Final Unit Exam

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

a. "Are you thinking of suicide?"

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult."

The nurse planning to assess the structure of a family would which question? a. "Who lives with you?" b. "Who does the grocery shopping?" c. "Who provides support in your family?" d. "How old are the members of your family?"

a. "Who lives with you?"

A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend's apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. e. Exhibit a nonjudgmental attitude.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. d. Reassure the person that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver.

A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.

a. Leave a night light on in the room at all times.

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Anger b. Concern c. Empathy d. Compassion

a. Anger

A nursing student is doing a survey of fellow nursing students. Which ethical concept is the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were associated with a survey? a. Beneficence b. Human dignity c. Justice d. Human rights

a. Beneficence

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

a. Chronic low self-esteem, related to negative feedback from parents

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

a. Confusion and disbelief

An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

a. Dementia

When an emergency department nurse teaches a victim of the rape about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams

The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis (marijuana) and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes. e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.

a. Do not use substances such as cannabis (marijuana) and alcohol. b. Wear helmets when riding bicycles and motorcycles. e. Wear a seat belt whenever riding in a motorized vehicle.

In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use e. January birth date f. Physical abuse by the father

a. Father diagnosed with paranoid schizophrenia c. Recent immigration from Ecuador e. January birth date f. Physical abuse by the father

A nurse on the unit makes a error in the calculation of the dose of medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics? a. Fidelity b. Individuality c. Justice d. Values clarification

a. Fidelity

Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation

a. Hallucinations d. Delusions e. Agitation

A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

a. History of family violence

A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

A nursing student is preparing a care plan for an assigned patient. When accessing the electronic medical record, what is acceptable information to view? (Select all that apply.) a. Laboratory data of the assigned patient b. Admission diagnosis for a patient who is a former neighbor c. The patient's age, date of birth, and gender d. The history and physical of the assigned patient e. A classmate's brother's chest x-ray report

a. Laboratory data of the assigned patient c. The patient's age, date of birth, and gender d. The history and physical of the assigned patient

An 82-year-old patient who is in the hospital awakens from sleep disoriented to where she is. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion? a. Pain medication received earlier in the night b. The death of the patient's spouse 2 years ago c. The patient's history of diabetes d. The age of the patient

a. Pain medication received earlier in the night

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support

An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

a. Risk of intimate partner violence

Nurses can be health advocates in which of the following ways? (Select all that apply.) a. Supporting their professional nursing organization when discussing upcoming legislation b. Discussing the upcoming classes with a neighbor c. Rallying for coverage for childhood immunizations d. Arranging for a patient to meet with case management for home health care e. Discussing a patient they are concerned about with a fellow student in the public cafeteria

a. Supporting their professional nursing organization when discussing upcoming legislation c. Rallying for coverage for childhood immunizations d. Arranging for a patient to meet with case management for home health care

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

a. Use accepting, nurturing, and empathetic communication techniques.

The nurse is faced with an ethical issue. When assessing the ethical issue, the nurse must first a. ask, "What is the issue?" b. identify all possible alternatives. c. select the best option from a list of alternatives. d. justify the choice of action or inaction.

a. ask, "What is the issue?"

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

a. expresses frustration verbally instead of physically.

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

a. maintaining the airway.

. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, she would a. notify the physician. b. document the finding in the records. c. recheck the reflex after several hours. d. monitor the eye movements and pupil reactions closely.

a. notify the physician.

A 28-year-old married woman received word that she is pregnant. Sadly, the patient is not able to carry the pregnancy because she suffers from long QT syndrome, which causes an abnormality of the heart, meaning any rush of adrenaline could prove fatal. The pregnant patient states, "I want to have this baby." The nurse realizes that this is a conflict that involves the ethical principle of a. utilitarianism. b. deontology. c. autonomy. d. veracity.

a. utilitarianism.

