wellness exam 3

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A A. CORRECT: By threatening the client, the AP is committing assault. Her threats could make the client become fearful and apprehensive. B. INCORRECT: Battery is actual physical contact without the client's consent. Because the AP has only verbally threatened the client, battery has not occurred. C. INCORRECT: Unless the AP restrains the client, there is no false imprisonment involved. D. INCORRECT: Invasion of privacy most often involves disclosing information about a client to an unauthorized individual.

Three weeks after delivery, a patient started a diet of 800 calories per day and began jogging 2 miles twice per day. The nurse recognizes the patient's behavior may be influenced by which motivating factor? a. Body image b. Family roles c. Illness behavior d. Chronic illness

A Body image is a self-ascribed attribute that influences a person's ability and desire to change, and it may be a motivating factor to maintain the change. Self-concept is a general and broader factor that motivates less specific responses. Family roles are not an influencing factor because this is a personal and possibly self-destructive behavior pattern for weight loss. Pregnancy is not a chronic illness.

When the nurse is establishing goals for a community health initiative, which strategy is most important to incorporate in the planning process? a. Collaboration with key stakeholders b. Help from professional interpreters c. Location of schools and businesses d. Gender of primary care providers

A Collaboration with key stakeholders is critical to effective goal planning in a community. Valuing the ideas of stakeholders increases support for initiatives and has the potential to increase participation and improve outcomes. Help from professional interpreters, the location of schools and businesses, and the gender of health care providers are factors to be considered after goals are established and interventions are being considered for a specific target population.

When a patient reports having dyspareunia, which question is it most appropriate for the nurse to ask? a. "Have you talked with your partner about this discomfort?" b. "Have you had these spasms since you became sexually active?" c. "Does the bleeding continue longer than 5 days?" d. "Do your breasts swell up large enough for you to need a larger bra?"

A Dyspareunia is painful intercourse, and the sexual partner should be made aware of this to foster understanding and adjustment of sexual practices. Spasms, bleeding, and breast swelling are not associated with this condition.

A famous rock star has just been admitted to Unit 12A after an automobile accident. A nurse on Unit 12B who is a fan of the musician uses the electronic health record (EHR) to find out how the patient is doing. Which is true regarding the use of a patient's EHR? a. Only staff caring for the patient should access this record. b. Permission from a supervisor is needed to read this record. c. The patient's record can be discussed with the nurse's co-worker. d. The nurse can call a friend who works at the local newspaper.

A Patient information should be accessed only by staff caring for that patient. Security codes are required for EHR access, and access of records can be monitored. Professional ethics should dictate the nurse's behavior, and only the records of patients being cared for should be accessed. A patient's record can be discussed only with those who are caring for the patient, and, because the nurse is not on the same unit, the records should not be accessed or discussed by that nurse. Health Insurance Portability and Accountability Act (HIPAA) laws prevent the discussion of private patient information with anyone outside of the team providing care.

Cody is going to document in Mr. Brown's medical record. Which of the following is appropriate to document? A. Patient rates headache pain as a 6. Pain is in L temporal area and does not get better with any positioning. B. IV site looks good. C. Voiding without difficulty. D. Is pleasant to care for.

A Rationale: Documentation is to be factual, accurate, and thorough. Vague terms do not capture the intent of the reason for documentation.

Which statement is an example of the use of situational leadership? a. The emergency room manager takes a vote on holiday coverage and then responds to a Code Blue by directing orders at the nursing staff. b. The manager in surgery uses the vacation policy to grant time off and then performs a surgical count in an operating room using a checklist. c. A vice president of nursing allows the department directors to make a decision about a hospital policy on holiday time and then sides with a nurse who does not want to work the required time. d. The CEO of the hospital instructs the nursing senate to develop a dress code and then changes the dress code after determining he does not like it.

A Situational leadership adjusts leadership styles to fit the situation. In the correct option, the manager moved from a democratic to an authoritarian leadership style to fit the change in situation. The manager in surgery follows a bureaucratic style by strictly following policy and procedure. The vice president of nursing is following a laissez-faire style, because responsibility for the decision is abdicated, and he or she does not support the policy when needed. The CEO of the hospital is following an authoritarian style of leadership because input of the staff is not valued.

Which activity best illustrates use of the Health Promotion Model (HPM) by the nurse to increase the level of well-being for a patient immediately after surgery? a. Holding a pillow across his chest when coughing and deep breathing b. Encouraging the patient to eat his entire evening meal c. Changing his surgical dressing daily as ordered by the physician d. Asking his family to step out of the room during dressing changes

A The HPM describes an individual's interaction with his environment as he engages in behaviors that promote health. The patient using a pillow as a splint is interacting with his environment to prevent atelectasis and infection.

When teaching the patient mechanical barriers for birth control, the nurse would include which method? a. Diaphragm b. Transdermal patch c. Hormone injection d. Oral contraceptives

A The diaphragm is the only mechanical barrier listed for birth control. Oral contraceptives are absorbed through the gastrointestinal tract, hormones in injections, and transdermal patches are absorbed systemically.

On which ethical theory do nurses implement their care when they act on the basis of the needs of one specific patient rather than the potential consequences to other patients? a. Deontology b. Autonomy c. Utilitarianism d. Nonmaleficence

A The ethical theory of deontology focuses on the act rather than on the consequences. Autonomy is an ethical concept that values an individual's right to make personal decisions. Utilitarianism is an ethical theory that focuses on the consequences of an action and the good of many rather than of an individual. The ethical principle of nonmaleficence asserts an obligation to "do no harm."

A nurse delegates a bed bath to unlicensed assistive personnel (UAP). After lunch, the patient complains that he has not yet been cleaned up. He is very upset and angry. What should the nurse's next action be? a. Assist the patient in getting cleaned up. b. Write up the UAP for not carrying out the assignment. c. Report the UAP to the unit manager. d. Go find the UAP, and tell her to complete the bath immediately.

A The goal of delegation of any assignment is to provide efficient, patient-centered care. In this case, the patient is angry and upset, and the nurse should first see to the patient's needs and address the issue with the UAP after the situation is resolved.

