extreme anxiety and should be clustered together. Ease of falling asleep and being able to focus on a challenging task, such as giving an injection, are not indicative of a patient experiencing a high level of anxiety.

The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented.

Answer: c Although the remaining options may be true, the primary reason for specific documentation of a patient's progress in a teaching plan is to ensure that other nurses or members of other disciplines can pick up the teaching plan and know precisely what the patient has accomplished and where to begin additional sessions.

Which action by the day-shift nurse provides objective data that enables the night-shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before the shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions

Answer: c Documentation of assessment findings is the only objective form of data listed as an option that can support the night nurse in evaluating whether the patient achieved short-term goals. Patient observations are subjective in nature. Leaving a message with the charge nurse produces secondary subjective data, and checking for drug interactions is unrelated to the evaluation process.

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation

Answer: c It is most important to involve the patient in developing realistic, attainable, patient-centered plans of care. Involving others in care planning is secondary to involving the patient, unless the patient is cognitively impaired.

Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.

Answer: c Knowing the scope of practice of the other team member is critical to understanding what is appropriate and safe to delegate to that person. It is unnecessary to locate or meet with all members of the health care team prior to delegation. Physicians are already aware of potential complications related to patient care.

Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC)

Answer: c Maslow's hierarchy of needs and the airway, breathing, circulation (ABCs) of life support are the most helpful tools in identifying priorities of care. Functional health patterns is one method of organizing assessment data. NOC and NIC are resources for identifying outcomes and interventions to include in a patient's care plan after priorities have been established.

On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses

Answer: c Nursing diagnoses emerge from groupings of clustered data collected during the assessment phase of the nursing process. The nurse documents the patient's medical diagnosis as one piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse's intuition and first impressions may also be listed in the patient's assessment findings as long as they are objectively recorded without prejudice and are not judgmental in nature.

Written instructions showing pictures of the steps necessary to test a blood sugar, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive

Answer: c Psychomotor learning involves physical movement and the use of motor skills such as demonstration and return demonstration. The affective domain involves emotion, and the cognitive domain is memorization and recall. VARK (verbal, aural, read/write, kinesthetic) refers to a method of assessing learning style.

Which phrase best represents a related factor in an actual nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness

Answer: c Related factors are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient's data. Redness and swelling, unsteady gait, and complaint of restlessness are specific defining characteristics that would be clustered with other data to support the existence of an actual or health-promotion nursing diagnosis.

What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.

Answer: c The nurse should evaluate the need to continue or discontinue a plan of care if a patient has met a short-term goal. It is unnecessary to consult the surgeon unless there is a concern. Discontinuing the care plan may be premature, and the decision needs to be evaluated before taking action. The patient's intake and output will continue to be monitored throughout hospitalization, not just for 1 hour after surgery.

What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team

Answer: c The nursing process is the methodology used to "think like a nurse." Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.

The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint. b. Request that another nurse be assigned to this patient. c. Review data about the medical diagnosis and routine management. d. Complete a physical assessment of the patient.

Answer: c The priority action is to find the necessary information/data needed to guide the nursing care. The nurse cannot apply critical thinking about something that is unknown. If the nurse asks the patient to describe the chief complaint or completes the physical assessment with limited knowledge of the disease process, the nurse has nothing to corroborate or compare. Requesting another nurse to care for the patient does not address the lack of knowledge.

Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right-sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications

Answer: c Transporting the stable patient for discharge can be delegated immediately to UAP. A patient with new neurologic symptoms needs to be assessed before being ambulated. Patients who have recently choked need to be evaluated for their ability to swallow before being fed. Administering medication is not within the UAP's scope of practice and can never be delegated

Which intervention would be most important for the nurse to include in the care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously. b. Discourage the patient from bathing while hospitalized. c. Encourage the patient to rest between bathing activities. d. Ask the patient's spouse to assist with all bathing.

Answer: c When patients are unable to complete their personal care without fatigue, it is best to encourage them to rest between activities. All patients should be encouraged to wash during hospitalization and to complete as much of their personal care as independently as possible. Patients who tire easily should not be encouraged to shower and shave simultaneously but should space out personal care while seated.

Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relation of this information to other data?

Answer: c Determining relationships is effective in establishing the relevance of data. Verification of information is related to accuracy, making "sense" relates to logic, and significance more closely relates to depth. The routine use of the intellectual standards helps improve critical thinking.

Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care

Answer: d Encouraging the patient to explore options for care empowers the patient to have some control over the situation and to be actively involved in care planning. It is a form of informal counseling. Reassessment and teaching are not immediately indicated at this time. Although referring a patient with a new cancer diagnosis may be helpful, it is an indirect care intervention.

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting

Answer: d In an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.

Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress.

Answer: d Long-term goals are very useful in determining patient progress. Both short-term and long-term goals need to be measurable. Goal attainment is based on patient actions, not nursing actions.

Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.

Answer: d Nursing diagnoses consider the underlying etiology, needs, potential concerns, and patient response to a patient's medical diagnosis, so the two types of diagnoses are interrelated. Medical diagnoses are not imbedded or derived from medical diagnoses because that would limit the scope of assessment and care that is provided for patients. Nurses consider the medical diagnosis as one aspect of concern when identifying an actual or potential health problem and the patient's response, so medical diagnoses are relevant, but not the focus of nursing diagnoses.

Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.

Answer: d Option d is the only notation that indicates whether the goal was met and how all of the outcome criteria were attained.

The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching? a. Do it right before the patient's next intravenous pain medication. b. Wait until tomorrow morning because he is in too much pain today. c. Leave written materials on his over-the-bed tray that he can read at his convenience. d. Wait until 10 to 15 minutes after his next intravenous pain medication.

Answer: d Patients in pain are unable to focus on learning. Waiting 10 to 15 minutes after the administration of intravenous pain medication allows it to provide relief, but the patient is not sedated or resting soundly. Waiting until the following day is inappropriate because early intervention and prevention are necessary to avoid the development of deep vein thrombosis. Leaving important information where it can be easily covered up, set aside, or overlooked is not an effective method of patient education. The nurse should remember the concepts of health literacy and consider the potential effects of visual impairments, reading ability, and pain level in ensuring patient comprehension.

Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options. b. Identify realistic outcome indicators. c. Consult with health care team members. d. Rank patient concerns from assessment data.

Answer: d Prioritizing or ranking patient needs precedes the identification of outcome indicators, consulting with team members, or consulting with interdisciplinary team members.

What is the primary purpose of quality improvement? a. Recognizing the need to discipline employees violating policies b. Preventing patient injury that may contribute to the death of others c. Increasing institutional profits to support further scientific research d. Enhancing current practice to improve patient outcomes and care

Answer: d Quality improvement focuses on improving processes. This has many benefits and is not primarily directed at preventing the death of patients, providing discipline, or making money.

What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I? a. Insurance documentation b. Professional autonomy c. Role delineation d. Patient safety

Answer: d Safety is the most important reason for using standardized language to communicate patient's needs and information. Using the same definitions of terms helps nurses and other health care professionals interpret the information. Helping with insurance documentation, supporting professional autonomy, and clarifying the nursing role in patient care are uses for NANDA-I taxonomy, but they are not the most important.

What is the most important action for a nurse to take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy? a. Share concerns with the nurse manager on the nursing unit. b. Offer alternative care for a patient and family members. c. Discuss how to address patient needs with physicians. d. Provide evidence-based research to support nursing care.

Answer: d Supporting a suggestion for a new nursing diagnostic label with research is required for consideration by NANDA-I. Sharing concerns, providing alternative care, and advocating for patients are all a part of the nursing role, but are not the most important part of having a diagnosis considered for inclusion in the NANDA-I taxonomy.

An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient

Answer: d The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.

The nurse obtains a lower than normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply.) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient

Answers: a, b, c Analysis involves assessing a situation and determining what should be done based on an appropriate rationale. In this case, assessing the patient for symptoms of hypoxia, providing oxygen as ordered, and elevating the head of the bed help determine the extent of air hunger, promote increased gas exchange, and ease the effort of breathing. Leaving a patient who has a low pulse oximetry reading alone is potentially dangerous. Discussing nonemergent information with a patient experiencing air hunger requires increased oxygen consumption and is inappropriate.

Which action does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Thoroughly review the patient's medical history b. Analyze the nursing assessment data to determine whether information is complete c. Outline an individualized plan of care to address each concern d. Consider potential complications to which the patient is susceptible e. Evaluate how the patient has responded to treatment

Answers: a, b, d Before determining the types of nursing diagnoses that are appropriate for a patient, the nurse must review and analyze all of the patient's data, including the medical history, for completeness and accuracy. Considering the vulnerability of a patient to potential complications permits the nurse to identify the need for risk nursing diagnoses. Outlining an individualized plan of care takes place during the planning stage of the nursing process after the nursing diagnoses have been identified. Evaluation of a patient's response to treatment is part of the evaluation stage of the nursing process.

If the nurse chooses the Nursing Outcome Classification (NOC) Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections

Answers: a, b, d Sharing a desire to eat, reporting that food smells good, and preparing meals are indications of an increased appetite. Although relaxation techniques may decrease anxiety associated with eating, they do not indicate an increase in appetite. Reading nutrition labels is unlikely to increase a person's appetite.

