EAQ - Safety and Infection
Which leadership style is best to achieve the group members' goal to participate more fully in life by gaining insight and changing behavior? 1. Democratic and guiding 2. Autocratic and directing 3. Laissez-faire and observing 4. Passive and nonconfrontational
Answer: 1 A democratic and guiding leader aims to facilitate and balance the group's forces; this maximizes group potential for growth and change. An autocratic and directing leader makes most of the decisions and controls the group, thereby limiting growth potential. A laissez-faire, observing leader allows group members to take over the group; if there are no members with leadership skills, little is gained from the group. A passive and nonconfrontational leader does not provide adequate leadership to make the group effective.
Which method would the nurse expect to be used successfully with a client who has a phobia about closed spaces? 1. Desensitization 2. Contracting 3. Role playing 4. Assertiveness training
Answer: 1 Desensitization is a method that is used successfully with a client who has phobias. Contracting, role playing, and assertiveness training are all useful general behavioral approaches, but these types of techniques are not as successful as desensitization.
For a client with an obsessive-compulsive disorder, which rationale explains the function of obsessions and compulsions? 1. Unconscious control of unacceptable feelings 2. Intentional act to punish self for shortcomings 3. Obedience to voices that direct behaviors 4. Symbolic reenactment of punishing others
Answer: 1 In carrying out the compulsive ritual, the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The compulsions do not fill the need to punish self or others. Hallucinations are not part of this disorder.
Which advice would the school nurse provide to the parent who wants to improve their child's performance on schoolwork? 1. "Praise your child's accomplishments." 2. "Compare your child's work with that of more successful children." 3. "Allow your child to play more and don't focus too much on academics." 4. "Complete some of the harder tasks until your child gains comprehension."
Answer: 1 Praising accomplishments motivates a child to continue to do well because the child associates effort with increased success. Comparing a child with other children may result in decreased self-confidence, which in turn could result in poorer performance. Although it is important to allow children time for play, it is also important that the school-aged child achieve mastery of the tasks necessary for school success. Completing tasks for the child fosters dependence and a sense of inferiority.
The 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." Which does this nurse's comment reflect? 1. Demonstration of a personal bias 2. Problem solving based on assessment 3. Determination of client acuity to set priorities 4. Consideration of the complexity of client care
Answer: 1 When nurses make judgmental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments would be objective, not subjective and biased. There is no information about the client's acuity to come to this conclusion regarding priorities. The statement does not reflect information about complexity of care.
Which is prevented by providing warm, humidified oxygen to a preterm infant? 1. Apnea 2. Cold stress 3. Respiratory distress 4. Bronchopulmonary dysplasia
Answer: 2 By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress.
Which approach would the nurse take for a client with schizophrenia who refuses to get out of bed and becomes upset? 1. Requiring the client to get out of bed at once 2. Allowing the client to stay in bed for a while 3. Staying at the bedside until the client calms down 4. Giving the prescribed as-needed tranquilizer to the client
Answer: 3 The nurse would stay at the bedside until the client calms down. This approach provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set (to get out of bed), but this is not the immediate nursing action and it does not have to be at once. Allowing the client to stay in bed for a while ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the immediate problem that requires support from the nurse.
On the day after admission, which response would the nurse make to a suicidal client who asks, "Why am I being watched around the clock, and why can't I walk around the whole unit?" 1. "Why do you think we're observing you?" 2. "What makes you think we're observing you?" 3. "We're concerned that you might try to harm yourself." 4. "We're following orders, so there must be a reason."
Answer: 3 The statement "We're concerned that you might try to harm yourself" is honest and helps establish trust. Also, it may help the client realize that the staff members care. "Why do you think we're observing you?" will put the client on the defensive, and asking "why" should be avoided. "What makes you think we're observing you?" is an inappropriate response when the answer is so obvious. The response "We're following orders, so there must be a reason" is evasive.
The nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe? 1. Insulin glargine 2. Insulin detemir 3. Insulin lispro mix 75/25 4. Isophane insulin neutral protamine hagedorn (NPH)
Answer: 4 Isophane insulin NPH is safe to mix with regular human insulin. No other insulin type should be mixed with insulin glargine, insulin detemir, or insulin lispro mix 75/25.
