FOUNDATIONS FINAL EXAM

Which factors should the nurse assess to determine a patient's ability to learn? a. Developmental capabilities and physical capabilities b. Sociocultural background and motivation c. Psychosocial adaptation to illness and active participation d. Stage of grieving and overall physical health

a. Developmental capabilities and physical capabilities

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal? a) The client's pupils dilate when looking at a near object and constrict when looking at a distant object. b) The client's pupils are black, equal in size, and round and smooth. c) The client's eyes do not converge when the nurse moves a finger toward his nose. d) An older adult's pupils are pale and cloudy.

b) The client's pupils are black, equal in size, and round and smooth.

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? a) Increased heart rate b) Respiratory depression c) Numbness and tingling of the extremities d) Heightened alertness

b) Respiratory depression

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? a) The fingertips b) The dorsum c) The palm d) The knuckles

b) The dorsum

What did Peplau's theory focus on?

interpersonal relations between nurse, patient, and patients family * the development of the nurse-patient relationship

Respite care provides

short-term relief or "time off" for persons providing home care to an ill, disabled, or frail older adult.

Henderson's theory

there are 14 basic needs of humans. If one of these needs isn't met then theats where nursing is needed.

In Neuman's theory what is the role of nursing?

to stabilize the patient or situation

What is the purpose of Watson's theory?

to understand the interrelationships among health, illness, and human behavior

Susan quizzes Bill about the core concept of Benner and Wrubel's theory. Benner and Wrubel's theory is based on the premise that persons, events, projects, and things matter to people.

true

Nursing Paradigm

links person, health, environment/situation, and nursing- we are anticipating the human needs, anticipating the "what ifs"

Capitation

means that the providers receive a fixed amount per patient or enrollee of a health care plan

What does Orem's theory focus on?

patient's self-care needs

Rehabilitation includes

physical, occupational, and speech therapy, as well as social services

Maintenance stage

Sustained change over time; begins 6 months after action has started and continues indefinitely

A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a A. Primary care center. B. Restorative care center C. Assisted-Living center. D. Respite center.

B. Restorative care center

A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a A. Primary care center. B. Restorative care setting. C. Assisted-living center. D. Respite center.

B. Restorative care setting.

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response? 1. "It is a process of learning a different culture to adapt a new or changing environment." 2. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." 3. "It is a group of individuals in a society who are culturally distinct and have a unique identity." 4. "It is a group that shares some of the characteristics of the larger population group of which it is a part."

1. "It is a process of learning a different culture to adapt a new or changing environment."

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The client should implement which best action. 1. Continue with instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

1. Continue with instructions, verifying client understanding.

Maslows Hierarchy of Needs

1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem 5. Self-actualization

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting cultural value 2. An acceptance of treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

1. Reflecting cultural value

what is Benner's States of Nursing Proficiency?

1. novice 2. advanced beginner 3. competent 4. proficient 5. expert

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2. Arrange for an interpreter to translate.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action? 1. Tell the client herbal substances are not safe and should never be used. 2. Teach the client how to take their blood pressure so that is can be monitored closely. 3. Encourage the client to discuss the use of an herbal substance with the health care provider. 4. Tell the client that if they take the herbal substance they will need to have their blood pressure checked frequently.

3. Encourage the client to discuss the use of an herbal substance with the health care provider.

An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang

3. Foods considered to be yin (yin=cold; yang=hot)

Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1. Pork roast, rice, vegetables, mixed fruit, milk 2. Crab salad on a croissant, vegetables with dip, potato salad, milk 3. Sweet and sour chicken with rick and vegetables, mixed fruit, juice 4. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea

3. Sweet and sour chicken with rick and vegetables, mixed fruit, juice

The role of the nurse regarding complementary and alternative medicine should include which action? 1. Advising the client about "good" versus "bad" therapies 2. Recommending herbal remedies that the client should use 3. Discouraging the client from using any alternative therapies 4. Educating the client about therapies that he or she is using or is interested in using

4. Educating the client about therapies that he or she is using or is interested in using

The nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and should document which information? 1. The client believes the soul lives on after death. 2. Medication administration is not allowed. 3. Surgery is prohibited in this religious group. 4. The administration of blood and blood products is not allowed.

4. The administration of blood and blood products is not allowed.

The nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, would indicate an understanding of the five categories of CAM? 1. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care 2. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch 3. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and aroma therapy 4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine

4. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine

Definition of health

A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A) Risk for aspiration B) Acute confusion C) Readiness for enhanced coping D) Sedentary lifestyle

A) Risk for aspiration

Which activity represents secondary prevention? A. A home health care nurse visits a patient's home to change a wound dressing. B. A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked. C. The school health nurse provides a program to the first-year students on healthy eating. D. The patient attends cardiac rehabilitation sessions weekly

A. A home health care nurse visits a patient's home to change a wound dressing. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. The home health nurse changing the wound dressing is an activity that is focused on preventing complications. Much of the nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities. Awarded 1.0 points out of 1.0 possible points.

A nurse demonstrates caring by helping family members: A. Become active participants in care. B. Provide activities of daily living (ADLs). C. Remove themselves from personal care. D. Make health care decisions for the patient

A. Become active participants in care.

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? A. Caring touch B. Protective touch C. Task-oriented touch D. Interpersonal touch

A. Caring touch

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) A. Difficulty paying his bills B. Seeing his pastor as a means of support C. Family practice of not routinely seeing a health care provider D. Stress from the divorce and the loss of a job

A. Difficulty paying his bills C. Family practice of not routinely seeing a health care provider D. Stress from the divorce and the loss of a job External factors impacting health practices include family beliefs and economic impact. How patients families use health care services generally affects their health practices. Their perceptions of the serious nature of diseases and their history of preventive care behaviors (or lack of them) influence how patients will think about health. Economic variables may affect a patients level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system.