An adult has cared for a debilitated parent for 10 years. The parent's condition recently declined, and the health care provider recommended placement in a skilled care facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to: a. resolving the feelings associated with the threat to the person's self-concept. b. maintaining the ability to identify situational supports in the community. c. relying on the assistance from role models within the person's culture. d. mobilizing automatic relief behaviors by the person.

a. resolving the feelings associated with the threat to the person's self-concept.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

a. "Breathing so quickly can be dehydrating."

A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states."

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

a. "High glucose is common in shock and needs to be treated."

A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best? a. "It mechanically removes biofilm on teeth." b. "It's easier to clean all surfaces with a brush." c. "Oral care is important to all our clients." d. "Toothbrushes last longer than oral swabs."

a. "It mechanically removes biofilm on teeth."

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's evaluate what went wrong and develop policies for future incidents." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

a. "You are free to express your feelings; whatever is said here stays here."

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

a. 22-year-old client with asthma c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

a. A 35-year-old female with severe chest pain: red tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

a. Administer antibiotics. b. Draw serum lactate levels. e. Obtain blood cultures.

A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr

a. Administer oxygen at 4 liters per nasal cannula.

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective

a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions e. Thinning skin that is less protective

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

a. Alert and oriented, answering questions

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin)

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

a. Anaerobic metabolism c. Hypotension

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

a. Antibiotics started before admission

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain "universal" donor blood. d. Prepare the client for emergency surgery.

a. Apply personal protective equipment.

The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment

a. Appropriate drug b. Proper route of administration d. Sufficient dose e. Sufficient length of treatment

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

a. Ask the spouse to explain the fear of visiting in further detail

A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best? a. Assess the client frequently for worsening of his or her condition. b. Delegate comfort measures to unlicensed assistive personnel. c. Ensure the client is placed on Contact Precautions. d. Restrict visitors to the immediate family only.

a. Assess the client frequently for worsening of his or her condition.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members' hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods

a. Auditing staff members' hand hygiene practices

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

a. Bringing the client warm blankets d. Reorienting the client as needed e. Sitting with the client for reassurance

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

a. Client with a blood pressure change of 128/74 to 110/88 mm Hg

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? a. Consult with the provider about obtaining stool cultures. b. Delegate frequent perianal care to unlicensed assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an anti-diarrheal medication.

a. Consult with the provider about obtaining stool cultures.

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? Select all that apply. a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

a. Difficulty using a cell phone d. Rapid speech e. Trembling

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

a. Educating the client on adherence to the treatment regimen

A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the client's temperature every 4 hours.

a. Elevate the arm above the level of the heart.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? a. Ensure that the radiology department is aware of the isolation precautions. b. Plan to travel with the client to ensure appropriate precautions are used. c. No special precautions are needed when this client leaves the unit. d. Notify the physician that the client cannot leave the room for the CT scan.

a. Ensure that the radiology department is aware of the isolation precautions.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the client's bed. d. Tell the client everything possible is being done.

a. Offer to remain with the client for awhile.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

a. Partial-thickness burns covering both legs c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes f. Bruising and pain in the right lower abdomen

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.

a. Prepare to administer vancomycin (Vancocin).

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

a. Provide a calm location for the family to cope and discuss needs.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

a. Provide water and healthy snacks for energy throughout the event.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

a. The Medical Reserve Corps

The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.

a. is experiencing a state of disequilibrium.

While conducting the initial interview with a patient in crisis, the nurse should: a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know that the nurse is in control.

a. speak in short, concise sentences.

A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on: a. supporting emotional security and reestablishing equilibrium. b. offering long-term resolution of issues precipitating the crisis. c. promoting growth of the individual. d. providing legal assistance.

a. supporting emotional security and reestablishing equilibrium

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." b. "Both of my children have the same eye medication, which is a real bonus, because I need only buy one bottle." c. "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" d. "I see now why when my child has a cold, he complains about everything tasting blah!"

b. "Both of my children have the same eye medication, which is a real bonus, because I need only buy one bottle."

