Exam 3

In initiating care for a client from a different culture than the nurse, which of the following would be an appropriate statement? A. "Since, in your culture, people don't drink ice water, I will bring you hot tea." B. "Do you have any books I could read about people of your culture?" C. "Please let me know if I do anything that is not acceptable in your culture." D. "You will need to set aside your usual customs and practices while you are in the hospital."

"please let me know if I do anything that is not acceptable in your culture"

When a client is experiencing prolonged unresolved grief and engages in detrimental activities, the nursing diagnosis will most likely be which of the following? 1. unresolved grieving 2. dysfunctional grieving 3. abnormal grieving 4. pathological grieving

2. dysfunctional grieving; Dysfunctional grieving is the state in which an individual or group experiences prolonged unresolved grief and engages in detrimental activities.

The nurse helps a 50-year-old client with diabetes who is to begin giving insulin injections identify previously successful coping strategies that may be useful in the current situation. Which stressor is closely related to the new stressor? 1) Interviewing for a new job. 2) Death of a pet while the person was a teenager. 3) The person's partner filing for a divorce. 4) Starting to wear eyeglasses at age 30.

4) Starting to wear eyeglasses at age 30.

A patient newly diagnosed with type 2 diabetes says, "My blood sugar was just a little high. I don't have diabetes." The nurse responds: 1."Let's talk about something cheerful." 2."Do other members of your family have diabetes?" 3."I can tell that you feel stressed to learn that you have diabetes." 4. With silence.

4. With silence.

Which of the following best represents the dominant values in American society on individual autonomy and self-determination?

Advance Directive

Before collecting a stool sample for occult blood, the nurse instructs the NAP to:

Ask the patient to void.

Which action represents the appropriate nursing management of a client wearing a condom catheter? Ensure that the tip of the penis fits snugly against the end of the condom. Check the penis for adequate circulation 30 minutes after applying. Change the condom every 8 hours. Tape the collecting tubing to the lower abdomen.

Check the penis for adequate circulation 30 minutes after applying. Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is taped to the lower abdomen or upper thigh. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.

evaluating

Client's cultural perspectives Actual clients outcomes compared with the goals and expected outcomes If not achieved, must carefully consider whether the client's belief system has been adequately included as an influencing factor

When action is taken on one's prejudices:

Discrimination Occurs

To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own:

Engagement in Cross-Cultural Interactions

Nurses discourage patients from straining on defecation primarily because it causes: (Select all that apply.)

Hemorrhoids.; Dysrhythmias.

The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? Ileal conduit Kock pouch Neobladder Vesicostomy

Kock pouch Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment.

Regarding the request for organ and tissue donation at the time of death, the nurse needs to be aware that:

Specially Educated Personnel Make Requests

You are going to have a client collect a stool sample for a guaiac test, on three consecutive stools. In order to avoid false positive results, you will instruct your client about the foods to eat and foods to avoid for a day or two prior to the test. Which of the following meals selected by the client would indicate they understood your instructions? (Select ALL that apply) sirloin steak, a garden salad, and bread fried chicken, mashed potatoes, and cake fresh fruit salad bowl and cookies a hamburger and a bowl of chili

sirloin steak, a garden salad, and bread fried chicken, mashed potatoes, and cake False positive results can occur in a guaiac test if the client has recently ingested red meat, raw vegetables, fruits, especially radishes, turnips, horseradish, and melons, or taken medications such as aspirin, iron preparations, and anticoagulants that irritate the gastric mucosa.

The colon's three main functions include which one of the following in addition to that of fecal elimination? [Hint] to eliminate excess fluid to excrete excess electrolytes with the fecal matter excretion of a substance that sloughs off dead cells to excrete mucus and protect the intestine from bacteria

to excrete mucus and protect the intestine from bacteria The colon's main functions are the absorption of water and electrolytes, the mucal protection of the intestinal wall, and fecal elimination.

The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, states that she does not believe the treatments will make any difference, does not ask about her progress, and missed two chemotherapy sessions. Based on the above assessment data, the nurse gathers more information to consider making which of the following nursing diagnoses?

Hopelessness

A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for:

Infection; Reflux of Urine

A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department, and detects disparities in health outcomes between the rich and poor. This is an example of a(n):

Influence of Socioeconomic Factors in Morbidity and Mortality

While preparing the client for a colonoscopy, the nurse's responsibilities include: Explaining the risks and benefits of the exam Instructing the client about the bowel preparation prior to the test Instructing the client about medication that will be used to sedate the client Explaining the results of the exam

Instructing the client about the bowel preparation prior to the test

A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflect a helpful understanding of patient self-care at the end of life?

"Which Activities are Most Important to You, and How can You Continue to do Them?"

When one of your assigned clients dies, an autopsy will most likely be performed in which of the following circumstances? 1. when one of the family members requests it 2. when death occurs suddenly or within 48 hours of hospital admission 3. if the client was sick for a long period of time 4. if, prior to death, the client suspected others of causing harm

2. when death occurs suddenly or within 48 hours of hospital admission; The law requires that an autopsy be performed when death is sudden or occurs within 48 hours of admission to a hospital.

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: 1. A situational crisis. 2. A maturational crisis. 3. An adventitious crisis. 4. A developmental crisis.

3. An adventitious crisis.

You answer the call light of a hospitalized client who states they are having a lot of flatulence and asks for a carbonated drink with a straw. Which of the following things would be best for you to do to help this client reduce the amount of flatulence? [Hint] Get the client a cola drink with a straw. Offer the client some chewing gum. Give the client a straw but offer a noncarbonated drink Give the client a noncarbonated drink without a straw

Give the client a noncarbonated drink without a straw.

A student nurse (SN) is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site? Option 1 Option 2 Ascending Colon Option 3 Transverse Colon Option 4 Descending Colon Option 5 Sigmoid Colon

Option 5 Rationale: Option 5 is a sigmoidostomy site. Option 1 is an ileostomy site, option 2 is ascending colostomy, option 3 is transverse colostomy, and option 4 is descending colostomy.

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. Perineal skin irritation Fluid intake of less than 1,500 mL/day History of antihistamine intake History of frequent urinary tract infections A fecal impaction

Perineal skin irritation Fluid intake of less than 1,500 mL/day History of frequent urinary tract infections A fecal impaction Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment.

When doing an assessment of a young woman who was in an automobile accident 6 months before, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as ____________.

Posttraumatic stress disorder (PTSD)

A client is to have a thoracentesis in order to aspirate pleural fluid for biopsy. In order to prepare the client for the procedure, the nurse best positions the client in which manner? Lying in a lateral position with the affected lung down and back, curved into a fetal position. The head is supported with a pillow. The arms are positioned comfortably away from the chest wall. Lying in a 10-degree reverse Trendelenburg position with the arms over the head. Small pillows allowed under the head and arms. Sitting in a Fowler's position with the arms abducted and supported by pillows placed on each side of the body. The head is lying flat against the mattress. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow

Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow

A primary care provider is going to perform a thoracentesis. The nurse's role will include which action? Place the client supine in the Trendelenburg position. Position the client in a seated position with elbows on the overbed table. Instruct the UAP to measure vital signs. Administer an opioid analgesic.

Position the client in a seated position with elbows on the overbed table.

A nurse cares for a client following a liver biopsy. Which nursing care plan reflects proper care? Position in a dorsal recumbent position, with one pillow under the head Bed rest for 24 hours, with a pressure dressing over the biopsy site Position to a right side-lying position, with a pillow under the biopsy site Neurological checks of lower extremities every hour

Position to a right side-lying position, with a pillow under the biopsy site

Which noninvasive procedure provides information about the physiology or function of an organ? Angiography Computerized tomography (CT) Magnetic resonance imaging (MRI) Positron emission tomography (PET)

Positron emission tomography (PET) Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ.

A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? Instruct the client to empty his bladder and save this voiding to start the collection. Instruct the client to use sterile individual containers to collect the urine. Post a sign stating "Save All Urine" in the bathroom. Keep the urine specimen in the refrigerator.