When a nurse enters a pt's room and says "Good morning" before starting care, the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to... A. Establish a relationship B. Gather assessment data C. Treat discomforts quickly D. Assess the patient's emotional needs

A. Establish a relationship

You will use the concept of primary prevention when instructing a patient to A. Get a flu shot every year. B. Take a blood pressure reading every day. C. Explore hiring a patient with a known disability. D. Undergo physical therapy following a cerebrovascular accident.

A. Get a flu shot every year.

Because a client recently diagnosed with diabetes mellitus is confident that blood sugar control can be improved with diet and exercise alone, and recently checked out a video on the management of diabetes at the HMO education center, the client's actions are most representative of which model? A. Health belief model B. Clinical model C. Role performance model D. Agent-host-environment model

A. Health belief model

When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? A. Holistic B. Health belief C. Transtheoretical D. Health promotion

A. Holistic The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care.

The nurse is caring for a patient who is actively bleeding. The physician orders blood transfusions. The nurse notes in the chart that the patient is a Jehovah's Witness and informs the patient of the physician's order. The patient states that she is a Jehovah's Witness and does not want blood products. The nurse contacts the physician to tell him that blood cannot be given to this patient and requests alternative treatment. In doing so, the nurse is operating within which of the following theories? A. Leininger's cultural care diversity and universality theory B. Roy's adaptation theory C. Watson's philosophy of transpersonal caring D. Orem's self-care deficit theory

A. Leininger's cultural care diversity and universality theory

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: A. Instilling hope and faith. B. Forming a human-altruistic value system. C. Cultural caring D. Being with

A. Instilling hope and faith.

The nurse is caring for a patient who is known as a "frequent flyer," and who has been labeled as "noncompliant" by most of the staff because she does not follow her prescribed regimen for diabetes management. As a prescriber to Orem's theory, the nurse interviews the patient in an attempt to identify the cause of the patient's "noncompliance." This is because Orem's theory? A. Is useful in designing interventions to promote self-care. B. Does not allow for environmental influences on care. C. Allows for development of a plan of care that the patient must follow. D. Is not useful in promoting self-care regimens.

A. Is useful in designing interventions to promote self-care.

Information regarding a patient's health status may not be released to non-health care team members because A. Legal and ethical obligations require health care providers to keep information strictly confidential. B. Regulations require health care institutions to document evidence of physical and emotional well-being. C. Reimbursement issues related to patient care and procedures may be of concern. D. Fragmentation of nursing and medical care procedures may be identified

A. Legal and ethical obligations require health care providers to keep information strictly confidential.

As an advocate for the client, the nurse must make sure that "safe, effective care" is given in conformity with the A. Nurse Practice Act (NPA). B. American Nursing Association (ANA) C. National Council for Lisensure Examinations D. State Board of Licensure

A. Nurse Practice Act (NPA).

Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the A. Orientation stage. B. Working stage. C. Termination stage. D. Preinteraction stage.

A. Orientation stage.

The nurse is visiting a patient at home after he was discharged from the hospital following a heart attack. She listens to the patient's concerns about being an invalid for the rest of his life because of his bad heart, but he is afraid of having "open heart" surgery. The nurse explains the different surgical procedures that are available to the patient, as well as other options such as cardiac rehabilitation. After several such visits, the patient states that he believes that cardiac rehabilitation therapy would be best for him, and asks the nurse how he can get in. The nurse calls the patient's physician and sets up a referral for cardiac rehabilitation. This action most closely fits which of the following theories? A. Peplau's theory B. Henderson's theory C. Nightingale's theory D. Orem's self-care deficit theory

A. Peplau's theory

A paradigm is useful in describing the domain of a discipline. Nursing's paradigm includes which of the following? (Select all that apply.) A. Person B. Disease C. Health D. Environment E. Nursing

A. Person C. Health D. Environment E. Nursing

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Quaternary prevention

A. Primary prevention Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protection such as immunization for influenza.

A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit smoking. When approached by the nurse, he states that he would be "better off dead." He states that he has always supported his family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse should a. Develop a plan of care for the family. b. Contact psychiatric services. c. Assure the patient that things will work out. d. Focus the plan of care on maximizing patient function.

ANS: A Because of the effects of illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable.

Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. An example of an internal variable would be a. Perception of functioning. b. Family practices. c. Socioeconomic factors. d. Cultural background.

ANS: A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient who says that she wants to be "detoxified." It is important for the nurse to a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Instruct the patient that she will have to change her lifestyle. d. Instruct the patient that relapses are not tolerated.

ANS: A Processes of change, or nursing interventions, should be appropriately chosen to match the stage of change. Most behavior change programs are designed for those people who are ready to take action regarding their health behavior problems. Only a minority of people are actually in this action stage. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

The nurse is preparing a smoking cessation class and is amazed at how many people still smoke even with the information on lung cancer so readily available. She believes that her class will convert many smokers to nonsmokers once they get all the latest information. The nurse is a believer in which of the following health care models? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: A The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model is more complex than the Health Belief Model in that it notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. Education is important but is not the sole determinant of change.