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. "She was very beautiful." b. "I gave her what she wanted." c. "I have issues with my mother." d. "I've been depressed for a long time."

b. "I gave her what she wanted."

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision.

A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a. An infant who is being fed reconstituted powdered formula b. A toddler living in an older home that is being remodeled c. A preschooler who attends a play group 3 days a week d. A school-age child who rides a school bus 5 days a week

b. A toddler living in an older home that is being remodeled

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

b. Acute phase

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school, but we can't afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

b. Child and siblings are experiencing neglect.

Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

b. Collecting and preserving evidence d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

An unconscious patient is treated in the emergency department for head trauma. The patient is unconscious and on life support for 2 weeks prior to making a full recovery. The initial actions of the medical team are based on which ethical principle? a. Utilitarianism b. Deontology c. Autonomy d. Veracity

b. Deontology

A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

b. Have the patient complete an abuse assessment screen.

The nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is essential to include? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight

b. Reminder to call the clinic if fever, sore throat, or malaise develops

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

b. Report the suspected abuse or neglect according to state regulations.

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

b. Reported c. Penetration f. Declined

After treatment for a detached retina, a victim of intimate partner violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

b. Risk for injury, related to partner's physical abuse when intoxicated

Which of the following components are included in health policy at the state level? a. Americans with Disabilities Act of 1990 b. Scope of nursing practice c. Health Insurance Portability and Accountability Act (HIPAA) of 1996 d. Patient Safety and Quality Improvement Act of 2005

b. Scope of nursing practice

An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care.

Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Assessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program.

b. Teaching stress reduction techniques to a beginning student nurse.

An 80-year-old patient has a hearing deficit which he states is getting worse; his hearing aid needs to be replaced. He states he attends church but cannot understand the sermon anymore. He hates to go out to events because his hearing aid makes everything "noisy." He notes "nothing is the same." During the assessment he asks the nurse to repeat the question frequently. Nursing diagnoses would include which of the following? (Select all that apply.) a. Altered growth and development b. Social isolation c. Chronic confusion d. Activity intolerance e. Hopelessness f. Spiritual distress

b. Social isolation e. Hopelessness f. Spiritual distress

Which level of government is responsible for the regulation of a nurse's license? a. Federal government b. State government c. Local government d. International coalition

b. State government

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment.

A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

b. Survivor

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b. Sympathy for the victim and anger toward the abuser

A male patient suffered a brain injury from a motor vehicle accident and has no brain activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse, "Do you think when he moves his hands he is responding to my voice?" The nurse feels bad because she believes the movements are involuntary, and the prognosis is grim for this patient. She states, "He can hear you, and it appears he did respond to your voice." The nurse is violating which principle of ethics? a. Autonomy b. Veracity c. Utilitarianism d. Deontology

b. Veracity

A patient suffered a brain injury from a motor vehicle accident and has no brain activity. The patient has a living will which states no heroic measures. The family requests that no additional heroic measures be instituted for their son. The nurse respects this decision in keeping with the principle of a. accountability. b. autonomy. c. nonmaleficence. d. veracity.

b. autonomy.

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

b. explain that washing would destroy evidence.

A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. The nurse's best response to this behavior is to a. ignore his remarks. b. express doubt that there are spiders on the wall. c. ask the client if he also sees spiders in the day room. d. tell the client there are no spiders and he should stop worrying about it.

b. express doubt that there are spiders on the wall.

During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for a. tympanoplasty. b. irrigation of the ear. c. pure tone test. d. otoscopic exam by a specialist.

b. irrigation of the ear.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

b. name two community resources that can be contacted.

A survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

b. plans coping strategies for fearful situations.

When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

b. provide referral information verbally and in writing.

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

b. provide written information concerning the physical and emotional reactions that may be experienced.

A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse's best initial statement to this patient. a. "Everything is going to be all right. You are here at the clinic, and the staff will keep you safe." b. "I see you are feeling upset. I am going to stay and talk with you to help you feel better." c. "You need to try to stop crying so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

b. "I see you are feeling upset. I am going to stay and talk with you to help you feel better."