Post a sign stating "Save All Urine" in the bathroom. Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration.

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. Voids each time there is an urge. Practices slow, deep breathing until the urge decreases. Uses adult diapers, for "just in case." Drinks citrus juices and carbonated beverages. Performs pelvic muscle exercises.

Practices slow, deep breathing until the urge decreases. Performs pelvic muscle exercises. Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the BEST indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation.

The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states:

"I Drink Two Glasses of Wine with Dinner."

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? "I need to drink one and a half to two quarts of liquids each day." "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." "If my bowel pattern changes on its own, I should call you." "Eating my meals at regular times is likely to result in regular bowel movements."

"I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." Rationale: The standard of practice in assisting older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults (option 2). In addition, a normal stool pattern for an older adult may not be daily elimination.

Following a gastroscopy, a client asks for something to eat. The nurse correctly responds: "I will first check your gag reflex." "I will first listen for bowel sounds." "I will first have you cough and deep-breathe." "I will first listen to your lungs."

"I will first check your gag reflex."

The nurse is administering a medication containing iron to a client. The nurse does some teaching about the iron medication. Which of the following statements will the nurse most need to make when instructing the client about taking iron? [Hint] "Diarrhea may result from taking iron supplements." "Iron may cause your stools to appear black in color." "The urine may become brown when taking iron." "You will need additional vitamin C when taking iron."

"Iron may cause your stools to appear black in color."

Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? "I will keep the collecting bag below the level of the bladder at all times." "Intake of cranberry juice may help decrease the risk of infection." "Soaking in a warm tub bath may ease the irritation associated with the catheter." "I should use clean technique when emptying the collecting bag."

"Soaking in a warm tub bath may ease the irritation associated with the catheter." Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (option 1). Intake of cranberry juice creates an environment nonconducive to infection (option 2). Clean technique is appropriate for touching the exterior portions of the system (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation.

A certified nursing assistant is collecting a 24-hour urine specimen from a client. Which statement by the assistant indicates that the specimen collection will need to be restarted? "I used a container from the lab that has a preservative in it." "The client voided in it right away, and I wrote the time on the container." "I have the container in a plastic bucket with ice in it." "I told the client that every single urination must be put in the container. If one is missed, call one of us."

"The client voided in it right away, and I wrote the time on the container."

A client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure? "I should use all of the towelettes in the kit and use each only once." "Urinate into the cup as soon as I start to go." "I don't have to fill the cup. Just get an ounce or two." "Put the cover on right away, without touching the inside of the cover or the cup."

"Urinate into the cup as soon as I start to go."

verbal communication

**Vocabulary, grammatical structure, voice qualities, intonation, rhythm, speed, pronunciation, and silence **Initiating communication influenced by cultural values **Interaction between people who speak different languages become difficult ---Translator converts written material from one language to another --- Interpreter transforms the message expressed in a source language into its equivalent

folk medicine

*Beliefs and practices relating to illness prevention and healing that derive from cultural traditions rather than modern medicine *Thought to be more humanistic than biomedical health care Consultation and treatment takes place in the community *May be less expensive than scientific or biomedical care *Frequently includes ritual practice on the part of the healer or the client *More comfortable and less frightening to the client

A practice guideline for nurses to use in preventing catheter-associated urinary infection includes which of the instructions listed below? Open Hint for Question 9 in a new window. Maintain clean technique when inserting the catheter into the client. Disconnect the catheter and drainage tubing once a shift to rinse the unit in cleaning the device. Since you are wearing gloves, it is not necessary to wash your hands. Prevent contamination of the catheter with feces in the incontinent client.

Prevent contamination of the catheter with feces in the incontinent client. Rationale: Keeping the perineal area free of feces eliminates the possible spread of any bacteria that may colonize in the feces and travel up the catheter to the bladder. Sterile or aseptic technique is used when inserting Foley catheters into clients to prevent the spread of infection with the process. Catheter tubing should not be disconnected once put into use. Connections are usually taped to help secure their seal. Wearing gloves with this procedure is part of the practice of Universal Precautions utilized when health care workers come in contact with most tubes and body fluids.

The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to:

Prevent gastric mucosal damage.

An appropriate health goal for clients with urinary elimination problems would include: Open Hint for Question 2 in a new window. Ignoring normalization of voiding pattern. That the patient has the ability to void is the most important aspect of care. Encouraging the client to follow measures to show a larger than normal urine output to flush to kidneys Always assisting the client with toileting activities in order to monitor amount Preventing associated risks, such as infections and fluid and electrolyte imbalances.

Preventing associated risks, such as infections and fluid and electrolyte imbalances. Rationale: Preventing associated risks related to urinary disease is the only appropriate goal noted.

A nurse is providing postmortem care. Which action is the priority?

Providing Culturally and Religiously Sensitive Care in Body Preparation

Two people have been in a motor vehicle crash and have similar injuries. According to the transaction-based model, their degree of stress from the crash would be 1) Based on previous experience and personal characteristics. 2) Extremely similar since they had the same stimulus. 3) The identical physiological alarm reaction. 4) Different depending on their external resources and support levels.

1) Based on previous experience and personal characteristics.

Which of the following defense mechanisms for coping with stress could be considered effective and constructive? (Select all that apply.) 1) Compensation 2) Displacement 3) Minimization 4) Repression 5) Regression

1) Compensation 2) Displacement 5) Regression

The nurse has recently changed jobs to work with young adults and recognizes that sources of stress common to that population include which of the following? (Select all that apply.) 1) Marriage 2) Aging parents 3) Starting a new job 4) Leaving the parental home 5) Decreased physical abilities 6) Changing body structure

1) Marriage 3) Starting a new job 4) Leaving the parental home

A client newly diagnosed with a chronic condition that will significantly change the lifestyle needs to learn some aspects of self-care. The client exhibits severe anxiety: increased blood pressure and pulse, headache, and nervousness. Based on this situation, how would the nurse appropriately plan the teaching? 1) Recognize that the client's ability to learn is severely impaired and teach only the immediate, critical needs and plan to follow up and reinforce this teaching later. 2) Recognize that the client's learning will be adaptive and begin immediately to implement the full teaching and learning plan. 3) Recognize that the client's ability to learn will be slightly impaired and modify the usual teaching strategies to accommodate for this impairment. 4) Recognize that the client is unable to learn at this time, that the level of anxiety must first be reduced, and then teaching can be based on this new level of anxiety.

1) Recognize that the client's ability to learn is severely impaired and teach only the immediate, critical needs and plan to follow up and reinforce this teaching later.

Which of the following may be considered normal or "healthy" types of grief? Select all that apply. 1. Abbreviated grief 2. Anticipatory grief 3. Disenfranchised grief 4. Complicated grief 5. Unresolved grief 6. Inhibited grief

1, 2, & 3. Abbreviated grief, anticipatory grief, and disenfranchised grief. Abbreviated grief (normal grief that is briefly experienced), anticipatory grief (experienced before the loss/death but appropriate), and disenfranchised grief (the emotions are felt privately, just not expressed in public). Unhealthy/abnormal types of grief include complicated grief (option 4) in several different forms; unresolved grief is extended in length and severity (option 5). With inhibited grief, symptoms are suppressed, and other effects, including somatic, are experienced instead (option 6).

The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate? 1. "I'm very sorry for your loss." 2. "I'll take you in to view the body." 3. "I didn't know your father but I am sure he was a wonderful person." 4. "How long will you want to stay with your father?"

1. "I'm very sorry for your loss"; This statement acknowledges the family's grief simply. Avoid statements that may be interpreted as overly impersonal (option 2) , false support (option 3), or harsh (option 4).

When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response? 1. "Tell me what it means to you to have this surgery." 2. "You must be very glad to be having this lesion removed." 3. "I cry when I am happy or relieved sometimes, too." 4. "Isn't it wonderful that the lesion is not cancer?"