Models of health offer a perspective by which to understand the relationships between the concepts of health, wellness, and illness. Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health because nurses (Select all that apply.) a. Understand the challenges of today's health care system. b. Identify actual and potential risk factors. c. Have coined the term "illness behavior." d. Can minimize the effects of illness and assist to the return of optimal health

ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system and embrace the opportunity to use wellness activities to promote health and wellness and to prevent illness. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Medical sociologists call the reaction to illness "illness behavior."

Health Promotion Model (Pender)

Directed at increasing a patient's level of well-being

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and his wife refuse to talk about it and refuse to be taught about how to care for it. The nurse realizes that the patient and his wife are in which stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

ANS: B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment when they accept the loss, and rehabilitation when the patient is ready to learn how to adapt.

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. What level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

The patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. She is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. The nurse recognizes that the patient is in which stage of the change process? a. Precontemplation b. Contemplation c. Preparation d. Action

ANS: B These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). This patient is planning to make the change within the next 6 months and is in the contemplation stage.

The nurse is caring for a patient who has been trying to quit smoking. She has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and never will quit smoking. b. The patient will return to the contemplation or precontemplation phase. c. The patient will need to adopt a new lifestyle for change to be effective. d. The patient must pick up her attempt right where she left off.

ANS: B When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up her attempt where she left off. It is believed that change involves movement through a series of stages. These stages range from no intention to change (precontemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintenance. The action phase indicates a desire to change and a potential to do so. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle.

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a nonjudgmental attitude. Why does the nurse do this? a. Noncompliant patients thrive on the disapproval of authority figures. b. External variables have little effect on compliance. c. A person's compliance is affected by economic status. d. Employment status is an internal variable that impacts compliance.

ANS: C A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices. Internal and external variables influence how a person thinks and acts toward health care. Employment status is an external variable, not an internal variable.

An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2020 goal of a. Increasing quality of life in America. b. Prolonging healthy life in America. c. Eliminating health disparities in America. d. Promoting healthy behaviors.

ANS: C Healthy People 2020 promotes a society in which all people live long, healthy lives. This program has four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages. Providing health care to all would eliminate disparities in health care by ensuring access. Perhaps the best way to increase quality and years of healthy life is to promote healthy behaviors. However, providing access to health care would not guarantee changes in behaviors, increased quality of life, or prolonged healthy life.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses, and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

The health care model that utilizes Maslow's hierarchy as its base is the _____ Model. a. Health Belief b. Health Promotion c. Basic Human Needs d. Holistic Health

ANS: C The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy.

Just as health and health behavior are affected by internal and external variables, so are illness and illness behavior. Which external variables can affect illness and behavior? (Select all that apply.) a. Perception of the seriousness of the illness b. Patient's coping skills c. Cultural background d. Social support e. Socioeconomic status

ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. In doing so, the nurse is fostering the concept of a. Illness prevention. b. Active health promotion. c. Wellness education. d. Passive health promotion.

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

The patient has quit smoking and has been smoke free for the past 2 years. Of the following stages, which best fits her current stage of change? a. Contemplation b. Preparation c. Action d. Maintenance

ANS: D These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). Because she has been smoke free for 2 years, she is in the maintenance stage.

Transpersonal Caring

Across person (spirituality)

Action

Actively engaged in strategies to change behavior; lasts up to 6 months

What does Roy's view the patient as?

An adaptive system; when the patient cannot adapt to stressors

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness? A. "I don't have time to exercise because I have to work after school every night." B. "I'm worried about becoming overweight and getting diabetes because my father has diabetes." C. "The statistics of how many teenagers are overweight is scary." D. "I've decided to start a walking club at school for interested students."

B. "I'm worried about becoming overweight and getting diabetes because my father has diabetes." The statement indicates that the patient is concerned about developing diabetes and believes that there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the patient may perceive the personal risk for diabetes.

A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise? A. "Walking is OK. I really think running is better." B. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" C. "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables." D. "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good."

B. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" The patient's response indicates that the patient is in the contemplative state, possibly intending to make a behavior change within the next 6 months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin a walking plan.

Which individual appears to have "taken on" the sick role? A. An obese client states, "I deserve to have a heart attack." B. A mother is ill and says, "I won't be able to make your lunch today." C. A man with low back pain misses several physical therapy appointments. D. An elder states, "My horoscope says I will be well again."

B. A mother is ill and says, "I won't be able to make your lunch today."

While admitting a patient, during the initial interview, a family member tells you, "My mom really means that she does not understand her medical diagnosis." The communication form used by the family member is A. Focusing. B. Clarifying. C. Summarizing. D. Paraphrasing.

B. Clarifying.

Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor modification? A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance

B. Contemplation

The nurse puts a restraint jacket on a client without the client's permission and without the physicians order. The nurse may be guilty of assault. A. True B. False

B. False

The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic and physiological? (Select all that apply.) A. Sedentary lifestyle B. Father died from CAD at age 50 C. History of hypertension D. Eats diet high in sodium E. Elevated cholesterol level F. Age is 44 years

B. Father died from CAD at age 50 C. History of hypertension E. Elevated cholesterol level F. Age is 44 years Genetic and physiological risk factors include those related to heredity, genetic predisposition to an illness, or those that involve the physical functioning of the body. Certain physical conditions such as being pregnant or overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. A person with a family history of coronary artery disease is at risk for developing the disease later in life because of a hereditary and genetic predisposition to the disease.

