Exam 3 PrepU Quizzes

Which is the initial stage of grief, according to Kübler-Ross? ○ Anger ○ Bargaining ○ Denial ○ Depression

Denial Explanation: The stages of grief include denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.

After educating a client on MyPyramid recommendations, the nurse realizes more education is needed when the client makes which of the following remarks? ○ "Limiting the amount of butter in my diet is necessary" ○ "I need to do at least 15 minutes of physical activity one day a week" ○ "Two and a half cups of a variety of vegetables are recommended" ○ "Frying foods is not recommended; baking or broiling are better options"

"I need to do at least 15 minutes of physical activity one day a week" Explanation: MyPyramid recommends physical activity 30 minutes on most days, not 15 minutes only one day. The other options are MyPyramid recommendations about the major food groups.

A waist circumference greater than which value indicates excess abdominal fat in men? ○ 63.50 cm (25 in) ○ 76.20 cm (30 in) ○ 88.90 cm (35 in) ○ 101.60 cm (40 in)

101.60 cm (40 in) Explanation: A waist circumference >101.60 cm (>40 in) for men or >88.90 cm (>35 in) for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.

A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be? ○ "This must be very difficult for you" ○ "Let me explain to you what is happening" ○ "I'm so sorry. I know how you must feel" ○ "You know you're dying?"

"This must be very difficult for you" Explanation: Using open-ended questions allows the nurse to elicit the patient's and family's concerns, explore misconceptions and needs for information, and form the basis for collaboration with physicians and other team members. For example, a seriously ill patient may ask the nurse, "Am I dying?" The nurse should avoid making unhelpful responses that dismiss the patient's real concerns or defer the issue to another care provider. In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind").

The nurse observes a serum albumin level of 2.50 g/dL in an older adult patient who lives at home alone. What does this level likely indicate? ○ A severe protein deficiency ○ Low levels of serum protein ○ An acceptable amount of protein ○ An extremely high measurement of protein

A severe protein deficiency Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficit in adults. Albumin synthesis depends on normal liver function and an adequate supply of amino acids. Because the body stores a large amount of albumin, the serum albumin level may not decrease until malnutrition is severe; therefore, its usefulness in detecting recent protein depletion is limited. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss owing to burns, major surgery, infection, or cancer.

For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? ○ Increased wakefulness ○ Increased eating ○ Increased restlessness ○ Increased urinary output

Increased restlessness Explanation: As the oxygen supply to the brain decreases, the patient may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.

A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss? ○ Preparation ○ Maintenance ○ Precontemplation ○ Contemplation

Preparation Explanation: This client is in the preparation stage, as the client is actively making changes to lose weight. During the precontemplation stage, the client is not even thinking about or considering making a change. During the contemplation stage, the client is considering making a change. During the preparation stage, the client has decided to make a change and is preparing for it. During the maintenance stage, the client attempts to maintain the change in lifestyle begun in an earlier stage.

A nursing student is learning to complete a focused abdominal assessment. She understands the necessity for altering the assessment skill sequence when examining this body region. Therefore, she will complete which skill after inspection? ○ Percussion ○ Light palpation ○ Auscultation ○ Deep palpation

Auscultation Explanation: The traditional sequence in the focused portion of the examination is inspection, palpation, percussion, and auscultation, except in the case of the abdomen. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.

Which of the following may be contained in an "emergency kit" for a hospice patient exhibiting restlessness? ○ Benzodiazepine ○ Oral sucrose ○ Laxative ○ Atropine sulfate drops

Benzodiazepine Explanation: A kit might contain small doses of oral morphine liquid for pain or shortness of breath, a benzodiazepine for restlessness, and an acetaminophen suppository for fever. Atropine sulfate drops may be used for excess respiratory secretions.

Which documentation example best reflects the complexity of client teaching by the nurse? ○ "Told client to take antibiotic as ordered" ○ "Client return demonstrated how to use glucometer" ○ "Taught client about peak flows; client verbalized understanding" ○ "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal"

"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal" Explanation: The nurse should document who the teaching was provided to, what was taught, the teaching method, and the evidence of learning. The other answer choices are not as comprehensive and, therefore, are not the best examples of teaching.

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? ○ "I can lower my blood pressure by losing weight" ○ "Osteoarthritis in my knees may be because of my weight" ○ "I can monitor my caloric intake by measuring portions" ○ "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week"

"I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week" Explanation: Blood pressure can be reduced with weight loss. Osteoarthritis may be caused by destruction of cartilage from the pressure on the knee joints caused by excessive weight. Measuring portions is essential to understanding caloric intake. Healthy weight loss is generally accepted as 1 to 2 lb (0.45 to 0.90 kg) per week, or a reduction of 500 to 1,000 calories per day, which includes decreased intake of foods and burning calories with exercise.

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment? ○ A 45-year-old female who is unsure of the benefit of psychiatric care, on a fixed income, and has good family support ○ A 51-year-old male who walks to most places because of a lack of transportation, has a low income, and works days ○ A 36-year-old male who uses public transportation, is unable to read, and wants to confer with a pastor ○ A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment

A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment Explanation: Cultural issues, a low income, poor family support, and lack of transportation are potential barriers to obtaining needed care. If a client must choose between work and keeping an appointment, scheduling is an important factor. The characteristics of a client who will keep appointments with specialists include those clients who have been well educated about the importance of the referral, understand the benefit to seeing a specialist, and will not have to struggle to keep the appointment. A client who agrees, who has input in scheduling, and shows curiosity or hope about the benefit of the referral is more likely to keep the appointment.

Which is important to remember when teaching adult learners? ○ A focus on the immediate application of new material ○ A need for support to reduce anxiety about new learning ○ That older students may feel inferior in terms of new learning ○ That all students, regardless of age, learn the same

A focus on the immediate application of new material Explanation: Adults need to be taught differently. Andragogy, the study of teaching adults, is based on several principles. One of the principals is that most adults' orientation to learning is that new material should be immediately applicable. All learners have some degree of anxiety with regard to learning and testing but all learners do not learn the same. Older students do not feel inferior to learning as many of them have life experiences that have allowed them to seek additional information pertinent to what they want to know.

Which describes the inability to recognize the values, beliefs, and practices of others because of one's strong ethnocentric preferences? ○ Acculturation ○ Cultural imposition ○ Cultural blindness ○ Cultural taboos

Cultural blindness Explanation: Cultural blindness is an inability to recognize the values, beliefs, and practices of others because of strong ethnocentric preferences. Cultural taboos are activities governed by rules of behavior that a particular cultural group avoids, forbids, or prohibits. Acculturation involves adapting to or taking on the behaviors of another group. Cultural imposition is an inclination to impose one's cultural beliefs, values, and patterns of behavior on people from a different culture.

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers? ○ Telling the mothers to avoid taking over-the-counter drugs while breastfeeding ○ Showing charts to the mothers that illustrate the types of breast milk ○ Observing a mother expressing the breast milk ○ Advising the mothers to drink plenty of water

Observing a mother expressing the breast milk Explanation: Observing is one of the levels of psychomotor skills, which involves watching an experienced person perform a physical skill. Telling, showing, and advising are examples of addressing the cognitive domain, which helps the mothers process information by listening or reading facts.

A nurse may attempt to help a client solve a situational crisis during what type of counseling session? ○ Long-term counseling ○ Motivational counseling ○ Short-term counseling ○ Professional counseling

Short-term counseling Explanation: Short-term counseling would help a client solve a situational crisis. A client experiencing a developmental crisis, for example, might need long-term counseling. Motivational counseling is an evidence-based counseling approach that involves discussing feelings and incentives with the client. Professional counseling is a general term.

The nurse has completed teaching. Which client behavior demonstrates understanding within the affective domain? ○ Provides return demonstration of use of an inhaler ○ States, "I feel comfortable using my walker" ○ Verbalizes key points of a brochure about diabetes that was read ○ Provides a description of how appropriate wound healing should look

States, "I feel comfortable using my walker" Explanation: A client's learning style refers to how a person prefers to acquire knowledge. Learning styles fall within three general domains: cognitive, affective, and psychomotor. The cognitive domain is a style of processing information by listening or reading facts and descriptions (such as verbalizing key points of a brochure or describing wound healing). The affective domain is a style of processing information that appeals to a person's feelings, beliefs, or values. The psychomotor domain is a style of processing information that focuses on learning by doing (such as demonstrating the use of an inhaler). In this scenario, the client has shown learning in the affective domain by expressing feelings.

As the moment of death approaches, which of the following does the nurse encourage the family to do? ○ Have the family sit in front of the client so they can be seen ○ Rub the client's hand and arm to comfort the client ○ Speak to the client in a calm and soothing voice ○ Lie next to the client and hold the client

Speak to the client in a calm and soothing voice Explanation: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

The nurse is providing care to a hospitalized client who is not sure what the health problem is or what will be done. The nurse teaches the client the "Ask Me 3" questions and tells the client to ask these questions when the primary care provider visits. What are the "Ask Me 3" questions? Select all that apply. ○ When will I be discharged? ○ What is my main problem? ○ What do I need to do? ○ Is this contagious? ○ Why is it important for me to do this? ○ Will I require surgery?

What is my main problem? What do I need to do? Why is it important for me to do this? Explanation: The "Ask Me 3" tool is intended to improve communication between the client and the health care provider. The three questions are: What is my main problem? What do I need to do? and Why is it important for me to do this? These three questions will provide the client with the most information. The other questions listed provide limited information.

A 90-year-old home care client's son has been designated to make decisions regarding the client's medical care when the client is no longer able to do so. As the client nears the end of life, the son is consulted on an ever-increasing basis. What legal instrument activates the son's decision-making designation? ○ durable power of attorney for health care ○ power of attorney ○ living will ○ designated signer

durable power of attorney for health care Explanation: A durable power of attorney (DPOA) for health care or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want to be implemented, avoided, or withdrawn and offers reassurance that others will carry out their wishes. Power of attorney is a legal term used in a different context. A living will is a written or printed statement describing a person's wishes concerning medical care and life-sustaining treatments that are wanted or unwanted in the event that a person is unable to personally make those decisions. Although a living will describes a person's wishes, it does not designate decision-making power to another person in the same was as a DPOA. Designated signer is not a term used in healthcare.

A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client? ○ "Let's take this one day at a time; remember you have your daughter's dance recital next week" ○ "You should seek a second medical opinion about your diagnosis" ○ "I believe that you will fight hard to beat this and see your babies grow up" ○ "I know another client with the same diagnosis who has been in remission for 10 years"

"Let's take this one day at a time; remember you have your daughter's dance recital next week" Explanation: Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism.