1. "Tell me what it means to you to have this surgery"; The nurse needs to assess and explore the meaning of the client's crying. Options 2 and 4 leap to assumptions about the meaning of the tears and ignore the possibility of the client's distress. Option 3 suggests that the client has the same feelings as the nurse, which may not be correct.

The ability of an individual to cope with death is dependent upon a number of factors. Which person likely will have the most difficulty coping with a death? 1. A parent whose 17-year-old child died in an auto accident the night before graduation 2. A child of 8 years whose grandparent dies a week before a planned visit 3. The spouse of an alcoholic who is killed in an automobile accident 4. The grandparent of a child born with Tay-Sachs disease

1. A parent whose 17-year-old child died in an auto accident the night before graduation; Many factors affect the grieving experience. These include age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, social support systems, and the cause of the death. In our culture, the death of an older person is accepted more easily than that of a younger person. The death is more easily accepted if it is anticipated, and if the person who died did not contribute to the death. Usually, the closer the individual is to the person who died, the more difficult it is to cope with the death.

In working with a dying client, the nurse demonstrates assisting the client to die with dignity when performing which action? 1. Allows the client to make as many decisions about care as is possible. 2. Shares with the client the nurse's own views about life after death. 3. Avoids talking about dying and focuses on the present. 4. Relieves the client of as much responsibility for self-care as is possible.

1. Allows the client to make as many decisions about care as is possible; Assisting the client to die with dignity involves allowing the client to participate in and choose the direction of the remainder of his or her life. Sharing the nurse's own views about life after death (option 2) does not enhance client dignity. The nurse should not assume that avoiding talking about death and dying and emphasizing the present (option 3) is therapeutic for the client. Only if the client wishes to have someone else perform care is doing so supporting death with dignity (option 4). Otherwise is may have the opposite effect.

When working with clients of other religions and cultures, which of the following groups of clients and their families would most likely agree to and encourage organ donation? 1. Buddhists 2. Jehovah's Witnesses 3. Muslims 4. Mormons

1. Buddhists; Organ donation is prohibited by Jehovah's Witnesses and Muslims, whereas Buddhists in America consider it an act of mercy and encourage it.

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." The patient is using the defense mechanism: 1. Denial. 2. Conversion. 3. Dissociation. 4. Displacement.

1. Denial.

Following the death of a child, one of the parents begins to falsely accuse other members of the family of blaming the child's death on the parent. This leads to family members avoiding the mentioned parent for fear of the false accusation. The parent takes this as proof that the family truly believes the accusation. This sets up a destructive cycle of family dysfunction. Which nursing diagnosis is most appropriate for this family? 1. Impaired family processes related to impaired adjustment 2. Impaired adjustment related to loneliness 3. Loneliness related to fear 4. Dysfunctional grieving related to loss of relationships

1. Impaired family processes related to impaired adjustment; The first part of the diagnostic statement reflects the concern at hand, while the second part is the etiology or cause. There are a number of concerns present in this scenario. Following the child's death, the whole family is impaired in processing the event, adjusting, and grieving. In addition, the parent is alienating the family with false accusations, resulting in lack of support, dysfunctional grieving, and loneliness. If the parent improved adjustment to the death, family processing would improve.

Which of the following statements best reflect the law in Oregon regarding euthanasia, which took place in 1997? 1. Physicians can prescribe lethal medication doses to people meeting criteria. 2. It is illegal to assist any client in hastening their death under any circumstances. 3. Significant others may assist a client in hastening their own death. 4. It is illegal for a client to approach a physician about assisted suicide.

1. Physicians can prescribe lethal medication doses to people meeting criteria; After several legal challenges, an Oregon law took effect in 1997 to permit physicians to prescribe lethal doses of medications to clients who meet certain criteria and who request these lethal doses of medication.

Proper handling of the body following death is an important intervention for the client, family, and nurse. An intervention that reflects an important principle of postmortem care is: 1. Preparing the body to look as clean and natural as possible 2. Pulling the sheet over the patient's face until the family is comfortably seated in the room 3. Humor is helpful in relieving stress. However, use humor only after family has left. 4. Calling the physician to verify the time of death before taking the body to the morgue

1. Preparing the body to look as clean and natural as possible; The body is to be handled with dignity at all times. This does not include using humor at this time. After the body is cleaned and the linen freshened, the sheet is pulled to cover the patient's shoulders. Laws and policies differ regarding the nurse's ability to declare death. Even if a physician is required to declare death, the time of death cannot be verified exactly.

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? 1. Results in neurophysiological response. 2. Reduces body temperature 3. Causes a person to be hypervigilant 4. Reduces level of consciousness to conserve energy.

1. Results in neurophysiological response.

When working with a client who has recently experienced the loss of a family member, you find that the client talks about the loss frequently, complains of sleep disturbances, loss of appetite, and difficulty concentrating. You realize that these signs and symptoms indicate which of the following things? 1. a normal reaction 2. severe depression 3. exaggerated grief response 4. a pathological grief response

1. a normal reaction, The client is experiencing normal manifestations of grief.

A 34-year-old man who is anxious, tearful, and tired from caring for his three young children tells you that he feels depressed and doesn't see how he can go on much longer. Your best response would be which of the following? 1."Are you thinking of suicide?" 2."You've been doing a good job raising your children. You can do it!" 3."Is there someone who can help you?" 4."You have so much to live for."

1."Are you thinking of suicide?"

How high above the rectum should the nurse giving a high-cleansing enema hold the enema solution? [Hint] 5 to 7 inches 8 to 9 inches 10 to 12 inches 14 to 16 inches

10 to 12 inches During the high-cleansing enema, the solution container is usually held 30 to 45 cm (12 to 18 inches) above the rectum because the fluid is instilled further to clean the entire bowel.

After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output?

1320 mL

The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by:

1700

Immediately after the parents of a hospitalized child are informed that the child has leukemia, the father responds by continuing his usual work schedule, rarely visiting, and asking when the child can return to school. Of the following, which is the least likely to be an appropriate nursing diagnosis at this time? 1) Ineffective Denial 2) Caregiver Role Strain 3) Fear 4) Compromised Family Coping

2) Caregiver Role Strain

A middle-aged male client is experiencing job-related stress associated with the fear of being laid off, resulting in his accepting projects that require a great deal of travel. Which of the following would be the most important health promotion strategy for this client? 1) Exercise 2) Sleep 3) Nutrition 4) Time management

2) Sleep

A crisis intervention nurse working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her entitlement check while the child is hospitalized can expect the mother to regain stability after how long? 1. After 2 weeks when the child's pneumonia begins to improve 2. After 6 weeks when she adjusts to the child's respiratory status and reestablishes the entitlement checks 3. After 1 month when the child goes home and the mother gets help from a food pantry 4. After 6 months when the child is back in school

2. After 6 weeks when she adjusts to the child's respiratory status and reestablishes the entitlement checks

A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 PM when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? 1. Gently explain the policy to the family and then implement it. 2. Inquire of the nursing supervisor how an exception to the policy could be made. 3. Call the client's primary care provider for advice. 4. Move the deceased to an empty room and assign an aide to stay with the body.

2. Inquire of the nursing supervisor how an exception to the policy could be made; When possible, modifications of policy that demonstrate respect for individual differences should be explored. The primary care provider is in no position to modify the implementation of hospital policy (option 3). Utilizing an empty room and a staff member is an inappropriate use of resources.

After a nurse questions a client about relationship abuse, the client responds the she is ready to leave the abusive relationship, although past attempts were not successful due to fear, lack of support, lack of confidence, and financial considerations. She asks the nurse for help. An example of perceived loss is: 1. Loss of partner 2. Loss of dreams 3. Loss of residence 4. Loss of current lifestyle

2. Loss of dreams; Perceived loss is experienced by one person but cannot be directly verified by others. Loss of partner, residence, and lifestyle can be seen and acknowledged by others, even if they are not favorable. Dreams are something of which only the client is aware. She may have dreamed of a happier relationship that she finally acknowledge was not forthcoming, or the dream may be of a different origin. Only the client knows.