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?" A. Sharing feelings about the importance of having regular woman's health examinations B. Gaining an understanding of what a woman's health examination means to the patient C. Recognizing that the patient is modest; obtaining gender congruent caregiver D. Explaining the risk factors for cervical cancer

B. Gaining an understanding of what a woman's health examination means to the patient

When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness? A. Health belief B. Illness behavior C. Health promotion D. Illness prevention

B. Illness behavior Illness behavior involves how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system. Personal history, social situations, social norms, and past experiences can affect illness behavior.

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record A. An interpretation of patient behavior. B. Objective data that are observed. C. Lengthy entry using lay terminology. D. Abbreviations familiar to the nurse.

B. Objective data that are observed.

The patient is newly diagnosed with diabetes and will be discharged in the next day or so. The nurse is teaching the patient how to draw up and self-administer his insulin. Which nursing theory is the nurse utilizing? A. Watson's philosophy of transpersonal caring B. Orem's self-care deficit theory C. Rogers' theory D. Henderson's theory

B. Orem's self-care deficit theory

Nursing theories provide nurses with perspectives from which to A. Analyze patient data. B. Predict phenomena. C. Formulate legislation. D. Link science to nursing.

B. Predict phenomena.

The type of theory that is used to develop and test specific nursing interventions is known as _____ theory. A. Grand B. Prescriptive C. Descriptive D. Middle-range

B. Prescriptive

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow? A. Physiological B. Safety and security C. Love and belonging D. Self-actualization

B. Safety and security The teaching addresses the need for safety and security. The throw rugs, low lighting, and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults.

A patient is suffering from shortness of breath. The correct goal statement would be written as A. The patient will be comfortable by the morning. B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. The patient will not complain of breathing problems within the next 8 hours. D. The patient will have a respiratory rate of 14 to 18 breaths per minute.

B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift.

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A) Data collection. B) Data clustering. C) Data interpretation. D) Making a diagnostic statement.

C) Data interpretation.

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A) The nurse who listens to lung sounds after a patient reports "difficulty breathing" B) The nurse who considers conflicting cues in deciding which diagnostic label to choose C) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D) The nurse who identifies a diagnosis on the basis of a single defining characteristic

C) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D) The nurse who identifies a diagnosis on the basis of a single defining characteristic

Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, exercise? I haven't done that since junior high gym class, and I hated it then!" A. "That's fine. Exercise is bad for you anyway." B. "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month." C. "I understand. Can you think of one reason why being more active would be helpful for you?" D. "I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day."

C. "I understand. Can you think of one reason why being more active would be helpful for you?" The patient's response indicates that the patient is in the precontemplation stage and does not intend to change his behavior in the next 6 months. In this stage the patient is not interested in information about the behavior and may be defensive when confronted with it. Asking an open-ended question may stimulate the patient to identify a reason to begin a behavior change. Nurses are challenged to motivate and facilitate change in health behavior when working with individuals.

Which one of the following is an example of the emotional component of wellness? A. The client chooses healthy foods. B. A new father decides to take parenting classes. C. A client expresses frustration with her partner's substance abuse. D. A widow with no family decides to join a bowling league.

C. A client expresses frustration with her partner's substance abuse.

A female pt has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the pt into the proper position and offers support during biopsy. The nurse is demonstrating... A. Enabling B. Comforting C. A sense of presence D. Maintaining belief

C. A sense of presence

The student nurse is learning nursing theories but fails to see how they relate to the nursing process. The professional nurse realizes that nursing theory A. Has a minor role in professional nursing. B. Requires the nursing process to develop knowledge. C. Can direct how a nurse uses the nursing process. D. Is specific to certain patients only.

C. Can direct how a nurse uses the nursing process.

When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a A. Critical pathway. B. Nursing care plan. C. Concept map. D. Diagnostic label.

C. Concept map.

Presence involves a person-to-person encounter that: A. Enables patients to care for self. B. Provides personal care to a patient. C. Conveys a closeness and a sense of caring. D. Describes being in close contact with a patient.

C. Conveys a closeness and a sense of caring.

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? A. Increasing the working hours of the staff B. Increasing salary benefits of the staff C. Creating a setting that allows flexibility and autonomy for staff D. Encouraging increased input concerning nursing functions from physicians

C. Creating a setting that allows flexibility and autonomy for staff

Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes? A. Knowing B. Enabling C. Doing for D. Being with

C. Enabling

Nursing has its own body of knowledge that is both theoretical and practical. Which of the following is an example of theoretical knowledge? A. Reflection on care experiences B. Synthesis and integration of the art and science of nursing C. Reflection on basic values and principles D. Creating a narrow understanding of nursing practice

C. Reflection on basic values and principles

A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception.

C. Narrative charting.

Consultation occurs most often during which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

C. Planning

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch? A. Caring touch B. Protective touch C. Task-oriented touch D. Interpersonal touch

C. Task-oriented touch

A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Quaternary prevention

C. Tertiary prevention Tertiary prevention involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration following the myocardial infarction. Tertiary-prevention activities are directed at rehabilitation rather than diagnosis and treatment. Care at this level aims to help patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. This level of care is called preventive care because it involves preventing further disability or reduced functioning.

A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? A. The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. B. The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. C. The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. D. The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.

C. The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.

The patient is admitted to the ICU to rule out a myocardial infarction (MI). During the admission process, the patient is noted to have a history of methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and the patient declared noninfectious. During the isolation process, the nurse encourages family visits, realizing that which level of Maslow's hierarchy of needs is at risk? A. First level B. Second level C. Third level D. Fourth level E. Fifth level

C. Third level

Contemplation

Considering a change within the next 6 months

Professional standards review organizations (PSROs)

Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid

Leninger's theory

Cultural care diversity and univerality - it considers social structure factors

A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image? A. "I just don't have any energy to get out of bed in the morning." B. "I've been attending church regularly with my wife since I got out of the hospital." C. "My wife has taken over paying the bills since I've been in the hospital." D. "I don't go out very much because everyone stares at me."

