Adaptive Quizzing

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?

pulmonic

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis?

gather more information, identify related factors, review all defining characteristics

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied?

malpractice

A nurse caring for a pregnant client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client does the nurse consider to be a self-esteem need?

"I deserve ill treatment from my husband as I am incapable of doing even simple things perfectly"

In the orientation phase, a nurse and a client meet and get to know each other. Which actions should the nurse follow in this phase?

In the orientation phase, the nurse and the client meet and get to know each other. During this phase, the nurse prioritizes the client's problems and clarifies the client's and the nurse's roles.

Which act protects a person who is HIV positive?

The Americans with Disabilities Act (ADA) protects a person who is HIV positive.

Which feature according to Benner is observed in a nurse at the "proficient" level

The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills.

A nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty?

advocacy

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse may identify which ocular problem common to persons at this client's developmental level?:

presbyopia

How is public health nursing different from community health nursing?

public health nursing focuses on the population

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client?

A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation.

A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction?

An ethical issue is challenging and generally cannot be solved through logical decision-making. An ethical issue cannot be solved solely through a review of scientific data. If the answer to a specific problem has a profound relevance for areas of human concern, then it is an ethical issue.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results provide objective data about , as well as about hemoglobin and hematocrit.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions?

I should carry objects close to my body

During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding?

Reminiscence theory involves helping the client to recall past experiences to help resolve current conflicts. A nurse who builds a client's self-esteem by asking about his or her previous achievements is using the theory.

Which principles are appropriate for promoting older adult learning?

The nurse should use past experiences while teaching an older client, keep environmental distractions to a minimal and use audio, visual, and tactile cues to enhance learning. This helps the client to remember all the information. The nurse should emphasize concrete material. The nurse should teach clients by using one example at a time.

A nursing student is listing the points that need to be remembered regarding the United Network for Organ Sharing (UNOS) program. Which point listed by the nursing student is accurate?

UNOS has contact with the federal government

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect?

demonstration of a personal bias

Which healthcare system focuses solely on palliative care?

hospice

The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is decreased glucose available for energy and fat is metabolized for energy, resulting in an increased production of which substance in the urine?

ketones. ketone bodies are formed, and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis.

What is the difference between risk nursing diagnoses and actual nursing diagnoses?

Actual nursing diagnoses have related factors that show a causality relationship between the diagnosis and the etiology. Risk nursing diagnoses have a risk factor which may predispose a client to a disease. Both the types of diagnoses are mentioned in the NANDA-I classification. Both types of diagnoses may have associations with environmental and physiological factors. Both types of diagnoses can be established in vulnerable population.

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning?

Bulimia nervosa is an eating disorder in which the client has an obsessive desire to lose weight. In this condition, bouts of extreme overeating are followed by fasting or self-induced vomiting. A recurrent episode of binge eating is an indicator of bulimia nervosa.

Which domain of the nursing intervention phase includes electrolyte and acid-base management?

Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiologic complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

According to Erikson's theory of psychosocial development, individuals need to accomplish a particular task before effectively grasping this stage and progressing to the next one. What does the Initiative versus Guilt stage include?

In the Initiative versus Guilt stage, a 3 to 6 year old child likes to pretend and try out new roles. In this stage, a child may develop a superego or a conscience. Also, a child may fantasize and imagine discovering the environment in this stage. In the Industry versus Inferiority stage, a 6 to 11 year old child may thrive on his or her accomplishments and praise. In the Autonomy versus Sense of Shame and Doubt stage, a 1 to 3 year old child may develop his or her autonomy by making choices.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client?

Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death?

Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time. Crying and talking openly about death are signs of depression.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate?

The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock.

A nursing student is listing the steps that need to be followed to provide competent care for vulnerable populations. Which point listed by the nursing student is accurate?

The nurse should understand the client's cultural beliefs, values, and practices to determine their specific needs and interventions to provide competent care for vulnerable populations.