During the assessment interview of an older woman experiencing a developmental crisis, the nurse asks which of the following questions? 1. How is this flood affecting your life? 2. Since your husband has died, what have you been doing in the evening when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help.

2. Since your husband has died, what have you been doing in the evening when you feel lonely?

A terminally ill client tells the nurse that they do not want to be placed on a ventilator, have CPR, or be intubated to prolong their life. Which of the following actions would most ensure that the client's wishes are carried out? 1. the nurse writing these instructions in the client's care plan. 2. the client preparing and signing an advanced directive 3. the client preparing and signing a health-care proxy 4. the physician writing an order to this effect in the chart

2. the client preparing and signing an advanced directive; The living will provides specific instructions about what medical treatment the client chooses to omit or refuse (e.g. CPR, intubation, ventilatory support) if the client is unable to communicate those decisions. A health-care proxy, also referred to as durable power of attorney, is a written statement appointing someone to make health-care decisions if the client is unable to do so.

A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse's first assessment for stress the nurse says: 1."Tell me who I can call to help you." 2."Tell me what bothers you the most about this experience." 3."I'll contact someone who can help get you temporary housing." 4."I'll sit with you until other family members can come help you get settled."

2."Tell me what bothers you the most about this experience."

A client who was informed of a cancer diagnosis assures the nurse he is fine. Which of the following is the most indicative physical evidence to the nurse of the client's stress? 1) Constricted pupils 2) Dilated peripheral blood vessels (flush) 3) Hyperventilation 4) Decreased heart rate

3) Hyperventilation

After the death of several long-term clients, which action indicates the nurse is demonstrating ineffective coping? 1) The nurse talks at length to her partner about the deaths. 2) The nurse keeps busy with other actions and doesn't think about the deaths for several days. 3) The nurse offers to work extra shifts for several weeks. 4) Several nurses schedule a group session with the agency clergy to discuss the deaths.

3) The nurse offers to work extra shifts for several weeks.

While the nurse is discussing a client's likely death with family members, one of the offspring inquires, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is close?" The nurse's best response is: 1. "Often, there is a lucid moment during the last hour that lasts about 15 minutes. First look for relaxation followed by clearing of the eyes, looking around, focusing on faces, and clearing of the throat. Call the others in at that time." 2. "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." 3. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." 4. "You can expect the muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with nuchal rigidity. Don't be alarmed when you hear a death rattle in the throat. "

3. "You can expect more muscle relaxation and less movement. Breathing will become irregular and shallow, and change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease."; Muscles relax with decreased activity. Muscle rigidity is not a usual pattern. The gag reflex is lost, and mucus accumulates in the back of the throat. Vision is blurred. A lucid moment is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical death can be detected.

At which age does a child begin to accept that he or she will someday die? 1. Less than 5 years old 2. 5-9 years old 3. 9-12 years old 4. 12-18 years old

3. 9-12 years old; Until children are about 5 years old, they believe death is reversible. Between ages 5 and 9, the child knows death is irreversible but believes it can be avoided (option 2). Between 9 and 12 years of age, the child recognizes that he or she, too, will someday die (option 3). At 12 to 18 years old, the child builds on previous beliefs and may fear death, but often pretends not to care about is (option 4).

A family with five children experiences a stillbirth. While intervening with the family, one member expresses a view that causes special concern for the nurse. This person is: 1. A 3-year-old who wonders if the baby will come home after it gets better 2. A 5-year-old who cries, believing the death occurred because the child drew with magic markers on one of the baby blankets 3. A 13-year-old who assumes blame as punishment for shoplifting 4. A 15-year-old who says, "I still can't believe it is true."

3. A 13-year-old who assumes blame as punishment for shoplifting; A child of 3 does not understand the concept of death, or its permanence. A child of 5 may associate death with unrelated actions. A 15-year-old is expected to follow similar stages of grief, including denial.

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3. A thorough physical assessment

The nurse working in a long-term care facility is assigned to a client who is in a persistent vegetative state and who has a nasogastric feeding tube. The family asks to have the tube removed. What is the nurse's best course of action? 1. Remove the nasogastric feeding tube. 2. See if the physician objects to the removal of the tube. 3. Check facility policy and laws regarding this situation. 4. Get a doctor's order for tube removal

3. Check facility policy and laws regarding this situation; Legal issues related to death are prescribed by the laws of the region and the policies of the health-care institution. In some states this nasogastric tube can be removed at the request of the family and/or the physician; in other states it can be removed only if the client has an advanced directive.

A nurse observes that a patient whose home life is chaotic with intermittent homelessness, a child with spina bifida, and an abusive spouse appears to be experiencing an allostatic load. As a result, the nurse expects to detect which of the following while assessing the patient? 1. Posttraumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Return of vital signs to normal

3. Chronic illness

The client has been close to death for some time and the family asks how the nurse will know when the client has actually died. Which of the following would be the most accurate response from the nurse? 1. When the blood pressure can no longer be 2. When the gag reflex is no longer present. 3. When there is no apical pulse. 4. When the extremities are cool and dark in color.

3. When there is no apical pulse; If there is no heartbeat, the client has died. Before death, the blood pressure may not be able to be heard on auscultation because it is very low (option 1). Loss of the gag reflex (option 2) occurs with loss of muscle tone but can exist in many circumstances unrelated to dying. Vasodialation and pooling of fluids at the end of life may cause cool and darkened extremities, but these are not reliable signs of death (option 4).

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. The nurse's first response is which of the following? 1."Don't be sad. People live with cancer every day." 2."Have you thought about how you are going to tell your family?" 3."Would you like for me to sit down with you for a few minutes so you can talk about this?" 4."I know another patient whose colon cancer was cured by surgery."

3."Would you like for me to sit down with you for a few minutes so you can talk about this?"

The first time the nurse enters the client's room, the client is on the phone. Immediately, the client slams down the phone, sweeps everything off the overbed table, and demands that the nurse perform several duties "this very minute." Which of the following would be the most appropriate response for the nurse? 1) Tell the client "I will return" and then leave the room. 2) Tell the client no care will be given until the screaming ends. 3) Begin providing needed care calmly and quietly. 4) Allow the client to complete venting, then respond calmly.

4) Allow the client to complete venting, then respond calmly.

A 22-year-old client with recent paraplegia lashes out and curses at the nurse about the breakfast meal. The nurse's best response is: 1. "I know you are angry, but I cannot let you make me become the object of your anger. I will send up the dietician." 2. "This is not about breakfast. Tell me what you are really angry about." 3. "I understand you are angry. I'll shut the door and let you cool off." 4. "I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?"

4. "I hear a lot of anger in your voice that is quite normal and healthy to hear. Is it a new breakfast you want or something else?"; Acknowledging the client's anger and helping the client understand the source of the anger is helpful. Do not take the anger personally. Allow choices and control when possible.

An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss? 1. "I told the doctor I would stop driving, but I am not going to yet." 2. "I always knew this day would come, but I hoped it wouldn't be now." 3. "What does he know? I'm a better driver than he will ever be." 4. "Well, at least I have friends and family who can take me places."

4. "Well, at least I have friends and family who can take me places"; Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping with the loss. Although the other options are responses the client might likely give and feel, and are not pathologic, they do not demonstrate movement toward a goal of adaptation nor problem solving.

A client on artificial life support meets the criteria for death when the electroencephalogram (EEG) has been flat for which of the following periods of time? 1. one hour 2. four hours 3. eight hours 4. 24 hours

4. 24 hours; When a client on artificial life support has an electroencephalogram that has had a flat reading for at least 24 hours, the person can be considered dead.

The nurse is caring for a family in a shelter 2 days after the loss of their home due to a fire. The fire caused minor burns to several members of the family but no life-threatening conditions. Which of the following is the most important assessment data for the nurse to gather at this time? 1. Availability of insurance coverage for rebuilding the house. 2. Family members' understanding of the extent of their physical injuries. 3. Psychological support resources available from friends or other sources. 4. Family members' grief responses and coping behaviors.

