ALL CONCEPT (2)

A client with schizophrenia is hearing voices that tell the client to kill the self. What term is used to identify this type of false sensory perception?

Hallucination

The nurse is speaking to a client regarding sexual history. The client states, "I was born with a penis but I should have had a vagina." The nurse would document the client's gender identity aS

transgender.

Which statement is the most empathic response to a client's disclosure that the client's father abandoned the family when the client was a young child?

"That must have been terribly hurtful experience for you."

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve."

A 12-year-old child tells the school nurse, "I do not understand why my parents will not allow me to go to concerts without chaperones like some of my friends' parents. I feel like a baby compared to my friends." How will the nurse respond?

"Have you given any thought to why they do not let you go without a chaperone?"

A nurse confides in a nurse friend, "I never report minor incidents. The charge nurse always wants a variance report filled out and they take so much time." Which responses by the friend are indicated? Select all that apply.

"Having documentation might keep you out of trouble someday." "Reporting helps us fix problems that result in danger to clients."

A nurse working on a psychiatric unit receives a telephone call from a client's employer. The employer asks for a copy of the client's latest laboratory work and psychological testing results so that client's medical records in employee health can be updated. Based on the nurse's knowledge of breach of confidentiality, which response would be appropriate?

"I am unable to acknowledge whether or not your employee is a client on this unit."

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?

"I need to inform you that your behavior is within the definition of assault."

A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?

"The most common cause of dementia in the elderly is Alzheimer's disease."

A couple has just been notified that their unborn child carries a genetic disorder. The couple expresses concern that the insurance company will not cover the costs associated with the medical bills for the child. What is the most appropriate response by the nurse?

"There are laws in place that prohibit that from happening."

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?"

The client presents with signs and symptoms of anxiety. What conversation initiated by the nurse demonstrates an ineffective therapeutic use of self?

"What types of dresses do you like wearing?"

While interviewing the wife of a patient with multiple health problems, the spouse states, "I'm not the one who is ill, but I feel like I'm getting sick all the time." Which response by the nurse would be most appropriate?

"When one family member becomes ill, other members are affected."

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

The parent of a client who has a delusional disorder spends a great deal of time and energy trying to convince the client that the client is not actually the focus of a nationwide, secret plot to track the client's activities. Which of the client's responses is most typical of an individual with a delusional disorder?

"You're so naïve. You just don't understand what's really happening out there."

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to have his child declared legally incompetent. Which response by the nurse is most therapeutic?

"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary."

The nurse at an elementary school is explaining the concept of industry versus inferiority to a group of nursing students. What is part of this stage of Erikson's theory?

A sense of competence, mastery, and worth

A client has blindness in the right eye. The nurse documenting in the electronic medical record would use which term for blindness in one eye?

Anopia

The nurse is caring for a 12-month-old with autism spectrum disorder (ASD). What description would you expect to elicit from his mother on history-taking?

He stares at a rotating wheel on his crib mobile.

A nurse is caring for a client with advanced dementia and depression who states, "I don't want to live with my family, because they are mean and they think I have lost my mind." The nurse observes that the family members are attentive and supportive when they visit. What will be the nurse's initial action?

Ask the family about how the client was functioning at home when they next visit.

A client with a diagnosis of bipolar I disorder has been presented with a coping strategy by the therapist that may help the client manage behavior during manic episodes. The client has responded to the therapist's suggestion by saying, "What's the use? I don't ever see this changing." The client's statement is suggestive of a potential problem with what factor that influences communication?

Attitude

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?

Hepatitis

A client was admitted for electroconvulsive therapy (ECT). The physician performing the procedure failed to obtain informed consent before the ECT was administered. The physician could be charged with what?

Battery

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

Which of the following nursing interventions contributes to achieving a client's goal for pain relief?

Collaborate with the client about his or her goal for a level of pain relief.

Which includes the circumstances or parts that clarify the meaning of the content of the message?

Context

When attempting to preserve evidence from a possible rape with no report of oral sex, the female victim should be instructed that which self-care activities are permitted?

Drinking a glass of water

The nurse is preparing a school-age child for a diagnostic procedure. What is an important nursing role in relation to obtaining informed consent for this procedure for this client?