After abdominal surgery a client reports pain. What action should the nurse take first?

determine the characteristics of pain

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

elevate the head of the bed 30-45 degrees

To decrease abdominal distention following a client's surgery, what actions should the nurse take?

encourage ambulation

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when?

last

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client?

certified nurse midwife (CNM)

A nurse is evaluating scenarios that are based on the responses of several clients. Which statement of a client confirms that he or she has reached the Intimacy versus Isolation stage according to Erikson's theory of psychosocial development?

"I did so much for my partner but I was dumped for someone more attractive"

hypoxia

deficient amount of oxygen going to the tissues

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?

CN 11

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client?

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client?

A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain?

A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon

A client says "I feel frustrated because I do not spend enough time with my partner because of my job." According to Maslow's hierarchy of needs, which level of need does the given scenario refer?

The love and belonging need is the third level of need in the Maslow's hierarchy of needs.

A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important?

keep a diary of food eaten during that day

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate?

magicorereligious belief. An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe that illness is a punishment for sins.

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates?

previous exposure to the organism

The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved?

when a client who is anxious about the disease recovery starts expressing acceptance of his or her health status by the day of discharge, it reflects that the desired nursing goal is achieved.

A nurse is hired to work in a healthcare facility that has a completely computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says what?

"client information is directly available when this system is used"

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number.

13

A nurse educates a client about the role played by an individual in taking responsibility for health and wellness and its impact. What instructions should the nurse give?

A client should understand that making appropriate lifestyle choices can affect his or her quality of life and well-being. An individual should take responsibility for his or her health and wellness by making proper lifestyle choices. The client should also realize that illness prevention has a positive economic impact by decreasing health care costs.

Which carative factor of Watson's transpersonal caring theory is reflected when the nurse practices loving kindness in practice?

A human-altruistic value system is formed in nursing practice by using loving kindness. The nurse should use self-disclosure appropriately to promote a therapeutic alliance with the client.

What does "access to care" include according to the Picker Institute's eight dimensions of patient-centered care?

Clients want to be able to see a professional when a referral is made. Clients want to schedule appointments at convenient times without trouble. Clients need to be able to find conveyance when travelling to different healthcare settings.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to do what?

Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions, but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

A nurse is changing the dressing of a postoperative client. The nursing assistant informs the nurse that another client has fallen down near the nursing station after losing consciousness. What is the best nursing action in this situation?

attend the client who has lost consciousness

A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain?

can you describe your pain to me?

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

exhale completely, then take a slow, deep breath through the spirometer and hold it as long as possible.

Which skill in critical thinking requires to be orderly in data collection?

interpretation involved in the orderly collection of data.

The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source?

severity of pain

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include?

teach family members to assist with basic care. Because the family members are old enough to understand the client's needs, they should be encouraged to participate in the care.

A nursing student is recalling the order of priority for giving consent to perform an autopsy in cases where a medical examiner review is not needed. Which person receives the highest priority for giving consent?

the client is writing before death

A nurse is providing care to a client 8 hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon?

urine output 20mL per hour

A registered nurse is educating a nursing student about the relationship between nursing theory and nursing research. What information should the nurse provide?

A nurse should understand that theory-generating research helps to discover and describe the relationships of phenomena without the imposition of preconceived notions of what the phenomena under study means. Theory-testing research helps in determining the accuracy with which a theory describes a nursing phenomenon. The relationship between nursing theory and nursing research builds the scientific knowledge base of nursing.

According to Piaget's theory, what are the cognitive or moral developmental changes in children aged 6 to 12 years?

According to Piaget's theory, a child is in the concrete operations period between the ages of 6 and 12 years and he or she develops logical thinking. According to Piaget's theory, a child from the age of 18 months is in the sensorimotor period. A child from the age of 18 months to three years is in the preoperational period. A child between 18 months and 3 years old progresses from reflex activity to simple repetitive actions.

What statements about culturally congruent care by the student nurse are correct?

