Fundamentals Questions
Keloid formations (abnormal scar formations) are more common in which group of people?
African American
Which intervention would most likely appear in the care plan of a client with dissociative identity disorder (DID)?
Arrange to have staff check on the client every 15 to 30 minutes (A common reason for hospitalization in clients with DID is suicidal ideations or gestures)
A nurse is assisting in developing a plan of care for an older adult client. Which challenges, faced by clients in this age group, should the nurse consider in this plan of care development?
Adjusting to retirement, deaths of family members, and decreased physical strength
A patient who is Islamic says she cannot sign the surgical consent form without her husbands consent. You would respond:
"Call me when your husband gets here and you have spoken with him."
A client is concerned about severe abdominal pain. During the focused assessment, the nurse asks which question to elicit as much information as possible about the pain?
"Can you describe the pain?"
The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation?
"S1 is loudest at the apex, and S2 is loudest at the base."
While assessing a client, the registered nurse (RN) with the assistance of the practical/vocational nurse is in the planning step of the nursing process. The RN asks the LVN which activities would be performed during this phase. Which responses given by LVN would indicate to the RN that the LVN is knowledgeable of activities performed in the planning phase?
"We will develop the goals of client care."
Carbohydrates
A quick source of energy
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
An isolation room close to the nurses' station
Skills
Apply technology to support patient care.
ATTITUDES
Appreciate the need to seek continuous learning of information technology skills.
Nutrients
Are biochemical substances used by the body that must be supplied in adequate amounts from foods consumed.
A client who underwent surgery 1 day ago is concerned about worsening incision pain and isn't scheduled to receive pain medication for 2 hours. Which action by the nurse is most appropriate?
Assess the incision and then notify the charge nurse of the client's worsening pain.
Your 45-year old, mentally competent patient is having excessive blood loss from surgery. She is a Jehovah's Witness and refuses a blood transfusion. Her blood pressure has been falling, and she has rapid heart rate. What would an appropriate nursing intervention be?
Assist the RN in administering IV fluid blouses and medications to support the blood pressure.
Culturally competent care is best defined as:
Care adapted to the patients beliefs and values
Compare the death rituals between the Catholic and Eastern Orthodox religions
Catholic: Death: the dying must receive the sacrament of the sick and make a confession; all body parts must be cremated or buried. Eastern Orthodox Death: priest must be called while the patient is conscious for the patient to receive last rites. The Orthodox Church discourages assisted deaths, autopsy, cremation, and organ donation
The largest religion in the world is:
Christianity
Term that involves knowledge of a people's history and an appreciation for their customs?
Cultural awareness
Which change occurs in the digestive system with aging?
Decreased peristalsis may increase the risk of constipation
Knowledge
Describe examples of how computerized information is related to patient care quality and safety.
Skills
Document patient care in an electronic health record
The nurse is revising a client's plan of care. Revision of the care plan takes place in which step of the nursing process?
During the evaluation step of the nursing process, the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan.
Minerals
Essential for metabolism and cellular function.
The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client?
Face rating scale.
A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?
Hyperthermia
Knowledge
Identify essential information needed in a dat base to support patient care.
After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client?
Inability to speak clearly
Checklist for Orienting the Patient
Introduction of self and personnel on unit Personal belonging storage Instructions for operating the bed, lights, call button, bath-room call button, drapes, television, and telephone Policies for visitors and phone calls Daily routine including meal times and time of shift change When lab work is drawn (if ordered) What diagnostic tests are ordered and when they are likely to be performed Any printed material on hospital amenities (gift shop hours, cafeteria hours, etc.)
A patient refuses to eat pork and drink alcohol and fasts during the month of Ramadan. The patient's religion is likely to be:
Islam
A 25-year-old female is involved in an auto accident and needs a blood transfusion; however, she refuses a transfusion based on her beliefs. The woman is most likely a
Jehovah's Witness
Knowledge
Knowledge of why information and technology skills are essential for safe patient care.
Skills
Learn how data are managed in care setting before performing patient care
Skills
Navigate the electronic health record
The quality control nurse is reviewing clients' charts on the medical-surgical unit. When reviewing the nursing staff nursing notes, the quality control nurse expects to find which factors? Select all that apply.
Nursing notes follow chronological order Nurses end each entry with the nurse's signature and title.
Which branch of Judaism follows the strictest interpretation of Jewish law?
Orthodox Jews
The first postoperative dressing should be changed by the:
Physician, not the Nurse.