Which cardiac disease has the lowest risk for maternal mortality? 1. Endocarditis 2. Aortic stenosis 3. Patent ductus arteriosus 4. Pulmonary hypertension
Answer: 3 A client with patent ductus arteriosus has the lowest risk for maternal mortality. A client with aortic stenosis has a higher risk of maternal mortality. A client with endocarditis or pulmonary hypertension has the highest risk of maternal mortality.
Which sexually transmitted infection is caused by protozoa? 1. Scabies 2. Chancroid 3. Pediculosis 4. Trichomoniasis
Answer: 4 Trichomoniasis is caused by protozoa. A parasite causes scabies. Bacteria cause chancroid. A parasite also causes pediculosis.
According to current studies, what percentage of adolescents have used alcohol by the end of their high school years?
Answer: 85%
Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? 1. Infuse intravenous fluids. 2. Monitor the level of anxiety. 3. Obtain frequent vital signs. 4. Administer chlordiazepoxide.
Answer: 4 The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic hyperactivity but does not directly affect client safety.
The nurse is working with an older adult brought to the emergency department after sustaining multiple falls at home. The nurse suspects alcohol abuse. Which finding places the client at risk for injury? 1. Depression 2. Self-neglect 3. Malnutrition 4. Lack of insight
Answer: 4 Lack of insight can occur in older adults who have excessive alcohol intake. This can place the client at risk for injury because the client is unable to think through the ramifications of his or her actions. Depression, self-neglect, and malnutrition are physical and mental manifestations of alcohol abuse but do not directly place the client at risk for injury.
Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes? 1. Neuman's system theory 2. Swanson's theory of caring 3. Orem's self-care deficit theory 4. Mishel's theory of uncertainty in illness
Answer: 2 Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.
The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? 1. Don an N95 respirator mask before entering the room. 2. Put on a permeable gown each time before entering the room. 3. Implement contact precautions and post appropriate signage. 4. After finishing with client care, remove the gown first and then remove the gloves.
Answer: 1 An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions, are required. When finished with care, gloves would be removed first because they are the most contaminated.
At which age would the nurse assess the school-age client for mastery of the concept of conservation of volume? 1. 6 years 2. 7 years 3. 8 years 4. 9 years
Answer: 4 Mastery of the concept of conservation of volume occurs between the ages of 9 and 12 years; therefore the nurse would include this in the assessment for the 9-year-old school-age client. Volume conservation is not assessed for the 6-, 7-, or 8-year-old school-age child.
Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections (CAUTIs)? 1. Removing the catheter 2. Keeping the drainage bag off of the floor 3. Washing hands before and after assessing the catheter 4. Cleansing the urinary meatus with soap and water daily
Answer: 1 Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent CAUTIs. Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.
To which disaster triage class would the nurse infer a client with a green triage tag belongs? 1. Class I 2. Class II 3. Class III 4. Class IV
Answer: 3 The green disaster triage tag is issued to nonurgent or "walking-wounded" clients who belong to class III. A red disaster triage tag is issued to clients who require immediate treatment and belong to class I. Clients with yellow and black tags belong to class II and IV respectively.
Which primary objective of nursing interventions would the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders? 1. Safety within the environment 2. Enhancement of psychological faculties 3. Participation in educational activities 4 Face-to-face contact with other clients
Answer: 1 Safety within the environment is the primary objective of nursing interventions. Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other neurocognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. The primary objective is not to participate in education activities or have face-to-face contact with other clients. People with dementia, delirium, and other neurocognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.
Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior? 1. Sets limits 2. Has variety 3. Is group oriented 4. Allows freedom of expression
Answer: 1 The therapeutic milieu characteristic would be to set limits. Because clients with socially aggressive behavior have poor control, these individuals require a therapeutic environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.
How do toddlers learn self-protection? 1. Through trial-and-error strategies 2. By imitating playmates and siblings 3. By obeying orders from mother and father 4. By playing with age-appropriate toys and puzzles
Answer: 1 The toddler is developing autonomy, is curious, and learns self-protection from experience. Toddlerhood play is parallel, not interactive. The struggle for autonomy at this age limits learning from siblings, even though the toddler attempts to copy their behavior. The toddler is still learning from experiences, not from others. The toddler is still attempting to distinguish the self as separate from the parents; the struggle for autonomy limits learning from parents. Toddlers learn gross and fine motor skills as they play with their toys, not self-protection.