The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning

Answers: a, d, e Interpersonal skills such as teamwork, conflict management, and advocacy engage others in the process of critical thinking. Intuition, judgment, and reasoning are intrapersonal aspects of critical thinking that the nurse may use personally to better understand a situation.

A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse gives his wife a packet of registration paperwork and asks her to complete the forms. Which observed actions may indicate a health literacy issue? (Select all that apply.) a. Putting on glasses before beginning the paperwork b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses— these just don't work" c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms d. Setting the clipboard aside and staring tearfully out the window e. Returning the forms only partially filled out, with missing or inaccurate information

Answers: b, c, e Asking someone else to read the form, waiting for help with the forms, and partially or inaccurately filled-out forms are behaviors indicative of potential health literacy issues. Needing glasses does not correlate directly with health literacy. A tearful spouse requires additional assessment to see whether health literacy is a problem. The wife may be overwhelmed and feel unable to complete the forms, or she may need to collect her thoughts in the midst of a stressful time.

Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Noncompliance b. Readiness for Enhanced Knowledge c. Ineffective Coping d. Health-Seeking Behaviors e. Anxiety

Answers: b, d Readiness for Enhanced Knowledge and Health-Seeking Behaviors are appropriate nursing diagnoses for use in developing a patient teaching plan. Noncompliance would be an appropriate nursing diagnosis for a patient who has not followed a teaching plan or treatment regimen. Ineffective Coping is not a nursing diagnosis used in developing a teaching plan, but if a patient is not coping effectively, it may affect the ability to learn. A nursing diagnosis of Anxiety may affect the patient's ability to learn but is not directly related to developing a teaching plan.

How best can a nurse evaluate goal attainment for a patient with a culturally diverse background? a. Assume that gender roles will be a challenge to overcome regardless of the patient's ethnicity. b. Base decisions on feedback from the patient and the nurse's professional judgment. c. Collaborate with future community care providers to determine patient strengths. d. Seek input from members of the patient's support system to avoid biased patient responses.

B Decisions about whether a patient has met treatment goals or outcomes should be based on patient feedback and a nurse's professional judgment. Gender role considerations are unlikely to play a role in evaluation. Future community care providers are unable to help in the evaluation of patient goals before participating in a patient's care. The patient is the primary person from whom information should be obtained in evaluating goals and outcomes.

If a patient's primary language differs from that of the health care professionals providing care, which action is most appropriate for the nurse to take? a. Use colorful pictures, white boards, and gestures to communicate all important information. b. Recognize that continuous affirmative answers by the patient require verification of understanding. c. Arrange for a professional language translator to sit with the patient throughout the hospitalization. d. Decrease interaction with the patient and family to avoid making them uncomfortable for not understanding.

B. Consistent affirmative answers from a patient in the form of verbal responses of nods may indicate that a patient does not really understand what is being asked and is just trying to be cooperative. It is important for the nurse to double check to make sure a patient understands instructions and questions to ensure safety and proper care. Not all information can be conveyed via pictures or gestures, and professional interpreters typically are not used as patient sitters. Ignoring or avoiding patients or families with culturally diverse backgrounds serves to isolate them and is never appropriate.

Which action taken by a nurse would reflect application of an appropriate generalization in a patient care setting? a. Assigning same-gender nurses to all patients admitted to the unit b. Sharing with unlicensed assistive personnel that Muslim patients typically do not eat pork c. Telling the radiology technician that every Latino family is late for appointments d. Assuming that Asians share financial responsibility for medical bills

B. Muslims typically do not consume pork products. This generalization would be helpful to use as a baseline for caring for Muslim patients. It is always important, however, for nurses to ask patients to verify whether they adhere to cultural norms. Same-gender nurses need not be assigned to all patients. Making broad statements that are unkind regarding people of one culture is stereotyping and hurtful. The Amish, not Asians, typically share responsibility for medical

Which nursing diagnosis is most appropriate for a young Middle Eastern immigrant who expresses concern for the safety of his family members who were unable to relocate with him out of a war zone? a. Risk for Spiritual Distress b. Impaired Role Performance c. Interrupted Family Processes d. Ineffective Coping

C. A key-related factor in interruption of family processes is a situational crisis that causes a change in communication and emotional and mutual support, which all are present in this case. None of the information provided indicates a spiritual crisis, ineffectiveness of coping, or impairment of role performance.

Which statement best serves as a guide for nurses seeking to learn more about ethnicity? a. Ethnicity, like culture, generally is based on genetics. b. A patient's ethnic background is determined by skin color. c. Ethnicity is based on cultural similarities and differences in a society. d. Culture and socialization are unrelated to the concept of ethnic origin.