After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question should the nursing supervisor ask at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"

b. "Do all areas of the hospital have the supplies and personnel they need?"

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"

b. "I hope I can get my water turned back on when I get home."

During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better."

b. "In the past, how did you handle difficult or stressful situations?"

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

b. "Older people often have vague symptoms, so an x-ray is essential."

A nurse assesses an adult experiencing a crisis. An appropriate question for the nurse to ask to determine situational support is: a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

b. "Who can be helpful to you during this time?"

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

b. Adventitious

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3

b. Alanine aminotransferase (ALT): 180 U/L

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the client's jaw while swallowing.

b. Assess the client for pain when swallowing.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

b. Assess the client's tissue perfusion further.

A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.) a. Administer antipyretics around the clock. b. Change the client's gown and linens when damp. c. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin. e. Provide a fan to help cool the client

b. Change the client's gown and linens when damp. c. Offer cool fluids to the client frequently.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

b. Client who had open reduction and internal fixation of a femur fracture 3 days ago e. Client on the medical unit for wound care

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

b. Cohort the "clients" in the same area of the unit.

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? a. Assessing skin and mucous membranes b. Consistently using appropriate hand hygiene c. Monitoring daily white blood cell counts d. Teaching visitors not to visit if they are ill

b. Consistently using appropriate hand hygiene

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

b. Drink fluids on a regular schedule.

Which branch of government is responsible for the execution of laws passed by legislatures? a. Legislative b. Judicial c. Executive d. Local

c. Executive

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

b. Ensure the client has a patent airway.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

b. Facilitate polymerase chain reaction testing

Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

b. Giving direction

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic - Decides the number, acuity, and resource needs of clients b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan c. Public information officer - Provides advanced life support during transportation to the hospital d. Triage officer - Rapidly evaluates each client to determine priorities for treatment e. Medical command physician - Serves as a liaison between the health care facility and the media

b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan d. Triage officer - Rapidly evaluates each client to determine priorities for treatment

The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir

b. Host c. Mode of transmission d. Portal of entry e. Reservoir

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.

b. Inform the client that antibiotics will be needed for 60 days.

A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Inform them that the infection is the issue, not the client. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.

b. Inform them that the infection is the issue, not the client. c

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

b. Lactate: 6 mmol/L

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

b. Lower blood volume lowers MAP.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

b. Measure urine output from the catheter.

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation.

b. Notify the provider and request antibiotics.

A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first? a. Obtain cultures of the lesions. b. Place the client on Airborne Precautions. c. Prepare to administer antibiotics. d. Provide comfort measures for the rash.

b. Place the client on Airborne Precautions

An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

b. Powerlessness The patient describes feelings of the lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not shown to be altered at this point.

Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

b. Take all antibiotics as directed.

A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is: a. suicidal. b. anxious and fearful. c. misperceiving reality. d. potentially homicidal.

b. anxious and fearful

A woman says, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." If this person's immediate family is unable to provide sufficient situational support, the nurse should: a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the patient, "You must be strong. Don't let this crisis overwhelm you." d. foster insight by relating the present situation to earlier situations involving loss

b. ask what other relatives or friends are available for support. The focus of crisis intervention is on the most recent problem—"the straw that broke the camel's back." The patient has coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving. DIF: Cognitive Level: Application (Applying) REF: Pag

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

c. "How did this happen to you?"

Mr. K, an 80-year-old patient, is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident in when the daughter says which of the following? a. "I will make sure that Dad always wears warm socks." b. "Dad needs to wear his glasses so he can delay the onset of macular degeneration." c. "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe." d. "We will give him only warm foods, so that he doesn't burn his mouth."

c. "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe."

A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. "Don't worry; the patient should be fine once they are in a familiar environment." b. "I can make a referral for a home health aide to assist with the patient." c. "Once the dehydration is corrected, the patient's confusion should improve." d. "I can show you how to care for the patient once you return home."

c. "Once the dehydration is corrected, the patient's confusion should improve."