Which action made by the client indicates that she or he is in the precontemplation stage of the transtheoretical model of change? 1. Refuses to think about changing 2. Intends to change in the next 60 days 3. Sustains the changed action for 6 months 4. Recognizes the advantages of the change
Answer: 1 The transtheoretical model of change model defines changing patterns in an individual in five stages based on beliefs of readiness to change. The phases are precontemplation, contemplation, preparation, action, and maintenance. The client refuses and does not think about the change in the precontemplation stage. The client intends to change in next 60 days in the preparation stage. The client recognizes the beneficial effects of the change and thinks about the change within 6 months in the contemplation stage. In the maintenance stage, the client sustains the changed action for 6 months and follows preventive measures to prevent relapse.
Which information regarding risks that may result from an untreated chlamydia infection would the nurse include when providing education for a female client? Select all that apply. 1. Sterility 2. Ectopic pregnancy 3. Blocked Fallopian tubes 4. Pelvic inflammatory disease 5. Increased likelihood of HIV infection
Answer: 1, 2, 3, 4, 5 Untreated chlamydia can result in sterility in both women and men, an increased risk for ectopic pregnancy, blocked Fallopian tubes, pelvic inflammatory disease, and a five-time greater risk for contracting HIV infection.
Which sexually transmitted infection (STI) is most commonly reported? 1. Syphilis 2. Chlamydia 3. Gonorrhea 4. Human immunodeficiency virus
Answer: 2 Chlamydial infections are the most commonly reported STIs. Syphilis, human immunodeficiency virus, and gonorrhea are not the most commonly reported STIs.
Which type of sexual disorder describes a client who has a sexual obsession with shoes? Select all that apply. One, some, or all responses may be correct. 1. Sexual sadism 2. Fetishistic 3. Pedophilic 4. Voyeuristic 5. Frotteuristic 6. Exhibitionistic
Answer: 2 Having a fetish is to become sexually aroused by something that would not be typically arousing. A fetishistic disorder is characterized by a sexual focus on objects (such as shoes, gloves, pantyhose, and stockings) that are intimately associated with the human body. Sadism is achievement of sexual satisfaction from the physical or psychological suffering (including humiliation) of a victim. Pedophilic disorder is a predominant or exclusive sexual interest toward prepubescent children. Voyeurism is characterized by seeking sexual arousal through the viewing (usually secret) of other people engaged in intimate situations. Rubbing or touching a non-consenting person is frotteuristic disorder. Exhibitionistic disorder involves the intentional display of the genitals in a public place.
The client gives a long, drawn-out explanation with excessive and irrelevant detail before answering the nurse's question. Which mental process is the client displaying? 1. Flight of ideas 2. Circumstantiality 3. Thought blocking 4. Tangential thinking
Answer: 2 In a circumstantial thought process, excessive and unnecessary detail is included before getting to the answer. Flight of ideas is rapid shifting from one topic to another and fragmentation of ideas. Thought blocking is a sudden stoppage of the train of thought or in the middle of the sentence. Tangential thinking is similar to circumstantial thought processes, but the person never answers the question or returns to the central point of the conversation.
Which action relates with the relevance strategy of the motivational learning model proposed by Keller? 1. Extrinsic and intrinsic reinforcements for any learning effort 2. Linking the person's needs, interests, and motives for learning 3. Arousing and sustaining a person's curiosity and interest in learning 4. Having positive hope for successful achievements as a result of learning
Answer: 2 Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.
According to Erikson's theory, at which stage does a child start to have fantasies and an active imagination? 1. Trust versus mistrust 2. Initiative versus guilt 3. Identity versus role confusion 4. Autonomy versus sense of shame and doubt
Answer: 2 The initiative versus guilt stage is characterized by a child having fantasies and imaginations that motivate the child to explore the environment. The stage from birth to 1 year old when an infant develops trust toward his or her parents or caregivers is known as the trust versus mistrust stage. The identity versus role confusion stage begins after adolescence; during this stage, an individual tries to figure out his or her own identity. Between the ages of 1 to 3 years old, a child starts walking, feeding, using the toilet, and handling some basic self-care activities. This stage is one of autonomy versus sense of shame and doubt.