Which activity by a unit nurse demonstrates information literacy? a. Researching a patient's diagnosis online b. Entering patient data into the electronic health record (EHR) c. Organizing patient data to study trends d. Learning a new electronic health record system

A The nurse is demonstrating information literacy (the ability to recognize when information is needed and to locate and use that information) when researching a patient's diagnosis online. Entering patient data into the EHR or learning a new EHR system demonstrates beginner nursing informatics competency. Organizing patient data to study trends demonstrates an experienced level of nursing informatics competency.

A nurse providing preventive care to an overweight patient with a family history of diabetes should engage in which priority care-planning activity for this patient? a. Calculating the patient's body mass index (BMI) and recommending a daily exercise routine b. Instructing the patient to perform blood glucose monitoring once daily c. Giving the patient a month's supply of insulin needles and syringes d. Participating in diabetes education classes offered at a local health facility

A The patient does not have diabetes but is overweight and at risk due to a family history of diabetes. The best way to prevent diabetes is to keep the BMI in the optimal range (<25). Beginning an exercise program with walking and progressing as tolerated increases muscle mass, improves depression, and strengthens the heart.

A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preoperative care regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.

A, B A. CORRECT: It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that he understands the information the surgeon gave him. B. CORRECT: It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that he is consenting voluntarily and appears to be competent to do so. The nurse also should verify that he understands the information the surgeon gave him. C. INCORRECT: It is the surgeon's responsibility, not the nurse's, to explain the risks and benefits of the procedure. D. INCORRECT: It is the surgeon's responsibility, not the nurse's, to describe the consequences of choosing not to have the surgery. E. INCORRECT: It is the surgeon's responsibility to tell the client about any available alternatives to having the surgery

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A, B, C A: correct: the nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation B. correct: having another nurse listen to the telephone prescription is a safety precaution that helps prevents medication errors due to miscommunication C: correct: the provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr). D. unrelieved pain can become an emergency situation without the appropriate pain management interventions E. there is no need to inform the charge nurse every time a nurse receives a medication prescription, whether by telephone, verbally, or in the medical record

Michelle sits in on a counseling session with her nursing mentor and a childless couple. The choices for infertile couples include which of the following? (Select all that apply.) A. Pursuing adoption B. Remaining childless C. Undergoing fertilization treatment D. Medicating with St. John's wort

A, B, C Choices for the infertile couple include pursuit of adoption, medical assistance with fertilization, or adapting to the probability of remaining childless. St. John's wort is an herbal treatment used for depression management.

Whom should the school nurse engage in discussion when conducting a needs assessment related to the high incidence of obesity in the school system? (Select all that apply.) a. Parents b. Students c. School staff d. Community members e. Firefighters and police

A, B, C, D To address the concern regarding obesity, the nurse will need to engage each of these groups, as well as school administrators and teachers, to gain insight into the needs and identify resources. The nurse could form a task force with representatives of each group to work on necessary interventions to address the high incidence of obesity. It would not be necessary for the nurse to speak with firefighters or police, in this case.

Which items are supported by point-of-care use of information technology? (Select all that apply.) a. More accurate documentation b. Direct access to diagnostic results c. Confidentiality d. Direct access to records by patients e. Access to medication profiles

A, B, C, E Point-of-care use of information technology provides more accurate documentation because the nurse documents patient information in real time. Diagnostic results are immediately available to the nurse. Confidentiality is protected when the nurse documents at the bedside using a secure log-in and password. Medication profiles are available to the nurse at bedside. Patients do not have direct access to their medical records because these records are secured by log-ins and passwords accessible to only health care providers caring for each patient.

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (select all) A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Complaint from a client's family member

A, B, D A: correct: complete an incident report regarding a medication error B: correct: complete an incident report regarding a needlestick C: report a conflict with a provider and nursing staff to the charge or nurse manager D: correct: complete an incident report following an omission of a prescription E: documentation should be current. waiting until the end of the shift can result in data omission

The registered nurse on an inpatient medical unit delegates vital signs and morning care to the UAP for five stable patients. The nurse asks the UAP to document the vital signs and report any abnormal results immediately. Which rights of delegation is the nurse demonstrating? (Select all that apply.) a. Right person b. Right circumstance c. Right time d. Right supervision e. Right patient

A, B, D The nurse is demonstrating all of the rights of delegation. Right time and right patient are not part of the Five Rights of Delegation. They are a part of the Rights of Medication Administration. The Five Rights of Delegation are 1. Right task 2. Right person 3. Right circumstance 4. Right communication 5. Right supervision

What consequences may a nurse experience if the nurse is convicted of a crime? (Select all that apply.) a. Loss of nursing licensure b. Employment affirmation c. Monetary penalty d. Imprisonment e. Promotion

A, C, D Nurses who are convicted of a crime may have their nursing licenses revoked, be required to pay fines or pay restitution to patients or their families for damages, and be incarcerated for various periods, depending on the severity of the crime. Nurses who commit crimes are most often placed on probation pending the outcome of court proceedings or dismissed from their employment, not affirmed or promoted.

Which behaviors are expected of the nurse at the experienced informatics competency level? (Select all that apply.) a. Collect accurate assessment data. b. Conduct informatics research. c. Group assessment data. d. Document data appropriately on the electronic health record (EHR). e. Integrate information science, computer science, and nursing science.

A, C, D The nurse at the intermediate level of informatics competency can see data relationships and is able to collect and group data. The nurse is skilled in the use of computer technology and can document in the EHR. Conducting informatics research and integration of the sciences is the advanced level of informatics competency.

Which intrinsic factor(s) would be of major concern to the nurse about when the community has an outbreak of pertussis? (Select all that apply.) a. Age b. Gender c. Ethnic group d. Cultural background e. Immunization status

A, E Age and immunization status would be of most concern because people who have not had a pertussis vaccine could be a source of potentially fatal infection in infants. In the case of pertussis vaccination, gender ethnicity and cultural background are not of particular concern.

Jay delegates the task of taking vital signs to a new nursing assistant on the unit with whom Jay has never worked before. Which of the following questions asked of the new nursing assistant will help Jay determine that it is safe to delegate the task of taking vital signs? (Select all that apply.) A. "How long should you keep the thermometer in the patient's mouth?" B. "How do you apply a blood pressure cuff to an obese patient?" C. "How do you take a patient's pulse?" D. "Do you know how to take vital signs?"

A,B,C Rationale: Open-ended questions elicit a conversation and details to help the nurse assess the knowledge and skills on the nursing assessment. The question "Do you know how to take vital signs?" is a closed-ended question that does require further exploration.