C. Ethnicity is based on cultural similarities and differences in a society or nation. The similarities are with members of the same ethnic group; the differences are between that group and others. Ethnicity is not based on or determined by genetics or skin color. Culture, ethnicity, and socialization are all related concepts.

What is the best method for the nurse to ensure that a Croatian patient's nutritional needs are met during hospitalization? a. Preorder a diet that is consistent with the typical Croatian patient's dietary preferences. b. Ask a Croatian coworker for ideas on what would be best to order for the patient's meals. c. Request that a variety of dietary entrees be provided to the patient to provide options. d. Check with the patient on admission to determine dietary limitations and preferences.

D. The best way to provide for a patient's dietary needs is to ask the patient for personal preferences, limitations, allergies, and typical dietary intake. Preordering, checking with a co-worker, or ordering a variety of options without input from the patient first does not reflect patient-centered care.

Lalani reviews Ms. Lam's care plan to ensure accuracy. The main purpose of clinical pathways is to present an overview of the patient's care goals. A. True B. False

Rationale: The main purpose of clinical pathways is to deliver timely care at each phase of the care process for a specific type of patient.

a charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require providers prescription which of the following interventions should the charge nurse include (select all) a. writing a perscription for morhpine sulfate as needed for pain b, inserting a naogastric tube to relieve gastric distension c. showing a cleint how to use progressive muscle relaxation d. performing a dail ath after the vening meal e. repositioning a client every 2 hours to reduce pressure injury risk

a charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require providers prescription which of the following interventions should the charge nurse include (select all) a. writing a perscription for morhpine sulfate as needed for pain b, inserting a naogastric tube to relieve gastric distension c. showing a cleint how to use progressive muscle relaxation d. performing a dail ath after the vening meal e. repositioning a client every 2 hours to reduce pressure injury risk

A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. encourage the client to participate actively in learning b. Select instructional materials c. identity goals the nurse and the client agree are reasonable d. Determine what the client knows about stress incontinence

a. active participation in the learning process is essential for the success of the session. however, this is not the priority action b. it is essential to prepare and select instructional materials appropriate for the client's age, developmental level, and other parameters. however, this is not the priority action c. establishing mutually agreeable goals is essential for the success of the session. however, this is not the priority action d. correct: the first action to take using the nursing process is to assess or collect data from the client. determine how much the client knows about stress incontinence, the accuracy of this knowledge, and what the client needs to learn to manage this problem before instructing the client

a nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. which of the following actions should the nurse take a. contact the hospitals spiritual services b. ask what is making the patient cry c. ensure no visitors or staff enter the room for a short period of time d. turn on the television for a distraction

a. contacting the hospital's spiritual services presumes there is a problem and should not be done without asking the client's permission b. asking the client about the crying can be interpreted as discounting or being disrespectful of the client's beliefs c. correct: providing privacy and time for the reading of religious materials supports the client's spiritual health d. providing a distraction could be interpreted as discounting or being disrespectful of the client's beliefs

A nurse is preparing the discharge summary for a client who has had had knee arthroscopy and is going home. Which of the following information about the client should the nurse include in the discharge summary? (select all that apply) a. Advance directives status b. Follow up care c. Instructions for diet and medications d. Most recent vital sign data e. Contact information for the home health care agency

a. advance directives status is important in transfer documentation, when other care providers will take over a client's care. they are not an essential component of a discharge summary for a client who is returning to their home b. correct: it is essential to include the names and contact information of providers and community resources the client will need after they return home c. correct: the client will need written information detailing home medication and dietary therapy. a client who has had knee arthroscopy typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding posoperative complications (constipation) d. vital sign measurements are important in transfer documentation, when other care providers will take over a client's care. they are not an essential component of a discharge summary for a client who is returning to their home e. correct: it is essential to include the names and contact information of providers and community resources the client will need after returning home. for example, a client who had knee arthroplasty might require physical therapy at home until able to travel to a physical therapy department or facility

A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. cognitive b. Affective c. psychomotor d. kinesthetic

a. an example of cognitive learning is stating the behavior the child will demonstrate when ready to toilet train b. correct: affective learning has taken place because the client's ideas about toilet training changed c. an example of psychomotor learning is preforming the proper techniques for introducing the child to toilet training d. kinesthetic learning is a learning style, not a domain of learning

a nurse is assisting a client with selecting food choices on a menu. which of the following actions by the nurse demonstrates ethnocentrism a. asking the client about some favorite food choices b. notifying the dietician to complete the menu c. recommending one's own favorite foods d. asking the client's family to fill out the menu

a. asking the client about some favorite food choices demonstrates sensitivity to the clients food preferences b. calling the dietitian to fill out the menu does not demonstrate sensitivity to the client's food preferences however it is not an example of an ethnocentric approach c. correct: recommending one's own favorite foods is an example of enthnocentrism which is the belief that one's own cultural practices are the only correct behaviors/beliefs d. having the family fill out the menu does not demonstrate sensitivity to the client's food preferences. However, it is not an example of an ethnocentric approach

a nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motor vehicle crash. which of the following values indicates the client is in a catabolic state a. blood albumin 3.5 g/dl b. negative nitrogen balance c. bmi of 18.5 d. blood prealbumin 15 mg/dl

a. blood albumin should be 3.5 or 4.5 b. correct: negative indicates that protein is used at a greater rate than it is synthesized as in starvation c. ideal weight d. within expected range

