wellness final
A nurse asks a client to share personal stories. Which of the following types of interventions is the nurse using to promote the development of the nurse-client relationship? a) symbolic communication b) narrative interaction c) hand-off communication d) social conversation
b
A nurse at a health fair is assessing the weight status of 4 clients. Which of the following clients are classified as overweight? a) a female who has a BMI of 24 b) a male who has a BMI of 29 c) a female who has a waist circumference of 101.6 cm (40 inches) d) a male client who has a waist circumference of 96.52 cm (38 inches)
b
A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention? a) providing treatment for clients who have chronic obstructive pulmonary disease b) preforming screening for sexually transmitted infections c) administer influenza immunizations at a local health fair d) testing new nurses for exposure to tuberculosis
a
A nurse asks a client how he is feeling. The client states, "I am feeling a bit nervous today." Which of the following responses should the nurse make? a) "Please explain what you mean by the word 'nervous'" b) "what is making you feel nervous?" c) "would a backrub ease your nervousness?" d) "You shouldn't feel nervous"
a
A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? a) elicit information from the client b) encourage the client to use self- exploration c) review the client's progress towards personal objectives d) talk with others who have information about the client
a
A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take? a) check the patency of the client's airway b) determine the poison that was ingested c) identify the amount of poison that was ingested d) position the client side-lying
a
A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make? a) "This is a normal, expected reaction for a child of this age." b) "This is a response to an overstimulating environment" c) "This is a common reaction to an overexposure to caregivers" d) "This is a typical reaction for a child who is sick"
a
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? a) pain b) hearing loss c) the client's culture d) motor impairment
a
A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? a) they are more direct when dicussing issues b) they are likely to wait for others to initiate the conversation c) they tend to use more verbal communication d) they disclose more personal information
a
A nurse is planning to delegate tasks to a licensed practical nurse. Which of the following entities is important for the nurse to understand when delegating tasks to the LPN? a) the state nurse practice act b) the national association for practical nurse education and servuces c) the national council of state boards of nursing decision tree d) the ombnibus budget reconciliation act of 1987
a
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion? a) "What brought you to the hospital?" b) "Would you tell me about all of your medial issues?" c) "Do you want to talk about your health concerns?" d) "Would it help to discuss your feelings about this hospitalization?"
a
A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include? a) sliced bananas b) raw celery c) peanut butter d) grapes
a
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated a need for further teaching? a) "Information about a client can be disclosed to family members at any time" b) "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form" c) "A client's address would be an example of personally identifiable information" d) "HIPAA is a federal law, not a state law"
a
A nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. Which of the following information should the nurse include in this discussion? a) the client achieves optimal personal growth b) the client assumes responsibility for the interaction c) the client expects growth, not comfort, from the relationship d) the nurse's interventions take priority over the client's needs
a
A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence? a) a nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon b) a client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without knowledge. c) a client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. d) a nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
a
A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthoplasty. Which of the following responses by the nurse demostrates assertiveness? a) "I feel as thought I met the standards of care. Would you tell me more about your concerns?" b) "You should not make accusations. Your nursinf care does not always set a good example." c) "I am at a loss for words. I always do my best to give good care to my clients." d) "what do you have against me? It must be something or you would not be criticizing my care."