At the end of the shift, the registered nurse assigned to Mr. Brown asks Cody if he would give the hand-off report to the nurse coming on who is assigned to Mr. Brown. Which of the following statements are true regarding hand-off reports? Select all that apply. A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient C. Must be given face to face between the nurses D. Must include an opportunity for the receiver to ask questions of the person giving the report

A,B,D Rationale: One of the National Patient Safety Goals provides for standardized communication so there is continuity of care when handing care of a patient over to another caregiver.

Immunizations are not an objective as defined by Healthy People 2010 because immunizations are largely for children and children are not included in the Healthy People 2010 initiative. A. True B. False

Answer: B Rationale: Immunizations and infection control are a priority component of the Healthy People 2010 initiative for improving the health of all people in the United States.

Trevor knows that receiving an immunization is included in which hierarchy of need according to Maslow? A. Physiological B. Safety and security C. Love and belonging needs D. Self-esteem E. Self-actualization

Answer: B Rationale: Receiving an immunization falls into the "physical safety" subdivision of Maslow's "safety and security" hierarchy.

Before Jay delegates tasks, he must make sure that he is delegating in accordance with a registered nurse's legal scope of practice. Rank in order the five rights of delegation Jay must follow. A. Right supervision/evaluation B. Right person C. Right task D. Right circumstances E. Right direction/communication

Answer: C, D, B, E, A Rationale: The five rights of delegation are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.

Mrs. Brown asks Cody if she can look at her husband's medical record. On what legislation would Cody base his answer?

Answer: HIPAA Rationale: HIPAA is a federal law that protects the privacy of health care information. For Mrs. Brown to view Mr. Brown's medical record, her husband would have to give permission.

Trevor is assigned to the immunization station at the health drive where he is responsible for administering vaccines to the children. Immunizations are an example of _________________ and _____________ prevention.

Answer: primary and illness Rationale: Primary prevention precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. It includes health education programs, immunizations, and physical and nutritional fitness activities. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health.

What is the best method for the public health nurse to determine if community members are involved in outdoor physical activity? a. Meet with the parents of high school children. b. Complete a windshield survey of the community. c. Evaluate the number of community health club members. d. Check the local health statistics for the incidence of obesity.

B A windshield survey will allow the nurse to observe whether people are walking or engaged in physical activity. It also will help the nurse identify single- or multiple-family private and public housing units; health, safety, and social services agency availability; and other essential community attributes. Meeting with parents, evaluating health club membership, or obesity statistics will not assess the concern of the prevalence of outside physical activity.

A nurse manager of a medical‑surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)

B A. Although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs. B. CORRECT: A client returning from surgery requires an RN's assessment and establishment of a plan of care, especially if the client is potentially unstable. C. Although PNs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time. D. Although APs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time, particularly assessment.

An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

B A. INCORRECT: Assault is an action that threatens harmful contact without the client's consent. The nurse has made no threats in this situation. B. CORRECT: The nurse gave the medication as a chemical restraint to keep the client from leaving the facility against medical advice. This is false imprisonment because the client neither requested nor consented to receiving the sedative. C. INCORRECT: Negligence is a breach of duty that results in harm to the client. It is unlikely that the medication the nurse administered without his consent actually harmed the client. D. INCORRECT: The nurse has not disclosed any protected health information, so there is no breach of confidentiality involved in this situation

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Nonmaleficence

B A.INCORRECT:Fidelity is an agreement to keep promises. The nurse has not made any promises; this is the client's decision. B.CORRECT:In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy. C. INCORRECT:Justice is fairness in care delivery and in the use of resources. Because the client has chosen not to use them, this principle does not apply. D. INCORRECT: Nonmaleficence is the avoidance of harm or injury. In this situation, harm can occur whether or not the client has surgery. However, because he chooses not to, this principle does not apply

In using the PLISSIT model, what is the first action initiated by the nurse? a. Present basic information about sexual functioning. b. Ask permission to begin the sexual assessment. c. Inquire about any medications the patient is taking. d. Ask the patient about sexual activity and practices.

B Before initiating discussion via the PLISSIT model, the nurse should first seek permission to have the conversation with the patient. All of the other listed steps occur, but only after permission is obtained. Permission-gain and give permission Limited Information- answer questions with facts Specific Suggestions-effects of treatment Intensive Therapies- usually involve referral

Which description is an example of data? a. A printout of a patient's history and physical examination b. A patient's blood pressure and pulse rate c. The nurse's knowledge of a disease d. A nurse's interpretation of a change in the patient's condition

B Data are facts, observations, and measurements such as blood pressure and pulse rate. A printout of the patient's history and physical is organized information that is meaningful. Knowledge is organized and processed information such as a nurse's knowledge of a disease. When nurses interpret a change in the patient's condition, they are using wisdom or the use of knowledge and experience to manage and solve problems.

For which reason are patients unlikely to introduce the topic of sex with health care providers? a. Most patients have few, if any, questions or problems relating to this topic. b. They are too embarrassed to discuss the topic of sex with a health care provider. c. Female patients prefer to discuss problems with female health care providers. d. They assume that health care professionals know little about sexual functioning.

B Embarrassment to discuss a personal subject can cause the patient to avoid introduction of the topic. Gender is not a consideration in this question, and it cannot be generalized that patients have few questions or problems on any topics. Health care professionals generally are considered to be knowledgeable in subject matters associated with health and illness.

A patient is seeking information about leading indicators that show the importance of health promotion and illness prevention in the United States. To which government-sponsored program would the nurse refer the patient for the best source of information? a. American Cancer Society website b. Healthy People 2020 website c. Centers for Disease Control and Prevention (CDC) morbidity and mortality reports d. American Association of Hospitals home page

B Healthy People 2020 is the most up-to-date site for health indicators in the United States, and it is presented in a client-friendly format. The CDC Morbidity and Mortality Weekly Report does not cover all of the indicators, and it may be overly technical for the client. The same holds true for the American Cancer Society website and the American Association of Hospitals home page.

What action would be most appropriate for the home care nurse to take if an intrinsic factor appears to be contributing to a client's illness? a. Report the presence of multiple insects in the home to the health department. b. Document the intrinsic factor in the client's electronic health record. c. Explore the possible impact of changing jobs for stress reduction. d. Discuss the danger of having multiple throw rugs with the client.