A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline

a. confidence is feeling sure of one's own abilities. the nurse might feel confident of their physical assessment skills, but choosing a particular method or sequence requires another attitude b. perseverance is continuing to work at a problem until the nurse resolves it. this attitude does not apply here. c. integrity is practicing truthfully and ethically, this specific attitude does not apply here d. correct: discipline includes using a systematic approach to thinking. using a head-to-toe approach ensures the nurse is thorough and calculated in getting information about the client's physical status

a nurse is performing a nutrition assessment on a client which of the following clinical findings are suggestive of malnutrition a. poor wound healing b. dry hair c. blood pressure 130/80 d. weak hand grips e. impaired coordination

a. correct b. correct c. not associated w/ malnutrition d. correct e. correct

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (select all that apply) a. Ensure that the client has possession of their valuables b. Confirm that the rehabilitation center has a room available at the time of transfer c. Assess how the client tolerates the transfer d. Give a verbal transfer report via telephone e. Complete a transfer form for the receiving facility

a. correct: account for all of the client's valuables at the time of transfer b. correct: on the day of the transfer, confirm that the receiving facility is expecting the client and that the room is available c. it is the responsibility of the nurse to at the receiving facility to assess the client upon arrival to determine how they tolerate the transfer d. correct: provide the nurse at the receiving facility with a verbal transfer report in person or via telephone e. correct: complete any documentation for the transfer, including a transfer form and the client's medical records

a nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. which of the following interventions are mind-body therapies (select all) a. art therapy b. acupressure c. yoga d. therapeutic touch e. biofeedback

a. correct: art therapy is a mind-body therapy because it allows the client to express unconscious emotions or concerns about their health b. accupressure is a body based therapy because it focuses specifically on body structures and systems c. correct: yoga is a mind-body therapy because it focuses on achieving well-being through exercise posture, breathing, and meditation d. therapeutic touch is an energy therapy because it involves using the hands to balance energy fields e. correct: biofeedback is a mind-body therapy because it increases mental awareness of the body responses to stress

a nurse is caring for a client who is 24 hours postoperative following an inguinal hernia repair. the client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for real food. the nurse tells the client i will call the surgeon and ask for a change in diet. the surgeon hears the nurses report and prescribes a full liquid diet. the nurse used which of the following levels of critical thinking a. basic b. commitment c. complex d. integrity

a. correct: at the basic level, thinking is concrete and based on a set of rules (obtaining the prescription for diet progression) b. at the commitment level the nurse expects to have to make choices without help from others and fully assumes the responsibility for those choices. however, postoperative protocols generally involve obtaining a prescription for diet progression c. advanced experience and knowledge at the complex level will prompt the nurse to request diet progression to full liquids based on active bowel sounds and the clients tolerance of clear liquid not solely on the client's request d. integrity is a critical thinking attitude that comes into play when the nurses opinion differs from that of the client. the nurse must then review their own position and decide how to proceed to help achieve outcomes satisfactory to all parties

A nurse is caring for a client who has a new prescription for anti hypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? a. knowledge b. experience c. intuition d. competence

a. correct: by using the electronic database, the nurse takes the initiative to increase their knowledge base, which is the first component of critical thinking b. the nurse has had no prior experience with administering this medication to the client c. intuition requires experience, which the nurse lacks in administering this medication to the client d. competence involves making judgements, but no one can make a judgement about how the nurse handles researching and administering this medication to this client until they perform those tasks

a nurse is caring for a client scheduled for abdominal surgery. the client reports being worried. which of the following actions should the nurse take? a. offer information on a relaxation technique and ask the client if they are interested in trying it b. request a social worker see the client to discuss meditation c. attempt to use biofeedback techniques with the client d. tell the client many people feel the same way before surgery and to think of something else

a. correct: it is appropriate for the nurse to recommend a noninvasive technique to facilitate coping and to allow the client to make an informed decision about participating b. meditation does not require specialized training the nurse can use this therapy and does not need to request social worker consult c. recognize that biofeedback requires specialized training and licensing or certification. it is not appropriate for the nurse to attempt to use these techniques d. this response by the nurse is nontherapeutic because it uses stereotyping and dismisses the client's feelings use therapeutic communication to allow the client to further verbalize fears

a nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. which of the following should the nurse encourage them to use (select all that apply) a. guided imagery b. massage therapy c. meditation d. music therapy e. therapeutic touch

a. correct: nurses can use guided imagery with clients once they understand the general principles of this therapy b. massage therapists undergo training as well as certification or licensure c. correct: nurses can use meditation with clients once they understand the general principles of this therapy d. correct: correct: nurses can use music therapy with clients once they understand the general principles of this therapy e. therapeutic touch practitioners undergo specific training

a charge nurse is reviewing the steps of the nursing process with a group of nurses. which of the following data should the charge nurse identify as objective data (select all) a. respiratory rate is 22/min with even unlabored respirations b. the client's partner states they said they hurt after walking about 10 minutes c. the client's pain rating is a 3 on a scale of 0-10 d. the client's skin is pink, warm, and dry e. the assistive personnel reports that the client walked with a limp

a. correct: objective data includes information the nurse measures (vital signs) b. subjective data includes a client;s reported manifestations even if a secondar source gave the nurse the information c. subjective data includes a client;s reported manifestations d. correct: objective data includes information the nurse observes (skin appearance) e. correct: objective data includes information from the observations of others (family and staff)

a nurse is discussing the nursing process with a newly licensed nurse which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process a. i will determine the most important client problems that we should address b. i will review the past medical history on the client's record to get more information c. i will carry out the new prescription from the provider d. i will ask the client if their nausea has resolved

a. correct: prioritize the clients problems during the planning step of the nursing process b. review the client's history during the assessment/data collection step of the nursing process c. implement nurse- and provider-initiated actions during the intervention step of the nursing process d. gather information about whether the clients problems have been resolved during the evaluation step of the nursing process

a nurse is assessing a client as part of an admission history. the client reports drinking an herbal tea every afternoon at work to relieve stress. tea includes which of the following ingredients a. chamomile b. ginseng c. ginger d. echinacea

a. correct: tea containing chamomile which produces a calming effect or valerian which reduces anxiety. attempt to gain further information to confirm the ingredients of any herbal or natural products the client can use b. expect a client to use ginseng tea to improve physical endurance c. expect a client to use ginger tea to prevent or relieve nausea d. expect a client to use echinacea tea to boost the immune system

A nurse is admitting a client who has acute cholecystitis to a medical surgical unit. Which of the following actions are essential steps of the admission procedure? (select all that apply) a. Explain the roles of other care delivery staff b. Begin discharge planning c. Inform the client that advance directives are required for hospital admission d. Document the client's wishes about organ donation e. Introduce the client to their roommate

a. correct: the client's hospitalization is likely to be more positive if the client understands who can perform which care activities b. correct: unless the client is entering a long-term care facility, discharge planning should begin upon admission c. The patient self-determination act does not require that clients have advance directives prior to hospital admission. The act requires asking clients if they have advanced directives d. correct: upon hospital admission, required request laws direct providers to ask clients older than 18 years if they are organ or tissue donors e. correct: any action that can reduce the stress of hospitalization is therapeutic. introductions to other clients and staff can encourage communication and psychological comfort

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? a. orient the client to their room b. conduct a client care conference c. Review medical prescriptions d. develop a plan of care

a. correct: the greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient this client to their room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside b. conduct a client care conference, however another action is the priority c. review prescriptions in the medical record. however another action is the priority d. develop a plan of care however another action is the priority

a charge nurse is observing a newly licensed nurse care for a client who reports pain. the nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. the prescription reads every 4 hours PRN for pain. the nurse administered the medication and checked with the client 40 min later when the client reported improvement. the newly licensed nurse left out which of the following steps of the nursing process a. assessment b. planning c. intervention d. evaluation

a. correct: the newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0-10 scale the nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain b. the newly licensed nurse used the planning step of the nursing process when deciding that it was the right time to administer the medication c. the newly licensed nurse used the implementation step when administering the medication d. the newly licensed nurse used the evaluation step of the nursing process when checking the effectiveness of the pain medication in relieving the client's pain

a nurse is teaching a group of female clients about risk factors for developing osteoporosis which should the nurse include a. inactivity b. family history c. obesity d. hyperlipidemia e. cigarette smoking

a. correct: weight bearing exercises are a primary intervention for osteoporosis b. correct c. weight loss more of a concern d. e. correct