Which nursing intervention would be indicated for a client with an anxiety disorder? 1. Encouraging suppression of anger by the client 2. Promoting verbalization of feelings by the client 3. Limiting involvement of the client's family during the acute phase 4.Explaining why the client should accept the psychological factors that are precipitating the anxiety
Answer: 2 The nurse would promote verbalization of feelings by the client. Freedom to express feelings serves as a safety valve to reduce anxiety. Suppression of anger or hostility may add to the client's anxiety. Limiting involvement of the client's family during the acute phase may or may not be helpful; the client's family members may provide support. Explaining why the client should accept the psychological factors that are precipitating the anxiety is not therapeutic; accepting current situational stresses may not be possible.
When providing a change-of-shift report, which explanation would the nurse use to describe a schizophrenic client who is experiencing opposing emotions simultaneously? 1. Double bind 2. Ambivalence 3. Loose association 4. Inappropriate affect
Answer: 2 The nurse would use the term ambivalence to describe opposing emotions simultaneously. Ambivalence is the existence of two conflicting emotions, impulses, or desires. Double bind means having two conflicting messages, not emotions, in a single communication. Loose associations are not two conflicting emotions but instead the loosening of connections between thoughts. Inappropriate affect is the incongruous expression of emotions when compared with behavior or content of speech.
According to Erikson's theory of psychosocial development, which is the correct order of a child's behavior as he or she ages? 1. The child concentrates on work and play. 2. The child develops autonomy by making choices. 3. The child is concerned about appearance and body image. 4. The child develops feelings of superego or conscience.
Answer: 2,4,1,3 According to Erikson's theory, a toddler develops his or her autonomy by making choices. The child moves on to the next stage and develops a superego, or conscience. During the industry versus inferiority stage, the child learns to work and play with their peers. During the identity versus role confusion stage, an adolescent can be seen having a marked preoccupation with his or her appearance and body image.
Which nursing behavior is essential when working with leadership personnel during the activation of the emergency preparedness plan? 1. Triage 2. Assessment 3. Collaboration 4. Resource management
Answer: 3 During an actual disaster, the nurse works in collaboration with leadership personnel to organize nursing and ancillary services to meet client needs. Although essential nursing skills, triage, assessment, and resource management are not identified as being essential when working with leadership personnel during a disaster.
Which information would the nurse include in family teaching regarding the client's use of confabulation? 1. The client is fantasizing about past experiences. 2. This indicates poor control over disorganized thoughts. 3. The client is making up what cannot be remembered. 4. This indicates opposing feelings are occurring simultaneously.
Answer: 3 The client will make up what cannot be remembered when using confabulation. Confabulation is a deliberate face-saving defense wherein stories are made up to fill in gaps and disguise memory loss. A client does not fantasize when confabulating. Having poor control over disorganized thoughts reflects loose associations, not confabulation. Experiencing opposing feelings simultaneously is ambivalence, not confabulation.
Which is the nurse's priority intervention after discovering an infant is apneic? 1. Call for help. 2. Begin cardiopulmonary resuscitation (CPR). 3. Stimulate the trunk. 4. Place the infant prone.
Answer: 3 The initial action of the nurse who observes an infant experiencing apnea is stimulation of the trunk. The next action is to call loudly for help, place the infant in a prone position and flick the heels. If there is still no response, the nurse will immediately begin CPR and after 2 minutes of CPR activate the emergency system.
The day after receiving instructions regarding dressing changes and care of a recently inserted nephrostomy tube, the client states, "I hope I can handle all this at home; it's a lot to remember." Which response would the nurse use? 1. "I'm sure you can do it." 2. "Oh, a family member can do it for you." 3. "You seem to be nervous about going home." 4. "Perhaps you can stay in the hospital another day."
Answer: 3 The response "You seem to be nervous about going home" is the best reply. Reflection conveys acceptance and encourages further communication. The response "I'm sure you can do it" is false reassurance that does not help reduce anxiety. The response "Oh, a family member can do it for you" provides false reassurance and removes the focus from the client's needs. The response "Perhaps you can stay in the hospital another day" is unrealistic, and it is too late to suggest this.