ATTITUDES
Protect patient privacy and confidentiality in electronic health records
Which nutrient plays a role in maintaining fluid balance, transportation of nutrients, and antibody production?
Protein
Which nursing intervention might be considered insensitive by some culture groups?
Providing a pitcher of lice water at the bedside
A nurse is performing a focused assessment on a client who had major surgery five days ago. Which data collection finding would be the best indication of a wound infection in this client?
Purulent wound drainage.
Which is a main characteristic that differentiates cultural groups from one another?
Race,Color,Gender,Religious affiliation
Knowledge
Recognize the time, effort, and skill needed for technology to become a effective and reliable tool for patient care
A client returns to the client care area after undergoing abdominal surgery. As the nurse inspects the client's dressing, she notes that it's completely saturated with bright-red blood. Which action should the nurse take?
Reinforce the dressing and contact the physician.
How does spirituality differ from religion?
Religion: formalized system of belief and worship; its rituals related to health, illness, birth, death, and behavior are part of the organized religion Spirituality concerns the spirit or soul and is an element of religion
Skills
Respond appropriately to clinical decision making alerts, in collaboration with the RN
A client who received general anesthesia returns from surgery. Postoperative, which nursing diagnosis takes highest priority for this client?
Risk for aspiration related to general anesthesia (Risk for aspiration related to general anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. )
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for the client at this time?
Risk for injury (This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation.)
A nurse is caring for a client with a diagnosis of Impaired gas exchange. Which outcome is most appropriate based upon this nursing diagnosis?
The client has normal breath sounds in all lung fields.
A nurse is reviewing the care plan of a client who has been receiving an intravenous solution. What appropriate expected outcome for this client should the nurse expect to find on the care plan?
The client remains free of signs and symptoms of phlebitis.
A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client's return visit to the physician's office, the nurse assesses his gait. Which finding indicates the need for further education about walker use?
The client's arms are fully extended when using the walker.
A nurse is performing a focused abdominal assessment. When can the nurse document that her client's bowel sounds are absent after listening for how long over each quadrant?
The nurse can document that bowel sounds are absent after listening for a full 5 minutes over each quadrant.
Trans-cultural nursing
The nursing theorist who described care that recognizes cultural diversity and is sensitive to the cultural needs of the patient and family is a term used by Dr. Madeline Leininger
The parotid gland is part of which structure?
The parotid glands are the largest of the salivary glands
The gastrointestinal (GI) system includes:
The pharynx is a fibromuscular passageway in the GI system that connects the nasal and oral cavities to the larynx and esophagus.
A nursing faculty is preparing a lecture on the foundation of nursing knowledge. Which framework for nursing education and clinical practice would faculty include in the lecture?
Theoretical and conceptual models
A client with terminal cancer is referred to a local hospice. The nurse is aware that which of the following is the goal of this referral?
To provide support for the client and family in coping with terminal illness
ATTITUDES
Value nurses' involvement in design of information technology systems for patient care
ATTITUDES
Value technology that supports clinical decision making
Checklist for Orienting the Patient
Where cafeteria, visitor's lounge, and chapel are located How valuables are safeguarded When doctor might be expected Send valuables home or use process for safeguarding them Answer all questions Verify accuracy and then attach the patient identification band Have patient disrobe and put on a gown Take vital signs, height, and weight Obtain a urine specimen if one is ordered
stereotype
a set opinion or belief about the group that is applied to an individual
In Maslow's hierarchy of needs, pain relief is on the first tier. Safety (as in wrist restraints) is on the second tier. Love and belonging (as in family or a support group) are on the third tier.
administering pain medication.
Edema and warmth
are objective assessment findings
The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is:
diminished reflexes
Risk for infection
example of a nursing diagnosis
Monitoring fluid intake and output is a:
example of a nursing intervention
A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should:
palpate the bladder above the symphysis pubis.
A formalized system of belief and worship is:
religion
Endocrine glands
secrete the chemical
A saturated dressing might:
signal postoperative hemorrhage
"All Hispanics like hot peppers" is an example of
stereotype
Christianity
three main divisions: Roman Catholic, Eastern Orthodox, Protestant faiths.
Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:
withhold food and fluids.
A 20-year-old seeks treatment at a local emergency care center after spraining his ankle while playing football with friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply.
• Initially apply the cold pack. • Instruct the client to elevate the ankle for 48 to 72 hours. • Provide crutch-gait training. • If needed, apply an elastic bandage from the toes to mid-calf.