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique B. The client is able to demonstrate the appropriate technique c. The client states an understanding of the process d. The client is able to write the steps on a piece of paper

a. discussing the appropriate technique demonstrates learning, but it does not involve the use of motor skills b. correct: demonstrating the appropriate technique indicates that psychomotor learning has taken place c. verbalizing understanding demonstrates learning, but it does not involve the use of motor skills d. writing steps on paper demonstrates learning, but it does not involve the use of motor skills essential for performing the procedure

a nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not acceptable treatment option. which of the following responses should the nurse make a. i believe in this case you should really make an exception and accept the blood transfusion b. i know your family would approve of your decision to have a blood transfusion c. why does your religion mandate that you cannot receive any blood transfusions d. let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution

a. do not impose an opinion onto the client and ask them to go against their religious beliefs b. do not make an assumption on behalf of the client's family c. asking "why" can appear judgmental or accusatory d. correct: involving the client's religious or spiritual leaders is a culturally responsive action at this point. alternative forms of blood products can be discussed and a plan reasonable to all can be reached

a nurse is caring for a client who has hypertension. which of the dietary patterns is sometimes followed by Asian clients and places clients at risk for this condition a. incorporation of plant-based foods in the diet b. consumption of raw fruits c. preparation of foods using sodium d. focus on shellfish in the diet

a. encourage plant-based foods to increase nutrients in the diet b. encourage raw fruits in the client's diet to increase vitamin intake c. correct: the preparation of foods using sodium places the client at risk for hypertension. many spices in the asian diet contain sodium or it is used as a preservative. the client should reduce sodium consumption d. encourage the consumption of shellfish because it is a good source of proteins and vitamins

a nurse receives a prescription for an antibiotic for a client who has cellulitis. the nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. which of the following critical thinking strategies did the nurse demonstrate? a. fairness b. responsibility c. risk-taking d. creativity

a. fairness is using a nonjudgmental, objective approach in looking at clients and situations. this attitude does not apply here b. correct: the nurse is responsible for administering medications in a safe manner and according to standards of practice. checking the medical record for allergies helps ensures safety c. risk-taking is a calculated approach to solving a problem that is not responding to traditional methods. this attitude does not apply here. d. creativity is an approach that uses imagination to find solutions to unique client problems. this problem is not unique, and it requires a straightforward solution

a charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require providers prescription which of the following interventions should the charge nurse include (select all) a. writing a prescription for morphine sulfate as needed for pain b, inserting a nasogastric tube to relieve gastric distension c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every 2 hours to reduce pressure injury risk

a. have a prescription from the provider to administer medication. after obtaining the prescription the nurse has the ability to determine when to administer a PRN medication b. have a prescription from the provider for insertion of an NG tube this is a provider-initiated intervention c. correct: showing a client how to use progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief unless there is a contraindication for a specific client use this technique with the client without a provider's prescription d. correct: performing a bath is a routine nursing care procedure unless there is a contraindication for a specific client. determine when bathing is optimal for a client without a provider's prescription e. correct: repositioning a client every 2 hours is an appropriate nurse initiated intervention for clients unless there is a contraindication for a specific client, use this strategy without a provider's prescription

a nurse in a nutrition clinic is calculating BMI for several clients. the nurse should identify which BMI as overweight? a. 24 b. 30 c. 27 d. 32

a. healthy is 18.5-24.9 b. obesity is greater than or equal to 30 c. correct: BMI 25-29.9 d. obesity greater than or equal to 30

As part of admission process, nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family? A: BMI B: usual times for meals/snacks C: favorite foods D: any difficulty swallowing

a. it is important to calculate BMI to determine the client's weight status and related risks, however there is a higher priority b. it is important to try and know know and try to follow the usual meal schedule the client follows at home, however there is a higher priority c. it is important to know which foods are the client's favorite in case it becomes difficult to get the client to consume adequate nutrients, however there is a higher priority d. correct: the greatest risk to this client related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. it puts the client at risk for aspiration, which can be life-threatening

a nurse is caring for two clients who report following the same religion. which of the following information should the nurse consider when planning care for these clients? a. members of the same religion share similar feelings about their religion b. a shared religious background generates mutual regard for one another c. the same religious beliefs can influence individuals differently d. the nurse and client should discuss the differences and commonalities in their beliefs

a. it would be stereotyping to assume that all members of a specific religion have the same beliefs. feelings and ideas about religion and spiritual matters can be quite diverse, even within a specific culture b. mutual regard does not necessarily follow a shared religious background c. correct: members of any particular religion should be assessed for individual feelings and ideas d. due to boundary issues, the nurse's beliefs are not part of the therapeutic client relationship. it is the client's beliefs that are important

a nurse is discussing the plan of care for a client who reports following Islamic practices. which of the following statements by the nurse indicates culturally responsive care to the client a. "i will make sure the menu includes kosher options" b. "i will ask the client if the want to schedule some times to pray during the day" c. "i will avoid discussing care when the client's family is around" d. " i will make sure daily communion is available for this client"