Ensure the child understands and assents to the test.

The nurse is preparing to assess the pain of a developmentally and cognitively delayed 8-year-old. Which pain rating scales should the nurse choose?

FACES pain rating scale

Which statement about gonorrhea is correct?

Gonorrhea is a reportable sexually transmitted infection.

Which statement by the nurse reflects the nurse's attempt to establish rapport and reduce patient anxiety?

Good morning, Mr. Jones. The last time you were here you were planning a vacation. Tell me about your trip."

The nurse is caring for a child with a life-threatening illness. The parents of the child want to introduce acupuncture and herbal medicines into the treatment regime. What is the most effective way for the nurse to react to this request?

Have the family discuss the options with the physician.

After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply.

Poor abstract reasoning Decreased attention span Short- and long-term memory loss

A college student has come to the health clinic complaining of heavy bleeding during and between her menstrual periods. The nurse practitioner will document this as

Menometrorrhagia.

A nurse is caring for an 8-year-old female with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the girl a stern warning not to discuss the matter. What is the priority action for the nurse?

Notify the nursing supervisor and the authorities of the possibility of abuse.

The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

A client with delusional disorder believes that the cook at the psychiatric hospital is trying to poison the client. The nurse would record this type of delusion as what?

Persecutory

A nurse is completing an abdominal assessment on a client suspected to have appendicitis. When the nurse applies and then releases pressure in the client's right lower quadrant, the client experiences tenderness. The nurse is documenting the presence of

Rebound tenderness

A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What is the nurse's first responsibility in caring for this child?

Report the incident to the proper authorities.

A terminally ill client has a health care directive (advanced directive) that indicates "do not intubate" in the event of respiratory failure. The client is now unresponsive and the family requests that "everything be done" to support the client's breathing. What action(s) should the nurse take in this situation? Select all that apply.

Request the health care provider speak with the family related to prognosis and realistic expectations should intubation be performed for the client. Interview the family members about their wishes for spiritual and psychological supports related to the anticipated death and dying process.

A 15-year-old client with type 1 diabetes has been noncompliant with the dietary regimen. When educating the adolescent, what is the most important thing the nurse can do to allow the adolescent to be in control and involved in the decision-making process?

Speak directly to the adolescent and consider the client's input in the decisions about care and education

A charge nurse is making shift assignments when a staff nurse requests to not be assigned to a particular child because of the quantity of time the child requires. The charge nurse knows that the child and family have bonded with the staff nurse. What should the charge nurse do next?

Talk with the staff nurse about the assignment and the concerns voiced

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do?

Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed.

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case?

The Good Samaritan law will provide legal immunity to the nurse.

A 29-year-old first-time mother has been diagnosed with postpartum psychosis after her partner reported the client was hearing voices and told the partner she "saw someone trying to steal the baby." In the planning of this client's care, which outcome should the nurse prioritize?

The client will demonstrate the ability to differentiate between perceptual disturbances and reality.

A nurse chooses a quiet, private area to conduct an end-of-shift report to the oncoming nurse. Following this procedure is necessary because of what ethical problem in nursing?

The right of confidentiality is essential to protect each client's private information.

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?

Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent.

When assessing a client with dementia, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common?

Visual

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

What is your name?

A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse?

Write down the steps of the procedure for the patient to read before beginning the treatment.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction

A nurse touches the client's hand while discussing the client's diagnosis.

a communication channel

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device

A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss?

concerns regarding the cancer and how the surgery will affect the client

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients

have the right to copy their health records.

The skin assessment of a black client reveals the presence of white areas on the skin that are flat, nonpalpable, less than 1 cm in diameter, and have a circumscribed border. How does the nurse document the finding?

macule

The nurse is caring for a client that is confused. The nurse, while giving the client a bed bath leaves the room to get supplies. The nurse returns to find the client on the floor with the bed in high position, and side rails down. What law has been broken?

negligence

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating

orthopnea.

While responding to a client's call for help, the nurse finds the client lying on the floor. After assisting the client to bed and performing an assessment, the nurse informs the healthcare provider. In completing an incident report, the nurse documents that the client

was found lying on the floor.