A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. ○ Palliative care ○ Radiation ○ Angiogenesis ○ Respite care

Palliative care Explanation: In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? ○ Inpatient respite care ○ Palliative care ○ Continuous care ○ General inpatient care

Palliative care Explanation: Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress? ○ Reinforcement ○ Motivation ○ Health promotion ○ Positive feedback

Positive feedback Explanation: Important keys to success when evaluating learning are consistent, immediate, and frequent positive reinforcement, and teaching a small number of skills at any one time, thus creating a high possibility that the learner will master them. Positive reinforcement is also known as positive feedback, which is what the nurse is providing in this case. Negative reinforcement or feedback would be attempting to change a client's behavior by pointing out and criticizing or even punishing mistakes or undesirable behaviors. Motivation refers to the client's desire to learn or make a change. Health promotion is a topic that may be covered in client teaching and that pertains to optimizing one's health through maintaining proper nutrition, exercise, and hygiene.

A nurse is assessing a client who has come to the clinic for a follow-up appointment. The client was diagnosed with asthma several months ago and has missed several appointments since that time. The client also has not been following the medication plan and has not kept the appointment for allergy testing. The nurse suspects that the client may be experiencing problems with health literacy. The nurse teaches the client about the condition and prescribed treatment. Which question from the nurse would help to assess the client's health literacy about the condition? ○ "Do you understand what asthma is?" ○ "How are you supposed to take your medication?" ○ "Are you having trouble getting your medications filled?" ○ "Do you have any questions about what you are supposed to do?"

"How are you supposed to take your medication?" Explanation: The teach-back method assesses health literacy, seeking to confirm that the learner understands the health information received from the health professional. The question about how to take the medication reflects this method. Clients and caregivers have the opportunity to repeat back to the health care provider the key points they understand from a teaching session. Asking whether the client understands, has questions, or is having trouble getting the medications are "yes" or "no" type questions, which do not allow the nurse to determine the client's ability to obtain, read, understand, and act on health information.

The nurse arrives to the home of a client with a terminal illness who has just passed away. Which response will the nurse make when the family member states that the last dose of pain medication provided caused the death? ○ "Do you remember what the medication was that you think caused the death?" ○ "It is likely that the medication caused the body systems to slow, which precipitated the death" ○ "There is always a chance that pain medication will cause death in a client with a terminal illness" ○ "It is possible that your family member died close to the time of the medication but the medication did not cause the death"

"It is possible that your family member died close to the time of the medication but the medication did not cause the death" Explanation: The nurse teaches the family caregivers about comfort measures and pain medications when caring for a dying client. At the end-of-life, clients may receive more frequent doses of pain medication; however, there is always a strong possibility that a client approaching end-of-life will die in close proximity to the time of the medication. It will not help to comfort family members if a nurse asks what medication was given last. Family members should be prepared for this possibility and be reassured that they did not cause the death of the client by giving a dose of the medication. The last dose of pain medication given to a dying client will not cause death. There is no evidence to support that the medication caused the body systems to slow which precipitated the death. There is also no evidence to support that pain medication will cause death in a client with a terminal illness.

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate? ○ "Tell me about what signs of infection you will report to the health care provider" ○ "I would like you to demonstrate how to change the dressing on your leg" ○ "Let's see how you irrigate the wound with saline" ○ "I notice that you do not have the dressing secured. Place a piece of tape on the wrap"

"Tell me about what signs of infection you will report to the health care provider" Explanation: Cognitive domain learning may be evaluated through oral questioning. The return demonstration is an excellent way of evaluating psychomotor domain learning. Providing an opportunity for and encouraging clients to change their own dressing, for example, provides concrete evidence of satisfactory or unsatisfactory performance of the procedure.

A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? ○ Participating in assisted suicide violates the Code of Ethics for Nurses ○ Nurses may administer medications prescribed by physicians to hasten end of life ○ A client has the right to make independent decisions about the timing of his or her death ○ Most states have enacted laws that allow for physician-assisted suicide

Participating in assisted suicide violates the Code of Ethics for Nurses Explanation: The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. Proponents of physician-assisted suicide argue that terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives and the timing and circumstances of their deaths. However, this is not the case at the present time. Two states have enacted legislation for physician-assisted suicide. These laws provide access to physician-assisted suicide by terminally ill clients under very controlled circumstances.

At which body mass index (BMI) value are patients considered to have increased risk for problems associated with poor nutritional status? ○ lower than 18.5 ○ between 25 and 29 ○ between 30 and 39.9 ○ higher than 40

lower than 18.5 Explanation: People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Additionally, higher mortality rates in hospitalized patients and community-dwelling elderly are associated with individuals who have low BMI. People who have a BMI 25-29 are considered overweight. People who have a BMI 30-39 are considered obese. People who have a BMI higher than 40 are considered morbidly obese.

A client 36 years of age is able to understand the health education when given the opportunity to put the education into practice. The nurse helps the client to self-administer the medication dosage before the client is discharged from the health care facility. Which domain correctly identifies the client's learning style? ○ Cognitive ○ Affective ○ Psychomotor ○ Interpersonal

Psychomotor Explanation: The client's learning style falls into the psychomotor domain, which is a style of processing that focuses on learning by performing what has been learned. The cognitive domain is a style of processing information by listening or reading facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values. The interpersonal domain is a style of processing that focuses on learning through social relationships.

At completion of a teaching session with a client, the nurse documents the details of this education encounter in the client's health record. What should another nurse be able to determine from reading this documentation? ○ The client's highest level of formal education achieved ○ The client's response to the health education that was provided ○ The client's long-term application of the health education ○ The client's prognosis for recovery

The client's response to the health education that was provided Explanation: The client's response to health education should be documented. The nurse should assess the client's learning style and education level prior to providing health education, but these are not necessarily documented in the health record. It would not be possible to identify the client's long-term application of the education or the prognosis for recovery from documentation completed immediately after the teaching.

Which observation during the nursing assessment of a client supports the documentation of low health literacy? ○ The client is provides a coherent health history ○ The client's health forms are complete ○ The client complies with the medication regimen despite financial difficulties ○ The client avoids health care screenings and seeks care in the local emergency department

The client avoids health care screenings and seeks care in the local emergency department Explanation: Lack of follow-up on tests and referrals, missing appointments (such as health care screenings), being unable to provide a coherent health history, having incomplete health forms, and exhibiting noncompliance with the medication regimen are indications that the client has low health literacy.

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply. ○ The nurse fails to accept that clients have the right to change their minds ○ The nurse negotiates goals with the client ○ The nurse uses medical jargon frequently when discussing the teaching plan ○ The nurse ignores the restrictions of the client's environment ○ The nurse evaluates what the client has learned ○ The nurse reviews educational media when planning learner objectives

The nurse fails to accept that clients have the right to change their minds The nurse uses medical jargon frequently when discussing the teaching plan The nurse ignores the restrictions of the client's environment Explanation: Common teaching mistakes made by health care professionals would include the following: the nurse failing to accept that clients have the right to change their minds; the nurse using medical jargon frequently when discussing the teaching plan; and the nurse ignoring the restrictions of the client's environment. The nurse does negotiate goals with the client. The nurse would evaluate what the client had learned. The nurse would review educational media when planning learner objectives.

The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: ○ care that will reduce the client's physical discomfort and manage clinical symptoms ○ care that is provided at the very end of an illness to ease the dying process ○ an alternative therapy that uses massage and progressive relaxation for pain relief ○ offered to terminally ill clients who wish to remain in their homes in lieu of hospice care

care that will reduce the client's physical discomfort and manage clinical symptoms Explanation: Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.

The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate? ○ "His moaning does indicate pain, so we'll increase his pain medication" ○ "The moaning you hear is from air moving over very relaxed vocal cords" ○ "He has secretions that are collecting at the back of the throat" ○ "He is getting less oxygen to the brain, so the moaning means he is dreaming"

"The moaning you hear is from air moving over very relaxed vocal cords" Explanation: As a client approaches death, certain signs appear. The family is reporting irregular breathing with periods of apnea. The moaning that they hear reflects the sound of air passing over very relaxed vocal cords. It does not signify pain or distress. Therefore, no additional pain medication would be needed. Secretions collecting at the back of the throat are noted by a rattling or gurgling sound. Decreased oxygen to the brain would lead to confusion, which may be reported by the client as strange dreams or visions.

A client is meeting with the nurse to discuss options for smoking cessation. Which statement by the nurse is most appropriate for this client? ○ "There are many options available. Which options have you previously tried?" ○ "What do you see as your biggest hurdle to stopping?" ○ "Some people find that reducing cigarette consumption slowly over time is an effective option" ○ "Most clients are successful when they use over-the-counter nicotine patches or gum"

"What do you see as your biggest hurdle to stopping?" Explanation: When counseling a client, the focus should be on assisting the client to make one's own decisions, finding ways to reach goals, and supporting the client. The nurse should never give advice, such as reducing cigarette consumption over time or using nicotine patches or gum. Asking open-ended questions that encourage the client to speak freely about the topic at hand and help define goals is the best option. Asking the client which options have previously been tried is a closed question and limits the response to a list of things the client has tried and would not encourage the client to share other information important to form a smoking cessation plan, such as a spouse that smokes.

A new client walking in to the health care center is actively wheezing and reports frequent episodes of wheezing. Based on the client's responses during the interview, the nurse suspects the client has a variety of food allergies. What nutritional assessment method should the nurse include in the plan of care? ○ A 3- to 7-day food record ○ Biochemical assessment ○ Nitrogen balance comparison ○ Body mass index (BMI) calculation

A 3- to 7-day food record Explanation: The food record is used most often in nutritional status studies. A 3- to 7-day food record can be used to associate allergic reactions with specific food intake. Physical measurements (BMI, waist circumference) and biochemical, clinical, and dietary data are used in combination to determine a client's nutritional status, but information obtained through these assessments will not help determine the possibility of allergies to food.

Which statement describes the person who is likely the most motivated to learn? ○ A 29-year-old male whose significant other is insisting on the client receiving the education ○ A 52-year-old male who has been hired to drive the client home from the clinic ○ A 70-year-old female who is the client's spouse and is learning the care so the client can come home ○ A 25-year-old female who just completed a course of physical therapy

A 70-year-old female who is the client's spouse and is learning the care so the client can come home Explanation: Adults learn best when the information given to them is something they need to use immediately, when they are strongly motivated to learn, and when they have an internal motivation to learn the topic. When the adult learner does not see the importance of the topic or has no emotional need to learn (such as the client who appears to be undergoing the education only at the insistence of the client's significant other), motivation is low. Motivation to learn may also be lacking if the adult learner has just reached completion of a major task, such as the client who just completed a course of physical therapy. The adult learner who is seeking knowledge to assist a loved one may be the most motivated. On the other hand, a stranger to the client who has just been hired to bring the client home from the clinic is the least likely to be motivated to learn.