a. jewish culture not islam requires food to be kosher b. correct: islamic practices include praying 5 times a day. work with the client to establish a schedule for the day, noting which time the client prefers to pray and scheduling treatments around those times when possible c. american culture appreciates direct eye contact in middle eastern cultures direct eye contact can be perceived as rude, hostile, or sexually aggressive d. daily communion is a ritual for a catholic client

a nurse is using an interpreter to communicate with a client. which of the following actions should the nurse use when communicating with a client and family members (select all that apply) a. talk to the interpreter about the family while the family is in the room b. determine client understanding several times during the conversation c. look at the interpreter when asking the family questions d. use lay terms if possible e. do not interrupt the interpreter and the family as they talk

a. talking to the interpreter about the family while the family is in the room would hinder communication between the family and the nurse/interpreter b. correct: determining client understanding throughout the conversation ensures the client comprehends the information and the nurse will know how to direct the conversation c. looking at the interpreter instead of the family while the family is in the room would hinder communication between the family and the nurse/interpreter d. correct: using lay terms will promote effective communication between the family and the nurse/interpreter e. correct: not interrupting will promote effective communication between the family and the nurse/interpreter

a nurse is planning to use healing intention with a client who is recovering from a lengthy illness. which of the following is a priority action to take before attempting this mind-body intervention a. tell the client the goal of the therapy is to promote healing b. ask whether the client is comfortable with using prayer c. encourage the client participate actively for best results d. instruct the client to relax during the therapy

a. tell the client the goals of therapy to provide information to the client, however there is another action to take first b. correct: the first action to take using the nursing process is to assess or collect data from the client. because people can have personal, cultural, or religious sensitivities or aversions to religious practices (prayer), the nurse must first determine that the client is comfortable with a therapy that involves prayer c. encourage the client to participate to improve the effectiveness of the therapy however, there is another action to take first d. instruct the client to relax to promote the client's ability to focus during the therapy, however, there is another action to take first

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision." b. "Will you give me pain medicine after the surgery." c. Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say."

a. the client's concern about their spouse seeing the incision should indicate anxiety or depression b. the client's request for pain medicine could indicate fear and anxiety. c. correct: asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. the client's new diagnosis of cancer can cause anxiety, fear, or depression, all of which can interfere with the learning process d. the lack of privacy due to the presence of a roommate can be a barrier to learning

A nurse is evaluating how well a client learned the information presented in a instructional session about following a heart-healthy diet. Which of the following actions should the nurse take to evaluate the client's learning? a. Encourage the client to ask questions b. Ask the client to explain how to select or prepare meals c. Encourage the client to fill out an evaluation form about how the nurse presented the information d. Ask whether the client has resources for further instruction on this topic

a. the clients cultural values about the nurse as an authority figure or other factors could prevent the client from asking questions. this method is not an accurate way to evaluate client understanding b. correct: having the client explain the information in their own words will allow the nurse to evaluate exactly what the client remembers and whether the client comprehends the information c. evaluating the nurses performance might not offer clues about what the client has learned d. identify the clients resources early in the instructional process. at this point, the exploration of resources does not help the nurse evaluate the client's learning

a nurse educator is teaching a class on culture and food to a group of newly hired nurses. which of the following statements by a nurse indicates and understanding of the teaching a. most clients who practice roman catholicism do not drink caffeinated beverages b. most clients who practice orthodox judiasm do not eat meat with dairy products c. most clients who are mormon eat only the protein of animals that are slaughtered under strict guidelines d. most cleints who practice hinduism do not eat dairy products

a. this is generally not a practice for roman catholics caffeinated beverages are often not consumed by mormons and muslims because caffeine is a stimulant b. correct: most clients who practice orthodox judaism do not eat meat with dairy products c. most clients who follow the teachings of islam eat only the protein of animals that are slaughtered under strict guidelines d. most clients who practice hinduism believe dairy products enhance spiritual purity

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (select all that apply) a. Find a mentor b. Use a journal to write about the outcomes of clinical judgments c. Review articles about evidence based practice d. Limit consultations with other professionals involved in a client's care e. Make quick decisions when unsure about a client's needs

a.correct: learning from the experience of peers can improve critical thinking b. correct: journaling about decision-making can assist the nurse with self-reflections and improve critical thinking c. correct: improving knowledge by learning new information about evidence-based practice improves the nurses ability to think critically d. although nurses who have advanced critical thinking can do so independently, the nurse should talk to other professionals to share information and remain open-minded and inquisitive e. quick decision-making can lead to errors. a nurse's intuition might cause feelings of uncertainty, which should lead the nurse to ask questions about whether the plan of care makes sense and to gather more information