The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. How does the nurse respond? a. "Hormone therapy will reverse the condition." b. "Vitamin C and zinc will reverse the condition." c. "There is no treatment that reverses dementia." d. "Dementia can be reversed with diet, exercise, and medications."

c. "There is no treatment that reverses dementia."

A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

c. "You believe this would not have happened if you had not been alone?"

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

c. Honeymoon

An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which signs and symptoms would the nurse expect to be exhibited by the patient? a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose

c. Increased confusion

An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

c. Physical

Jane and Janet have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of baby Joan. Jane and Janet would be considered which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent

c. Same-sex

The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a. The patient prescribed an antibiotic for a urinary tract infection b. The patient prescribed a cholinesterase inhibitor for early Alzheimer's disease c. The patient prescribed a beta-blocker for hypertension d. The patient prescribed a bisphosphonate for osteoporosis

c. The patient prescribed a beta-blocker for hypertension

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

c. Women's shelter

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. c. bite marks. d. croup.

c. bite marks.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

c. helping the victim feel safe.

When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family a. development. b. function. c. political views. d. structure.

c. political views.

The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. To provide recreational activities during the rehabilitation phase, the nurse should a. place the television to the left or right of patient's visual field. b. encourage the patient to learn braille. c. suggest use of talking books. d. provide headphones for listening to music.

c. suggest use of talking books.

The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express concern. c. the ill member demands attention. d. memories are shared.

c. the ill member demands attention.

A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is _______ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

c. 4 to 6 The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

c. "I will take this medication on an empty stomach."

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

c. "In a disaster, extensive resources are not used for one person at the expense of many others."

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."

c. "Try warm, moist heat packs on your face."

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I can't believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond? a. "Please accept my sympathies for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

c. "You sound anxious about being a single parent."

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

c. Arrange for critical incident stress debriefing.

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

c. Fexofenadine (Allegra)

An adult tells the nurse, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending breast surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

c. Ineffective coping, related to perceived loss of daughter

After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

c. Maturational

Which agency provides coordination in the event of a terrorist attack? a. U.S. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

c. National Incident Management System (NIMS)

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

c. Notify the health care provider immediately

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

c. Provide oral care every 4 hours.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

c. Removing the IV bag from the brown plastic cover

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

c. Report of chest heaviness

A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client's bed linens. What action by the UAP requires intervention by the nurse? a. Not using gloves while combing the client's hair b. Rinsing the client's commode pan after use c. Shaking dirty linens and placing them on the floor d. Wearing gloves when providing perianal care

c. Shaking dirty linens and placing them on the floor

A woman says, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

c. Situational

At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance." The nurse responds, "I think it would be worthwhile to have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency.

c. The nurse is having difficulty terminating the relationship.

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: (pic of arm with positive TB test) What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

c.. Immediately place the client on Airborne Precautions.

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. "This will help us to identify your baby's risk for ear infections the first year of life." b. "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." c. "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." d. "Imitation of sounds is the first step in language development, and it is important to identify alterations early."

d. "Imitation of sounds is the first step in language development, and it is important to identify alterations early."

A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

d. respiratory depression.

Mr. Smith is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. The nurse's best response would be which of the following? a. "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." b. "Notify your doctor immediately, because this is a concerning reaction to the medication." c. "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." d. "You should see an improvement in the next week or so. Call if this continues."

d. "You should see an improvement in the next week or so. Call if this continues."

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

d. Denial

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

d. Desire to humiliate or control others

An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the employee says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

d. Document injuries with a body map.