A nurse has permission from the homebound client to educate any of the family members about providing care for the client. Which family member is the most appropriate choice? ○ A son who works full time and is trying to save time off for emergencies ○ A brother who visits daily, does laundry, and cooks all meals for the client ○ A sister who lives next door to the client and telephones for updates frequently ○ A daughter who is a registered nurse and lives in a different state

A brother who visits daily, does laundry, and cooks all meals for the client Explanation: The son is not available while at work, the sister lives physically close but is maintaining distance from the client, and the daughter lives too far away to be the person to provide care for the client. The client's brother shows interest in helping the client and would be the best choice to assess for readiness to learn to provide client care.

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care? ○ Asking only the client's parents to be present at the education session ○ Including a note about who was taught this new information in the client's chart ○ Assuring the client that the conversation is confidential except under extreme circumstances ○ Answering questions openly and honestly

Asking only the client's parents to be present at the education session Explanation: Peers are often more influential than parents, nurses, or teachers at this age. It is often appropriate to include a close friend in on the education session. The other answers are developmentally appropriate for a 15-year-old.

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate? ○ Assess for cultural differences ○ Boost the morale of the client ○ Delegate the health education to a colleague ○ Replace one-on-one teaching with written materials

Assess for cultural differences Explanation: When the client is having difficulty learning, it may be possible that the client does not understand the language that the nurse speaks. In such a case, the nurse should take the necessary steps to break the cultural barrier and then proceed with the education. Written materials can enhance many clients' learning, but will not necessarily overcome many of the common barriers to understanding, including cultural and linguistic factors. The nurse should take action to overcome any barriers to the learning process before delegating to a colleague. The client's morale is not pertinent to the client's difficulty understanding the teaching.

The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client? ○ Taught lesson at a school-age developmental level in an authoritarian style while the client was at meal time ○ Taught lesson at an adult developmental level (age 35) using short sentences and assessed motor skills ○ Assessed the client's understanding of health and answered questions on an age-appropriate level while the television was on in the room ○ Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification

Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification Explanation: Distractions to learning, such as the television being on or the client being at meal time, diminish the effectiveness of any education plan. An authoritarian style of teaching does not honor the client as a partner in the learning process. Age does not necessarily determine developmental stage. Assessing the client's developmental stage and understanding of the health problem, clarifying information that is difficult for the client to understand, and ensuring that the client is physically able to perform the task are all aspects of a well-planned education session for all clients.

A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client? ○ Assessing importance ○ Elicit-provide-elicit ○ Evoking change talk ○ Prioritizing

Assessing importance Explanation: Using the 0 to 10 scale is a key aspect of assessing importance with motivational interviewing. It helps the nurse to understand the client's feelings toward the recommended activity and can help start a conversation about why the client chose that rating number-and what the nurse could do to increase the number. In the elicit-provide-elicit strategy, the nurse elicits information from the client about a topic, provides teaching on the topic, and then further elicits information from the client. Evoking change talk is when the nurse presents a potential change to the client for consideration. Prioritizing is helping a client determine how to order one's priorities.

A nurse is preparing to educate about the importance of contraception and safe-sex practices to a group of college students. Which factors can affect the nurse's teaching strategies? Select all that apply. ○ Availability of resources ○ Learning style preferences of students ○ Literacy level of target audience ○ Family background of target audience ○ Economic status of target audience

Availability of resources Learning style preferences of students Literacy level of target audience Explanation: Availability of resources, learning style preference, and literacy level affect the planning of effective teaching strategies. Education sessions can be individual, small group, or large group sessions. The family background or the economic status of the target audience should not affect a nurse's teaching strategy because the nurse will be teaching the same thing to the entire group.

The nurse is caring for a client who is a recent immigrant. Which of the following variables should the nurse prioritize when performing an assessment of the client's cultural beliefs? ○ Client's previous medical history ○ Client's marital status ○ Client's age ○ Client's communication style

Client's communication style Explanation: Assessment of a client's culture should include the client's country of origin, language (communication style), food preferences or restrictions, health maintenance practices, and religious preferences and practices. This aspect of assessment does not explicitly include the client's support systems, marital status, or age, though each of these parameters would be assessed at different points.

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory? ○ Adaptive learning theory ○ Behavioral learning theory ○ Cognitive learning theory ○ Developmental learning theory

Cognitive learning theory Explanation: Cognitive learning theory is the result of people wanting to make sense of the world around them by assimilating and processing information to gain new understandings and insights. Developmental learning theory focuses on considering the client's physical maturation and abilities, psychosocial development, and cognitive capacity when providing education. Behavioral learning theory focuses on how one learns and unlearns behaviors. Adaptive learning theory explains how learning is optimized when teaching is adapted to the particular learning style of the learner.

When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard? ○ Dull sound ○ Flat sound ○ Resonant sound ○ Tympanic sound

Dull sound Explanation: The sound produced reflects the density of the underlying structure. Certain densities produce sounds as percussion notes. These sounds, listed in a sequence that proceeds from the least to the densest, are tympany, hyperresonance, resonance, dullness, and flatness. Tympany is the drum-like sound produced by percussing the air-filled stomach. Hyperresonance is audible when one percusses over inflated lung tissue in a person with emphysema. Resonance is the sound elicited over air-filled lungs. Percussion of the liver produces a dull sound, whereas percussion of the thigh produces a flat sound.

A new client comes into the urgent care center with the spouse with a report of severe itchy rash with small blisters on the arms and hands. The nurse is documenting assessment data for the client. What is the nurse's best assessment action? ○ Ask the spouse about know allergies ○ Ask the client about known allergies ○ Make an open-ended statement to the client to elicit the history of the rash ○ Make an open-ended statement to the spouse to elicit the history of the rash

Make an open-ended statement to the client to elicit the history of the rash Explanation: The best source of assessment information for the nurse is the client. Nursing care is individualized to the needs of the client. In emergency situations, other sources might be used, such as family and friends. The rash could be due to an allergic reaction; however, asking a closed question about a specific topic will result in a list of responses and limit the information shared by the client, family member, or friend. Making an open-ended statement, such as, "tell me about this rash," will give the client the opportunity to share everything the client knows about the rash, such as when it was first noticed, if it spread, and what home treatment the client has tried.

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client? ○ Motivational ○ Long-term ○ Developmental ○ Situational

Motivational Explanation: Motivational counseling involves discussing feelings and incentives with the client. Long-term counseling extends over a period of time. Developmental counseling occurs when a client is going through a developmental stage or passage. Situational counseling occurs when a client faces an event or situational crisis.

A client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client? ○ Barbiturate coma ○ Palliative sedation ○ Conscious sedation ○ Patient-controlled analgesia

Palliative sedation Explanation: Effective control of symptoms can be achieved under most conditions; however, some clients may experience distressing, intractable symptoms and other clients may be incapacitated. Although palliative sedation remains controversial, it is offered in some settings to clients who are close to death or who have symptoms that do not respond to conventional pharmacologic and nonpharmacologic approaches, resulting in unrelieved suffering. Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Proportionate palliative sedation uses the minimum drug necessary to relieve the symptom while preserving consciousness, whereas palliative sedation induces unconsciousness, which is more controversial. Barbiturate coma is a technique used to induce a coma in clients with specific conditions. Conscious sedation is used for some diagnostic tests and procedures. Clients who are incapacitated are not likely candidates for patient-controlled analgesia.

The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation? ○ Sit with the client's daughter privately and encourage her to express her feelings frankly ○ Remind the daughter of the client's impending death and the importance of expressing herself ○ Remain focused on the client's needs and care because these are your main responsibilities. ○ Insist that the daughter try her best to make the client's final days happy ones

Sit with the client's daughter privately and encourage her to express her feelings frankly Explanation: Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation. Although the client is the nurse's main priority, it is the nurse's role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? ○ The client describes signs and symptoms of hypoglycemia ○ The client demonstrates proper technique for injecting insulin ○ The client expresses a desire to improve nutritional intake and lose weight ○ The client prepares the skin for the administration of an insulin injection

The client describes signs and symptoms of hypoglycemia Explanation: The client's ability to describe the signs and symptoms of hypoglycemia demonstrates cognitive learning (the storing and recalling of new knowledge in the brain). Demonstrating a skill, such as insulin injection, is an example of psychomotor learning. Affective learning includes changes in attitudes, values, and feelings (e.g., desire to lose weight).

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill? ○ The client states understanding and passes a written test ○ The client organizes materials needed and gives return demonstration ○ The client verbalizes items needed and how to perform the skill ○ The client nods when asked about process and assists with cleanup

The client organizes materials needed and gives return demonstration Explanation: Confirmation that a client has learned a skill requires more than the client verbalizing understanding, passing a written test, nodding, or assisting with cleanup. Being able to gather all equipment needed for a skill and then perform it demonstrates proficiency.

The nurse is caring for a client who just learned of a terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? ○ The principle of justice ○ The principle of nonmaleficence ○ The principle of fidelity ○ The principle of autonomy

The principle of autonomy Explanation: By promoting open discussion and informed decision making, the nurse is empowering the client to make decisions independently. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.

The nurse will be caring for a client with a new diagnosis of hypertension. The client will be arriving for laboratory testing. When should the nurse begin client teaching? ○ during the admission process ○ after testing is completed ○ when results are available ○ immediately prior to discharge

during the admission process Explanation: Limited hospitalization time demands that nurses begin teaching as soon as possible. The client should be educated during the process of admission regarding what to expect, client rights, etc. The client should be educated prior to diagnostic testing. Although the client may require additional education when the test results become available, education should begin earlier. Waiting until immediately prior to discharge to begin teaching does not give the opportunity for return demonstration or to adequately determine whether the education was successful.

A nurse is showing an older adult client with severe diabetes the correct method of self-administering an insulin injection. What comment(s) is acceptable if the client continues making mistakes when learning how to self-administer an insulin injection? Select all that apply. ○ "Why are you repeatedly holding the injection at the wrong angle?" ○ "First-time learners often have this same concern" ○ "You have just about figured out how to give yourself an injection" ○ "It will be better if you ask someone responsible to administer the injection" ○ "Try to angle the syringe a little more this way"

"First-time learners often have this same concern" "You have just about figured out how to give yourself an injection" "Try to angle the syringe a little more this way" Explanation: Many adults are intimidated by learning a new skill, so encouragement and praise almost always improve performance. Comments such as, "Lots of people have that same concern" will help the client to feel less isolated. Positive corrective feedback such as, "You've just about figured out how to give yourself an injection; now, angle the syringe a little more this way," acknowledges and reinforces learning accomplishments, but at the same time provides significant correction to facilitate a better performance. Negative comments such as, "Why are you repeatedly holding the injection at the wrong angle?" or "It will be better if you ask someone responsible to administer the injection," will only make the client feel more nervous and intimidated.