4. Family members' grief responses and coping behaviors; To plan with and assist the family, the nurse needs more data regarding the family's reactions to their loss. Information on issues such as insurance coverage (option 1) can wait until later and may be more appropriately the responsibility of social services rather than the nurse. It is important for the nurse to determine their understanding of their injuries but they are stated as minor (option 2). Once the nurse as assessed the family's responses, it will be important to determine the availability of outside resources to assist them (option 3).

When the body of a deceased client is prepared prior to removal by the undertaker, it is most important that the nursing staff in a health-care facility do which of the following? 1. Wash the body. 2. Remove any dentures, hearing aides, and glass eyes. 3. Say the last rites. 4. Have two correct identification tags on the body.

4. Have two correct identification tags on the body; If the body is inappropriately identified and prepared incorrectly for burial or funeral, legal problems may result. In the hospital, the wrist identification tag is left on and another tag is tied to the ankle in case one of the tags becomes detached. In other facilities, which do not have a wrist tag system, two tags need to be on in case one is lost.

While talking to adult children of a dying client, the nurse finds them tearful, with ambivalent feelings toward the client. The client often expresses beliefs of a wasted life. The children say that the client was a parent who often showed love but followed it with criticism, anger, damaging accusations, and emotional abuse. The nurse suggests an intervention that may be helpful to the client and other family members. The most likely intervention to be helpful is: 1. Listening to relaxation tapes before visiting each other. If negative feelings arise, listen to the tapes together. 2. Having a nurse present in the room at all times when one of them visits the client. The nurse will intervene with conflict resolution if problems arise. 3. Assuring the client and children that the past no longer matters. The only time that matters is the present and the future. 4. Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together.

4. Making a videotape of each child telling a story of a time when the client showed love, while the client tells of a special love for each child. Plan a time to watch it together; Relaxation tapes help with stress reduction, but do not help resolve problems experienced by the client and children. Staffing needs do not permit a nurse to be with one client continually, and families require privacy as well. Assurance that the past no longer matters is an assurance lacking concrete properties.

A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. The supervising nurse recognizes that: 1. Nurses who feel stress usually pass the stress along to their patients. 2. A nurse who feels stress is ineffective as a nurse and should not be working. 3. Nurses who talk about feeling stress are unprofessional and should calm down. 4. Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring.

4. Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring.

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? 1. Loss of autonomy caused by health problems 2. Physical appearance, family, friends, and school 3. Self-esteem issues, changing family structure 4. Search for identity with peer groups and separating from family

4. Search for identity with peer groups and separating from family

A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met? 1.The client demonstrates having adequate financial resources to pay for health care for many more years. 2. The client spends the majority of his or her time in spiritual reflection. 3. The client has no signs or symptoms of preventive complications of the illness. 4. The client verbalizes satisfaction with current relationships with other persons.

4. The client verbalizes satisfaction with current relationships with other persons; Quality of life is determined by the client and expressed in terms of his and her satisfaction with a variety of aspect of life. Although being able to pay for care (option 1), having apparent spiritual peace (option 2), and absence of physiological complications (option 3) may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal.

A client questions the nurse about the difference between a living will and power of attorney. The nurse's best response is: 1. A lawyer carries a living will, while a designated family member or friend carries 2. In a living will, the client specifies medical treatments to be carried out when incapable of making decisions, while durable power of attorney allows the client to include both treatments to be carried out and treatments to be omitted in the event of terminal illness. 3. The living will indicates when a client wishes life support to be discontinued, while durable power of attorney give that power to another in the event of terminal illness. 4. The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client.

4. The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client; A living will is a legal document that expresses an individual's decision on the use of artificial life support systems. Power of attorney is a written instrument which authorizes one person to act as another's agent or attorney.

The physician tells your assigned client that their chest X-ray shows they have lung cancer. Based on your understanding of the work of Kubler-Ross, which of the following reactions would you most expect from this client during the next day or two? 1. acceptance 2. anger 3. depression 4. denial

4. denial; The five phases or stages of grieving, according to Kubler-Ross, are denial, anger, bargaining, depression, and acceptance.

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. The nurse realizes that the patient is coping successfully when the patient says: 1."I'm going to learn to drive a car so I can be more independent." 2."My sister says she feels better when she goes shopping, so I'll go shopping." 3."I've always felt better when I go for a long walk. I'll do that when I get home." 4."I'm going to attend a support group to learn more about multiple sclerosis."

4."I'm going to attend a support group to learn more about multiple sclerosis."

A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is:

750 to 1000 mL.

The nurse recognizes which patient needs to use a fracture pan for a bowel movement?

A patient recovering from hip surgery

immigration

Acculturation Assimilation

Which of the following is required in the delivery of culturally congruent care?

Acquiring Specific Knowledge, Skills, and Attitudes

A 46-year-old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United States because she:

Adapted to and Adopted the American Culture

A client has had a stroke, and can no longer move her bowels on her own accord. A bladder-training program is to be established for her. Before beginning this program, the client and her family members must understand what is involved with this care. Which of the following would be the most appropriate directions or information to share? Maintain the daily routine for six weeks Only allow client to defecate once a day Administer a cathartic suppository 30 minutes before the client's defection time to stimulate peristalsis Fluid intake, decreased fiber in diet, intake of hot drinks, and increased exercise all influence one's ability to perform the action of defection on a regular basis.

Administer a cathartic suppository 30 minutes before the client's defection time to stimulate peristalsis Rationale: The best results can be obtained by inserting the suppository 30 minutes before the client's usual defecation time, or when the peristaltic action is greatest. The daily routine in bowel training is recommended to be 2-3 weeks. When the client experiences the urge to defecate, assist the client to the toilet/commode/bedpan to defecate. Fluid intake, increased fiber in the diet, intake of hot drinks, and increased exercise all influence one's ability to perform the action of defecation on a regular basis.

A nursing student is taking postoperative vital signs in the postanesthesia care unit. She knows that some ethnic groups are more prone to genetic disorders. Which of the following patients is most at risk for developing malignant hypertension?

African American

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? Prepare to irrigate the colostomy. After assessing the stoma and surrounding skin, notify the surgeon. Assess bowel sounds and administer antiemetic. Administer a bulk-forming laxative, and encourage increased fluids and exercise.

After assessing the stoma and surrounding skin, notify the surgeon. Rationale: The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated.

During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client? Select all that apply. Alanine aminotransferase (ALT) Myoglobin Cholesterol Ammonia Brain natriuretic peptide or B-Type natriuretic peptide (BNP)

Alanine aminotransferase (ALT) Ammonia ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver. The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease.

A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Which type of client would this type of procedure would benefit from this procedure? Open Hint for Question 8 in a new window. An abdominal trauma victim A renal failure client A client with kidney stones An individual suffering from a urinary tract infection

An abdominal trauma victim Rationale: The abdominal trauma victim is the only appropriate answer here. The remaining problems can be treated with less traumatic care measures.

The nurse encounters a 75-year-old in the emergency department, with complaints of nausea, diarrhea, and anorexia. He has been evaluated, and it is determined that he can be treated at home. In discussing the guidelines of managing diarrhea, the nurse knows the client understands his care measures when he says: "I will drink two glasses of water a day to prevent dehydration." "I will drink tea when I get home." "I will increase foods with fiber, like oatmeal." "I will eat fried chicken for supper."

Answer: "I will increase foods with fiber, like oatmeal." Rationale: Increasing roughage (fiber) in the diet helps to add bulk to the stool. Eight glasses of water remains the recommended fluid recommendation, although there is some disagreement. Beverages with caffeine, like tea, and fatty foods like fried chicken aggravate diarrhea.

At the local wellness fair, the nurse is asked to share information on having healthy bowel life. Included in this area is the topic of having a healthy defecation. The nurse should include which of the following information as appropriate action to follow? Eliminating high-fiber foods in your diet Defecating only once a day. Ignore any other urges. Establishing a regular exercise regimen Drinking four glasses of water a day

Answer: Establishing a regular exercise regimen Rationale: Exercise helps to stimulate muscle functioning and metabolic activity, thus promoting healthy defecation. High-fiber foods are encouraged in the diet of this client. Do not avoid the urge to defecate, because this conditioned reflex tends to weaken or is ultimately lost. Six to eight glasses of water are recommended to maintain fluid balance in the body.