a
A nurse is teaching a class of older adults about the expeced physiological changes of aging. Which of the following changes should the nurse include in the discussion? SATA: a) more difficulty seeinf due to a greater sensitivity to glare b) decrease cough reflex c) decreased bladder capacity d) decreased systolic BP e) dehydration of intervertebral discs
a,b,c,e
A nurse is caring for a client within the intimate zone of the client's personal space. The nurse should perform which of the following activities in this space? SATA: a) auscultating heart sounds b) teaching about a medication c) changing a dressing d) discussing intake and output e) talking with the client's partner
a,c
A nurse is about to explain a therapeutic procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? a) ask a family member to translate b) have a medical interpreter present during the teaching c) tell the client that he will receive written information in his language after the procedure d) use nonverbal gestures to assure the client that the procedure is safe and will help him
b
A nurse is caring for a client of Chinese heritage. Which of the following actions should the nurse take to demonstrate cultural competence? a) make sure the dietary department does not serve the client pork b) ask the client's permission to add ice to drinking water c) maintain direct eye contact with the client d) place a hand on the client's head
b
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? a) logging out of the computer before leaving a terminal b) sharing computer passwords with coworkers c) using a computer terminal in a non-pubic area d) preventing an unidentified heath care worker from viewing a health record on the computer screen
b
A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI? a) a client with a weight of 128 pounds and height of 70 inches b) a client with a weight of 150 pounds and height of 68 inches c) a client with a weight of 200 pounds and height of 72 inches d) a client with a eight of 133 pounds and height of 60 inches
b
A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? a) determining the client's length of stay b) assigning tasks to an assistive personnel c) providing anticipatory guidance to a client in crisis d) establishing the client's secondary medical diagnosis
b
A nurse is observing an assistive personnel performing postmortem care for a client who is Muslim. Which of the following actions should prompt the nurse to intervene? a) leaves dentures in the mouth b) prepares to cleanse the body c) disconnects the cardiac monitor d) removes soiled linens from the room
b
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? a) adjust the water temperature to feel hot b) apply 4 to 5 mL of liquid soap to the hands c) hold the hands higher than the elbows d) rub hands and arms to dry
b
A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipated which of the following activities first in delivering client care using the nursing process? a) critically analyze client data to determine priorities b) collect and organize client data c) set client-centered, measurable and realistic goals d) determine effectiveness of interventions
b
A nurse is working with an assistive personnel while caring for a surgical client who 1 day postoperative. Which task should the nurse take responsibility for completing? a) measuring vital signs b) removing the abdominal dressing c) helping the client into the shower d) ambulating the client in the hallway
b
A nurse notices an assisticec personnel preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? a) allow the AP to deliver the food tray to the client b) call the dietary department and ask for a kosher tray c) replace the nonfat milk with apple juice d) explain to the client that hes needs the protein in the beef and milk
b
A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent? a) providing a passive response b) showing disproval c) offering false reassurance d) offering sympathy
c
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? a) blood pressure b) cynosis c) nausea d) petechiae
c
A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? a) "I will begin 48 hours before the client's discharge" b) "I will begin once the client's discharge order is written" c) "I will begin upon the client's admission to the facility" d) "I will begin once the client's insurance company approves the discharge coverage"
c
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? a) perform wound irrigation for a client b) evaluate pain relief for a client following the administration of a pain medication c) measure and record intake and output for a client d) teach a client about low-sodium foods
c
A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? a) serve foods that have hot/cold balance b) serve milk products separately from meals c) request a meal tray without pork d) remove tea and coffee from meal trays
c
A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first? a) establish short-term, realistic goals for the client b) give the client access to a video about diabetes c) determine what the client knows about managing diabetes d) evaluate the effectiveness of the client's admission teaching plan
c
A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning? a) autonomy vs shame and doubt b) initiative vs guilt c) industry vs inferiority d) identity vs role confusion
c
A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? a) transpersonal b) intrapersonal c) interpersonal d) public
c
A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse? a) speak using his usual tone of voice b) stand directly in front of the client c) rephrase statements the client does not hear d) determine if the client uses hearing aids
d
A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development? a) autonomy vs shame and doubt b) generativity vs stagnation c) identity vs role diffusion d) integrity vs despair
d
A nurse is admitting a client from a long-term care facility the nurse should use close-ended questions when assessing which of the following factors? a) when determining if the client is eating a well-balanced diet b) when asking the client about his receptiveness to the transfer c) when asking the client how he completes his ADLs d) when asking if the client took his medications this morning
d
A nurse is providing dietary teaching fro a client who is Asian-American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demostrate culturally sensitive nursing care? a) stop the instructions to see what is on the floor b) emphasize the significance of the information c) move closer to the client for eye contact d) continue with the discussion
d