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn? ○ "May I have something to eat?" ○ "The pain in my chest has gone" ○ "I am having difficulty breathing" ○ "Finally, I am getting medical attention"

"I am having difficulty breathing" Explanation: The statement "I am having difficulty breathing" indicates that the client is not physically well and that the client is unable to learn effectively until comfort is restored. "The pain in my chest has gone" and "May I have something to eat?" is suggesting that the client is physically well and is ready to learn. "Finally, I am getting medical attention" is suggesting that the client is psychologically ready to learn.

Which statement(s) by the nurse could be a barrier to a nurse-client relationship? Select all that apply. ○ "I slept poorly last night because of the storm too" ○ "Your previous nurse should have applied the ointment to your wound when the dressing was changed" ○ "I am sorry for the delay. The client in the next room had a seizure" ○ "I will assist you to the bathroom after I complete vital signs on the rest of the clients" ○ "Can you tell me that story when I am not so busy?"

"I slept poorly last night because of the storm too" "Your previous nurse should have applied the ointment to your wound when the dressing was changed" "I am sorry for the delay. The client in the next room had a seizure" "I will assist you to the bathroom after I complete vital signs on the rest of the clients" "Can you tell me that story when I am not so busy?" Explanation: All of the nursing statements are inappropriate and would be a barrier to a positive nurse-client relationship. The nurse does not share personal problems with the client. The nurse does not gossip about other staff members, particularly to indicate if the staff member failed in performance. The nurse does not reveal confidential information about other clients. It is not necessary for a client to know about others' health problems. The nurse does not want to be inattentive to the client's request, such as assistance with toileting. By focusing on a task, such as the vital signs of other clients, the nurse minimizes the importance of this client. The nurse does not show a lack of interest in what the client is saying. This action also minimizes the importance of the client.

A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse? ○ "I can't do that, I will go to jail" ○ "I am surprised that you would ask me to do something like that" ○ "I will see if the physician will order enough for that to occur" ○ "I will notify the physician that the current dose of medication is not relieving your pain"

"I will notify the physician that the current dose of medication is not relieving your pain" Explanation: Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Palliative sedation is most commonly used when the patient exhibits intractable pain, dyspnea, seizures, or delirium, and it is generally considered appropriate in only the most difficult situations.

A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning? ○ "I'm starting to see how my lifestyle has caused me to end up here" ○ "I understand why they're not letting me eat anything for the time being" ○ "My intravenous drip will keep me from getting dehydrated right now" ○ "I can see how things could have been much worse if I hadn't gotten to the hospital when I did"

"I'm starting to see how my lifestyle has caused me to end up here" Explanation: The client's understanding of the client's own contribution to the problem demonstrates a shift in attitude and feelings that is characteristic of affective learning. Understanding the treatment, course, and prognosis of the illness are aspects of cognitive learning.

A client has a newly diagnosed heart murmur. During the nurse's subsequent health education, he asks if he can listen to it. What would be the nurse's best response? ○ "Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur" ○ "Listening is called palpation, and I would be glad to help you to palpate your murmur" ○ "Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction" ○ "If you would like to listen to your murmur, I'd be glad to help you and to show you how to use a stethoscope"

"If you would like to listen to your murmur, I'd be glad to help you and to show you how to use a stethoscope" Explanation: Listening with a stethoscope is auscultation and it is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs, whereas the bell is used to assess low-frequency sounds such as diastolic heart murmurs. It is also important to provide education whenever possible and actively include the client in the plan of care. Teaching an interested client how to listen to a murmur should be encouraged. Many heart murmurs are benign and do not require surgery.

A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? ○ "It will hasten the death of the patient" ○ "It will prolong life in a dignified manner" ○ "It will use artificial means of life support if the patient requests it" ○ "It will enable the patient to remain home if that is what is desired"

"It will enable the patient to remain home if that is what is desired" Explanation: The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means.

A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give? ○ "Why do you think that?" ○ "Did someone tell you that you are dying?" ○ "Tell me more about what's on your mind" ○ "I am not at liberty to disclose that information"

"Tell me more about what's on your mind" Explanation: In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind"). The nurse then needs to listen intently, ask additional questions for clarification, and provide reassurance only when it is realistic.

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client? ○ "Your doctor wants you to take your warfarin every day, go to the clinic every week to have blood drawn, and then wait for any dosage change. Do you understand?" ○ "You have to take your warfarin and go to the clinic every week for a blood draw. It's not the most convenient way to live, but you have to do it." ○ "The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?" ○ "Atrial fibrillation is when your upper heart beats ineffectively and blood clots can go to your brain. Would you like some printed information about this?"

"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?" Explanation: Adults learn best when the information given to them will be used immediately, is presented as important to the client, and when the client's autonomy is preserved. As with all learners, the teaching approach must reflect respect for what the client already knows. By presenting the facts in a way that gives the client control over a health alteration, and by assessing current knowledge, these qualities that are important to forming a learning plan for an adult are met. When education plans take control out of the client's hands (such as stating the doctor wants compliance) or when the lifestyle change is presented as a burden, motivation may be low. If the nurse shows interest in working with and discussing issues with the client, a partnership is formed that can boost motivation.

While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse? ○ "Use words that begin with 'f,' 's,' 'k,' and 'sh' to communicate" ○ "Use flash cards and writing pads" ○ "Limit communication to avoid frustration" ○ "Encourage family members to increase their vocal pitch"

"Use flash cards and writing pads" Explanation: Using flash cards and writing pads to communicate is a good substitute for verbal instructions for persons with hearing impairment. Speaking words that begin with "f," "s," "k," and "sh" typically requires forming high-pitched sounds, which are difficult for clients with hearing impairment to discriminate. Do not limit communication, because it will alienate the client from family and friends. Lowering (rather than increasing) the vocal pitch is better, as hearing loss is generally in the higher pitch ranges.

A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate? ○ "What do you know about support groups?" ○ "Support groups are for people like you who are depressed" ○ "I am sure you would feel better if you joined a support group" ○ "I am going to sign you up for a support group"

"What do you know about support groups?" Explanation: By asking the client an open-ended question the nurse can find out what the client knows about support groups. With the client's permission, the nurse can further educate on this topic. The nurse should acknowledge the client's ability to accept or reject the material to empower the client and lead to more healthy decision-making. The nurse cannot make the decision for the client by signing the client up for a support group. Although frustrating, the choice to follow suggestions in the end is the client's and the nurse must respect it as such. The nurse who states emphatically that the nurse is correct and that the client's views are misguided and skewed loses all credibility and influence. The nurse should be nonjudgmental and nonthreatening and should not be more assertive than the client. However, the nurse should listen carefully to what the client values and work from there. Each type of support group has different goals and values.

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response? ○ "After I demonstrate it once, your mother will be able to do it" ○ "When 15 minutes have passed, I will ask your mother to show me how to instill the drops" ○ "We can never be completely sure that your mother understands instructions" ○ "I will have you bring your mother back next week to see how things are going"

"When 15 minutes have passed, I will ask your mother to show me how to instill the drops" Explanation: Older clients may interact in a socially appropriate manner and may indicate that they understand the material being taught. Asking a client to recall what has been discussed after approximately 15 minutes have passed may help determine what information has actually been retained. Saying that the client will understand what to do after observing the nurse demonstrate the skill is not necessarily true and does not address the daughter's concern. Waiting a week to determine whether the client understands the teaching is too late, as the client must begin using this skill before then.

The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? ○ "Let me document that you can walk" ○ "Those physical therapists work wonders" ○ "You have made an amazing recovery" ○ "Are you supposed to be out of the wheelchair?"

"You have made an amazing recovery" Explanation: Reinforcement of learning shows that the nurse supports and wants to encourage the client. Giving credit where it is due communicates these values. Documenting is necessary, but stating this does not show interest in the client's progress. Crediting the therapists does not encourage the client. Asking about permission to ambulate negates the goal for improving wellness.

A 25-year-old client with cancer who is experiencing unrelieved pain rated a 9 on the pain scale requests that the hospice nurse induce a state of unconsciousness until the client dies. Which statement by the nurse demonstrates an understanding of a key difference between conscious sedation and euthanasia? ○ "I cannot legally administer pain medications that will induce unconsciousness to relieve your pain" ○ "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death" ○ "Total sedation is a commonly practiced method used in this situation; I will contact your physician and begin treatment as soon as possible" ○ "I need to perform a complete pain assessment to confirm the amount of pain you are experiencing before recommending sedation"

"Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death" Explanation: When a terminally ill client or the client's legal proxy requests palliative sedation, the use of pharmacologic agents to induce sedation or near sedation when symptoms have not responded to other management measures), the purpose is not to hasten the client's death but to relieve intractable symptoms. Palliative sedation may be controversial, but it is not illegal. Total sedation is rarely indicated in hospice care to provide comfort. Continuous pain assessments are not indicated at this stage; the client requires intervention/treatment.

People are at increased risk for problems related to poor nutritional status if they have a BMI lower than ○ 18.5 ○ 25 ○ 29.9 ○ 30

18.5 Explanation: People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at risk for problems associated with poor nutritional status.

Which client would be the best candidate for the nurse to engage in motivational interviewing? ○ A 38-year-old client training to walk a half marathon ○ A 44-year-old client who brought a food log to weight loss counseling ○ A 66-year-old client who is showing improvement in range of motion ○ A 28-year-old client with elevated blood glucose for 8 months

A 28-year-old client with elevated blood glucose for 8 months Explanation: Clients who are working on improving their health and physical condition are already motivated and do not need motivational interviewing, such as the client who is training to walk a half marathon, the client who brings a food log to weight loss counseling, and the client who is showing improvement in range of motion. However, a client who has not shown positive changes in months, such as the client whose blood glucose level has remained elevated for 8 months, may benefit from motivational interviewing. The client's age has no bearing on whether the client would be a good candidate for motivational interviewing.

A nurse caring for clients in a skilled nursing facility assesses client motivation to participate in care. Based on the health belief model, which clients would be most motivated? Select all that apply. ○ A client who does not view oneself as susceptible to the disease ○ A client who views a disease as a serious threat ○ A client who believes there are actions that will reduce the probability of contracting the disease ○ A client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself ○ A client who believes that noncompliance is not an option ○ A client who believes that doing nothing is preferable to painful treatments

A client who views a disease as a serious threat A client who believes there are actions that will reduce the probability of contracting the disease A client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself Explanation: The individuals who would be most motivated to participate in care based on the health belief model would be a client who views a disease as a serious threat, a client who believes that there are actions that will reduce the probability of contracting the disease, and a client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself. Clients who would not be as motivated to participate in care include the client who does not view oneself as susceptible to the disease; the client who believes that noncompliance is not an option; and the client who believes that doing nothing is preferable to painful treatments.