The nurse is caring for a 32-year-old woman diagnosed with schizophrenia. The woman tells the nurse, "The news on TV last night was all about me." This is an example of what kind of thought content? a. Thought insertion b. Thought broadcasting c. Magical thinking d. Ideas of reference

d. Ideas of reference

Which of the following is the intent of HIPAA? a. Release of patient information for purposes of insurance reimbursement b. Prevent health care providers from billing for procedures done for the insured person c. Protect patients from reviewing their own medical records d. Limit the ability of health care providers to sell patient information to outside sources

d. Limit the ability of health care providers to sell patient information to outside sources

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

d. Patient agrees to keep a follow-up appointment with the rape crisis center.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

d. Physical injuries

The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? a. Allow food selections from a menu with several choices. b. Schedule frequent field trips off the unit for cognitive stimulation. c. Plan for attendance at activities with several other patients on the unit.

d. Plan for a structured daily routine of events and caregivers.

A definition of health policy includes which of the following elements? a. Funding for public education b. Appropriation of funds for roadwork c. Selection of congressional members of committees d. Public policy made to support health-related goals

d. Public policy made to support health-related goals

A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

d. Severe

A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

d. Support the victim to separate issues of vulnerability from blame.

A nurse working a rape telephone hotline should focus communication with callers to: a. arrange long-term counseling. b. serve as a sympathetic listener. c. obtain information to relay to the local police. d. explain immediate steps that a victim of rape should take.

d. explain immediate steps that a victim of rape should take.

Factors which would alert the nurse to negative/dysfunctional family dynamics include a. aging of family members. b. chronic illness of a family member. c. disability of a family member. d. intimate partner violence.

d. intimate partner violence.

Critical Thinking: The nurse identifies the family with a child graduating from college as being in the family life cycle of a. single young adult leaving home. b. new couple joins their families through marriage or living together. c. families with young children. d. launching children and moving on.

d. launching children and moving on.

Mrs. J, a 57-year-old woman, walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that Mrs. J has an open wound on the bottom of her foot, but the patient states she is not aware of this. The nurse interprets this response as a. normal in the older adult. b. a need for the patient to be evaluated for cognitive impairment. c. a side effect of anti-hypertensive medication. d. pathologic impairment of sensory responses.

d. pathologic impairment of sensory responses.

A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. Behavior which is most consistent with this stage of relapse would include a. expressing feelings of anxiety. b. expressing feelings of being overwhelmed. c. bizarre behaviors and speech. d. presence of hallucinations.

d. presence of hallucinations.

The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support.

d. role model appropriate support.

An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority question? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"

d. "Are you having thoughts of hurting yourself or others?"

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"

d. "What is your occupation?"

A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying." b. "How did your wrist get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started feeling this way?"

d. "What was happening just before you started feeling this way?"

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you'd like."

d. "You seem upset. I have time to talk if you'd like."

A woman says, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by "I can't take it anymore!"

d. Clarifying what the patient means by "I can't take it anymore!"

A woman says, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the husband's infidelity d. Coping with the reaction to the daughter's events

d. Coping with the reaction to the daughter's events

A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents. Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

d. Multiple fractured ribs and shortness of breath

A client is admitted with possible sepsis. Which action should the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.

d. Obtain specified cultures

A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a. Intravenous amphotericin B b. Long-term anti-inflammatories c. No specific treatment d. Oral fluconazole (Diflucan)

d. Oral fluconazole (Diflucan)

Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old d. Riot at a rock concert

d. Riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes

d. Skin and mucous membranes

A hospital unit is participating in a bioterrorism drill. A "client" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "client"? a. Airborne Precautions b. Contact Precautions c. Droplet Precautions d. Standard Precautions

d. Standard Precautions

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

d. Teach the client to sneeze in the upper sleeve.

Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions.

d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

d. Visiting Nurses for directly observed therapy

After completing the contracted number of visits to the crisis clinic, an adult says, "I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group." The nurse can evaluate the patient's feelings about the care received as: a. not at all satisfied. b. somewhat satisfied. c. moderately satisfied. d. very satisfied.

d. very satisfied. The patient mentions a number of indicators that suggest a high degree of satisfaction with the Nursing Outcomes Classification of patient satisfaction: psychological care. No indicators express low-tomoderate satisfaction.