B Intrinsic factors include variables such as genetics, age, gender, and ethnic group. These should be documented in the client's electronic health record so that their impact can be taken into consideration in assessing the client's health status. The presence of insects and throw rugs in a client's home and where the client works are extrinsic factors.

Jay begins to plan Ms. Osborne's care and decides to delegate Ms. Osborne's assessment to the nursing assistant because he is behind on his patient rounds. It is acceptable for Jay to delegate the task of assessment according to the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). A. True B. False

B Rationale: The nurse does not delegate the steps of the nursing process of assessment, planning, and evaluation because these steps require nursing judgment according to the ANA and NCSBN.

When a patient is beginning a regimen of an antidepressant medication, which information should the nurse include in the medication teaching as it pertains to sexuality? a. "Your partner will be pleased because your sexual functioning is going to improve." b. "You may find that your desire for sex will decrease while on this medication." c. "Your skin will probably become supersensitive to touch, so you may need to change your activity during sex." d. "You will be unable to have an erection while taking your antidepressants."

B Reduced sexual desire can be a side effect of antidepressant use. Skin sensitivity and erectile dysfunction are not side effects. Improved sexual function is not a specific effect of antidepressant administration.

A normally active, older patient has been frequently evaluated for minor problems at the clinic since the death of her husband 3 months earlier. During one of her visits she states that she has no energy to get through the day and no desire to keep up with her Tuesday night bridge club. Which type of holistic health model intervention should the nurse use to help the patient cope with the loss of her husband? a. Encouraging use as needed of a drug for anxiety ordered by her provider b. Teaching the value of music therapy to address anxiety about her loss c. Explaining that she will be over the loss of her husband in a few months d. Encouraging a gradual reentry into social interaction and activities with friends

B Teaching the patient to use music therapy when she feels anxious about her loss is the most appropriate intervention listed. This type of distraction is a holistic technique that works well in the form of music, painting, and expressive dance. Instructing the patient to use drugs is not part of the holistic approach. The patient may not be ready to re-engage in a full activity schedule, and it is unlikely that her feelings of loss will ever totally resolve.

What is the best way for a nurse to avoid crossing professional practice boundaries with patients? a. Spend extensive time with a patient without visitors. b. Focus on the needs of patients and their families. c. Intervene in problematic patient relationships. d. Discuss personal information excessively.

B The best way to avoid breaching professional practice boundaries is to focus on the patient's needs and those of the patient's family. Nurses should consistently avoid excessive self-disclosure of personal information, intervening in patient relationships, and spending excessive amounts of time with one patient. In addition to keeping patients' secrets, gaining personally from a relationship with a patient, and engaging in sexual overtures or behavior with a patient, these actions are considered violations of professional boundaries.

When teaching female reproduction to a group of high school students, the nurse uses what term to indicate the cessation of a woman's menstrual activity? a. Menarche b. Menopause c. Premenstrual syndrome d. Menstrual dysfunction

B The definition of menopause is the cessation of a female's menstrual activity. Menarche is the onset of menstruation. Premenstrual syndrome is a set of specific symptoms that occur before the monthly menstrual cycle. Menstrual dysfunction refers to altered patterns of menstruation associated with various disorders.

The hospital has implemented a new electronic medication administration record (MAR). What is true about the use of this new tool? a. Verifies medication dosages b. Reduces medication administration errors c. Eliminates the need to count narcotics d. Requires a hard copy of the MAR to be printed

B The electronic MAR reduces medication errors by requiring the nurse to scan the patient's identification band and the medication. Although the electronic MAR alerts the nurse to potential errors such as the wrong dose, it is the nurse's responsibility to verify all information before administration of a medication. Narcotic counts are still kept in the electronic system. A hard copy of the MAR is not necessary.

A nurse manager is trying to improve patient satisfaction ratings for her area of responsibility. The manager meets with the staff and forms an ad hoc committee to address the issues around the problem. This is an example of what style of leadership? a. Bureaucratic b. Democratic c. Laissez-faire d. Autocratic

B The nurse manager fits the description of the democratic style because the staff members have input into the solution of the problem. A bureaucratic manager develops policies and procedures to follow or reinforces existing policies and procedures. A laissez-faire manager presents the problem to the employees, but rather than offering a plan for addressing it, he or she asks employees to solve the problem on their own. An autocratic manager uses the threat of punishment or promise of rewards to solve the problem.

A nurse is volunteering in the community to educate parents to increase the number of children in the school district who are immunized. The nurse oversees the activities of a group of volunteers. Which role best describes the nurse's activity in this situation? a. Management b. Leadership c. Volunteerism d. Activism

B The nurse meets the criteria for leadership because the nurse is acting in an informal role, not as part of a managerial structure in an organization. Volunteerism and activism are not defined as management or leadership functions.

The nurse enters a patient's room to deliver a dinner tray and notices that the patient has not been out of bed since the previous day. The patient states that his condition has made him bedridden, although the nurse knows that he is capable of independent ambulation. Which type of reaction is the patient exhibiting? a. Ambivalence to symptoms b. Illness behavior c. Diminished functional ability d. Overreaction to illness

B The patient is defining and interpreting his disease symptoms according to his beliefs about illness and how to respond to it. The patient's ability to ambulate is intact. Overreaction to illness is a subjective anomaly, and the patient is not ambivalent about his diagnosis.

A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization.The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements is an appropriate response by the nurse? A."Sounds like something you should discuss with her when you get home." B."It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C."Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D."Just make sure you take your medication as directed, and you should be fine."

B CORRECT: The nurse is acknowledging and allowing the client to discuss his concerns regarding sexual functioning.

A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A."I was having difficulty with attaching the appliance at first, but my wife was able to help." B."I'll never be able to care for this at home. Can't you just send a nurse to the house?" C."I met a neighbor who also has a colostomy, and he taught me a few things." D."It may take me a while to get the hang of this. I have to admit, I am pretty nervous."

B CORRECT: This client is displaying a lack of interest in learning how to care for the colostomy and dependence on others to care for him. The nurse should suspect issues with self-concept with this client.

a charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record (select all that apply) A. Cover errors with correction fluid, and write in the correct info. B. Put the date and time on all the entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of shift to document.