The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? ○ Perform surgery to remove the tumor from the brain ○ Begin radiation therapy to prevent cellular growth ○ Obtain a biopsy to analyze the lymph nodes ○ Add haloperidol to the client's treatment plan

Add haloperidol to the client's treatment plan Explanation: Haloperidol may reduce hallucinations. Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Biopsy is used to analyze the lymph nodes or to destroy the tissues surrounding the tumor.

Based on the most common concern of a dying patient, the hospice nurse should: ○ Administer pain medication on a schedule that prevents pain from intensifying ○ Position the patient to prevent difficulties with breathing ○ Offer supplemental fluids to prevent dehydration ○ Turn the patient every 2 hours to prevent decubitus ulcers

Administer pain medication on a schedule that prevents pain from intensifying Explanation: Pain management is the most common concern for the dying patient. Medication should be given on a PRN schedule that keeps the patient comfortable.

How can a nurse improve his or her transcultural sensitivity and demonstrate culturally competent nursing care? ○ All of the responses are correct ○ The nurse can learn to speak a second language ○ The nurse can become familiar with physical differences among ethnic groups ○ The nurse can perform a cultural and health beliefs assessment and plan care accordingly

All of the responses are correct Explanation: Culturally sensitive nursing care is evidenced by examining your personal beliefs, communication habits, and healthcare practices.

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? ○ Allows for the nurse to facilitate the grieving process ○ Allows for the nurse to take the client through in the appropriate order ○ Allows for the nurse to understand when the grieving process should be concluded ○ Allows the nurse to express his or her feelings

Allows for the nurse to facilitate the grieving process Explanation: Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? ○ Denial ○ Anger ○ Bargaining ○ Acceptance

Anger Explanation: Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.

The client has Alzheimer disease and is a new admission to the nursing home. The client was transferred from the hospital. When first meeting the client, what technique(s) will the nurse use to facilitate communication with this client? Select all that apply. ○ Approach the client from the front of the client ○ Call the client by the client's preferred name ○ Use simple words and short sentences when talking with the client ○ Correct the client when the client communicates erroneous information ○ Fill in information when the client has difficulty answering questions

Approach the client from the front of the client Call the client by the client's preferred name Use simple words and short sentences when talking with the client Explanation: When communicating with a client who has Alzheimer disease, the nurse must use techniques that will facilitate communication. The nurse will approach from the front of the client to obtain the attention of the client. Coming from the side or the back of the client may startle or agitate the client. Using the client's preferred name will also gain the client's attention. The nurse will use simple words and short sentences to allow the client to understand the nurse. The nurse must show patience and allow the client time to respond. The client may have difficulty finding the correct words or expressing thoughts. Correcting the client or providing information may confuse or agitate the client even more.

The nurse is teaching a client with diabetes how to inject daily insulin. Which method is most effective in evaluating the teaching? ○ Ask the client to repeat the steps of injection in order ○ The nurse uses a brochure to explain how to give an injection ○ Ask the client to demonstrate how to self-inject the morning insulin ○ Provide a teaching session that includes a question and answer discussion

Ask the client to demonstrate how to self-inject the morning insulin Explanation: By using the teach-back method, the nurse teaches and demonstrates a skill, then the client returns the skill as if teaching the nurse how it is done. This is an effective way to determine the client's ability to independently perform a skill. Asking the client to repeat the steps is good, but self-administering the injection is a better indicator. A brochure could be used as a teaching aid, but it is not the most effective means of determining if the client can perform the skill. Providing a teaching session that includes questions and answers should be done; however, the client should demonstrate the skill.

The nurse is caring for a 70-year-old client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught? ○ Observe the change in client's behavior for a month ○ Ask the client to recall after approximately 15 minutes ○ Test the client on the health education and information imparted ○ Ask the client to administer the doses of drug himself

Ask the client to recall after approximately 15 minutes Explanation: Asking a client to recall what has been discussed after approximately 15 minutes helps determine what information the client has actually retained. Observing the change in the client's behavior for a month is not feasible or timely. Testing the client on the health education and information imparted would be time-consuming and unnecessarily involved. Asking the client to self-administer the doses of drug (if even appropriate) would help demonstrate the client's understanding of how to actually administer the drug but not any other aspect of teaching related to a fracture.

The nurse is caring for a 5-year-old child on the pediatric unit. Which activities would promote the psychomotor skills of this child? Select all that apply. ○ Labeling a diagram ○ Assembling blocks ○ Identifying the caregiver ○ Watching television ○ Building a house with popsicle sticks ○ Removing the toys from the toy box

Assembling blocks Building a house with popsicle sticks Removing the toys from the toy box Explanation: Assembling blocks, building a house with popsicle sticks, and removing toys from the toy box are examples of activities that promote psychomotor skills. Labeling a diagram and identifying the caregiver promotes cognitive skills of a 5-year-old child. Watching television does not promote psychomotor skills because it is a stagnant activity.

A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply. ○ Available resources ○ Learning style preferences ○ Literacy level ○ Size of family ○ The client's job

Available resources Learning style preferences Literacy level Explanation: Availability of resources, learning style preference, and literacy level affect the planning of effective teaching strategies. The size of family and client's job would not be factors which the nurse should prioritize when planning this teaching session. They would only be considered if the nurse determined they could affect the outcome of the teaching session.

Which action(s) will the nurse take when preparing for and conducting a teaching session for clients with visual impairment? Select all that apply. ○ Using color print on white paper ○ Avoiding standing in front of the clients ○ Increasing the volume of the microphone ○ Avoiding the use of materials printed on glossy paper ○ Using a lamp that shines over the clients' shoulders ○ Ensuring that the clients are wearing prescription eyeglasses

Avoiding the use of materials printed on glossy paper Using a lamp that shines over the clients' shoulders Ensuring that the clients are wearing prescription eyeglasses Explanation: The nurse should avoid using materials printed on glossy paper, because glossy paper reflects light, causing a glare that makes reading uncomfortable. The usage of a lamp that shines over the clients' shoulders concentrates light on a small area where the clients need to focus. Ensuring the clients are wearing prescription eyeglasses will maximize their ability to perceive sensory stimuli. The usage of color print on white paper provides minimum contrast and makes letters more illegible. Standing in front of the client enhances learning. Increasing the volume of the microphone does not compensate for reduced vision.

The parents of an infant with apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents? ○ Educational levels ○ Home environment ○ Infant bonding ○ Baseline knowledge of these concepts

Baseline knowledge of these concepts Explanation: Before educating parents on the apnea monitor and cardiopulmonary resuscitation, the nurse should determine the parents' baseline knowledge so that the nurse knows where to begin. Educational level would be the next assessment in order to plan the appropriate teaching delivery method. Infant bonding and the parents' home environment are less relevant to this scenario.

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client? ○ Refer the client to internet resources on proper bowel health ○ Have the client join a small group of other clients with the same problem and facilitate group discussions ○ Begin the session with a reference to the client's actual experience ○ Talk to the client's relatives and get a detailed account of the client's history

Begin the session with a reference to the client's actual experience Explanation: Beginning the session with a reference to the client's actual experience will help provide a link to which the new learning can connect. Although it may be appropriate to refer the client to online resources on proper bowel health, to encourage the client to join a support group, and to consult the client's family regarding the client's history, the nurse should first engage with the client to find out the client's experience and specific issues.

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching? ○ Blocking 30 minutes of time for skill teaching ○ Using dolls to demonstrate psychomotor skills ○ Ensuring the client's parents are present ○ Giving stickers as a reward for task completion

Blocking 30 minutes of time for skill teaching Explanation: Preschool age children (2 to 5 years) have short attention spans. Five- to ten-minute blocks of time are age appropriate. A 30-minute block is more appropriate for an older client. The other answers are developmentally appropriate for a 4-year-old.

Which is an essential component of the definition of learning? ○ Increases self-esteem ○ Decreases stress ○ Can be measured ○ Requires formal education

Can be measured Explanation: Learning is the process by which a person acquires or increases knowledge, or changes behavior in a measurable way, as a result of an experience. Learning does not directly decrease stress, impact self-esteem, or require formal education.

What word or phrase best describes an effective counselor? ○ Technically skilled ○ Knowledgeable ○ Practical ○ Caring

Caring Explanation: An effective counselor needs to be a caring individual with the interpersonal skills of warmth, friendliness, openness, and empathy. Having knowledge and being technically skilled are effective traits for teaching but not for counseling. Being practical is related to doing something or using something rather than to theory and ideas, which does not suit the compassionate functionality of an effective counselor.

Which statement about providing client education before discharge is most accurate? ○ Client education focuses on identified home needs ○ Client education opens up communication with the community ○ Standardized plan of care is emphasized in client education ○ A client's beliefs and culture can hinder the success of education

Client education focuses on identified home needs Explanation: Client education is a therapeutic relationship that should focus on the client's specific needs. A client's educational needs can differ; educational needs change with acute or chronic conditions, short- or long-term health conditions, or ones that will require temporary or long-term adjustments to client lifestyles. Clients also have unique values, beliefs, cognitive abilities, and preferential ways of learning that affect involvement and educational outcomes that are unique to each client. Allowing clients to share their beliefs, culture, and preferences enables nurses to better understand this uniqueness and to individualize education to the client's needs.

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? ○ Physician's orders ○ Client's goals ○ Length of required treatment ○ Invasiveness of the treatment

Client's goals Explanation: When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs. Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.

Based on research, which health beliefs are critical for client motivation? Select all that apply. ○ Clients view themselves as susceptible to the disease in question ○ Clients view the disease as a serious threat ○ Clients believe there are actions they can take to reduce the probability of contracting the disease ○ Clients believe that the risks of taking these actions are greater than the risks posed by the disease itself ○ Clients view themselves as victims of the disease in question

Clients view themselves as susceptible to the disease in question Clients view the disease as a serious threat Clients believe there are actions they can take to reduce the probability of contracting the disease Explanation: A client's health beliefs can have great influence on motivation. The health belief model identifies several health beliefs as critical for client motivation. Motivation is enhanced when clients view themselves as susceptible to the disease in question; when clients view the disease as a serious threat; when clients believe there are actions they can take to reduce the probability of contracting the disease; when clients believe the risks of taking these actions are not as great as the risks posed by the disease itself. If a client views oneself as a victim of the disease, the client is practicing passive influence—this is not a part of the health belief model constructs.