A client suffering with ulcerative colitis has discussed the need for a temporary colostomy to rest the colon and help the healing process. The colostomy will be located in the descending colon. The type of stool that the client can expect from this stoma is: Liquid that cannot be regulated Malodorous and mushy drainage Increasingly solid Liquid fecal drainage

Answer: Increasingly solid Rationale: Stool in the descending colon is often formed, and the tissue can be trained for periodic defecation. Liquid stool and malodorous stool that cannot be controlled is found within the ascending colon. Malodorous, mushy stool is noted in the transverse colon. Output is always expected at some point in time from ostomies as evidence of their functioning.

After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include: Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection Nothing can be done about the concerns of odor with the appliance. Ordering appliances through the client's health care provider The appliance will not be needed when traveling.

Answer: Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection Rationale: Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies avaliable for clients to help control odor that may be incurred because of the ostomy. Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling.

The elderly population is known to use laxatives with regularity. In advising an older adult practicing this habit, the nurse would identify all of the following except: (Select all that apply.) Consistent use of laxatives inhibits natural defecation reflexes, and is thought to cause rather that cure constipation. Habitual use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced. Laxatives may interfere with fluid and electrolyte balance. Laxatives increase the absorption of certain vitamins.

Answers: Consistent use of laxatives inhibits natural defecation reflexes, and is thought to cause rather that cure constipation. Habitual use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced. Laxatives may interfere with fluid and electrolyte balance. Rationale: Laxatives decrease the absorption of vitamins. The remaining answer choices are true.

When checking the stool of a client, you notice there is a whitish discoloration and some white specks in the stool. Which of the following medications do you suspect the client is taking? [Hint] Non-enteric coated aspirin Antacids New-generation cephalosporins Antimalarials

Antiacids

A family member of a recently deceased patient talks casually with the nurse at the time of the patient ' s death and expresses relief that she will not have to visit at the hospital anymore. What theoretical description of grief best applies to this family member?

Anticipatory Grief

When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT):

As part of a routine examination for colon cancer.

Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care?

Ask Family Members if They Prefer to Help with the Care of the Body After Death

The nurse at an outpatient clinic asks a patient who is Chinese American with newly diagnosed hypertension if he is limiting his sodium intake as directed. The patient does not make eye contact with the nurse but nods his head. What should the nurse do next?

Ask the Patient How Much Salt He is Consuming Each Day

You have identified three nursing diagnoses for a patient who is having anxiety and hopelessness as a result of a loss. Which general approach do you take to prioritize the nursing diagnoses?

Ask the Patient to Identify the Most Distressing Symptom and First Address that Diagnosis; Use Nursing Knowledge to Address the Problem that is the Underlying Cause of other Diagnoses

Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? (Select all that apply.)

Aspirin; Non-steroidal anti-inflammatory drugs (NSAIDs)

When assisting with a bone marrow biopsy, the nurse should take which action? Assist the client to a right side-lying position after the procedure. Observe for signs of dyspnea, pallor, and coughing. Assess for bleeding and hematoma formation for several days after the procedure. Stand in front of the client and support the back of the neck and knees.

Assess for bleeding and hematoma formation for several days after the procedure. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture.

The patient is incontinent, and a condom catheter is placed. The nurse should take which action?

Assess the Patient for Skin Irritation

The nurse is requested to perform teaching to a client in the Emergency Department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes: Open Hint for Question 4 in a new window. Avoid tight-fitting pants or clothing Drink six glasses of water per day Type of soap when bathing has no significance in this area. Voiding pattern in the course of the day has no significance with this problem.

Avoid tight-fitting pants or clothing Rationale: Tight-fitting clothing creates irritation to the urethra and prevents ventilation of the perineal area. It is recommended that eight glasses of water be drunk to flush out the urinary system. Avoid harsh soaps, bubble bath, powders, and sprays in the perineal area, because they can have an irritating effect on the urethra, encouraging inflammation and a bacterial infection. Practice frequent voiding (q 2-3 hours) to flush bacteria out other the urethra and prevent organisms from ascending into the bladder.

A family member asks a home care nurse what he should do if the patient's serious chronic illness worsens even with increased medical interventions. How does the nurse best begin a conversation about the goals of care at the end of life?

Begin the Discussion by Asking the Patient to Identify His or Her Beliefs about the Goals of Care While the Family Member is Present

Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply. Bowel Incontinence Risk for Deficient Fluid Volume Disturbed Body Image Social Isolation Risk for Impaired Skin Integrity

Bowel Incontinence Disturbed Body Image Social Isolation Risk for Impaired Skin Integrity Rationale: Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, client may not feel as comfortable around others. In option 5, increased tissue contact with fecal material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

culturally responsive care

Centered on the client's cultural perspectives Integrates the client's values and beliefs into the plan of care Develop self-awareness of his or her own culture, attitudes, and beliefs Examine the biases and assumptions he or she holds about different cultures Gain knowledge and skills to create an environment where trust can be developed Nurse must respond to client's needs not vice versa

The goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. Which of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? Open Hint for Question 7 in a new window. Having the client drink up to 3000mL per day Encouraging the client to eat foods that increase the acid in the urine Routine hygienic care Changing indwelling catheters every 72 hours.

Changing indwelling catheters every 72 hours. Rationale: Retention catheters are removed after their purpose is achieved; routine changing of the catheter or drainage system is not recommended. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Eating foods that increase the acid in urine helps to reduce the risk of urinary tract infections and stone formation. Hygiene care related to catheters is set by hospital policy.

Since removal of the patient's Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first?

Check for Bladder Distention

The nurse notes that the patient's Foley catheter bag has been empty for 4 hours. The priority action would be to:

Check for Kinks in the Tubing

The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. Mixes the reagent with the stool sample before applying to the card. Collects a sample from two different areas of the stool specimen. Assesses for a blue color change. Asks a colleague to verify the pink color results. Asks the client if he has taken vitamin C in the past few days.

Collects a sample from two different areas of the stool specimen. Assesses for a blue color change. Asks the client if he has taken vitamin C in the past few days. Rationale: The nurse should obtain the stool specimen from two different areas of the stool. The nurse should observe for a blue color change, which is indicative of a positive result. The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification.

A client is admitted with gastrointestinal bleeding. One of the earliest and most important blood tests completed will be: Electrolyte Panel Arterial Blood Gases Liver Panel Complete Blood Count

Complete Blood Count

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? Constipation Diarrhea Incontinence Hemorrhoids

Constipation Rationale: Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result—if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool (option 2). Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence (option 3). Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool (option 4).

Which focus is the nurse most likely to teach for a client with a flaccid bladder? Habit training: attempt voiding at specific time periods. Bladder training: delay voiding according to a preschedule timetable. Credé's maneuver: apply gentle manual pressure to the lower abdomen. Kegel exercises: contract the pelvic muscles.

Credé's maneuver: apply gentle manual pressure to the lower abdomen. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation.

implementing

Cultural preservation and maintenance Cultural accommodation and negotiation If client chooses to follow only cultural practices the nurse and the client must adjust the clients goals

communication style

Cultural variation 1. Verbal communication 2. Nonverbal communication 3. paraverbal -- how you say what you say

During their clinical post-conference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that her patient was homeless. This is an example of caring for a patient from a different:

Culture

cultural concepts

Culture Subculture Bicultural Diversity Race Ethnicity Nationality Religion Ethnocentrism Prejudice Racism Discrimination Generalizations Stereotyping

A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:

Cystitis

The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider?

Dehydration

heritahe assessment

Depicts the questions to ask Designed to enhance the process Determine identification with traditional cultural heritage **Heritage consistent Acculturated into the dominant culture of the modern society in which they reside **Heritage inconsistent

nursing management

Developing Self-awareness Identify his or her own cultural, beliefs, and assumptions

A woman experiences the loss of a very early-term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others. What type of grief response is she most likely experiencing?