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often? 1. Every 4 to 8 hours 2. Every 12 to 24 hours 3. Every 24 to 48 hours 4. Every 72 to 96 hours
Answer: 4 Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.
Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection? 1. Soreness 2. Rust-colored semen 3. Light rectal bleeding 4. Discharge from the penis
Answer: 4 Discharge from the penis should be communicated to the health care provider for possible infection because discharge is an indication of infection. Soreness, rust-colored semen, and light rectal bleeding are expected after transrectal prostate biopsy.
Which assessment is necessary for the nurse to complete in a client with chronic kidney disease receiving loop diuretics? 1. Hemoglobin levels 2. Occurrence of nausea 3. Presence of constipation 4. Intake and output measurement
Answer: 4 Diuretics are administered to increase urine output, so the measure of intake and output are very important to diuretic use. Hemoglobin levels are important to monitor in the use of erythropoietin in the chronic kidney disease client. Nausea and constipation are important to monitor with the administration of iron-containing vitamins and mineral supplements.
Which defense mechanism would be exhibited when a client with alcohol use disorder states, "I function better when I'm drinking than when I'm sober"? 1. Sublimation 2. Suppression 3. Compensation 4. Rationalization
Answer: 4 The client is using rationalization. The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.
Which type of play would the nurse encourage when providing age-appropriate care to a preschool-age child who is hospitalized? 1. Team 2. Parallel 3. Solitary 4. Associative
Answer: 4 The nurse would encourage the hospitalized preschool-age client to participate in associative play. Team play is appropriate for the school-age child. Parallel play is appropriate for the toddler-age client. Solitary play is appropriate for the infant.
Which response would the nurse make while speaking to a client with schizophrenia who keeps interjecting sentences that have nothing to do with the main thoughts being expressed? 1. "You aren't making any sense; let's talk about something else." 2. "You're so confused; I can't understand what you're saying to me." 3. "Why don't you take a rest? We can talk again later this afternoon." 4. "I'd like to understand what you're saying, but I'm having difficulty following you."
Answer: 4 The nurse would say, "I'd like to understand what you are saying, but I'm having difficulty following you." This response lets the client know the nurse is trying to understand; it increases the client's self-esteem and points out reality. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic; thus talking about something else is ineffective. The statement, "You're so confused; I can't understand what you're saying to me," cuts off communication and blames the client. Using "why" and suggesting talking about the client's concerns again later in the day cuts off communication by abruptly ending the conversation, which is belittling to the client.
Which key factor assists the nurse in assessing how a client will cope with the body image change after an above-the-knee amputation? 1. Extent of the change 2. Suddenness of the change 3. Obviousness of the change 4. Personal perception of the change
Answer: 4 The reality of a situation is not the important issue at this time, but the client's feelings or perceptions about the change are the most important determinant of the client's ability to cope. The extent of change is not relevant; what is relevant is whether the client perceives the change as enormous or less important. Although suddenness of the change may influence a person's coping ability, this is not the primary factor influencing a client's coping mechanisms with body image changes. Although obviousness of the change may influence a person's coping ability, this is not the primary factor influencing coping mechanisms with body image changes.
After signing a legal consent for hip replacement surgery and within hours before the surgery, the client states, "I decided not to go through with the surgery." Which response would the nurse use initially? 1. "Then you shouldn't have signed the consent." 2. "I can understand why you changed your mind." 3. "Tell me why you decided to refuse the operation." 4. "Let's talk about your concerns regarding the procedure."
Answer: 4 The response, "Let's talk about your concerns regarding the procedure," attempts to explore why the client is refusing the procedure and promotes communication. The response, "Then you shouldn't have signed the consent," is accusatory; the client has the right to withdraw consent at any time. The response, "I can understand why you changed your mind," draws a conclusion without adequate data; also, the statement may increase the client's anxiety level. The response, "Tell me why you decided to refuse the operation," may be too direct and authoritative; also the statement may put the client on the defensive.
The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which? 1. Early rooming-in 2. Taking-in behaviors 3. Taking-hold behaviors 4. Parent-child attachment
Answer: 4 There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychological behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychological behavior described by Rubin that occurs after the third postpartum day.