Which of the following remains the greatest barrier to improving end-of-life care? ○ Advances in technology available to prolong life ○ Clinician's attitudes toward the terminally ill ○ Client and family denial about the seriousness of terminal illness ○ Focus on managing acute illness to achieve a cure

Clinician's attitudes toward the terminally ill Explanation: The greatest barrier to improving care at the end of life is the clinicians' attitude toward the terminally ill and dying. Clinicians' reluctance to discuss disease and death openly with clients stems from their own anxieties about death and misconceptions about what and how much clients want to know about their illness. Technological advances for prolonging life have led to numerous ethical issues, but these issues have affected all aspects of end-of-life care--for example, how clinicians care for the dying, how family and friends participate in care, how families prepare for terminal illness and death, and how they feel after the death of a loved one. Client and family denial may be considered a barrier, but denial often is considered a useful coping mechanism. The management of acute illness to achieve a cure reflects the sociocultural context of death and dying in America setting up a cure/care dichotomy. However the focus is shifting to include a care-focused perspective for healing.

A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating? ○ Affective ○ Cognitive ○ Psychomotor ○ Emotional

Cognitive Explanation: Cognitive learning involves storing and recalling new knowledge in the brain. Cognitive learning may be evaluated through oral questioning. Affective learning involves a person's feelings or emotions about the attitude object. Psychomotor learning is demonstrated by physical skills such as movement, coordination, manipulation, and dexterity. Emotional learning is the process through which children and adults acquire and effectively apply the knowledge, attitudes, and skills necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, and establish and maintain positive relationships.

When deciding what information the client needs to meet the learner objectives successfully, the nurse is formulating which part of the teaching plan? ○ Content ○ Teaching strategies ○ Learning activities ○ Learning domains

Content Explanation: The nurse is planning the content when the nurse decides what information the client needs to meet the learner objectives successfully. To ensure the teaching was effective, the nurse would include teaching strategies. The learning activities would be designed by the nurse to meet the needs of the client. Learning domains—including cognitive, affective, psychomotor—are the different types of learning. Psychomotor is physical or kinesthetic based. Cognitive is knowledge based. Affective is feeling or emotion based.

A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. ○ Control the client's pain with prescribed medication ○ Advise the client's health care provider of the client's condition ○ Comfort the client by saying it will all be over soon ○ Encourage the client to explain his or her wishes ○ Recommend that the client consider physician-assisted suicide

Control the client's pain with prescribed medication Advise the client's health care provider of the client's condition Encourage the client to explain his or her wishes Explanation: This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.

Which of the following terms refers to Leininger's description of the person's inability to recognize his or her own values, beliefs, and practices and those of others? ○ Culture ○ Minority ○ Cultural blindness ○ Subculture

Cultural blindness Explanation: Leininger's description of cultural blindness is the person's inability to recognize his or her own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Leininger was the founder of the specialty called transcultural nursing and advocated culturally competent nursing care. Minority refers to a group of people whose physical or cultural characteristics differ from the majority of people in a society. Subculture refers to a group that functions within a culture.

Which of the following is an appropriate method of assessing the dying client? ○ Stimulate the client every 30 minutes ○ Focus on the client's basic needs ○ Repeat assessments as necessary ○ Sedate the client before completing range-of-motion exercises

Focus on the client's basic needs Explanation: Initially, nurses focus assessment on the client's basic physical needs, such as pain, breathing, nutrition, hydration, and elimination. The other options are inappropriate in the assessment of the dying client.

The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement? ○ Provide brochures about low-sodium foods ○ Ask a family member to do meal planning to alleviate the burden for the client ○ Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray ○ Have the client repetitively choose appropriate foods from various menus

Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray Explanation: Those who represent Generations X, Y, and Z may share many learning characteristics. They are or will be technologically literate, having used or grown up with computers, smart phones, and tablet devices. Therefore, it is most appropriate to teach them using some form of multimedia, such as a phone app. The other teaching approaches are less appropriate for this client population.

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan? ○ Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique ○ Discussed wet-to-dry dressing changes, and client stated understanding ○ Spouse taught to flush feeding tube before and after medication. Denied further instruction needed ○ Lecture provided about infection, and client stated understanding what infection is

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique Explanation: Documentation of teaching must include who was taught, the topic taught, and some indication of the success of the learning plan beyond a simple verbal statement by the client. Only the answer with a mother being taught cord care and then performing return demonstration is complete.

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain? ○ Demonstrating the technique for insulin self-injection ○ Describing the signs and symptoms of low blood sugar ○ Explaining what to do if hypoglycemia occurs ○ Reviewing with the client appropriate foods to eat

Demonstrating the technique for insulin self-injection Explanation: The psychomotor domain involves skill performance. In this case, demonstrating the insulin self-injection technique would apply. Describing signs and symptoms, explaining what to do if hypoglycemia occurs, and reviewing appropriate food choices are appropriate for the cognitive domain.

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? ○ Tell the client how to move the walker as the client ambulates ○ Explain how the walker supports the client's lower extremities ○ Fully discuss the rationale for using the walker ○ Describe how the walker can improve the client's quality of life

Describe how the walker can improve the client's quality of life Explanation: Motivating the older adult client can be done by showing the client how the new knowledge will improve the client's quality of life, regardless of how long that may be. It will also demonstrate how the new knowledge could improve the client's level of independence. Although demonstrating the use of the walker and explaining how the walker assists with ambulation (and the rationale for its use) can be used to educate the client, these actions would not promote motivation for the client to learn.

A nurse is designing an education program for individuals who have recently immigrated from Iraq. Which consideration is necessary for culturally competent client education? ○ Use materials developed previously for citizens ○ Use all visual materials when teaching content ○ Use a lecture format to teach content with few questions ○ Develop written materials in the client's native language

Develop written materials in the client's native language Explanation: With changes in society, nurses are faced with the challenge of teaching clients from different cultural and ethnic backgrounds. One of the strategies is to develop written materials in the native language of the client. Using a lecture format to teach content is a very passive teaching strategy. Using materials previously developed and using visual materials may be easy for the nurse when teaching but the key here is teach with the native language of the client.

The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports barriers to each action and continues to smoke. What is the best action of the nurse? ○ Inform the client that the results are disappointing ○ Refer the client for cognitive behavioral therapy ○ Discuss the client's case with a colleague ○ Inform the client that the client will be unable to quit without medication

Discuss the client's case with a colleague Explanation: The focus is not to have the client please the nurse, but to improve client health behaviors. Telling a client that the client's efforts are disappointing is not an effective communication technique and can result in disruption of the therapeutic trust relationship between the nurse and client. The client does not necessarily need therapy just because initial attempts have been unsuccessful. The client desires not to have medication, so arranging for medications goes against the client's wishes in the plan of care. A colleague may shed light on additional actions based on experience with similar issues in the past.

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? ○ Medical directive by proxy ○ Living will declaration ○ Durable power of attorney for health care ○ End-of-life treatment directive

Durable power of attorney for health care Explanation: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations? ○ Encourage the family members to express their feelings and listen to them in their frank communication ○ Encourage conversations on the impending death of the patient ○ Be a silent observer and allow the patient to communicate with the family members ○ Encourage the patient's family members to spend time with the patient

Encourage the family members to express their feelings and listen to them in their frank communication Explanation: Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying patient. It is not advisable for the nurse to encourage conversations on the impending death of the patient. Being a silent observer or encouraging the family members to spend time with the dying patient may not help the family members to express their feelings.

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation? ○ Encourage the family members to express their feelings and listen to them in their frank communication ○ Encourage conversations about the impending death of the client ○ Be a silent observer and allow the client to communicate with the family members ○ Encourage the client's family members to spend time with the client

Encourage the family members to express their feelings and listen to them in their frank communication Explanation: Family members usually find it difficult to communicate frankly with a dying person. When a nurse encourages family members to express their feelings and listens to them as they frankly communicate, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members express their feelings.

What is the most critical element to document regarding client education? ○ A summary of the education plan ○ The implementation of the education plan ○ The client's need for learning ○ Evidence that learning has occurred

Evidence that learning has occurred Explanation: Documentation of the education-learning process includes a summary of the learning need, the plan, the implementation of the plan, and the evaluation results. The evaluative statement is crucial and must show concrete evidence that demonstrates that learning has occurred. If the desired learning has not occurred, the notes should indicate how the problem was resolved. Documenting evidence that the client or significant other has actually learned the material taught is more important than documenting a summary of the education plan, implementation of the plan, or the client's need for learning.

The nurse is documenting a teaching session with a client. Which nursing documentation is the most appropriate and detailed? ○ Education provided. Spouse present during session. Client and spouse state understanding and provided return demonstration of skill. ○ Taught about need for INR monitoring after initiating warfarin therapy. Client's meter used for demonstration and return demonstration. Remediation provided twice to place strip in meter correctly. Questions answered. ○ Written material about diabetes mellitus reviewed. Observed demonstration of finger stick and use of glucometer. Will return demonstration with next scheduled glucose monitoring. ○ Family requested education on turning client. Explanation of use of draw sheet and body mechanics provided. Family coached through turning and repositioning client. Members state confidence and understanding.

Family requested education on turning client. Explanation of use of draw sheet and body mechanics provided. Family coached through turning and repositioning client. Members state confidence and understanding. Explanation: Complete documentation must always include the topic taught and who was present during the teaching session. Documentation of the teaching-learning process includes a summary of the learning need, the plan, the implementation of the plan, and the evaluation results. The evaluative statement is crucial and must show concrete evidence that demonstrates that learning has occurred.

A nurse is caring for an older adult client with arthritis. Which action is the priority for the nurse when conducting the health education for the client? ○ Divide information into manageable amounts ○ Find out what the client wants to know ○ Provide an environment that promotes learning ○ Identify how long the education session will last

Find out what the client wants to know Explanation: Finding out what the client wants to know helps the nurse in showing personal interest, which facilitates better learning to an adult client. Dividing information into manageable amounts, providing an environment that promotes learning, and identifying how long the education session will last can be done only when the assessment of the client is completed.

The nurse is caring for a client admitted with "fever of unknown origin." The client, who is aware that he has a fever, requests "yin" foods to combat the fever. The nurse is aware that the client is speaking of the yin/yang theory, which has to do with balance, harmony, energy, hot, and cold. Because the physician has ordered "diet as desired," the nurse encourages which of the following menu items? ○ Beef broth ○ Gelatin dessert ○ Meatloaf ○ Hot tea

Gelatin dessert Explanation: According to the yin/yang naturalistic theory, foods are classified as cold(yin) or hot (yang)and are transformed into yin and yang energy when metabolized. Cold foods are eaten when a person has a hot illness (e.g., fever, rash, sore throat, ulcer, infection), and hot foods are eaten when a person has a cold illness (e.g., cancer, headache, stomach cramps).