Disenfranchised

A registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient?

Do You Bathe and Use Deodorant More than One Time a Week?"

When interviewing a Native American patient on admission to the hospital emergency department, which questions are appropriate for the nurse to ask?

Do You Use Any Folk Remedies? Do You Have a Family Physician? Do You Use a Shaman?

You are instructing a client in the clinic about diphenoxylate (Lomotil), which the physician has just ordered for diarrhea. Which of the following instructions would be most important to give a client who is on this medication? [Hint] Take the medication with food. Increase the dose until results are satisfactory. Do not give to children under the age of 12. Do not take before driving or using running machinery.

Do not take before driving or using running machinery. Diphenonoxylate can cause drowsiness, so clients on this medication should not use this medication prior to driving or operating running machinery.

When using a rectal tube in helping a client expel flatulence, the most appropriate intervention to be followed by the nurse is Have client in the supine position Insert rectal tube, no lubrication needed Leave tube in for one hour Encourage the client to assume various positions in bed once the tube is inserted.

Encourage the client to assume various positions in bed once the tube is inserted. Rationale: Varying the position from side-lying to sitting to supine helps the client to expel flatus. The side-lying position is recommended for use during insertion. Lubrication of the tube helps to ease the insertion process and prevent damage to the tissue. The tube should not be left in the client for more than 30 minutes, to avoid irritation to the rectal mucosa.

A 6-month-old child from Guatemala was adopted by an American family in Indiana. The child's socialization into the American midwestern culture is best described as:

Enculturation

A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is:

Explore what has Prevented Her from Being at the Clinic in Time for Her Appointment

Urinary incontinence is not a normal part of aging. An intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include: Open Hint for Question 5 in a new window. Bladder training Habit training Prompted voiding Fluid restriction

Fluid restriction Rationale: Fluids would be encouraged, to allow the kidneys to be flushed and urine to be formed. Bladder training requires that the client postpone voiding, resist or inhinbit the sensation of urgency, and void according to a timetable, rather than according to an urge. Habit training is also referred to timed or scheduled voiding. There is no attempt to motivate the client to delay voiding if the urge occurs. Prompted voiding supplements habit training by encouraging the client to try to use the toilet and reminding the client when to void.

holistic health belief

Forces of nature must be maintained in balance or harmony Human life is one aspect of nature When the natural balance is disturbed then illness results

The nurse is presenting information at the community health fair about normal defecation patterns across the lifespan. Which of the following factors would not be part of the discussion? Diet Fluid intake and output Medications Gender

Gender Rationale: There is no relationship noted between gender and defecation pattern. Diet, fluids, and medications all can affect amount, consistency, or pattern of defecation.

The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information? Fasting blood glucose Capillary blood specimen Glycosylated hemoglobin GGT (gamma-glutamyl transferase)

Glycosylated hemoglobin A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose not the past history. Option 4 is used to assess for liver disease.

The nurse would call the primary care provider immediately for which laboratory result? Hgb = 16 g/dL for a male client. Hct = 22% for a female client. WBC = 9 x 10³/mL³ Platelets = 300 x 10³/mL³

Hct = 22% for a female client.

health disparties

Inadequate access to care Substandard quality of care United States Department of Health and Human Services (USDHHS) Houses the Office of Minority Health The Centers for Disease Control and Prevention (CDC) National Center on Minority Health and Health Disparities (NCMHD) Racial and Ethnic Approaches to Community Health Across the United States (REACH U.S.)

Elimination changes that result from inability of the bladder to empty properly may cause which of the following?

Incontinence; Frequency; Urgency; Urinary Retention; Urinary Tract Infection (UTI)

An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:

Initiate Kegel Exercises

Which behavior is most representative of a culturally competent nurse? A. Helps clients of Native-American heritage identify ways to relate more to their culture B. Helps parents of Latino heritage recognize that their children need to speak English C. Interprets and validates beliefs of a client with African-American heritage D. Asks a nurse of Japanese heritage to teach others dosage calculations since Asians are good at math

Interprets and validates beliefs of a client with African-American heritage

A client reports an iodine allergy. This information is most significant if the client is scheduled for which exam? Lung Scan Computed Tomography Magnetic Resonance Imaging Intravenous Pyelogram

Intravenous Pyelogram

Your assigned client, who has a history of heart disease, has a tendency to strain when having a bowel movement. You instruct the client not to strain for which of the following reasons? [Hint] It increases intrathoracic pressure. It can suddenly increase the blood pressure. Straining reduces the amount of available oxygen. The medial nerve is stimulated during straining.

It increases intrathoracic pressure. Straining during defecation uses the valsalva maneuver, which can present serious problems to people with heart disease because it increases intrathoracic and intracranial pressures and lowers heart rate.

The client has a urinary health problem. Which procedure is performed using indirect visualization? Intravenous pyelography (IVP) Kidneys, ureter, bladder (KUB) Retrograde pyelography Cystoscopy

Kidneys, ureter, bladder (KUB) A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cytoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization.

List Elizabeth Kubler-Ross's Stages of Grieving:

Kubler-Ross defined 5 stages of grieving including: denial, anger, bargaining, depression, and acceptance.

During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with:

Lactose intolerance.

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? Leaves the catheter in place and gets a new sterile catheter. Leaves the catheter in place and asks another nurse to attempt the procedure. Removes the catheter and redirects it to the urinary meatus. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

Leaves the catheter in place and gets a new sterile catheter. Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.

scienitifc (biomedical) health view ---> western medicine

Life is controlled by physical and biomechanical processes manipulated by humans Illness is caused by germs, bacteria, or a breakdown of the body Belief that pills, treatments, or surgery will cure

To minimize the patient experiencing nocturia, the nurse would teach him or her to:

Limit Fluids Before Bedtime

Which approach to helping grieving people is most consistent with postmodern grief theories?

Listen Carefully to a Person's Story of How His or Her Grief is Unfolding

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? Oil retention Return flow High, large volume Low, small volume

Low, small volume Rationale: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3).

health beliefs and practices

Magico-religious health belief Health and illness are controlled by supernatural forces May believe that illness a result of "being bad" or opposing God's will Getting well is also dependent on God's will Some cultures believe magic can cause illness

A self-care goal you set when caring for dying and grieving patients includes:

Maintaining Life Balance and Reflecting on the Meaning of Your Work

nonvervbal communication behaviors

Meaning to the client Meaning in the client's culture Use of Silence Touch Eye movement Facial expressions Body posture

diagnosing

NANDA focused on care provided in the United States Based on European-centric cultural beliefs Provide adequate care to client's of any culture Consider how culture influences his or her response to health conditions

A client has a streptococcal throat infection. The White Blood Cell count is elevated. When looking at the differential, the nurse expects which type of white blood cell to be elevated? Open Hint for Question 6 in a new window. Eosinophils Monocytes Lymphocytes Neutrophils

Neutrophils Neutrophil count is elevated when a client has a streptococcal infection. Eosinophil count is elevated in allergic reactions Monocyte count is elevated in chronic inflammatory disorders. Lymphocyte count is elevated in viral infections.

Which nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate? Open Hint for Question 3 in a new window. Client self-care abilities Distance and barriers to accessing the bathroom Need/use of ambulatory aids as required No dietary restrictions needed

No dietary restrictions needed Rationale: Dietary guides related to fiber and fluid balance are given to clients with this problem. The remaining actions are noted in the assessment guide, and are appropriate measures to use with clients.

The patient is to have an Intravenous Pyelogram (IVP). Which of the following apply to this procedure?

Note Any Allergies; Encourage Fluids After the Procedure

Regarding grief in older adults, which understanding helps guide your relationship with an elderly patient?

Older Adults have Usually Sustained Many Losses in Life, which Influence the Current Loss

The nurse suggests that a patient receive a palliative care consultation for symptom management related to anxiety and increasing pain. A family member asks the nurse if this means that the patient is dying and is now "in hospice." What does the nurse tell the family member about palliative care?