Culturally congruent care is tailored to the needs of people themselves, not delivered in accordance with predetermined criteria. This care may be different from the values and meanings of the professional health care system. The main goal of transcultural nursing is to provide culturally congruent care. Cultural competence is applied to ensure the delivery of this care. Culturally congruent care is provided in accordance with people's life patterns, values, and beliefs.

What nursing actions best promote communication when obtaining a nursing history?

Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response

The registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a healthcare setting. Which statement made by the nursing student indicates a need for further education?

I should avoid asking about OTC meds

While assessing a client, the nurse finds that the client has swelling and skin discoloration in the lower limbs. Which component of nursing process does this information indicate?

Input is the data or information that comes from a client's assessment, such as how the client interacts with the environment and the client's physiological function

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness?

Normally, nails should be cut after soaking them in warm water for 10 minutes. This action should not be performed for diabetic patients because soaking the nails will dry out the hands and feet, which may lead to infection

A nurse is informing a client about the benefits of rehabilitation. What information should the nurse provide?

Specialized rehabilitation services, such as cardiovascular, neurological, musculoskeletal, pulmonary, and mental health rehabilitation programs, enable clients and their caregivers to adjust to lifestyle changes and help them function with the limitations of their illness. At the initial stages, rehabilitation aims to prevent complications associated with the illness or injury. Rehabilitation enables clients to reach their highest physical, mental, social, vocational, and economic potential possible. Drug rehabilitation is only one type of rehabilitation program. Clients may require rehabilitation after a physical or mental illness, injury, or chemical addiction. When the client's condition stabilizes, rehabilitation helps to maximize his or her functioning and level of independence.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40

Which nurse is using complex critical thinking skills when caring for a client?

the nurse talks to the client to identify reasons for her particular behavior

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues?

percussion

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown?

pin the prayer cloth to the new gown

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?

arterial blood gas

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy?

ask client to sign post op consent after the client has been informed of the procedure and required care

What type of research explores the interrelationship among variables of interest without any active intervention by a researcher?

correlation research

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

cover infected site with a dressing

The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight?

Unintentional or undesired weight loss during a certain period of time may indicate a weight change due to a disease, such as gastrointestinal problems

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use?

focusing

A client reports to the hospital with skin lesions. Upon physical examination, the nurse notices circumscribed elevations of the skin, measuring about 0.5 × 0.5 cm. The lesions are filled with serous fluid. What is the suspected cause of these skin lesions?

herpes simplex infection

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. What could be the cause for this condition?

impairment of the extra ocular muscles

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client?

increased expired CO2

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?

instruct client to dangle legs

A nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions may be suspected in the older adult?

presbyopia and hyperopia

Which intervention reflects the nurse's approach of "family as a context"?

trying to meet the clients comfort

According to Quality and Safety Education (QSEN), what is patient-centered care?

understanding that the client is the source of control

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking?

"I run for 30 minutes a day and this increases my pain" A precipitating factor is an activity or factor that worsens the symptoms.

A client is receiving therapy that includes a radioactive sealed implant. What nursing intervention should be implemented to protect against exposure to radiation?

Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room.

Which domain of the Nursing Interventions Classification (NIC) Taxonomy includes care that supports the health of the community?

Domain 7 of the Nursing Interventions Classification (NIC) taxonomy includes care that supports the health of the community. Domain 1 includes interventions that support physical functioning. Domain 2 includes care that supports homeostatic regulation. Domain 6 incorporates interventions that support the effective use of the healthcare delivery system.

The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need?

"the measures required to decrease postoperative complications"

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan?

-whole grains -cooked fruits and veggies -milk and eggs

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning?

"I will avoid draining urine from the tubing before ambulating"

A registered nurse is instructing a trainee nurse on the various advantages of the team nursing care delivery model. Which statement provided by the trainee nurse post-training indicates a need for effective learning?

"this model is inflexible but uses a variety of staffing levels and mixes

What purpose does block and parish nursing serve in preventive and primary care services?