Which term is used to describe the personal feelings that accompany an anticipated or actual loss? ○ Bereavement ○ Grief ○ Mourning ○ Spirituality

Grief Explanation: Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life.

The nurse is teaching a client about enoxaparin sodium for the first time. This client has never given a self-injection before. Which action(s) are appropriate for the nurse to take? Select all that apply. ○ Have the client demonstrate the proper technique for injection ○ Provide a printed diagram highlighting the injection site ○ Gather all necessary supplies for injection teaching ○ Review medication data sheets to ensure correct dosage ○ Weigh the client to select the needle size

Have the client demonstrate the proper technique for injection Provide a printed diagram highlighting the injection site Gather all necessary supplies for injection teaching Review medication data sheets to ensure correct dosage Explanation: Have the client return demonstrate the proper technique for injection to ensure appropriate procedure. Because some clients learn more effectively using visual aids, the nurse will provide a visual printout of a body diagram to show the client the appropriate landmark for injection. Needle size is not determined by client weight or size. Before doing anything else, the nurse must first assess personal knowledge of enoxaparin sodium injections to ensure the client is taught accurately. Reviewing medication data sheets and gathering teaching equipment are appropriate actions.

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse? ○ Redirect the client to learning about self-care and begin education ○ Give written materials to the client and administer pain medication ○ Have the client rate pain level, and reschedule the teaching session ○ Assess the client's understanding of self-care and administer medication

Have the client rate pain level, and reschedule the teaching session Explanation: The client is not ready or able to learn and is reporting a need that first must be met. Assessing the client's knowledge of self-care or redirecting the client to discuss self-care only delays the care that must be done before the client is able to learn. Although providing written materials is an excellent supplement to a teaching session, it does not replace teaching the client. It is best to address the physical needs before attempting to educate the client.

A client age 42 years recovering from a myocardial infarction (MI) is having difficulty following the care plan to stop smoking and exercise. What is the nurse's best response to this client? ○ State that the client is not trying hard enough ○ Warn that the client will have another MI and that it will be the client's own fault ○ Explain that the client's cigarettes will be taken away if the client smokes again ○ Ignore the behavior and recommend a behavior modification program

Ignore the behavior and recommend a behavior modification program Explanation: Negative reinforcement (criticism or punishment) is generally ineffective; undesirable behavior is usually best ignored. Behavior modification programs that reward desired behaviors and ignore undesired behaviors might be best for this client. The other options are related to telling the client about the client's behavior, which focuses on negative reinforcement.

When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized? ○ Have the clients read material after client education ○ Be sure that clients are formally engaged ○ Include educational strategies that encourage clients to be active participants ○ Administer tests to evaluate learning

Include educational strategies that encourage clients to be active participants Explanation: The teaching-learning relationship is a dynamic, interactive process that involves active participation from the nurse and client. Having clients read material after teaching, being sure that clients are formally engaged (rather than actively engaged), and administering tests to evaluate learning are not dynamic, interactive approaches and thus would not likely optimize the client's learning.

During the health education session at the health care facility, the nurse notes that a client is able to recognize, describe to others, and explain the information learned. What is the final learning stage of the client in this case? ○ Recall of the information being taught ○ Independent use of new learning ○ Involvement in the education in an active way ○ Repetition of information for memorization

Independent use of new learning Explanation: The final learning stage for the client in this case is the independent use of the new learning. The client demonstrates the ability to recall the information being taught by describing it to others. Involvement of the client in the health education in an active way is required to maintain the attention and the concentration of the client. Repetition of information for memorization is a technique to teach illiterate clients.

A nurse in a neighborhood clinic is conducting educational sessions on weight loss. What aim of nursing is met by these educational programs? Select all that apply. ○ Practicing advocacy ○ Preventing illness ○ Restoring health ○ Facilitating coping ○ Maintaining and promoting health

Preventing illness Restoring health Maintaining and promoting health Explanation: If this education is directed toward those who are healthy, weight loss information can help maintain health and prevent illness. If this education is used in those already ill (hypertension, diabetes), weight loss can restore health. The nurse is not practicing advocacy or facilitating coping by providing weight loss education.

Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease? ○ Intellectual development ○ Motor development ○ Emotional maturity ○ Psychosocial development

Intellectual development Explanation: Piaget's theory of intellectual development is a major learning theory. By understanding how children and adolescents develop learning abilities, the nurse can use this knowledge when teaching clients. School-age children are capable of logical reasoning and should be included in the teaching-learning process whenever possible. Teaching strategies that include clear explanations and reasons for procedures, stated in a simple and logical manner, are most successful. These children are open to new learning experiences but need learning to be reinforced by either a parent or health care personnel as they become more involved with their friends and school activities. Motor development would be focused on a hands-on skill for example, not the scientific explanation of the disease. Psychosocial development looks at stages of development and goals or tasks for different stages.

What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women? ○ Role play ○ Lecture/discussion ○ Demonstration ○ Test taking

Lecture/discussion Explanation: Lecture/discussion is appropriate for this topic, audience, and group size. A lecture is a formal presentation of information by a teacher to a group of learners. This format is most effective when communicating facts. Role play would not be an appropriate teaching strategy for this topic, as key points cannot be acted out, or for this size of a group, as there are too many students for each one to be able to participate in role play. Demonstration would not be appropriate, either, as the topic does not focus on particular skills that can be demonstrated. Test taking is not appropriate for teaching but for evaluation of learning.

Which client characteristic is important to assess when using the health belief model as the framework for education? ○ Developmental level ○ Source of information ○ Motivation to learn ○ Family support

Motivation to learn Explanation: When assessing a client's learning readiness using the health belief model, it is important to consider the client's motivation. Motivation is influenced by an individual's health beliefs and plays a key role in the health belief model. Motivation encourages the client to adopt health promotion and disease prevention actions. The developmental level is pertinent to a child and not an adult. Family support and sources of information are not relevant to the health belief model constructs.

When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate? ○ Long-term counseling ○ Motivational counseling ○ Short-term counseling ○ Professional counseling

Motivational counseling Explanation: The most appropriate counseling for the situation at hand would be motivational counseling. With motivational counseling, the nurse would discuss feelings and incentives with the client. Short-term counseling focuses on the immediate problem or concern of the client or family. It can be a relatively minor concern or a major crisis, but in any case, it needs immediate attention. Long-term counseling extends over a prolonged period. A client might need the counsel of the nurse at daily, weekly, or monthly intervals. A client experiencing a developmental crisis, for example, might need long-term counseling. Professional counseling is a general term.

What should the nurse do when caring for a client with alcoholism who is diagnosed with Imbalanced Nutrition: Less than Body Requirements? ○ Obtain a baseline weight ○ Encourage daily exercise ○ Avoid providing liquid sleep medications ○ Avoid providing foods that contain alcohol

Obtain a baseline weight Explanation: The nurse should obtain a baseline weight. Documenting the client's current weight helps evaluate whether the client's nutritional intake is maintained or has increased. Encouraging daily exercise may not really help balance the client's nutrition. Avoiding liquid sleep medication or foods with alcohol content will not help the client balance nutrition requirements.

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? ○ Orthopedic surgical history ○ Personal perception of health and aging ○ Floor plan of the client's dwelling ○ Formal religious beliefs

Personal perception of health and aging Explanation: Knowing about the client's orthopedic history, religious beliefs, and barriers to mobility in the home are all helpful for an overall plan of care, but do not address individualism. Gaining insight into the client's own perceptions of health and aging, however, will allow the nurse to tailor the plan of care to the client's personal needs.

The nurse completed education with a client. Which documentation entry represents the most complete teaching plan? ○ Start warfarin therapy initiated as prescribed; instructed to return to clinic for testing in 2 weeks. ○ Written and oral instructions given. Return demonstration performed accurately. ○ Discussed "Therapeutic Lifestyle Changes," printed materials reviewed, follow-up scheduled. ○ Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled.

Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled. Explanation: Just like a plan of care, a teaching plan must show that evaluation of the intervention was performed, which demonstrates that learning occurred. Complete documentation records the topic taught, methods used to teach, clarification of concepts, and the method used to evaluate how well the client understands the material.

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall? ○ Cognitive ○ Affective ○ Psychomotor ○ Interpersonal

Psychomotor Explanation: Because the client learns better by practicing the self-administration of the insulin injection alone, the client's learning style falls in the psychomotor domain. The psychomotor domain is a style of processing that focuses on learning by doing. The client's learning style does not fall in the cognitive, affective, or interpersonal domain. The cognitive domain is a style of processing information by listening to, or reading, facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values. The interpersonal domain is a style of processing that focuses on learning through social relationships.

Which strategy should the nurse use when providing education to the older adult client? ○ Remain calm and conduct the teaching session in a quiet environment ○ Avoid the use of colorful materials and keep the session short ○ Teach in a monotone voice in a quiet environment ○ Teach from books only and remain calm

Remain calm and conduct the teaching session in a quiet environment Explanation: Remaining calm and conducting the teaching session in a quiet environment would decrease anxiety or distractions that interfere with learning for the older adult. Keeping the session short will increase concentration, but is not unique to older adults. The nurse is to use colorful materials in a variety of ways and the nurse's tone and pitch should vary.

Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? ○ Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview ○ Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice ○ Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care ○ Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Explanation: A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? ○ Respect the client's and family members' choices ○ Share emotional pain ○ Abide by the dying client's wishes ○ Ask the family members about spiritual care

Respect the client's and family members' choices Explanation: In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response? ○ Ask the client to restate the teaching that was provided ○ Reteach the length of time to take the prescription ○ Tell the client to take the antibiotic until symptoms subside ○ Proceed with teaching about the decongestant

Reteach the length of time to take the prescription Explanation: Client teaching requires a circular approach, specifically if the client has not understood the teaching. The nurse needs to reteach the information that has not been understood. Asking the client to restate the teaching, telling the client to take the antibiotic, and proceeding with teaching about the decongestant are not effective teaching methods.

The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation? ○ Sit with the client's daughter privately and encourage her to express her feelings frankly ○ Remind the daughter of the client's impending death and the importance of expressing herself ○ Remain focused on the client's needs and care because these are your main responsibilities ○ Insist that the daughter try her best to make the client's final days happy ones

Sit with the client's daughter privately and encourage her to express her feelings frankly Explanation: Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation. Although the client is the nurse's main priority, it is the nurse's role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept? ○ The nurse is the expert in the teaching-learning environment ○ The nurse must be able to handle criticism during the process ○ The client and the nurse are equal participants ○ Assimilation and application of psychomotor concepts is essential

The client and the nurse are equal participants Explanation: Effective learning occurs when clients and health care professionals are equal participants in the teaching-learning process, not when the nurse is viewed as the expert. Although it is important for the nurse to be able to handle criticism and to understand and apply psychomotor concepts when teaching, these are not as important as viewing the client and nurse as equal participants.