B, C A. correction fluid implies that the nurse might have tried to hide the previous documentation or deface the medical record B. correct: the day and time confirm the recording of the correct sequence of events C. correct: documentation must be factual, descriptive, and objective, without opinions for criticism D. too many abbreviations can make the entry difficult to understand. nurses should minimize use of abbreviations, and use only those the facility approves E. documentation should be current. waiting until the end of the shift can result in data omission.

Which descriptions are advantages of health care information technology (IT)? (Select all that apply.) a. Increases health care delivery costs b. Improves communication among providers c. Improves administration functions d. Increases time necessary to document care e. Decreases the safety of providing care

B, C Health care IT improves communication among providers by providing immediate access that is legible and standardized to patient data by all providers. IT improves administrative functions by addressing the issues of quality, cost-effectiveness, and outcomes of care. Although there are initial costs to purchase hardware and software, these systems are cost-effective in the long run. Systems that support data collection at the point of care can directly enhance patient care by decreasing the time spent on documentation, reducing the potential for errors, and supporting improved assessment and data communication

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front‑wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this morning.

B, C, D A. The AP does not need to know the status of the client's roommate to complete this assignment. B. CORRECT: To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. CORRECT: To complete this assignment safely, the AP should make sure the client uses a front‑wheeled walker. D. CORRECT: To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication. E. The AP does not need to know the client's allergy status to complete this assignment. F. The AP does not need to know the client's food intake to complete this assignment.

Which factor(s) should be considered by the public health nurse before scheduling community infant immunization clinics? (Select all that apply.) a. Individual infant allergies b. Transportation availability c. Cost of immunization services d. Local attitudes toward immunization e. Personal feelings about immunization effectiveness

B, C, D Transportation availability and the cost of immunizations as well as the attitude of the target population toward immunization should be considered before scheduling clinics. These factors should guide the choice of location at which services are provided and help identify possible funding sources that can be tapped and education resources that need to be incorporated into the plan. Individual infant allergies need not be addressed beforehand—they will be considered at the actual clinics just before vaccination. Research evidence, not a nurse's personal feelings about immunization effectiveness, should guide practice.

A nurse is preparing an in‑service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply.) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances

B, C, E A. The right client is one of the rights of medication administration, not of delegation. B. CORRECT: The right supervision and evaluation is one of the five rights of delegation. They also include the right task and the right person. C. CORRECT: Right direction and communication is one of the five rights of delegation. They also include the right task and the right person. D. Although the delegatee needs to know whether there is a time frame or a specific time to perform the task, the right time is not one of the five rights of delegation. It is one of the rights of medication administration. E. CORRECT: The right circumstances is one of the five rights of delegation. They also include the right task and the right person Right task, right circumstance, right person, right direction and communication, right supervision and evaluation

During the meeting the committee discusses ethical theories such as deontology. Which of the following terms are associated and mean that the value of something is determined by its usefulness? (Select all that apply.) A. Accountability B. Consequentialism C. Advocacy D. Teleology E. Utilitarianism

B, D, E Rationale: Consequentialism means that the main emphasis is on the outcome or consequence of the action. Teleology is the study of the end or final causes. Utilitarianism means that the value of something is determined by its usefulness and embodies the concepts of consequentialism and teleology

1. Nursing students are held to which standard by the Code of Ethics for Nurses? (Select all that apply.) a. Clinical skills performance equal to that of an experienced nurse b. Demonstration of respect for all individuals with whom the student interacts c. Avoidance of behavior that shows disregard for the effect of those actions on others d. Accepting responsibility for resolving conflicts in a professional manner e. Incorporating families in patient care regardless of patient preference

B,C,D Nursing students are expected to demonstrate respect, avoid hurting others by their actions, and take responsibility for resolving conflicts in a professional manner, much the same as professional nurses. Student nurses are not required to perform clinical skills at the level of expertise exhibited by an experienced nurse. Involving a patient's family in care without the patient's approval indicates a lack of respect for patient autonomy.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at high risk for body image disturbances? (Select all that apply.) A.30-year-old male following laparoscopic appendectomy B.45-year-old female following mastectomy C.20-year-old female following left above-the-knee amputation D.65-year-old male following cardiac catheterization E.55-year-old male following stroke with right-sided hemiplegia

B,C,E B. CORRECT:Having a mastectomy involves a change in the physical appearance of a woman and can lead to body image disturbances related to femininity and sexuality. C. CORRECT:Having an above-the-knee amputation involves a change in physical appearance and can lead to body image disturbances related to function, health, and strength. E. CORRECT:Having right-sided hemiplegia involves a change in physical appearance and can lead to body image disturbances related to function, health, and strength.

A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A."Really, you look just fine to me. There's no need to feel undesirable. B."I'm interested in finding out more about how your body feels to you." C."Consider an afternoon at a spa. A facial will make you feel more attractive." D."It's still too soon to expect to feel normal. Give it a little more time."

B. CORRECT:Showing interest in the client is applying the therapeutic communication technique of offering self; asking more about how the client feels is applying the therapeutic communication technique of encouraging a description of perception.

a nurse is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (select all that apply) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurse's station D. A client can request a copy of her medical record E. A nurse my photocopy a client's medical record for transfer to another facility.

BCDE A: The HIPAA Privacy Rule requires the protection of clients' electronic records. The rule states that electronic health records must be password-protected and each staff person should use an individual password to access information B: correct: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code C: correct: the HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location D:correct: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record E: correct: The HIPAA Privacy Rule states that nurses can only photocopy a client's medical record if it is to be used for transfer to another facility or provider

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit. B. Ask others on the team whether they have observed the same behavior. C. Report her observations to the nurse manager on the unit. D. Conclude that her coworker's fatigue is not her problem to solve.

C A. INCORRECT: Confronting the coworker might cause her to respond defensively and does nothing to resolve the problem. B. INCORRECT: Finding out whether others have noticed the problem is immaterial and should not affect the nurse's course of action. C. CORRECT: Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager. D. INCORRECT: The nurse may not be responsible for solving the problem, but she does have a duty to take action since she has observed the problem.

A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C A. INCORRECT: The client may designate any competent adult to be his health care proxy. It does not have to be his spouse. B. INCORRECT: Although the hospital staff must ask the client whether he has prepared advance directives and provide written information about them if he hasn't, they may not refuse care based on the lack of advance directives. C. CORRECT: The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arises. D. INCORRECT: The client does not need his provider's approval to submit his advance directives. However, he should give his primary care provider a copy of the document for his records.