D. "I don't go out very much because everyone stares at me." The amputation resulted in a change in physical appearance that caused a change in body image. Reactions of patients and families to changes in body image depend on the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at which changes take place, and the support services available. When a change in body image such as results from a leg amputation occurs, the patient generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation. The patient's statement indicates he is in the stage of withdrawal.

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: A. "Spiritual care should be left to a professional." B. "You are correct, religion is a personal decision." C. "Nurses should not force their religious beliefs on patients." D. "Spiritual, mind, and body connections can affect health."

D. "Spiritual, mind, and body connections can affect health."

The nursing process is A. The generation of nursing knowledge for use in practice. B. A systematic view of a phenomenon specific to inquiry. C. A method used to inform a system about how it functions. D. A systematic process for the delivery of nursing care.

D. A systematic process for the delivery of nursing care.

The patient states she joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change? A. Precontemplation B. Contemplation C. Preparation D. Action

D. Action The patient is in the action stage of behavioral change. In this stage the patient is actively engaged in strategies to change behavior. This stage may last up to 6 months.

A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to A. Exchange information among health care members. B. Provide information about patients from one unit to another unit. C. Ensure proper care for the patient. D. Aid in the hospital's quality improvement program.

D. Aid in the hospital's quality improvement program.

The NLN and ANA are professional organizations that deal with A. Nursing issues of concern B. Political and professional issues affecting health care. C. Financial issues affecting health care. D. All of the above issues

D. All of the above issues

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: A. Making health care decisions for patients. B. Having family members provide a patient's total personal hygiene. C. Injecting the nurse's perceptions about the level of care provided. D. Asking permission before performing a procedure on a patient.

D. Asking permission before performing a procedure on a patient.

Technological advances in health care A. Make the nurse's job easier. B. Depersonalize bedside patient care. C. Threaten the integrity of the health care industry. D. Do not replace sound personal judgment

D. Do not replace sound personal judgment

Every health care organization gathers data on health outcomes. Examples of data include: A. Discharges. B. Medications administered. C. Healthy births. D. Infection rates

D. Infection rates

Listening is not only "taking in" what a patient says; it also includes: A. Incorporating the views of the physician. B. Correcting any errors in the patient's understanding. C. Injecting the nurse's personal views and statements. D. Interpreting and understanding what the patient means.

D. Interpreting and understanding what the patient means.

A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model? A. Perceived threat of the disease B. Likelihood of taking preventive health action C. Analysis of perceived benefits of preventive action D. Perceived susceptibility to the disease.

D. Perceived susceptibility to the disease. The health belief model addresses the relationship between a person's beliefs and behaviors. It provides a way of understanding and predicting how patients will behave in relation to their health and how they will comply with health care therapies. In the perceived susceptibility to the disease phase, the patient recognizes the familial link to the disease.

A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take? A. Care for the boy as she would any other patient B. Ask the manager to talk with the father and keep him out of the unit C. Have another nurse care for the boy because maybe that nurse will do better with the father D. Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

D. Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community The nurse needs to understand how the Greek culture impacts the father's health beliefs and communication with health care providers. Cultural variables must be incorporated into the child's plan of care. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, personal health practices, and the nurse-patient relationship. Cultural background may also influence an individual's beliefs about causes of illness and remedies or practices to restore health. If nurses are not aware of their own and other cultural patterns of behavior and language, they may not be able to recognize and understand a patient's behavior and beliefs and may have difficulty interacting with the patient.

After evaluating a patient's external variables, the nurse concludes that health beliefs and practices can be influenced by A. Emotional factors B. Intellectual background C. Developmental Stage D. Socioeconomic Factors

D. Socioeconomic Factors

Swanson's Theory of caring

Defines caring as a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility

Hospice care

Focuses on palliative (not curative) care: comfort, independence, and dignity

Secondary prevention

Focuses on those who have a disease or are at risk to develop a disease

Continuing care

For people who are disabled, functionally dependent, or suffering a terminal disease

Resource utilization groups (RUGs)

Method of classification for health care reimbursement for long term care facilities

Preparation

Making small changes in preparation for a change in the next month

Precontemplation

Not intending to make changes within the next 6 months

Tertiary prevention

Occurs when a defect or disability is permanent or irreversible

Utilization review committees (URs)

Review admissions, diagnostic testing, and treatments provided by physicians who cared for patients receiving Medicare

Restorative Care

Serves patients recovering from an acute or chronic illness/disability

A client states, "I have trouble sleeping. I only sleep about 2 hours and then I wake up." This is: a) subjective data. b) objective data. c) focused data. d) comprehensive data.

a) subjective data.

T/F In some cultures it is considered insensitive to tell the patient that he/she is dying.

True

Primary prevention

True prevention that lowers the chances that a disease will develop

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? a) whether they have a program of regular physical activity b) whether they have home maintenance skills c) whether they have anemia d) whether they have proper dietary habits

a) whether they have a program of regular physical activity

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. The nurse would document these sounds as: a) Adventitious breath sounds b) Bronchovesicular breath sounds c) Vesicular breath sounds d) Bronchial sounds

a) Adventitious breath sounds

A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply. a) Are you able to dress yourself? b) Do you have a history of smoking? c) What is the problem for which you are seeking care? d) Do you prepare your own meals? e) Do you manage your own finances? f) Whom do you rely on for support?

a) Are you able to dress yourself? d) Do you prepare your own meals? e) Do you manage your own finances?

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the primary care provider? a) Auscultation of a bruit b) Auscultation of peristalsis sounds c) Percussion of dull sounds over the right upper quadrant d) Percussion of tympanic sounds over the intestines

a) Auscultation of a bruit

A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: a) Cannot speak due to airway obstruction. b) Is coughing vigorously. c) Can make only minimal vocal noises. d) Starts to become cyanotic.

a) Cannot speak due to airway obstruction.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? a) Control the pain and support breathing and oxygenation. b) Monitor and manage potential complications. c) Decrease the anxiety and reduce the workload on the heart. d) Reduce the nausea and vomiting and stabilize the blood glucose.

a) Control the pain and support breathing and oxygenation

A nurse is preparing to assess a client with abdominal pain. What should the nurse do when preparing the client for assessment? a) Explain the assessment procedure to the client. b) Gather equipment as required. c) Check equipment just before use. d) Avoid speaking during the assessment.

a) Explain the assessment procedure to the client.

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? a) Maternal hypotension b) Maternal tachycardia c) Fetal tachycardia d) Maternal oliguria

a) Maternal hypotension

A nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor? a) The client has a child with cystic fibrosis. b) The client has a history of preterm labor at 32 weeks' gestation. c) The client is 25 years old. d) The client was exposed to rubella at 36 weeks' gestation.

a) The client has a child with cystic fibrosis.

A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly? a) The nurse starts at the tail of Spence and moves in increasing smaller circles. b) The nurse uses the palms of the hands to gently compress the breast tissue against the chest wall. c) The nurse works in a counterclockwise direction and palpates from the periphery toward the areola. d) The nurse starts at the inner edge of the breast and palpates up and down the breast.

a) The nurse starts at the tail of Spence and moves in increasing smaller circles.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? a) The tympanic membrane is translucent, shiny, and gray. b) The ear canal is rough and pinkish. c) The ear canal is smooth and white. d) The tympanic membrane is reddish.

a) The tympanic membrane is translucent, shiny, and gray.

The client, Mrs. Rodrigquez, has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator? a) Translators may need additional explanations of medical terms. b) Talking loudly helps the translator and the client understand the information better. c) It is always okay to not use a translator if a family member can do it. d) Talking directly to the translator facilitates the transfer of information.

a) Translators may need additional explanations of medical terms.

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor's best response? a. "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." b. "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." c. "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." d. "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

a. "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care."

Before implementing any intervention, the nurse uses critical thinking to a. Determine whether an intervention is correct and appropriate for the given situation. b. Evaluate the effectiveness of interventions. c. Establish goals for a particular patient without the need for reassessment. d. Read over the steps and perform a procedure despite lack of clinical competency

a. Determine whether an intervention is correct and appropriate for the given situation.

You have finished with several nursing interventions. To evaluate interventions, you need to examine the: a. Appropriateness of the interventions and the correct application of the implementation process. b. Nursing diagnosis to ensure that they are not medical diagnoses. c. Care planning process for errors in other health care team members' judgments d. interventions of each nurse to enable the nurse manager to correctly evaluate performance.

a. Appropriateness of the interventions and the correct application of the implementation process.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Put all the patients' nursing diagnoses in order of priority. b. Consider time as an influencing factor. c. Set priorities based solely on physiological factors. d. Utilize critical thinking. e. Do not change priorities once they've been established

a. Put all the patients' nursing diagnoses in order of priority. b. Consider time as an influencing factor. d. Utilize critical thinking.

When the nurse describes a patient's perceived ability to successfully complete a task, which term should the nurse use? a. Self-efficacy b. Motivation c. Attentional set d. Active participation

a. Self-efficacy

The following statements are on a patient's nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. Which learning objective/outcome is most appropriate? a. The patient will walk to the bathroom and back to bed using a cane. b. The patient will understand the importance of using a cane. c. The patient will learn how to use a cane. d. The patient will know the correct use of a cane.

a. The patient will walk to the bathroom and back to bed using a cane.

A client with type 1 diabetes has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide? a) "Insulin requirements usually decrease during the last two trimesters." b) "Insulin requirements usually decrease during the first trimester." c) "Insulin requirements increase greatly during labor." d) "Insulin requirements don't change during pregnancy. Continue your current regimen."

b) "Insulin requirements usually decrease during the first trimester."

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? a) Slurred speech b) Alteration in level of consciousness (LOC) c) Bradycardia d) Decreased heart rate

b) Alteration in level of consciousness (LOC)

A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol abuse. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next? a) Nothing. The nurse shouldn't alarm her unnecessarily. b) Ask the client if she has noted any blood in her stools lately. c) Ask the client if she feels dizzy. d) Ask the client if her gums bled this morning when she brushed her teeth.

b) Ask the client if she has noted any blood in her stools lately.

A weak, thready pulse found after the nurse palpates peripheral pulses may indicate which condition? a) Inflammation of a vein b) Decreased cardiac output c) Hypertension and circulatory overload d) Impaired circulation

b) Decreased cardiac output

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? a) Heart sounds are caused by the opening of heart valves. b) Each lub-dub is one beat. c) The lub-dub sounds occur within 2 seconds of each other. d) Each lub-dub is two beats.

b) Each lub-dub is one beat.

A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply. a) Bring a penlight from the side of the patient's face and briefly shine the light on the pupil. b) Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4″ to 6″) from the bridge of the patient's nose. c) Hold a finger about 6″ to 8″ from the bridge of the patient's nose. d) Darken the room. e) Ask the patient to look straight ahead. f) Ask the patient to first look at a close object, then at a distant object, then back to the close object.

b) Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4″ to 6″) from the bridge of the patient's nose. f) Ask the patient to first look at a close object, then at a distant object, then back to the close object.

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? a) It is normal. b) It is distended. c) It is inflamed. d) It is dissecting.

b) It is distended.

A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test? a) Ask the patient to sit about 3 feet away facing the nurse. b) Keep a penlight about 1 foot from the patient's face and move it slowly through the cardinal positions. c) Move a penlight in a circular motion in front of the patient's eyes. d) Ask the patient to cover one eye with a hand or index card.

b) Keep a penlight about 1 foot from the patient's face and move it slowly through the cardinal positions.

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document? a) Awake and alert b) Lethargic c) Stuporous d) Comatose

b) Lethargic

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? a) Insert an indwelling catheter. b) Massage the fundus. c) Call the physician. d) Pack the vagina with sterile gauze.

b) Massage the fundus.

A client has been reporting persistent headaches. Which is an example of subjective data? a) The client is alert and oriented to person, place, and time. b) Pain is 4 out of 10 on a pain scale. c) The client appears lethargic. d) Temperature is 104.1°F (40.05°C)

b) Pain is 4 out of 10 on a pain scale.

Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply. a) The nurse compares the patient's bilateral body parts for symmetry. b) The nurse takes a patient's pulse. c) The nurse touches a patient's skin to test for turgor. d) The nurse checks a patient's lymph nodes for swelling. e) The nurse taps a patient's body to check the organs. f) The nurse uses a stethoscope to listen to a patient's heart sounds.

b) The nurse takes a patient's pulse. c) The nurse touches a patient's skin to test for turgor. d) The nurse checks a patient's lymph nodes for swelling.

The nurse is preparing a 45-year-old male client for emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action? a) Locate the laboratory test results in the chart. b) Verify that the procedural consent form is signed. c) Document that the preoperative medication was administered. d) Ensure that the preoperative check list is completed.

b) Verify that the procedural consent form is signed.

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's: a) thyroid gland. b) peripheral pulses. c) lymph nodes. d) liver.

b) peripheral pulses.

The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most appropriate? a. Assisting with activities of daily living b. Counseling about respite care options c. Teaching range-of-motion exercises d. Emphasizing the importance of exercise

b. Counseling about respite care options

Your patient has met the goals set for improvement of ambulatory status. You would now a. Modify the care plan b. Discontinue the care plan c. Create a new nursing diagnosis that states goals have been met d. reassesses the patient's response to care and evaluate the implantation step of the nursing process

b. Discontinue the care plan

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include? a. Sentinel events help determine reimbursement issues for health care. b. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. c. A clinical information system must be installed by 2014 to obtain health care reimbursement. d. HIPAA is the basis for establishing reimbursement for health care.

b. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.

A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include? a. The nurse is the center of the health care team. b. If you still do not understand, ask again. c. Ask a nurse to be your advocate or supporter. d. Inappropriate medical tests are the most common mistakes.

b. If you still do not understand, ask again.

The nurse establishes trust and talks with a school-aged patient before administering injections. This nurse is demonstrating which type of implementation skill? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

b. Interpersonal

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed

b. Turning side to back to side with assistance every 2 hours.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? a) Place the client in a semi-Fowler's position. b) Warm the equipment. c) Ask the client to empty her bladder. d) Measure height and weight.

c) Ask the client to empty her bladder.

During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next? a) Percussion b) Palpation c) Auscultation d) Whichever is more comfortable for the patient

c) Auscultation

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? a) Ask the client if he left his earplugs in his ears. b) Use facial expressions and sign language to communicate. c) Check the client's ear canals for cerumen. d) Speak to the elderly client in a high-frequency tone of voice.

c) Check the client's ear canals for cerumen.

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? a) Assess for asthma. b) Suspect an inflamed pleura rubbing against the chest wall. c) Document normal breath sounds. d) Recommend testing for pneumonia.

c) Document normal breath sounds.

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? a) Olfactory b) Optic c) Facial d) Vagus

c) Facial

The nurse performs a comprehensive assessment of a newly admitted client. What is the primary purpose of this admission assessment? a) Determine risk factors. b) Provide orientation to the facility. c) Identify baseline data. d) Initiate a therapeutic relationship.

c) Identify baseline data.

After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1 cm. What types of skin lesions might this describe? Select all that apply. a) Macule b) Patch c) Plaque d) Nodule e) Bulla f) Pustule

c) Plaque d) Nodule

A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? a) The client with a history of cardioversion for sustained ventricular tachycardia 2 days ago b) The client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday c) The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block d) The client with a history of heart failure who has bibasilar crackles and pitting edema in both feet

c) The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as: a) The patient can see twice as well as normal. b) The patient has double vision. c) The patient has less than normal vision. d) The patient has normal vision.

c) The patient has less than normal vision.

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for? a) a client recovering from brain surgery for repair of an aneurysm b) a client with a brain tumor who is in the hospital because of respiratory depression c) a client in the Intensive Care Unit for acute pancreatitis asking for pain medications d) a client in the Intensive Care Unit after having a stroke yesterday

c) a client in the Intensive Care Unit for acute pancreatitis asking for pain medications

The nurse should use the bell of the stethoscope during auscultation of: a) a client's bowel sounds. b) a client's breath sounds. c) a client's heart murmur. d) a client's apical heart rate.

c) a client's heart murmur.