The nurse is conducting discharge teaching for a client who has been diagnosed with type 2 diabetes. The nurse is teaching the client how to inject insulin at home. Which cue(s) will alert the nurse that the client has poor health literacy? Select all that apply. ○ The client does not speak the dominant language as a first language ○ The client has a history of several missed health appointments ○ The client's hospital admission forms were incomplete ○ The client has recently immigrated from another country ○ The client has a history of medication nonadherence ○ The client did not follow up when asked to book an appointment with a specialist

The client has a history of several missed health appointments The client's hospital admission forms were incomplete The client has a history of medication nonadherence The client did not follow up when asked to book an appointment with a specialist Explanation: Because many illiterate or functionally illiterate people are not always willing or able to volunteer information about their reading problems, literacy may be difficult to assess. Some indications that clients have low health literacy are missed appointments, incomplete health forms, nonadherence to medication regimen, unable to provide a coherent health history and lack of follow-up on tests and referrals. Language barriers and immigration are not signs that a client is health illiterate. Clients may be fully health literate in their first language. If a language barrier exists or the client is new to the country and requires further health information due to differences from their country of origin, the nurse must make a full effort to secure a medical interpreter and/or seek out educational material that helps the client learn more about local health resources. The nurse must not assume the client is not health literate.

A client, eager to go home from an acute care facility, calls out to have discharge education completed. The nurse is not able to get to the client's room until an hour later, and finds the client asleep. The client's significant other states, "She will be out for a couple hours after that pain medication." Which of the following best describes what must happen with the education session? ○ The nurse cannot determine the subject matter to teach if the client is asleep ○ The client is not demonstrating readiness to learn due to the effects of medication ○ The significant other can be taught now, and then teach the client later on ○ The client can be awakened when she falls asleep during the session

The client is not demonstrating readiness to learn due to the effects of medication Explanation: The nurse knows the client's plan of care and should know what needs to be taught to this individual. The client is experiencing a side effect of pain medication and is not ready to be taught at this time. The nurse, not the significant other, is responsible for teaching the client about self-care. If the client cannot remain awake, then the client is not able to learn.

When a nurse is planning for learning, who must decide who should be included in the learning sessions? ○ The health care team ○ The doctor and nurse ○ The nurse and the client ○ The client and the client's family

The nurse and the client Explanation: The nurse and the client should be the individuals who decide who should be included in the learning sessions. The nurse cannot assume that family members are wanted by the client to be included. The client must always be included in the learning session.

The nurse is completing a physical examination of a group of clients. What client situation is the nurse most likely to use percussion during the assessment? ○ The client who presents with a respiratory rate of 22 and a productive cough and reports shortness of breath when climbing stairs ○ The client who reports numbness and tingling in three fingers on each hand upon awakening in the morning ○ The client who presents with a mild pruritic rash on trunk and oral temperature of 101.1°F (38.4°C) ○ The client who reports increased sensitivity to cold, dry skin, and thinning hair

The client who presents with a respiratory rate of 22 and a productive cough and reports shortness of breath when climbing stairs Explanation: The assessment technique of percussion is most beneficial with clients suspected of disease processes in the chest and abdomen. It is a skill requiring practice and yields much information about disease processes in the chest and abdomen. Percussion is not the primary assessment technique in a musculoskeletal assessment. A client with a rash and fever is likely to be experiencing a disease process of the integumentary system; the nurse is most likely to rely on the assessment technique of inspection in this situation. The symptoms of dry skin and thinning hair could be indicative of thyroid disease and the nurse's assessment technique would include palpation and inspection.

A nurse is educating an older adult client with diabetes and family members about the importance of a nutritious diet. What outcomes does the nurse hope to achieve in the process of educating the client and family? Select all that apply. ○ The client will achieve optimal health ○ The client will cope with alterations in health status ○ The nurse will be more aware of the client's health ○ The nurse will be able to diagnose the client's illness earlier ○ The nurse will be well-informed about the client's care

The client will achieve optimal health The client will cope with alterations in health status Explanation: Nurses are involved in client education to promote wellness (primary prevention), prevent or diagnose illness early (secondary prevention), restore optimal health and function if illness has occurred (tertiary prevention), and assist clients and families to cope with alterations in health status. Learning outcomes pertain to the client and the client's family, not to the nurse. Moreover, increased awareness of the client's health and care and earlier diagnosis are not likely outcomes of client education.

The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education? ○ The client will demonstrate self-efficacy and improved body image ○ The client will have restoration of breast function ○ The client will be able to perform proper breast self-examination for breast cancer detection and prevention ○ The client will demonstrate improved coping skills

The client will be able to perform proper breast self-examination for breast cancer detection and prevention Explanation: This client education is focused on teaching the client a psychomotor skill for the purpose of early detection of breast cancer. Therefore, an appropriate learning outcome would be that the client is able to perform the skill properly. This client does not have any self-image problems, breast dysfunction, or poor coping skills, so outcomes related to these issues would not be appropriate.

The nurse is planning client education based on the developmental stage of the client. Which nursing actions best reflect this consideration? Select all that apply. ○ The nurse directs the health education for a 3-year-old to the parents ○ The nurse provides lengthy explanations of a procedure to a preschool child ○ The nurse includes a school-age child in the teaching and learning process ○ The nurse determines the learning needs of the client ○ The nurse avoids relating education for an adult to a social role ○ The nurse provides material that is useful immediately to adult clients

The nurse directs the health education for a 3-year-old to the parents The nurse includes a school-age child in the teaching and learning process The nurse determines the learning needs of the client The nurse provides material that is useful immediately to adult clients Explanation: Looking at clients' development stages, the nurse would develop and carry out actions based on the individual client needs. The nurse would direct the health education for a 3-year-old to the parents. The nurse would include a school-age child in the teaching-learning process. The nurse would use the same learning strategies for an adolescent as for an adult. The nurse would provide material that is useful immediately to adult clients. The nurse would not provide lengthy explanations for a procedure to a preschool child because of the client's development stage. The nurse would not avoid relating education for an adult to a social role.

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives? ○ The nurse writes one or two broad objectives rather than several specific objectives ○ The nurse writes general statements for learner objectives that could be accomplished in any amount of time ○ The nurse plans learner objectives with another nurse before obtaining input from the client and family ○ The nurse writes one long-term objective for each diagnosis, followed by several specific objectives

The nurse writes one long-term objective for each diagnosis, followed by several specific objectives Explanation: The statement that best describes the proper method for writing objectives would be that the nurse writes one long-term objective for each diagnosis, followed by several specific objectives. The nurse would not use general statements that could be accomplished in any amount of time because this action is not addressing the specific needs of the client, and the setting in which the client is in. The nurse would not plan learner objectives with another nurse and would not always obtain input from the family of the client. The objectives need to be specific so the outcomes can be measured in the evaluation phase.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? ○ Their readiness to learn is often related to a developmental task or social role ○ Peer group acceptance is a critical issue for this age group ○ The material presented should focus on future application ○ Previous experiences have little impact on learning

Their readiness to learn is often related to a developmental task or social role Explanation: An adult's readiness to learn is often related to a developmental task or social role. The previous experience of the adult is a rich resource for learning. Most adults' orientation to learning is that material should be useful immediately. Peer group acceptance is a critical issue for the adolescent group and not adults.

A new client is admitted to the unit, and the nurse's initial assessment will include a systematic appraisal of the client's cultural characteristics, health practices, and beliefs. What type of assessment will the nurse perform to gather this information? ○ cultural ○ biocultural ○ multicultural ○ procedural

cultural Explanation: A cultural nursing assessment is a systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices. The nurse should include cultural beliefs and health practices in any initial assessment. When assessing any client, the nurse must consider general appearance and obvious physical characteristics, components that make up biocultural assessment.

The nurse needs to understand the teaching-learning process when administering ○ health care provider-initiated interventions ○ educational interventions ○ technical interventions ○ psychosocial interventions

educational interventions Explanation: Educational interventions require the application of the teaching-learning process. The other interventions listed would not, as their primary goal is not to educate the client.

When the newly diagnosed client with insulin-dependent diabetes reports never having received instruction on the administration of injections, how will the nurse record this concern for use in care planning? ○ deficient in self-care related to lack of knowledge about injections ○ knowledge deficit related to lack of knowledge about injections ○ knowledge deficit regarding injection administration as verbalized by the client, related to the lack of instruction and experience ○ altered health care maintenance related to diabetes instructions

knowledge deficit regarding injection administration as verbalized by the client, related to the lack of instruction and experience Explanation: Many factors can contribute to a knowledge deficit, such as a lack of exposure, lack of recall, information misinterpretation, cognitive limitations, lack of interest in learning, and unfamiliarity with information resources. In this case, the client lacks knowledge of how to self-administer an insulin injection due to not having received instruction about it. Therefore, the most appropriate notation for care planning is "knowledge deficit regarding injection administration as verbalized by the client, related to the lack of instruction and experience." Because the client is newly diagnosed with diabetes, there is no evidence that the client has been deficient in self-care or ineffective in health care maintenance. The notation "knowledge deficit related to lack of knowledge about injections" is not enough information for the nurse to plan the client's care.

A type of comprehensive care for clients whose disease is not responsive to cure is ○ a terminal illness ○ palliative care ○ euthanasia ○ interdisciplinary collaboration

palliative care Explanation: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care.

A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about the disease process, diet, exercise, and medications. What is the goal of this education? ○ to help the client develop self-care abilities ○ to ensure the client will return for follow-up care ○ to facilitate complete recovery from the disease ○ to implement ordered teaching and counseling

to help the client develop self-care abilities Explanation: The basic purpose of educating and counseling is to help clients and families develop the self-care abilities (knowledge, attitude, skills) needed to maintain and improve health. Diabetes management is directed toward managing a chronic illness and not recovering from the disease. Teaching a client to develop self-care abilities does not ensure the client will return for follow-up care or to seek additional teaching and counseling.

A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? ○ altered gastrointestinal function ○ drop in blood pressure and rapid heart rate ○ weight loss and inadequate food intake ○ irregular eating habits

weight loss and inadequate food intake Explanation: The nurse should report weight loss and inadequate food intake so that the team can consider adding appetite stimulants and the nutritionist can alter the meal plan to give more satisfying meals as a comfort measure. The nurse knows that changes of gastrointestinal function such as irregular eating or bowel changes occur as part of the dying process and are not relevant to the desired intervention. Deteriorating vital signs are part of the dying process so that these signs are not relevant to the desired intervention.