A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A. The client's input and output for the shift B. The client's blood pressure from the previous day C. A bone scan that is scheduled for today D. The medication routine from the medication administration record

C A. INCORRECT: Unless there is a significant change in the client's intake and output, the oncoming nurse can read that information in the chart. B. INCORRECT: Unless there is a significant change since the client's blood pressure measurements the previous day, the oncoming nurse can read that information in the chart. C. CORRECT: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit. D. INCORRECT: Unless there is a significant change in the client's medication routine, the oncoming nurse can read that information in the chart.

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A.A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B.A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C.A family has conflicting feelings about the initiation of enteral tube feedings for their father, whois terminally ill. D.A client who is terminally ill hesitates to name her spouse on her durable power of attorney form

C A. INCORRECT:Delivering client care while showing signs of a substance use disorder is a legal issue, not an ethical dilemma. B. INCORRECT:A nurse who threatens to restrain a client has committed assault. This is a legal issue, not an ethical dilemma. C. CORRECT:Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. D. INCORRECT:The selection of a person to make health care decisions on a client's behalf is a legal decision, not an ethical dilemma

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Nonmaleficence

C A. INCORRECT:Fidelity is an agreement to keep promises. Because donor organs are a scarce resource compared with the numbers of potential recipients who need them, no one can promise anyone an organ. Thus, this principle does not apply. B. INCORRECT:Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved with the qualifications for organ recipients. C. CORRECT:Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. D. INCORRECT: Nonmaleficence is the avoidance of harm or injury. In this situation, harm can occur to organ donors and to recipients. The requirements of the organ procurement organizations are standard procedures and do not address avoidance of harm or injury

A nurse on a medical‑surgical unit has received change‑of‑shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer

C A. It would be inappropriate to delegate the feeding of a client who has aspiration pneumonia to an AP because the client is at risk for further aspiration. B. Either an RN or an PN, not an AP, may reinforce teaching. C. CORRECT: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to an AP. D. Either an RN or an PN, not an AP, may apply a sterile dressing.

A charge nurse is assigning client care for four clients. which of the following tasks should the nurse assign to a PN A. creating a plan of care for a client who is recovering following a stroke B. assessing a pressure injury on a client who is on bed rest C. providing nasopharyngeal suctioning for a client who has penumonia D. teaching a client who has asthma to use a metered-dose inhaler

C A. creating a plan of care requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN B. assessing a pressure injury requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN C: correct: providing nasopharyngeal suctioning is within the scope of practice of the RN D. teaching requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN

Processes used in management parallel the nursing process. Which sentence describes a nurse using a management principle paralleled with the nursing process? a. Planning is demonstrated when the nurse motivates others. b. Directing is demonstrated when the nurse plans care for the patient. c. Organizing is demonstrated when the nurse coordinates care for patients. d. Controlling is demonstrated when the nurse tells other staff members what to do.

C According to Fayol, the functions of managers are planning, organizing, directing, and controlling. The nurse demonstrates organizing by coordinating the care delivered to patients. Planning involves goal setting, assessment, and setting the plan and acting on it. Direction involves the ability to motivate others toward a common goal and includes good communication skills. Controlling involves comparing expected results of the planned work with actual results.

Which nursing intervention is the best example of patient advocacy? a. Collecting blood samples according to the physician's order each morning b. Assessing the vital signs of a patient who is receiving a blood transfusion c. Seeking an additional analgesic medication order for a patient who is experiencing severe pain d. Accompanying an ambulating patient who is walking for the first time after undergoing surgery

C Advocacy requires a nurse to work on behalf of others who may be unable to speak for themselves. When a patient is in pain and the physician or primary care provider is not present, a nurse must advocate for the patient's needs by initiating contact with the person responsible for addressing an immediate need. In this case, an order for additional pain medication is needed, which requires collaboration with the patient's physician. Collecting blood samples, assessing vital signs, and assisting a patient with ambulation are primary responsibilities of the nurse that do not require advocacy to meet the patient's need.

Cody wants to plan his morning. To which documentation form would Cody refer to find out activity orders, or what treatments Mr. Brown will be receiving today? A. Standardized care plan B. Flow sheet C. Kardex D. Admission history form

C Answer: C Rationale: The Kardex is a summary of the current list of orders, treatments, and diagnostic testing. This form allows the nurse to have all of these together instead of having to go to various places in the medical record.

Which intervention should the college health clinic nurse implement as a secondary prevention strategy to identify students at risk for diabetes? a. Nutrition education about high-protein food availability b. Promotion of registration in fitness classes c. Blood glucose screening at the health fair d. Administration of prescribed insulin

C Blood glucose screening is the only secondary prevention strategy listed. Education and promotion of fitness classes are primary prevention strategies, and administering insulin is a tertiary prevention intervention.

Making prejudicial, untrue statements about another person during a conversation may expose a nurse to being charged with what offense? a. Libel b. Assault c. Slander d. Malpractice

C Conversation that includes prejudicial and false statements about another person is an example of oral defamation of character or slander. Libel is the written form of defamation of character. Assault is a threat of bodily harm accompanied by a sense of imminent danger. Malpractice is professional negligence caused by unsafe practice.

An 8-year-old girl is newly diagnosed with type 1 diabetes. The nurse may expect fear and crying when teaching the child how to self-administer insulin injections because of which influencing factor? a. Self-concept b. Self-esteem c. Developmental level d. Hierarchy of needs

C Even when the child understands about having the disease, she is less likely to understand the need for insulin therapy due to her emotional and comprehension level of development. A child's self-concept is not well established at this point, and self-esteem is not a major factor. Hierarchy of needs is not yet fully developed because the child depends on her parents for the basic level of needs.

A nurse states she believes in the dignity of each patient. At break, she is overheard talking about a patient in a persistent vegetative state as a "lump." This represents an inconsistency in which quality of an effective leader? a. Dedication b. Magnanimity c. Integrity d. Humility

C Integrity refers to the alignment of stated values and actions. Dedication is the ability to spend the time to accomplish the task. Magnanimity means giving credit where credit is due. Humility is the ability to recognize that no one person is superior to another.