A nurse is teaching an older adult patient about strokes. Which teaching technique is most appropriate for the nurse to use? a. Use a pamphlet about strokes with large font in blues and greens. b. Speak in a high tone of voice to describe strokes. c. Begin and end each teaching session with the most important information about strokes. d. Provide specific information about strokes in frequent, large amounts.

c. Begin and end each teaching session with the most important information about strokes.

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system

c. Critical pathway design

A nurse is going to teach a patient about hypertension. Which action should the nurse implement first? a. Set mutual goals for knowledge of hypertension. b. Teach what the patient wants to know about hypertension. c. Assess what the patient already knows about hypertension. d. Evaluate the outcomes of patient education for hypertension.

c. Assess what the patient already knows about hypertension.

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? a. Patient went up and down stairs b. Deficient knowledge regarding crutches c. Demonstrated use of crutches d. Used crutches with no difficulties

c. Demonstrated use of crutches

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a. Focus charting using the DAR format. b. Add this data to the problem list. c. Document the variance in the patient's record. d. Report a positive variance in the next interdisciplinary team meeting.

c. Document the variance in the patient's record.

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. "Patient seems to be in pain and states, 'I feel uncomfortable.'" b. Status unchanged, doing well c. Left abdominal incision 1 inch in length without redness, drainage, or edema d. Patient is hard to care for and refuses all treatments and medications. Family present

c. Left abdominal incision 1 inch in length without redness, drainage, or edema

Which of these interventions, to be included in the plan of care, is appropriate for the patient outcome that states, "The patient will verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift."? a. Medicate the patient immediately after all procedures. b. Discuss only nonpharmacological methods of pain relief. c. Teach the patient about side effects of pain medications. d. Medicate the patient based on previous shift assessment findings

c. Teach the patient about side effects of pain medications.

A nurse has taught a patient about healthy eating habits. Which learning objective/outcome is most appropriate for the affective domain? a. The patient will state three facts about healthy eating. b. The patient will identify two foods for a healthy snack. c. The patient will verbalize the value of eating healthy. d. The patient will cook a meal with low-fat oil.

c. The patient will verbalize the value of eating healthy.

The nurse at the neighborhood family clinic is instructing a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client? a) "You should decrease your intake of fried foods." b) "It is important for you to do 30 minutes of exercise three times a week." c) "You need to sign up for the clinic's stop smoking program." d) "Take your blood pressure medications exactly as your doctor prescribed them."

d) "Take your blood pressure medications exactly as your doctor prescribed them."

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? a) Client describes shortness of breath and increased sputum production. b) Client reports respiratory distress and frequent spitting. c) Client reports breathlessness and productive cough. d) Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."

d) Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) Hyperventilation b) Semiconsciousness c) Delirium d) Hypoxia

d) Hypoxia

Mr. Sanchez is a 56-year-old Mexican American who has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention? a) Limit the client's activity. b) Assess fluid intake. c) Assess capillary refill. d) Measure the pulse oximetry.

d) Measure the pulse oximetry.

Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding is known as? a) Ectropion b) Entropion c) Miosis d) Ptosis

d) Ptosis

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? a) Enlist the help of another nurse to hold the client steady during the procedure. b) Reassure the client that the procedure will only take a few minutes. c) Administer a sedative to the client and try again when the sedative takes effect. d) Stop lifting the client and reassess him.

d) Stop lifting the client and reassess him.

When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What type of breath sound would the nurse document? a) Rhonchi b) Crackles c) Stridor d) Wheezes

d) Wheezes

To assess subjective data related to a client's elimination pattern, the nurse: a) palpates the abdomen for pain or distention. b) notes the frequency, amount, and time the client voids. c) reviews the latest laboratory report of the urine. d) asks the client about changes in elimination patterns.

d) asks the client about changes in elimination patterns.

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment? a) palpation of tactile fremitus over the posterior thorax b) percussion of loud, hollow sounds over the lateral lung fields c) an anteroposterior to lateral ratio of 1:2 d) auscultation of short, high-pitched popping sounds during inspiration

d) auscultation of short, high-pitched popping sounds during inspiration Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure.

When a client enters the acute care facility, the nurse should perform a: a) physical health assessment. b) focused health assessment. c) spiritual health assessment. d) comprehensive health assessment.

d) comprehensive health assessment.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of: a) subjective data. b) comprehensive data. c) baseline data. d) objective data.

d) objective data.

A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing intervention for this patient? a. Assist the patient to walk in the room with crutches. b. Obtain a walker for the patient. c. Consult physical therapy. d. Administer pain medication

d. Administer pain medication

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls? a. Encourage patient to remain in bed most of the shift. b. Keep all side rails down at all times. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 6 hours or as tolerated

d. Assist patient into and out of bed every 6 hours or as tolerated

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible

d. Involve the son in the plan of care as much as possible

Secondary and tertiary care focus on

diagnosis and treatment of disease

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

d. Reflex urinary incontinence

A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the nurse do first? a. Ask for at least two other assistive personnel to come to the room. b. Medicate the patient to alleviate discomfort while ambulating. c. Offer the patient a walker. d. Review the patient's activity orders

d. Review the patient's activity orders

After providing care, a nurse charts in the patient's record. Which entry should the nurse document? a. Appears restless when sitting in the chair b. Drank adequate amounts of water c. Apparently is asleep with eyes closed d. Skin pale and cool

d. Skin pale and cool

Diagnosis related groups (DRGs)

group of patients classified to establish a mechanism for health care