Block and parish nursing provides services to older clients or those who are unable to leave their homes.

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning?

A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in two years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in two months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in one month. If a client's BP is greater than 180/110 mm Hg, then he or she should be treated immediately or within 1 week.

While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be?

Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site. Observation is insufficient; the nurse manager must intervene to ensure that the vaccine is given using the correct technique. Povidone-iodine will deactivate the smallpox vaccine. The site should be dry before administering the vaccine.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last?

Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening, and the client can wait for care. A woman in active labor should be assessed immediately, because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.

In an ongoing research study a nurse asks participants, who are breast cancer survivors, to briefly share information about their lives after surviving cancer. The nurse then compiles the views to determine the cancer survivors' quality of life. Which type of study is being conducted?

Qualitative research involves inductive reasoning to develop an overview from specific observations or interviews. In this type of study, the nurse interviews the participants and then summarizes the common themes from all the interviews in order to develop generalizations or theories based on the observations.

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients?

Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to prevent complications and facilitate recuperation.

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process?

Slowing of neurologic responses is part of the aging process. Memory for short-term situations and events is reduced. The ability of the male to attain and sustain an erection is reduced. There should not be a loss of intellectual ability. Memory of long-term experiences and events should not be impaired.

Which carative factor is involved in creating a healing environment at all levels, physical and non-physical, according to Watson's Transpersonal Caring

The carative factor providing for a supportive, protective, and/or spiritual environment is related to create a healing environment at all levels, physical and non-physical. The carative factor promoting transpersonal teaching-learning is related to learning together while educating the client to acquire self-care skills. The carative factor developing a helping, trusting, and human caring relationship is related to learning to develop and sustain helping, trusting, and authentic, caring relationships through effective communication with the clients.

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning?

The client should consult a primary healthcare provider when there is a rash or ulcer on genitalia because these are the warning signs of a sexually transmitted infection (STI).

A registered nurse is educating a student nurse about the concept of "floating." What information should the nurse provide?

The nurse needs to request and receive an orientation to the unit. If a nurse is planning to join an institution, he/she should familiarize herself with the rules regarding floating before accepting employment. The nurses who need to float should inform the supervisors about any inability to carry out a desired task. The supervisors are liable to punishment if they assign any work to a nurse that is not related to their area of expertise or training. If the nurse is assigned more clients than is reasonable, the supervisor should be notified; however, this is related to short staffing issues.

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding?

This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent?

The nurse should know that a client with a mental illness has the right to refuse treatment until a court rules that he/she is incompetent for making health related decisions for himself/herself. The nurse should also remember that even clients with mental illnesses have to give their consent for medical procedures. Family members may give consent only if they are the healthcare proxies of the client.

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to?

The nursing student's act of discouraging interactions due to fear of the client's distraction may result in a lack of improvement.

A registered nurse is educating a student nurse regarding the role of value clarification in the resolution of ethical dilemmas. What information should the nurse provide?

The process of value clarification involves tolerating the differences of opinions with others. This often helps in the resolution of ethical dilemmas.

An adolescent tells the nurse, "I do not go to parties that serve alcohol, not because my dad doesn't like it, but because I know this is not right." What does the statement indicate according to Lawrence Kohlberg's Theory of Moral Development?

The statement provided by the adolescent specifies that he or she has reached the Society-Maintaining Orientation stage. In this stage, an individual expands his or her focus from a relationship with others to societal concerns and the moral decisions take into account societal perspectives.

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion?

foreign bodies in the rectum, urethra, and vagina

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make?

mixing meat and milk

Which situation is an accurate instance of false imprisonment?

nurse applies restraint to client while trying to feed them

In which role does the nurse oversee the budget of a specific nursing unit or agency?

nurse manager

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is what?

oral temp of 101.3

While caring for a client dealing with pain, the nurse assesses the health status and prioritizes his or her needs. Which phase of the helping relationship is observed?

orientation phase

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what?

percent of hemoglobin carrying oxygen