Which statement most closely reflects the differences between nurse leaders and managers? a. Nurse leaders are always in formal positions of authority. b. Nurse managers use transactional principles to accomplish goals. c. Nurse leaders rely primarily on interpersonal skills to accomplish goals. d. Nurse managers rely on supervisors for accountability and responsibility.

C Leaders influence others to effect change. They rely on personal characteristics to convince others that what they envision is worthwhile. Managers get their power from formal positions. Leaders may or may not be in formal positions of authority. Transactional leadership employs reward and punishment to gain the cooperation. Nurse leaders use a variety of leadership and management styles. Nurse managers maintain accountability and responsibility for their decisions.

What nursing intervention is best when a patient is struggling with the decision to abort an abnormally developing fetus discovered during genetic testing in the first trimester of pregnancy? a. Recommend additional testing. b. Refer the patient to an abortion clinic. c. Listen to the patient's concerns. d. Discuss regional adoption agencies.

C Listening is the best option for the nurse when patients are considering ethical care decisions. Patients often need someone to listen to their verbalized concerns to sort out feelings about the situation and make decisions that are best for them. The patient's primary care provider is responsible for recommending further testing or making requested patient referrals.

When developing treatment plans, which assumption should the nurse make about individual clients in vulnerable populations? a. Educational levels are minimal. b. Economic resources are strong. c. Personal beliefs are important. d. Support systems are extensive.

C Personal beliefs of clients within a vulnerable population are always important. They are a key to how people will respond to care that is offered. Educational levels, economic resources, and support systems vary dramatically by individual client within vulnerable populations.

A patient diagnosed with an aggressive cancer is estimated to have 6 months to live. Two months later, the patient's wife calls the nurse's office because she is upset that her husband has taken up motorcycle racing and has already been injured twice. The nurse knows that the patient is experiencing a behavioral change in which factor because of the prognosis of his illness? a. Spirituality b. Physical attributes c. Self-concept d. Personal affect

C Self-concept is profoundly affected by the diagnosis of a terminal disease. The individual often tries to reinvent himself or herself and behaves in an uncharacteristic manner.

The nurse is assigned to administer medications to a patient on a unit that has just implemented bar-code medication administration (BCMA). Which step is proper for the nurse to follow? a. Open the medication packages at the nurses' station. b. Ask the patient to verify his or her address. c. Scan the nurse's ID, the patient's ID, and the code on the medication package. d. Ask the patient to name two patient identifiers.

C The BCMA system scans the nurse's ID, the patient's ID, and the medication package to ensure that the proper drug is given to the correct patient. Asking the patient's address or two random identifiers that the patient may not be aware of would be inappropriate. Proper protocol for administration is to open the medication packages at the bedside. Use of a scanning device requires the medication to still be in the package while scanning to ensure that it is the proper medication

Which description is true about the Nursing Minimum Data Set (NMDS)? a. An admission assessment tool b. A discharge summary c. The core nursing data for collection across all sites d. An organization of nursing diagnoses

C The NMDS is a standardized collection of essential nursing data used by nurses to promote consistent, understandable documentation. Although standard terminology may be used during admission, and discharge, these tools are not a description of NMDS. Nursing diagnoses are organized using NANDA-I.

While performing a physical assessment on a female patient, the nurse finds several bruises on the patient's inner thighs that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. What should be the nurse's first action? a. Refer the patient to a sexual counselor. b. Tell the patient about the safe house for women. c. Ask the patient to describe how she got the bruises. d. Report the abuse immediately to the proper authorities.

C The nurse's first action is to gather more data that can confirm or negate the suspicion of sexual abuse. The other actions also could be appropriate after additional information is obtained.

Which statement is correct concerning the implementation of computerized provider order entry (CPOE)? a. The unit secretary transcribes the physician's orders into the computer. b. The nurse must ensure that orders go to the appropriate departments. c. Physician orders go directly to the appropriate department. d. Handwriting legibility is a major problem.

C Use of CPOE enables orders to go directly to the appropriate department decreasing the potential for errors. There is no transcription of orders and no need for someone to transcribe the orders. Because the orders are typed into the computer, handwriting legibility is not an issue.

Which statement is the best resource for the nurse to use when determining appropriate nursing care for a transsexual patient? a. Gender identity is altered by acute psychosis. b. Sexual attraction is to people of both genders. c. Gonadal gender, internal organs, and external genitals are contradictory. d. Anatomy associated with sexual identity is not consistent with gender identity.

D A transsexual's sex organs do not match gender identity. Being a transsexual is not a psychosis. Transsexuals usually are attracted to persons of the gender opposite their own gender identity. Gonadal gender and internal and external organs are not in contradiction.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Nonmaleficence

D A. INCORRECT:Fidelity is an agreement to keep promises. The nurse is not addressing a specific promise when she determines the appropriateness of a prescription for the client. Thus, this principle does not apply. B. INCORRECT:Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved when the nurse questions the client's prescription. C. INCORRECT:Justice is fairness in care delivery and in the use of resources. In this situation, the nurse is delivering responsible client care and not assessing available resources. This principle does not apply. D. CORRECT: Nonmaleficence is the avoidance of harm or injury. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Beneficence

D A.INCORRECT:Fidelity is an agreement to keep promises. Unless the nurse has specifically promised the client a pain-free recovery, which is unlikely, this principle does not apply to this action. B.INCORRECT:Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. In this situation, the nurse is delivering responsible client care. This principle does not apply. C. INCORRECT:Justice is fairness in care delivery and in the use of resources. Pain management is available for all clients who are postoperative, so this principle does not apply. D.CORRECT:Beneficence is taking positive actions to help others. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

A 65-year-old male patient has been a one-pack-a-day smoker for 40 years. He was recently diagnosed with early stage chronic obstructive pulmonary disease (COPD) and would like to attend a smoking cessation class. The nurse recognizes smoking cessation as which level of prevention for this patient? a. Primary prevention b. Secondary prevention c. Statutory prevention d. Tertiary prevention

D According to the stages for disease prevention, primary prevention is implemented for the absence of disease, secondary prevention applies to the early stages of disease or recently diagnosed risk factors, and tertiary preventive care is offered for permanent and irreversible disease.

What action should nurses who demonstrate accountability take if they forget to administer a patient's medication at the ordered time? a. Document the medication as refused by the patient. b. Administer the medication as soon as the error is discovered. c. Record the medication as given after making sure the patient is okay. d. Follow the administration and documentation procedures for medication errors.