Palliative Care is for Any Patient, Any Time, Any Disease, in Any Setting; Palliative Care Interventions Relieve the Symptoms of Illness and Treatment

A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the nurse anticipate the patient to have?

Red

A young man is diagnosed with a serious, life-changing illness. His conversations during his first 2 days of hospitalization are abrupt, superficial, and unrelated to his illness. What understanding about communication enhances your therapeutic communication with this patient?

Remain Alert for Signals that the Patient Wants to Discuss his Illness

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? Soapsuds Retention Return flow Oil retention

Return flow Rationale: This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief.

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. Limit fluids to avoid the burning sensation on urination. Review symptoms of UTI with the client. Wipe the perineal area from back to front. Wear cotton underclothes. Take baths rather than showers.

Review symptoms of UTI with the client. Wear cotton underclothes. Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation.

An 80-year-old client is in the emergency department. The client complains of diarrhea and vomiting for the past two days. In assessing the client, it is noted that his skin is dry and can be tented, he has lost eight pounds, and is itchy. Which NANDA diagnosis would be most appropriate to use with this client in making his plan of care? Risk for Deficient fluid volume related to prolonged diarrhea and vomiting Risk for fluid volume excess related to prolonged diarrhea and vomiting Risk for normal fluid volume related to prolonged diarrhea and vomiting Risk for hidden fluid related to prolonged diarrhea and vomiting

Risk for Deficient fluid volume related to prolonged diarrhea and vomiting Rationale: This client is showing signs of dehydration. The first answer is the only appropriate answer.

The nurse is caring for a patient with a colostomy. Which intervention is most important?

Selecting a bag with an appropriate-size stoma opening

Which of the following is most likely to validate that a client is experiencing intestinal bleeding? Large quantities of fat mixed with pale yellow liquid stool Brown, formed stools Semisoft tar-colored stools Narrow, pencil-shaped stool

Semisoft tar-colored stools Rationale: Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant, option 2 is normal stool, and option 4 is characteristic of an obstructive condition of the rectum.

The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. Collect the specimen in the evening. Send the specimen immediately to the laboratory. Ask the client to spit into the sputum container. Offer mouth care before and after collection of the sputum specimen. Collect a specimen for 3 consecutive days.

Send the specimen immediately to the laboratory. Offer mouth care before and after collection of the sputum specimen. Collect a specimen for 3 consecutive days.

A community health nurse is making a healthy baby visit to a new mother who recently emigrated to the United States from Ghana. When discussing contraceptives with the new mom, the mother states that she won't have to worry about getting pregnant for the time being. The nurse understands that the mom most likely made this statement because:

She Won't Resume Sexual Relations until Her Baby is Weaned

conveying cultural senstivity

Spend time with client and convey genuine desire to learn their values and beliefs Address by last names Introduce yourself by full name Be authentic and honest about the culture Use language that is culturally sensitive What does the client think about his or her health problem, illness, and treatment Ask anything you do not understand Show respect for clients values, beliefs, and practices Show respect for the clients support people Obtain client's trust

planning

Steps are involved in the process that leads to the development of cultural competence *Become aware of own cultural heritage *Become aware of the client's heritage and health traditions *Become aware of adaptations the client made to live in another culture Steps are involved in the process that leads to the development of cultural competence *Form a nursing plan with the client that incorporates cultural beliefs regarding the maintenance, protection, and restoration of health

The nurse is counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle exercises to strengthen her bladder muscles. What action would the nurse recommend to this client in order to perform this activity correctly? Open Hint for Question 10 in a new window. Stopping urination midstream Standing tall and stretching out her arms and touching her toes Emptying her bladder completely Moving her bowels

Stopping urination midstream Rationale: Stopping the flow of urination midstream focuses on the muscle used to control this activity. The remaining answers do not affect this muscle in the same manner.

A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first?

Stops the instillation and obtains vital signs

Culture strongly influences pain expression and need for pain medication. However, cultural pain is:

Suffered by a Patient Whose Valued Way of Life is Disregarded by Practitioners

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void?

Suggest He Stand at the Bedside

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? The bladder distends and its capacity increases. Older adults ignore the need to void. Urine becomes more concentrated. The amount of urine retained after voiding increases.

The amount of urine retained after voiding increases. Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment.

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? The client will wear a medical alert bracelet for antibiotic allergy. The client will return to his or her previous fecal elimination pattern. The client verbalizes the need to take an antidiarrheal medication prn. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

The client will return to his or her previous fecal elimination pattern. Rationale: Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug (option 1). Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock (option 3). Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not (option 4).

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? The stoma extends 1/2 in. above the abdomen. The skin under the appliance looks red briefly after removing the appliance. The stoma color is a deep red-purple. An ascending colostomy delivers liquid feces.

The stoma color is a deep red-purple. Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.

The nurse is working with a client whose main diet is rice, eggs, and lean meat. It is most important for the nurse to teach the client which of the following things about a diet high in these foods? [Hint] This diet needs more fluid intake to move it through GI tract. No additional fiber or bulk is needed, as this diet is rich in it. Eating this diet may result in the passage of watery stools. This diet may produce a significant amount of bloating and flatus.

This diet needs more fluid intake to move it through GI tract.

Urinary catheterization is carried out for clients only when absolutely necessary. Which of the following candidates/situations would not warrant the need for this procedure? Open Hint for Question 6 in a new window. A client having abdominal surgery A client who is completely paralyzed A client in need of decompression of the bladder To collect a random urine specimen for evaluation

To collect a random urine specimen for evaluation Rationale: Collection of a random urine specimen is not routinely obtained by use of the process of catheterization. The other candidates/situations are appropriate uses of this technique.

The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first?

Turn on the Bathroom Faucet as he Tries to Void

The nurse has completed the administration of a cleaning enema for a client being prepared for intestinal surgery. Complete documentation by the nurse of this event includes all but which of the following assessments? (Select all that apply.) Type of solution Length of time solution retained Relief of flatus and abdominal distention Amount of return

Type of solution Length of time solution retained Relief of flatus and abdominal distention Rationale: Document color, odor, amount and consistency of feces, and the condition of the perineal area. The remaining actions are also documented.

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? Stress Urinary Incontinence Reflex Urinary Incontinence Functional Urinary Incontinence Urge Urinary Incontinence

Urge Urinary Incontinence Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Diagnosis.

Question 1. A client comes to the primary care provider's office with the complaints of urinating all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. A urine specimen has been sent for analysis. Based on the signs and symptoms expressed by the client, which of the following health problems would be anticipated? Open Hint for Question 1 in a new window. Acute renal failure Renal stone Urinary tract infection Chronic renal failure

Urinary tract infection Rationale: The noted signs and symptoms help to identify the problem of urinary tract infection. The signs and symptoms noted are not common with the other diseases listed.

The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to:

Use Credé's Method

The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient?

When was the last time you moved your bowels?

The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. Which procedure will increase the blood flow to the area to ensure an adequate specimen? Raise the hand on a pillow to increase venous flow. Pierce the skin with the lancet in the middle of the finger pad. Wrap the finger in a warm cloth for 30--60 seconds. Pierce the skin at a 45-degree angle.

Wrap the finger in a warm cloth for 30--60 seconds.

The major factor contributing to the increased emphasis on the need for proficiency in cultural nursing practice in the United States is which of the following? A. An increasing birth rate B. Limited access to health care services C. Demographic changes D. A decreasing rate of immigration

demographic changes

Which of the following factors would be most likely to decrease the movement of chyme in the intestine? [Hint] depression anxiety exercise anger

depression

cultural competence

desire awareness knowledge skills encounters

Which behavior is an initial step in culturally responsive nursing practice? A. Help the client recognize the need to adapt health practices to fit commonly accepted practices. B. Discuss the meaning of the medical regimen with the client. C. Inform the client that lack of adherence to the medical regimen may be detrimental. D. Ask a cultural broker to explain the relevance of the intervention.

discuss the meaning of the medical regimen with the client