D Agency procedures must be followed after every medication error. Care must be taken to adhere to medication administration recommendations and documentation requirements to legally record the incident and provide patient safety. Documenting that the patient refused or already took the medication, when that is not factual, is illegal and unethical, regardless of the patient's condition. Administering the medication as soon as the error is discovered may not be recommended, depending on the medication's potency and frequency of administration.

If a student nurse overhears a peer speaking disrespectfully about a patient, nurse, faculty member, or classmate, what is the most ethical first action for the student nurse to take? a. Discuss the peer's actions during group clinical conference. b. Ignore the initial occurrence and observe if it happens again. c. Report the actions of the classmate to the clinical instructor. d. Speak to the peer privately to prevent further occurrences.

D Alerting the peer who has acted disrespectfully in a private setting is the most professional way to approach this situation. It is never appropriate for a professional to belittle or reprimand a peer in front of others. Ignoring disrespectful behavior may only perpetuate its occurrence. Seeking help from a clinical instructor would be appropriate if the peer does not respond to the initial intervention from the fellow student.

Effective nurse managers focus on which area? a. Cost-effective operation of the unit b. Motivation of staff c. Accomplishing organizational goals d. The patients and their needs

D All of the options are considerations of an effective manager. However, at the core of all nursing management actions must be the benefit of the patient or patient population that is served.

A 75-year-old male patient reports decreased frequency of sexual intercourse, although he does not express dissatisfaction or difficulty. He seems a little embarrassed by the discussion, but is engaged and asks some questions. Which nursing diagnosis does the nurse determine is most appropriate for this patient? a. Sexual Dysfunction b. Disturbed Body Image c. Sedentary Lifestyle d. Readiness for Enhanced Knowledge

D Because the patient is able to discuss the topic of reduced sexual frequency without noting difficulty or dysfunction, manages any embarrassment, is engaged in the conversation, and is able to ask questions, the most appropriate nursing diagnosis is Readiness for Enhanced Knowledge. These collective behaviors do not describe Sexual Dysfunction or Disturbed Body Image, and "sedentary lifestyle" is not a NANDA-I nursing diagnosis.

Which of the listed basic needs identified by Maslow must be addressed first when providing nursing care? a. Self-esteem b. Love and belonging c. Self-actualization d. Nutrition and elimination

D Nutrition and elimination must be addressed first before concerns about self-esteem, love and belonging, and self-actualization, according to Maslow's hierarchy of needs. According to Maslow, the lower-level needs must be fulfilled and maintained before the higher-level needs can be met.

A patient who had a hysterectomy 3 days ago says to the nurse, "I no longer feel like a real woman." Which response by the nurse would be most appropriate? a. "Don't worry about that. The feeling will probably go away." b. "You should talk to your doctor about how you feel." c. "I don't blame you. I would feel like half a woman also." d. "I hear your concern. Tell me more about your feelings."

D Providing an opportunity for communication with an open-ended response encourages the patient to discuss concerns. Telling the patient not to worry is dismissing those concerns and will hamper discussion. Agreeing with the patient also is nontherapeutic and does not foster dialogue. Telling the patient to talk with the doctor stops the chance of conversation and reduces the nurse's role in helping the patient to express feelings.

The outpatient clinic nurse develops a plan of care focusing on diet, exercise, and glucose monitoring for a preteen recently diagnosed with early-onset type 2 diabetes. On what type of interventions has the nurse based the client's care plan? a. Primary b. Progressive c. Secondary d. Tertiary

D The nurse has incorporated tertiary interventions, because the client has already been diagnosed with an illness. Tertiary interventions are implemented once a disease occurs, to prevent further deterioration.

The nurse manager is monitoring overtime for the unit. She closely monitors staff hours and does not allow staff to come in for extra hours if they are over their allotted time per week. This is an example of which of Mintzberg's decisional roles of the manager? a. Entrepreneur b. Disturbance handler c. Negotiator d. Resource handler

D The resource handler function of the decisional role of the manager includes monitoring the budget and regulating the use of personnel time. In the entrepreneur role, the manager is the problem solver. The disturbance handler responds to unplanned change. The negotiator works within and outside of the organization to intercede for resources and help.

What action should a nurse take if a patient who needs to sign an informed consent form for nonemergency surgery appears to be under the influence of drugs or alcohol? a. Contact the physician to see what should be done. b.Ask the patient's spouse to sign the form. c. Request permission to bypass the need for a signed consent form. d. Wait to have the informed consent form signed when the patient is alert and oriented.

D When a normally competent patient is assessed to be under the influence of alcohol or drugs, it is the nurse's responsibility to delay a nonemergency procedure until legal informed consent can be obtained from the patient. Only in the case of an emergency is it possible to obtain informed consent from a spouse or designated power of attorney for a temporarily impaired adult. It is not necessary to contact the physician for guidance on what should be done because there is an established legal procedure to follow. The nurse should contact the surgeon who is scheduled to perform the surgery and the operating room staff regarding the need to delay due to the patient's status.

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A."I'll be able to function exactly as I did before the accident." B."I just can't stop crying." C."I am so mad at that guy who hit us. I wish he lost a leg." D."I don't even want to look at my leg. You can check the dressing."

D CORRECT:Refusing to look at the leg or the dressing indicates that the client is having difficulty acknowledging the fact that the leg has been amputated. This would imply a distorted body image.

Bringing the different points of view of the ethics committee members to agreement and harmony is referred to as collective ethics. A. True B. False

False Rationale: Building consensus brings different points of view to agreement and is an act of discovery in which "collective wisdom" guides a group to the best possible decision.

Michelle knows that infertility is the inability to conceive after 6 months of unprotected intercourse. A. True B. False

False, Infertility is the inability to conceive after 1 year of unprotected intercourse.

During the counseling session with Michelle, the nursing mentor, and the childless couple, sexual dysfunction is discussed. Sexual dysfunction is higher in men than in women. A. True B. False

False, The general incidence of sexual dysfunction in the general population is estimated to be as high as 40% in men and 45% in women.

The committee evaluates the impact of relationships on health care. _____________ ethics looks to the nature of relationships to guide participants in making difficult decisions.

Feminist Rationale: Feminist ethics looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible.