H&W Exam 2 practice~

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A nurse assesses a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she urinates. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb) and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.) 1. Age 42 2. Dysuria 3. Difficulty performing perineal hygiene 4. Nocturia 5. Episode of diarrhea 6. Weighs 136 kg (300 lb) 7. Frequent voiding

2, 4, 7

A family includes a mother, a stepfather, two teenage biological daughters of the mother, and a biological daughter of the father. The father's daughter just moved home following the loss of her job in another city. The family is converting a study into a bedroom and is in the process of distributing household chores. Nursing assessment reveals that all members of the family think that their family can adjust to lifestyle changes. This is an example of family: 1. Diversity 2. Durability 3. Resiliency 4. Configuration

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Do you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."

A nurse is experiencing an ethical dilemma with a client. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? 1 Power inequities 2 Poor client communication 3 Presence of conflicting values 4 Judgmental perceptions of clients

A nurse is preparing to teach a patient who has sleep apnea how to use a continuous positive airway pressure (CPAP) machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works.

A nurse receives a medication prescription that seems incorrect based on the client's diagnosis and contacts the provider for clarification. The nurse understands that this action is an example of which ethical principle? 1 Autonomy 2 Fidelity 3 Nonmaleficence 4 Justice

A nurse who works in an outpatient chemotherapy infusion center is assigned to the care of a 56-year-old male patient who is receiving chemotherapy for colon cancer. This is the patient's first clinic visit. The nurse reviews the patient's medical record and sees a note about the patient receiving instruction on how chemotherapy treats cancer; the note does not summarize the patient's response. The nurse's assessment reveals that the patient is motivated to learn more about his chemotherapy and is alert and currently feeling well. The nurse has prepared the first infusion, regulated it, and now takes time to begin instruction. Which teaching approaches are best suited for this situation? 1. Use an entrusting approach in explaining how to monitor for side effects of chemotherapy. 2. Bring the patient together with two other patients in the clinic and conduct a group discussion. 3. Provide verbal one-on-one instruction, with the patient participating in selection of content. 4. Present the patient with a problem situation involving a serious side effect and have the patient decide what to do.

A nurse working in a large occupational health clinic knows that many of the workers at her company are marginalized and at risk for poor health outcomes. Which of the following individuals are most likely to be marginalized? 1. Wives of the employees 2. The head supervisors of the company 3. Workers who have a high school education 4. Workers employed for less than a year at the company

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray

A nursing student is giving a presentation to a group of other nursing students about the needs of patients with mental illnesses in the community. Which statement by the student indicates that the nursing professor needs to provide further teaching? 1. "Many patients with mental illness do not have a permanent home." 2. "Unemployment is a common problem experienced by people with a mental illness." 3. "The majority of patients with mental illnesses live in long-term care settings." 4. "Patients with mental illnesses are often at a higher risk for abuse and assault."

A nursing student is providing a hand-off report to the RN assuming the patient's care. The nursing student explains, "I ambulated him twice during the shift; he tolerated walking to end of hall and back each time with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS." Which intervention is a dependent intervention? 1. Providing hand-off report at change of shift 2. Enhancing the patient's sleep hygiene 3. Administering IV fluids 4. Taking vital signs

A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. REALM test

Family structure can best be described as: 1. A complex set of relationships 2. A basic pattern of predictable stages 3. The pattern of relationships and ongoing membership 4. Flexible patterns that contribute to adequate functioning

Interventions used by the nurse when providing care to a rigidly structured family include: 1. Attempting to change the family structure 2. Providing solutions for problems as they arise 3. Exploring with the family the benefits of moving toward more flexible modes of action 4. Administering nursing care in a manner that provides minimal opportunity for change

Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique? 1. Direct question 2. Problem solving 3. Problem seeking 4. Open-ended question

The ANA Code of Ethics for Nurses articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and right of the patient." This promise to protect includes a promise to protect patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? 1. Yes. Patient privacy would not be violated because patient identifiers were removed. 2. Yes. Respect for autonomy implies that you have the autonomy to decide what constitutes privacy. 3. No. A viewer might identify the patient based on other comments that you make online about the patient's condition and your place of work. 4. No. The principle of justice requires you to allocate resources fairly.

The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology? 1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action. 2. The single focus on power imbalances does not apply to all situations in which ethical problems occur. 3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. 4. The focus on consequences rather than on the "goodness" of an action makes decision makers uncomfortable.

The factor that best advanced the practice of nursing in the twentieth-first century was: 1. the growth of cities 2. the teachings of Christianity 3. better education of nurses 4. improved conditions for women

The first step in community assessment is determining the community's: 1. Goals 2. Set factors 3. Boundaries 4. Throughputs

The nurse works with pediatric patients who have diabetes. Which is the youngest age group to which the nurse can effectively teach psychomotor skills such as insulin administration? 1. Toddler 2. Preschool 3. School age 4. Adolescent

The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement 3. Setting goals and selecting interventions 4. Performing nursing actions and documenting them

When a patient-centered goal has not been met in the projected time frame, the most appropriate action by the nurse would be to: 1. Rewrite the plan using different interventions 2. Continue with the same plan until the goal is met 3. Repeat the entire sequence of the nursing process to discover needed changes 4. Conclude that the goal was inappropriate or unrealistic and eliminate it from the plan

Which organization is responsible for nursing's code of ethics? 1 American Nurses Credentialing Center 2 International Council of Nurses 3 American Nurses Association 4 American Association of Colleges of Nursing

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? 1. Knowing the source of the guideline 2. Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4. Explaining to a patient the purpose of the guideline

How many Standards of Professional Performance are there?

12: Ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality, pro prac eval, resource stewardship, and environmental health

How many total standards are presented in the Scope and Standards of Practice? 10 18 6 12

match: (1) Truth Seeking, (2) Open-mindedness, (3) Analyticity, (4) Systematicity a. Anticipate how a patient might respond to a treatment. b. Organize assessment on the basis of patient priorities. c. Be objective in asking patient questions. d. Be tolerant of the patient's views and beliefs.

1c, 2d, 3a, 4b

A nurse desires to communicate with a young woman who is Serbian and who has limited experience with being in a hospital. The nurse has 10 years of experience caring for Serbian women. The patient was admitted for a serious pregnancy complication. Apply the LEARN model and match the nurse's behaviors with each step of the model. ____ 1. L a. The nurse notes that she has learned that fathers can visit mothers at any time in both Serbia and the United States. ____ 2. E b. The nurse shares her perception of the woman's experiences as a patient. ____ 3. A c. The nurse asks the patient how she can maintain bed rest when she returns home. ____ 4. R d. The nurse attends to the patient and listens to her story about hospitals in Serbia. ____ 5. N e. The nurse involves the patient in a discussion of the treatment options for her condition.

1d, 2b, 3a, 4e, 5c

A community health nurse conducts a community assessment focused on adolescent health behaviors. The nurse determines that a large number of adolescents smoke. Designing a smoking-cessation program at the youth community center is an example of which nursing role? 1. Epidemiologist 2. Counselor 3. Collaborator 4. Case manager

A group that lobbies at the state and federal levels for advancement of nurses' role, economic interests, and health care is the: 1. State Boards of Nursing 2. American Nurses Association 3. American Hospital Association 4. National Student Nurses Association

A health care issue often becomes an ethical dilemma because: 1. Decisions must be made based on value systems. 2. The choices involved do not appear to be clearly right or wrong. 3. Decisions must be made quickly, often under stressful conditions. 4. A patient's legal rights coexist with a health professional's obligations.

A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. The nurse focuses on symptom management for the grandmother and on helping the family with developing coping skills. This approach is an example of which of the following? 1. Family as context 2. Family as patient 3. Family as a system 4. Family as structure

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Reflection 2. Clinical inference 3. Cue 4. Validation

A nurse offers pain medication to a client who is experiencing acute appendicitis. The nurse understands that this aspect of care delivery is an example of which ethical principle? 1 Fidelity 2 Beneficence 3 Justice 4 Autonomy

A nurse's assessment reveals a patient having frequent voiding and pain when she urinates. Her body temperature is 38°C (100.4°F). The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." When asked how often, the patient replies, "About three times a night." The nurse asks if having to urinate at night is recent or normal for the patient. The patient explains, "I usually go once a night but that is all." The nurse then asks, "When you feel the need to go, can you reach the toilet in time?" The patient says, "Oh, yes, I can." The nurse asks, "And have you had any leaking of urine?" The patient denies leaking. When asked if she is having any back or abdominal pain, the patient denies discomfort. The nurse then gathers a urine specimen from the patient and inspects its character, noting it is cloudy and foul smelling. Which of the following nursing diagnoses are indicated by cues in this patient's assessment? 1. Impaired Kidney Function 2. Impaired Urination 3. Urge Incontinence of Urine 4. Total Urinary Incontinence

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment to the abdomen, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? 1. Impaired Kidney Function 2. Impaired Urination 3. Urge Incontinence of Urine 4. Total Urinary Incontinence Incorrect clustering of data 2. Wrong diagnosis 3. Condition is a collaborative problem 4. Premature ending assessment

A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient's airways. When the nurse asks how the patient feels, he responds by saying, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is a subjective evaluative measure? 1. Counting respirations per minute 2. Asking the patient to describe how his breathing feels 3. Observing breathing pattern 4. Auscultating lung sounds 5. Having the patient explain purpose of the IV infusion

A patient suddenly experienced a severe headache with numbness and decreased movement in the left arm. An emergency brain scan confirmed a cerebral vessel clot. With a stroke confirmed, the emergency room physician consults with a neurosurgeon to schedule an emergent angiogram to remove the clot. Which teaching approach is most appropriate for explaining to the patient what to expect from the procedure? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach

An internal impulse that causes a person to take action is: 1. Anxiety 2. Motivation 3. Adaptation 4. Compliance

During a visit to a family clinic, a nurse teaches a mother about immunizations, the use of car seats, and home safety for an infant and toddler. Which type of nursing interventions are these? 1. Restorative 2. Health promotion 3. Acute care 4. Growth and development

Measuring the patient's response to nursing interventions and his or her progress toward achieving goals occurs during which phase of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Nursing diagnosis

The criteria used to determine the effectiveness of a nursing action are based on the: 1. Nursing diagnosis 2. Expected outcomes 3. Patient's satisfaction 4. Nursing interventions

The following statement appears on the nursing care plan for an immunosuppressed patient: "The patient will remain free from infection throughout hospitalization." This statement is an example of a (an): 1. Long-term goal 2. Short-term goal 3. Nursing diagnosis 4. Expected outcome

The information obtained in a review of systems (ROS) is: 1. Objective 2. Subjective 3. Based on the nurse's perspective 4. Based on physical examination findings

The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data interpretation 4. Termination

The nursing care plan calls for the patient, a 300-lb woman, to be turned every 2 hours. The patient is unable to assist with turning. The nurse knows that she may hurt her back if she attempts to turn the patient by herself. The nurse should: 1. Turn the patient by herself 2. Ask another nurse to help her turn the patient 3. Rewrite the care plan to eliminate the need for turning 4. Ignore the intervention related to turning in the care plan

To be effective in meeting various ethnic needs, the nurse should: 1. Treat all patients alike 2. Be aware of patients' cultural differences 3. Act as if he or she is comfortable with the patient's behavior 4. Avoid asking questions about the patient's cultural background

When designing a plan for pain management for a patient following surgery, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. If the nurse's actions are driven by respect for autonomy, what aspect of this scenario best demonstrates this action? 1. Assessing the patient's pain on a numeric scale every 2 hours 2. Asking the patient to establish the goal for pain control 3. Using alternative measures such as distraction or repositioning to relieve the pain 4. Monitoring the patient for oversedation as a side effect of his pain medication

When providing care to patients with varied cultural backgrounds, it is imperative for the nurse to recognize that: 1. Cultural considerations must be put aside if basic needs are in jeopardy. 2. Generalizations about the behavior of a particular group may be inaccurate. 3. Current health standards should determine the acceptability of cultural practices. 4. Similar reactions to stress will occur when individuals have the same cultural background.

Which of the following is the correctly stated nursing diagnosis? 1. Needs to be fed related to broken right arm 2. Impaired skin integrity related to fecal incontinence 3. Abnormal breath sounds caused by weak cough reflex 4. Impaired physical mobility related to rheumatoid arthritis

Why do nurses need a license? 1 To have a central database of care providers 2 To protect the public 3 To legitimize the profession 4 To collect fees for state funding

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the wound and ostomy care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the wound and ostomy care nurse specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity.

2, 3

A nurse is giving a patient a medication and notices the dosage. From the nurse's experience, the dosage is higher than what is normally given. Which of the following steps should the nurse take to ensure a safe outcome for the patient? (Select all that apply.) 1. Wait until end of shift when there is time to check dosage with pharmacy reference. 2. Recognize how the nursing team communicates problems, and consult with charge nurse. 3. Hold the dose and confer with the ordering health care provider now. 4. Assess patient knowledge of what has been the routine dose for this medication. 5. Administer the medication and closely monitor patient response.

2, 3, 4

A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in which of the following? (Select all that apply.) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Outcome setting

2, 3, 4

What are some of nursing's core professional values? Select all that apply. 1. Independence 2. Responsibility 3. Advocacy 4. Confidentiality 5. Accountability 6. Competition

2, 3, 4, 5

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in an apartment with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb). The nurse documents the assessment findings listed below. Which of the assessment findings require priority follow-up by the nurse? (Select all that apply.) 1. The patient has no history of chronic disease. 2. Patient urinates at night. 3. Patient reports having difficulty cleansing herself after voiding or passing stool. 4. Body temperature 38°C (100.4°F) 5. Recent history of weight gain 6. Knowledge of perineal care 7. Last normal bowel movement 2 days ago 8. Frequency of diarrhea

2, 3, 4, 5, 6, 8

A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient's airways. The patient tells the nurse after the first medication infusion, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.) 1. Asking patient to breathe deeply during auscultation 2. Counting respirations per minute 3. Asking the patient to describe how his breathing feels 4. Starting the intravenous infusion 5. Auscultating lung sounds

2, 3, 5

A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) because one of the nurses called in sick. Assistive personnel (AP) from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse's unit environment will affect the ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. Type of hospital unit 5. Competency of assistive personnel (AP)

2, 3, 5

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) 1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure. 2. The nurse directs the assistive personnel to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the assistive personnel to set up meal trays for patients. 4. The nurse directs the assistive personnel to gather a history from the newly admitted patient about his medications. 5. The nurse directs the assistive personnel to assist one of the stable patients to sit up in a chair for his meal.

2, 3, 5

A patient diagnosed with colon cancer has been receiving chemotherapy for six weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient's intravenous port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This occurred two weeks earlier as well. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.) 1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient. 2. Specifically identify the problem of port obstruction and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 4. Tell the IV nurse the problem is probably related to the physician who inserted the port. 5. Describe to the IV nurse the type and condition of the port currently in use.

2, 3, 5

An interprofessional health care team is developing health education program for middle-school. Which health topics are consistent with the goals of Health People 2020? (Select all that apply.) 1. Determining the best treatment for strep throat 2. Explaining why it is important to get immunizations as scheduled 3. Teaching about healthy snacks 4. Describing why genetically modified foods are controversial 5. Teaching different ways to fit exercise into the daily routine 6. Explaining the problems related to lead exposure in the environment

2, 3, 5

Which of the following is an example of a health disparity? (Select all that apply.) 1. A patient who has a homosexual sexual preference 2. A patient unable to access primary care services 3. Patients living with chronic disease 4. A family who relies on public transportation 5. A patient who has had a history of smoking for 10 years

2, 3, 5

A nurse who works in an outpatient chemotherapy infusion center is assigned to the care of a 56-year-old male patient who is receiving chemotherapy for colon cancer. This is the patient's first clinic visit. The nurse reviews the patient's medical record and sees a note about the patient receiving instruction on how chemotherapy treats cancer, but the note does not summarize the patient's response. The doctor makes a quick visit and tells the patient, "We will get your treatment started today and we will be checking your blood each week for any problems." The doctor leaves and the patient asks the nurse, "What are the blood tests for?" To determine this patient's learning needs, what should the nurse assess? (Select all that apply.) 1. Medical record summary of the stage of the cancer 2. The patient's behavior as the nurse interacts with him 3. The patient's level of knowledge about chemotherapy effects 4. The number of treatments the patient will be receiving 5. The patient's health literacy 6. The patient's self-description of severity of his cancer 7. The date of the medical record note describing patient instruction

2, 3, 5, 6

Scope and Standards: Standard 7. What must the nurse be competent in?

- Use the Code of Ethics for Nurses as a moral foundation to guide nursing practice and decision making. - Demonstrate that every person is worthy of nursing care through the provision of respectful, person-centered, compassionate care, regardless of personal history of characteristics (beneficence). - Advocate for client perspectives, preferences, and rights to informed decision making and self-determination (autonomy). - Demonstrate a primary commitment to the recipients of nursing and healthcare services in all settings and situations (fidelity). - Maintain therapeutic relationships and professional boundaries. - Act to prevent breaches of privacy and confidentiality. - Safeguard sensitive information within ethical, legal, and regulatory parameters (nonmaleficence). - Identify ethics resources within the practice setting to assist and collaborate in addressing ethical issues. - Integrate principles of social justice in all aspects of nursing (justice). - Refine ethical competences through continued professional education and personal self-development. - Depict one's professional nursing identity though demonstrated values and ethics, knowledge, leadership, and professional behavior. - Engage in self-care and self-reflection to support personal health and well-being. - Contribute to the establishment and maintenance of an ethical environment to support safe, quality care. - Collaborate with other healthcare professionals and the public to protect human rights, promote health diplomacy, enhance cultural sensitivity, and reduce health disparities. - Represent the nursing perspective in all ethical discussions.

A nurse is assigned to care for a woman who is expecting her first child. The nurse organizes herself and plans to gather data about the patient by applying Pender's health promotion model, including the patient's characteristics and experiences and situational influences. She plans to observe patient behavior and consider the patient's psychosocial issues. Such data will offer a clear understanding to help the nurse identify the patient's needs. This is an example of which of the following concepts? (Select all that apply.) 1. Diagnostic reasoning 2. Deductive reasoning 3. Inductive reasoning 4. Assessment 5. Problem solving

2, 4

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the health care provider's order. At the bedside, the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude? 1. Responsibility 2. Humility 3. Accuracy 4. Fairness

A nurse reports suspicious co-worker behavior to the nurse manager. What ethical principle is the nurse demonstrating? 1 Nonmaleficence 2 Justice 3 Autonomy 4 Fidelity

A patient who is newly divorced states, "Although I'm really scared about what happens next to my children and myself, I know that divorce is not uncommon today." What term does the nurse use in the patient's medical record to describe the characteristic displayed in this statement? 1. Durability 2. End-of-life care 3. Family functioning 4. Family's culture

Any variable increasing the vulnerability of an individual or a group to an illness or accident is a(an): 1. Risk factor 2. Illness behavior 3. Lifestyle determinant 4. Negative health behavior

During a nursing assessment a patient displayed several behaviors. Which behavior suggests the patient may have a health literacy problem? 1. Patient has difficulty completing a registration form at a medical office 2. Patient asks for written information about a health topic 3. Patient speaks Spanish as primary language 4. Patient states unfamiliarity with a newly ordered medicine

Graduate nurses must pass a licensure examination administered by the: 1. State Boards of Nursing 2. National League for Nursing 3. Accredited School of Nursing 4. American Nurses Association

Marsha states, "My chubby size runs in our family. It's a glandular condition. Exercise and diet won't change things much." The nurse determines that this is an example of Marsha's: 1. Health beliefs 2. Active strategy 3. Acute situation 4. Positive health behavior

Mary Jones is a newly diagnosed patient with diabetes. The nurse shows Mary how to administer an injection. This intervention activity is: 1. Teaching 2. Managing 3. Counseling

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap test. The nurse is functioning according to: 1. Protocol 2. Standing order 3. Nursing care plan 4. Intervention strategy

Resolution of an ethical problem involves discussion with the patient, the patient's family, and participants from appropriate health care disciplines. Which statement best describes the role of the nurse in the resolution of ethical problems? 1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations 2. To study the literature on current research about the possible clinical interventions available for the patient in question 3. To hold a point of view but realize that respect for the authority of administrators and health care providers takes precedence over personal views 4. To allow the patient and the health care provider private time to resolve the dilemma on the basis of ethical principles

The most important factor in providing nursing care to patients in a specific ethnic group is: 1. Communication 2. Time orientation 3. Biological variation 4. Environmental control

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Offer frequent skin care because of Impaired Skin Integrity 2. Risk for Infection 3. Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion 4. Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea 5. Lack of Knowledge related to laser surgery

2, 4

The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical elements of this case? 1. The health care team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources. 2. The patient should enroll in a clinical trial of a new technology that can do the work of the liver, similar to the way dialysis treats kidney disease. 3. The social worker should look into enrolling the patient in Medicaid, since many states offer expanded coverage. 4. A family meeting should take place in which the details of the patient's poor prognosis are made clear to his family so that they can adopt a palliative approach.

Which explanation provided by the nurse is the most accurate meaning for "providing culturally congruent care"? 1. It fits the patient's valued life patterns and set of meanings. 2. It is the same set of values as those of the health care team member providing daily care. 3. It holds one's own way of life as superior to those of others. 4. It redirects the patient to a more socially expected set of values.

Which of the following is an example of an intrinsic risk factor for homelessness? 1. Severe anxiety disorders 2. Psychotic mental disorders 3. Living below the poverty line 4. Progressive chronic alcoholism

Which organization is responsible for nursing's scope and standards of practice? 1 American Nurses Association 2 American Nurses Credentialing Center 3 International Council of Nurses 4 American Association of Colleges of Nursing

Which part of Provision 7 encourages professional collaboration to promote change? 1 Contributions through nursing and health policy development 2 This action is not addressed in Provision 7 3 Contributions through research and scholarly inquiry 4 Contributions through developing, maintaining, and implementing professional practice standards

While obtaining a health history, the nurse asks Mr. Jones if he has noted any change in his activity tolerance. This is an example of which interview technique? 1. Direct question 2. Problem solving 3. Problem seeking 4. Open-ended question

A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse's ability to perform patient evaluation? (Select all that apply.) 1. Comparing patient response with previous response 2. Examining results of clinical data 3. Recognizing error 4. Self-reflection 5. Checking medical record for when IV was inserted.

1, 2

A nurse is seeing all of these patients in the community health clinic. The nurse identifies which patient(s) as having a health disparity? (Select all that apply.) 1. A patient who has a homosexual sexual preference 2. A patient unable to access primary care services 3. A patient living with chronic schizophrenia 4. A family who relies on public transportation 5. A patient who has a history of hypertension

1, 2, 3

The public health nurse is working with the county health department on a task force to fully integrate the goals of Healthy People 2030. Most of the immigrant population do not have a primary care provider, nor do they participate in health promotion activities; the unemployment rate in the community is 25%. How does the nurse determine which goals need to be included or updated? (Select all that apply.) 1. Assess the health care resources within the community. 2. Assess the existing health care programs offered by the county health department. 3. Compare existing resources and programs with Healthy People 2030 goals. 4. Initiate new programs to meet Healthy People 2030 goals. 5. Implement educational sessions in the schools to focus on nutritional needs of the children.

1, 2, 3

What are the major responsibilities of the state board of nursing (BON)? Select all that apply. 1 Take disciplinary action against nursing licenses 2 Issue licenses to new graduates and nurses relocating to the state 3 Renew registered nurse licenses 4 Evaluate new graduate licensure applications 5 Publish a code of ethics for professional nursing practice

1, 2, 3, 4

Which statements made by a nursing student about the teach-back technique show understanding of the technique? (Select all that apply.) 1. "After teaching a patient how to use an inhaler, I need to use the teach-back technique to test my patient's ability to use the inhaler correctly." 2. "The teach-back technique is an ongoing process of asking patients for feedback." 3. "Using teach-back will help me identify explanations and communication strategies that my patients will most commonly understand." 4. "Using pictures, drawings, and models can enhance the effectiveness of the teach-back technique." 5. "When doing my patient teaching, I will use plain language to make the material easier to understand for the patient."

1, 2, 3, 4, 5

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure

1, 2, 3, 5

. A community health nurse is working in a clinic with a focus on asthma and allergies. What is the primary focus of the community health nurse in this clinic setting? (Select all that apply.) 1. Decrease the incidence of asthma attacks in the community 2. Increase patients' ability to self-manage their asthma 3. Treat acute asthma in the hospital 4. Provide asthma education programs for the teachers in the local schools 5. Provide scheduled immunizations to people who come to the clinic

1, 2, 4

A family consisting of a grandparent, two adults, and three school-age children just immigrated to the United States. They come to a community wellness center to establish health care. Which of the following questions does the nurse ask to assess the family's function? (Select all that apply.) 1. "What does your family do to keep members healthy?" 2. "How does your family usually make decisions?" 3. "What health services are available in your neighborhood?" 4. "Which rituals or celebrations are important for your family?" 5. "Is there a lot of crime in your neighborhood?" 6. "How many parks are there in your community?"

1, 2, 4

A family is facing job loss of the father, who is the major wage earner, and relocation to a new city where there is a new job. The children will have to switch schools, and his wife will have to resign from the job she enjoys. Which of the following contribute to this family's hardiness? (Select all that apply.) 1. Family meetings 2. Established family roles 3. New neighborhood 4. Willingness to change in time of stress 5. Passive orientation to life

1, 2, 4

A nurse is caring for a patient who is expressing pain. The patient has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.) 1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 3. The nurse reviews the policy and procedure for the cold application. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. 5. The nurse delegates the assistive personnel to prepare the patient's medication.

1, 2, 4

A nurse is conferring with another nurse about the care of a patient with a Stage 2 pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.) 1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 3. Eliminates the need to create an individualized care plan for the patient 4. Incorporates evidence-based interventions for stage II pressure injury 5. Provides for access to patient care information within the electronic health record

1, 2, 4

The nurse caring for a refugee community identifies that the children are undervaccinated and the community is unaware of resources. The nurse assesses the community and determines that there is a health clinic within a 5-mile radius. The nurse meets with the community leaders and explains the need for immunizations, the location of the clinic, and the process of accessing health care resources. Which of the following practices is the nurse providing? (Select all that apply.) 1. Raising awareness about community resources for the children 2. Teaching the community about health promotion and illness prevention 3. Promoting autonomy in decision making about health practices 4. Improving the health care of the community's children 5. Participating in professional development activities to maintain nursing competency

1, 2, 4

Which statements properly apply an ethical principle to justify access to health care? (Select all that apply.) 1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 3. Access to health care is a privilege in the United States, not a right. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

1, 2, 4

Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (Select all that apply.) 1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 3. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified. 5. Whether a person has a job is an objective measure, but it does not play a role in understanding quality of life.

1, 2, 4

Health care agencies must provide which of the following based on federal civil rights laws? (Select all that apply.) 1. Provide language assistance services at all points of contact free of charge. 2. Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services. 3. Use patients' family members to interpret difficult topics. 4. Ensure that interpreters are competent in medical terminology. 5. Provide language assistance to all patients who speak limited English or are deaf.

1, 2, 4, 5

While receiving a hand-off report, a nurse asks how a patient's condition from a serious infection changed since yesterday. The nurse leaving the shift reports that the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient's body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient's progress since the day before. The nurse asks an assistive personnel to measure intake and output during the shift. What critical thinking indicators reflect the nurse's ability to perform evaluation? (Select all that apply.) 1. Checking the summary notes 2. Asking the leaving RN about the patient's condition 3. Assigning assistive personnel to measure intake and output 4. Comparing current outcomes with those set for the patient's goals 5. Reflecting on patient's progress

1, 2, 4, 5

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1, 2, 4, 5 CLAS Standards include communication and language assistance

A nurse who has worked on a cardiac step-down unit for 4 years receives a new patient from the intensive care unit following a 3-day stay for postmyocardial infarction (MI). The nurse knows that the patient is at risk for a recurrent MI, heart failure, arrhythmias, or a stroke. The patient has stable vital signs when arriving at the new unit: pulse 82 and regular, blood pressure (BP) between 120 and 130 over 80 to 90, and denial of chest pain. The nurse checks the patient's IV for proper function, positions the patient comfortably, and explains that the patient will be checked frequently. Sixty minutes after the initial assessment, the nurse responds to the patient's call light. The patient states, "I am not feeling well." Which of the following are evaluative measures the nurse should perform in this situation? SATA. 1. Measurement of BP 2. Asking patient to self-report location and severity of pain 3. Asking patient to move both arms and legs 4. Measurement of heart rate rhythm 5. Questioning patient about risks following an MI 6. Asking patient, "Tell me what you mean by not feeling well"

1, 2, 4, 6

A nurse is teaching an older-adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Use basic one- or two-syllable medical terms. 5. Provide specific information in frequent, small amounts. 6. Speak quickly so that you do not take up much of the patient's time.

1, 2, 5

What is the purpose of the National Council of State Boards of Nursing (NCSBN)? Select all that apply. 1 Support nursing regulators in protection of the public 2 Collaboration of all state boards of nursing 3 Issue licenses to nurses 4 Oversee individual nursing practice 5 Develop and administer the nursing licensure exam

1, 2, 5

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1, 2, and 5. Lower tones easier for patients w/ hearing deficits. Good to reinforce info at beginning and end. Providing info in small amounts helps w/ understanding. Pamphlets should be written in color that contrasts w/ background, blues and greens are hard to distinguish!

A nurse in a community health clinic reviews screening results from students in a local high school during the most recent academic year. The nurse discovers a 10% increase in the number of positive tuberculosis (TB) skin tests when comparing these numbers to the previous year. The nurse contacts the school nurse and the director of the health department. Together they begin to expand their assessment to all students and employees of the school district. The community nurse is acting in which nursing role(s)? (Select all that apply.) 1. Epidemiologist 2. Counselor 3. Collaborator 4. Case manager 5. Caregiver

1, 3

Larry is helping to orient a new graduate and wants to discuss the definition of nursing. Where could Larry find the most common definitions of nursing? Select all that apply. 1 American Nurses Association 2 American Cancer Society 3 International Council of Nurses 4 American Holistic Nurses Association 5 American Diabetes Association

1, 3

Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.) 1. Priority setting establishes a preferential order for nursing interventions. 2. In most cases wellness problems take priority over problem-focused problems. 3. Recognition of symptom patterns helps in understanding when to plan interventions. 4. Longer-term chronic needs require priority over short-term problems. 5. Priority setting involves creating a list of care tasks.

1, 3

Which social media uses can be implemented with patients and families without violating confidentiality? (Select all that apply.) 1. Social media can be used to provide supportive information. 2. Results such as x-ray results can easily be sent via social media. 3. Family and friends who cannot be present can connect with the patient. 4. All health information can be shared on social media. 5. Social media should never be used with patients and families.

1, 3

The nurse in a new community-based clinic is requested to complete a community assessment. Order the steps for completing this assessment. 1. Structure or locale 2. Social systems 3. Population

1, 3, 2

A nurse is caring for a 66-year-old patient who lives alone and is receiving chemotherapy and radiation for a new cancer diagnosis. He is unable to care for himself because of severe pain and fatigue. He moves into his 68-year-old brother's home so his brother can help care for him. Which assessment findings indicate that this family caregiving situation will be successful? (Select all that apply.) 1. Both the patient and his brother attend church together regularly. 2. The brothers are living together and enjoy eating the same foods. 3. Other siblings live in the same city and are willing to help. 4. The patient and his brother have a close network of friends. 5. The patient has obsessive-compulsive disorder and has difficulty throwing away possessions.

1, 3, 4

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (Select all that apply.) Ethics of care: 1. pays attention to the context in which caring occurs. 2. is used only by nurses because it is part of the Nursing Code of Ethics. 3. requires understanding the relationships between involved parties. 4. considers the decision maker's relationships with other involved parties. 5. is an approach that suggests a greater commitment to patient care. 6. considers the decision maker to be in a detached position outside the ethical problem.

1, 3, 4

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data.

1, 3, 4

Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation involves reflection on the approach to care. 2. Evaluation involves determination of the completion of a nursing intervention. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is performed only when a patient's condition changes.

1, 3, 4

Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation usually reveals obvious changes in a patient. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills 5. Evaluation is performed only when the patient's condition changes.

1, 3, 4

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1, 3, 4 Spirituality good, close network of fam good Caregiver distress risk factor includes them living together

A nurse in a community health clinic has been caring for a young female teenager with Type 1 diabetes mellitus for several months. The expected outcome for this patient is to achieve self-management of insulin administration by discharge. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.) 1. Quality of life 2. Patient satisfaction 3. Clinic follow-up visits 4. Adherence to self-administration of insulin 5. Description of side effects of medications 6. Patient report of blood glucose level

1, 3, 4, 5

One element of clinical decision making is knowing the patient. Which of the following activities affect a nurse's ability to know patients better? (Select all that apply.) 1. Caring for similar groups of patients over time 2. Reading the evidence-based practices appropriate to patients 3. Learning how patients typically respond to their clinical situations 4. Observing patients 5. Engaging with patients experiencing illness

1, 3, 4, 5

What information is found in any given nurse practice act? Select all that apply. 1 Grounds for disciplinary action 2 Possible consequences of practice violations 3 Composition of the board of nursing 4 Program requirements for accreditation 5 Scope of nursing practice

1, 3, 5

A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this woman's health? (Select all that apply.) 1. Medicaid insurance 2. Annual screening 3. Mother's history of breast cancer 4. Lack of transportation 5. Woman's age

1, 4, 5

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1, 4, and 5. SDOH are conditions which people are born, grow, live, work, and age. SDOH mostly responsible for health disparities.

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1, difficulty concentrating. Behaviors that can show health literacy deficits can be difficulty completing registration forms or health histories, failing to make follow up appts, and asking few questions during a nursing history or physical exam.

Contemporary nursing requires that the nurse have knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples of these roles and responsibilities? (Select all that apply.)

1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion

When providing care to patients with varied cultural backgrounds, it is imperative for the nurse to recognize what?

1. Cultural considerations must be put aside if basic needs are in jeopardy. 2. Generalizations about the behavior of a particular group may be inaccurate. 3. Current health standards should determine the acceptability of cultural practices. 4. Similar reactions to stress will occur when individuals have the same cultural background.

The nurse is visiting a patient who lives alone at home. While talking with the patient's family caregiver, the nurse learns that the patient has been missing doses of medications. The patient currently self-medicates. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to help the patient improve adherence? (Select all that apply.) 1. Reviewing the family caregiver's understanding of purpose of medications 2. Determining the value the patient places on taking medications 3. Reviewing the number of medications and time each is to be taken 4. Determining patient's perceptions of consequences associated with missing specific medicines 5. Reviewing the therapeutic actions of the medications

2, 4

Which of the following scenarios demonstrate that patient learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors

2, 4

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the past month." 2. "My name is Terry. I'll be the nurse taking care of you today." 3. "I have no further questions. Is there anything else you wish to ask me?" 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite has been poor—correct?"

2, 4, 1, 5, 3

A mother and her two children are homeless and enter a free health care clinic. Which statements most likely describe the effects of homelessness on this family? (Select all that apply.) 1. The children have stability in their education. 2. The family members may have symptoms of malnutrition, such as anemia. 3. The family is at a low risk for experiencing violence. 4. The children are at higher risk for developing ear infections. 5. All family members may have mental health issues.

2, 4, 5

A nurse enters a patient's room at the beginning of a shift to assess his condition following a blood transfusion. The nurse cared for the patient on the previous day as well. The patient has several issues he wishes to share with the nurse, who takes time to explore each issue. The nurse also assesses the patient and finds no signs or symptoms of a reaction to the blood product. The nurse observed the patient the prior day and sees a change in his behavior—a reluctance to get out of bed and ambulate. Which of the following actions improve the nurse's ability to make clinical decisions about this patient? (Select all that apply.) 1. Working the same shift each day 2. Spending time during the patient assessment 3. Knowing the early mobility protocol guidelines 4. Caring for the patient on consecutive days 5. Knowing the pattern of patient behavior about ambulation

2, 4, 5

An 80-year-old female patient is admitted to the hospital through the emergency room with acute chest pain. Initial testing shows that the patient had a myocardial infarction. Her current vital signs are BP 156/90; HR 88; respirations 20; she is afebrile. The patient has osteoarthritis, causing chronic pain in both knees. She also has glaucoma. The patient is Bosnian and has been in the United States for 3 years. She requires a professional interpreter at bedside when explanations of treatment are provided. Which of the following factors might require you to adapt the way you assist this patient with ambulation? (Select all that apply.) 1. Patient is Bosnian 2. Had a recent myocardial infarction 3. Respirations 20 4. Osteoarthritis of both knees 5. Needs an interpreter 6. Patient is afebrile

2, 4, 5

A home health nurse is visiting a 62-year-old Hispanic woman diagnosed with type 2 adult-onset diabetes mellitus following a 2-day stay at a local hospital. The physician ordered home health with placement of the patient on a diabetic protocol for education about diabetes mellitus and a new medication and diet counseling. The patient lives with her 73-year-old husband, who has progressive dementia. Their daughter checks on her parents daily, buys groceries, and helps with home maintenance. The nurse conducts an initial history to gather information about the patient's condition. Which of the following data cues combine to reveal a possible health problem? (Select all that apply.) 1. First time hospitalized 2. Unable to describe diabetes 3. Takes antiinflammatory for arthritis 4. Has limited health literacy 5. Husband is able to perform self-bathing 6. Patient unable to identify food sources on prescribed diet 7. Patient has reduced vision and wears glasses 8. Patient prescribed an oral hypoglycemic drug

2, 4, 6, 7

The REFLECT model can improve learning after providing patient care. Place the steps of this model in the correct order: 1. Think about your thoughts and actions at the time of a situation. 2. Review the knowledge you gained from the experience. 3. Review the facts of the situation. 4. Set a schedule for completing your plan of action. 5. Consider options for handling a similar situation in the future. 6. Recall any feelings you had at the time of the situation. 7. Create a plan for future situations.

3, 1, 6, 2, 5, 7, 4

A married couple has three children. The youngest child has graduated from college and is moving to a different city to take a job. The other two children left the home several years ago. What developmental tasks does the nurse expect this family to experience at this point in time? (Select all that apply.) 1. Take on parenting roles 2. Making room for the wisdom of older adults 3. Refocusing on marital issues 4. Determining new focus on recreational activities 5. Developing intimate relations with others

3, 4

A married couple has three children. The youngest child just graduated from college and is moving to a different city to take a job. The other two children left home several years ago. The parents of both spouses are older and are beginning to need help to maintain their home. What assessment questions will help the nurse determine the family's functioning? (Select all that apply.) 1. "Which transitions or changes in your family are you currently experiencing?" 2. "Are your children having any problems that are affecting your family right now?" 3. "Describe a recent family conflict and how your family resolved it." 4. "What coping strategies do you typically use as a family?" 5. "Who is involved in helping care for your parents?"

3, 4, 5

A nurse has been caring for a patient with a chronic wound that has not been healing. The nurse talks with a nurse specialist in wound care to find alternative approaches from what the health care provider ordered for dressing the wound. The two decide that because of the patient's allergy to tape, a nonallergenic dressing will be used. The nurse obtains an order from the health care provider for the new dressing. After 2 days there is improvement in the wound. This is an example of which critical thinking standards? (SATA) 1. Clarity 2. Broadness 3. Relevance 4. Risk taking 5. Creativity

3, 4, 5

A 26-year-old patient visits a medical clinic and asks a nurse to provide instruction on how to perform a breast self-examination. "My mom had cancer so I want to learn how." Which domains are required to learn this skill? (Select all that apply.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain

3, 5

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 22 breaths/min compared with an average of 16 breaths/min during previous clinic visits. The patient tells the nurse, "It's hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) 1. Heart rate of 22 breaths/min and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 breaths/min 5. Patient report of sore throat and hoarseness

3, 5

A nurse is caring for a 58-year-old patient who had a stroke, causing loss of function of the left leg and reduced movement in the left hand and arm. The patient is alert and able to follow instructions. The patient's dominant side is left. While observing the patient attempt to eat, the nurse notes the patient is unable to use utensils easily in the right hand. The patient is able to lift a glass with the right hand but has trouble opening food containers. Because of weakness on the left side, the patient has limitations in chewing. The nurse identifies a nursing diagnosis of Self Care Deficit: Impaired Self Feeding. Which of the following are appropriate nurse-sensitive outcomes for this patient? SATA. 1. Patient provided left-handed assist device 2. The range of movement in left arm is 20 degrees flexion 3. Patient opens food container 4. Patient provided soft diet 5. Patient gets food onto utensil 6. Patient able to chew food

3, 5, 6

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3, set mutual goals. Planning should happen before any implementation or evaluation.

A 55-year-old man has been in the hospital for over a week following surgical complications. The patient has had limited activity but is now ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn

A 7-year-old child was recently diagnosed with asthma. A nurse is providing education to the child and her parents about the treatment and management of asthma and changes they need to make in their home environment to promote her health. Which statement made by the parents requires follow-up by the nurse? 1. "We've made an appointment to talk with the school nurse about the change in our child's health." 2. "We forgot to give our daughter her medications before bedtime, so we made a list of her medications to help us remember." 3. "We worked out a schedule to check on her before and after school." 4. "We haven't been spending time with our parents because we're so busy taking care of our daughter."

A mother is concerned about her child's flulike symptoms. You learn from the health assessment that the mother practices the use of "hot" and "cold" foods to treat ailments. Which of the following foods do you expect the mother to use to treat her child? 1. Chicken 2. Yogurt 3. Fresh fruits 4. Eggs

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last two days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every two hours within 24 hours. 2. Patient will have normal formed stool within 48 hours. 3. Patient's ability to turn self in bed improves. 4. Erythema of skin will be mild to none within 48 hours.

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: 1. Creativity 2. Fairness 3. Clinical reasoning 4. Applying ethical criteria

A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 1 hour ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient's heart rate is 92 compared with 76 immediately postoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postoperative dose of an ordered analgesic has not yet been given. Which of the following factors is most likely to cause the nurse to reflect on the patient's situation? 1. The patient is recovering normally. 2. The nurse observes symptoms of restlessness 3. The patient's blood pressure trend 4. The delay in administration of the analgesic

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster. 5. Validated data set

A nurse is caring for a patient who has poor pain control. The patient has a history of opioid abuse. During the day, the patient made frequent requests for a pain medication. To make an effective clinical decision about this patient, the nurse needs to ask questions about the data available on the patient to make a thorough and thoughtful decision. The nurse asks herself, "How does my view about the patient's pain tolerance compare with the patient's, and does that pose a problem?" This is an example of: 1. A question about assumptions 2. A question about evidence 3. A question about procedure 4. A question about perspective

A nursing diagnosis: 1. Identifies nursing problems 2. Is not changed during the course of a patient's hospitalization 3. Is derived from the physician's history and physical examination 4. Is a statement of a patient response to a health problem that requires nursing intervention

A student is participating in a postclinical conference with the other students in the clinical group and an instructor. The student states, "My patient has two nursing diagnoses I chose to focus on, Risk for Impaired Skin Integrity and Lack of Knowledge regarding diabetic diet restrictions. I observed no pressure areas this morning. Because of her weight (100 kg; 220 lb), I turned her every two hours, and we put her on a pressure-relieving surface. We discussed how diabetes mellitus affects her circulation. During the day she had a glucose tolerance test that was normal. We discussed her diet during lunchtime. She completed a menu for a day with food choices that fit her diet. Before the shift was over, I talked with her physician about the patient's medication plan; her blood glucose levels have been higher than desired." Which of the following taken from the student's summary is a nurse-sensitive outcome? 1. Normal glucose tolerance test 2. Discussion of diet restrictions 3. Use of turning and pressure relief 4. Menu completion with food choices fitting diet 5. Blood glucose level elevated 6. Discussion of influence diabetes has on circulation

Clinical decision making requires the nurse to: 1. Improve a patient's health 2. Standardize care for the patient 3. Follow the health care provider's orders for patient care 4. Establish and weigh criteria in deciding the best choice of therapy for a patient

Demonstration of the principles of body mechanics used when transferring patients from bed to chair would be classified under which domain of learning? 1. Social 2. Affective 3. Cognitive 4. Psychomotor

Internal variables influencing health beliefs and practices include: 1. Developmental stage 2. Intellectual background 3. Emotional and spiritual factors 4. All of the above

The first part of the nursing diagnosis statement: 1. May be stated as a medical diagnosis 2. Identifies the cause of the patient problem 3. Identifies appropriate nursing interventions 4. Identifies an actual or potential health problem

The following statements appear on a nursing care plan for a patient after a mastectomy: "Incision site approximated; absence of drainage or prolonged erythema at incision site; and patient remains afebrile." These statements are examples of: 1. Long-term goals 2. Short-term goals 3. Nursing diagnosis 4. Expected outcomes

The interview technique that is most effective in strengthening the nurse-patient relationship by demonstrating the nurse's willingness to hear the patient's thoughts is: 1. Direct question 2. Problem solving 3. Problem seeking 4. Open-ended question

The nurse has become aware of missing narcotics in the client care area. Which ethical principle obligates the nurse to report the missing medications? 1 Advocacy 2 Accountability 3 Confidentiality 4 Responsibility

The nurse is caring for a patient with an abdominal obstruction. The nurse irrigates the patient's nasogastric tube and reports the amount of fluid aspirated from the patient's stomach to the health care provider. The patient has an IV infusing; the nurse changes the transparent dressing over the IV site and instructs the patient to report any tenderness at the site. Which of these interventions is an indirect care measure? 1. Irrigation of nasogastric tube 2. Changing of transparent dressing 3. Instructing patient to report tenderness at IV site 4. Report of the amount of fluid aspirated

The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is: 1. Exploring reasonable courses of action 2. Identifying people who can solve the difficulty 3. Clarifying values related to the cause of the dilemma 4. Collecting all available information about the situation

The second part of the nursing diagnosis statement: 1. Is usually stated as a medical diagnosis 2. Identifies the expected outcomes of nursing care 3. Identifies the probable cause of the patient problem 4. Is connected to the first part of the statement with the phrase "related to"

What establishes and provides authority to the state board of nursing? 1 Constitution of the United States 2 Local community government 3 National Council of State Boards of Nursing 4 State government

What factor results in vulnerable populations being more likely to develop health problems? 1. The ability to use available resources to find housing 2. Adequate transportation to the grocery store and community clinics 3. Availability of others to help provide care 4. Limited access to health care services

When planning care for a patient and using the concept of family as patient, the nurse: 1. Includes only the patient and his or her significant other 2. Considers the developmental stage of the patient and not the family 3. Understands that the patient's family will always be a help to the patient's health goals 4. Realizes that cultural background is an important variable when assessing the family

When the community health nurse refers patients to appropriate resources and monitors and coordinates the extent and adequacy of services to meet family health care needs, the nurse is functioning in the role of: 1. Advocate 2. Counselor 3. Collaborator 4. Case manager

Which of the following is an appropriately stated learning objective for Mr. Ryan, who is newly diagnosed with diabetes? 1. Mr. Ryan will understand diabetes. 2. Mr. Ryan will be taught self-administration of insulin by 5/2. 3. Mr. Ryan will know the signs and symptoms of low blood sugar by 5/5. 4. Mr. Ryan will perform blood glucose monitoring with the EZ-Check Monitor by the time of discharge.

Which of the following is not one of the five steps of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Hypothesis testing

Which of the following is not true of standing orders? 1. Standing orders are commonly found in critical care and community health settings. 2. Standing orders are approved and signed by the health care provider in charge of care before implementation. 3. With standing orders, nurses have the legal protection to intervene appropriately in the patient's best interest. 4. With standing orders, the nurse relies on the health care provider's judgment to determine if the intervention is appropriate.

Which of the following patients is most ready to begin a patient-teaching session? 1. Ms. Hernandez, who is unwilling to accept that her back injury may result in permanent paralysis. 2. Mr. Frank, who is newly diagnosed with diabetes, who is complaining that he was awake all night because of his noisy roommate. 3. Mrs. Brown, a patient with irritable bowel syndrome, who has just returned from a morning of testing in the gastrointestinal laboratory. 4. Mr. Jones, a patient who had a heart attack 4 days ago and now seems somewhat anxious about how this will affect his future.

Which statement about an institutional ethics committee is correct? 1. The ethics committee would be the first option in addressing an ethical dilemma. 2. The ethics committee replaces decision making by the patient and health care providers. 3. The ethics committee relieves health care professionals from dealing with ethical issues. 4. The ethics committee provides education, policy recommendations, and case consultation.

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment findings, noting objective and subjective clinical cues. 3. Cluster cues that form a pattern. 4. Gather thorough patient data about the patient's health problem. 5. Identify the nursing diagnosis. 6. Consider whether data are expected or unexpected based on the patient's problem.

4, 2, 3, 6, 1, 5

A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming the patient's care at the end of the clinical day. The student states, "The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he walked to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after returning to chair. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints." Which expected outcomes aimed at improving the patient's activity tolerance were discussed in the hand-off? (Select all that apply.) 1. IV site not tender 2. Ambulated twice during shift 3. Uses walker to walk 4. Walked to visitors lounge 5. No shortness of breath 6. Tolerated dinner meal 7. Patient had a good day 8. Vital signs after ambulation

4, 5, 8

See image.

4. Defines principles of right and wrong to provide patient care.

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history? 1. Current medications 2. Patient expectations of planned surgery 3. Review of patient's family support system 4. History of allergies 5. Patient's explanation for what might be the cause of symptoms that require surgery

How many Standards of Practice are there?

6 -- nursing process (ADOPIE)

The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution? 1. List all the possible actions that could be taken to resolve the problem. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 3. Develop and implement a plan to address the problem. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 6. Recognize that the problem requires ethics.

6, 4, 5, 2, 1, 3

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A nurse in a health clinic is caring for a 21‑year‑old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate‑specific antigen

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C. "I will carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved."

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing the pain.

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs

A, B, C

A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

A, B, C

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

A, B, C, E

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) A. Use an open posture. B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.

A, C, E

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "They said they hurt after walking about 10 minutes." C. The client's pain rating is 3 on a scale of 0 to 10. D. The client's skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp

A, D, E

See image.

A, assessment. (didnt rate on scale of 1 to 10)

What is the term for this definition?: Occurs when an individual or group transitions from one culture and develops traits of another culture

Acculturation

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the operation to the family and discusses the patient's wishes with them. The nurse is acting as the patient's:

Advocate

The public health nurse is working with the local city/county health department during a pandemic that has created a crisis within the community. What are responsibilities of the public health nurse during the pandemic? (Select all that apply.) 1. Educate the public on disease prevention 2. Serve as liaison between patients and health care services and providers 3. Investigate cases as they arise 4. Monitor trends of the disease outbreak 5. Assist with testing for identification of the disease

All~

Which component of SMART is this?: Mutually set an outcome a patient agrees to meet.

Attainable

A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Providing cholesterol screening B. Teaching about a healthy diet C. Providing information about antihypertensive medications D. Developing a list of cardiac rehabilitation programs

A nurse at a provider's office is talking about routine screenings with a 45‑year‑old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 or 3 years." B. "For now, I should continue to have a mammogram each year." C. "Because the doctor just did a Pap smear, I'll come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again for 4 years.

A nurse in a provider's office is collecting data from the caregiver of a 12‑month‑old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

A nurse is caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating

A nurse is caring for a school‑age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm. B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options." B. "I will ask the client if they want to schedule some times to pray during the day." C. "I will avoid discussing care when the client's family is around." D. "I will make sure daily communion is available for this client."

A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart‑healthy diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select or prepare meals. C. Encourage the client to fill out an evaluation form about how the nurse presented the information. D. Ask whether the client has resources for further instruction on this topic.

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique. C. The client states an understanding of the process. D. The client is able to write the steps on a piece of paper.

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. Creativity

Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse‑client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse‑client relationship.

A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the examination.

B, C, D, E

A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and their last name. B. Use a mix of open‑ and closed‑ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination

B, C, E

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Determine client understanding several times during the conversation. C. Look at the interpreter when asking the family questions. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk.

B, D, E

Each _______ has the authority to legally regulate nursing in its jurisdiction and has four major responsibilities: evaluating licensure applications, issuing licenses, renewing licenses, and taking disciplinary action

BON (state board of nursing)

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital's spiritual services. B. Ask what is making the client cry. C. Ensure no visitors or staff enter the room for a short time period. D. Turn on the television for a distraction.

A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis. B. Tell the client to have a TB skin test every 2 years. C. Determine the client's health risks. D. Teach the client about exercise recommendations

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates mutual regard for one another. C. The same religious beliefs can influence individuals differently. D. The nurse and client should discuss the differences and commonalities in their beliefs

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical‑surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say."

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk

C, D, E

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

C, D, E

See image.

C. family has conflicting feelings about initiation of enteral tube feedings. (all other choices are legal issues)

Which publication incorporates 9 provisions?

Code of Ethics

What is the term for this definition?: A set of evidence-based, scientifically researched standards of care are key quality indicators that help healthcare institutions improve performance, increase accountability, and reduce costs.

Core Measures

Match the term to its definition: The motivation of a health care professional to "want to" engage in cultural competence

Cultural desire

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. "Why does your religion mandate that you cannot receive any blood transfusions?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials. C. Identify goals the nurse and the client agree are reasonable. D. Determine what the client knows about stress incontinence.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

A nurse uses a head‑to‑toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline

See image.

D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution. (asking why can appear judgmental, good to involve religious leaders)

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation, you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which statement best describes this code?

Defines the principles of right and wrong to provide patient care

The nurse spends time with a patient and family reviewing a dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role?

Educator

Match the term to its definition: Insider's perspective in an intercultural encounter

Emic worldview

Match the term to its definition: An outsider's perspective in an intercultural encounter

Etic worldview

A critical care nurse is using a new research-based intervention to correctly position patients who are on ventilators to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which QSEN competency?

Evidence-based practice

Match the term to its definition: A policy model that describes factors and power structures that shape and influence life

Intersectionality

Which model mneumonic can assist the nurse in reflecting upon in each patient encounter?

LEARN = Listen, Explain, Acknowledge, Recommend, Negotiate

Which component of SMART is this?: Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status.

Measurable

A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic for an annual mammogram because she had no transportation. She gets the annual screening because her mother had breast cancer. Identify some social determinants of this woman's health.

Medicaid, lack of transportation, age

Health care reform will bring changes in the emphasis of care. Which of these models is expected from health care reform?

Moving from an acute illness to a health promotion, illness prevention model

The nurse is caring for a client supported on a ventilator who has been unresponsive since arrival via ambulance a week ago. The client has not been identified and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to help resolve this ethical dilemma in the correct order. 1 Healthcare providers use negotiation to redefine the client's plan of care. 2 The nurse examines the issue to clarify opinions, values, and facts. 3 The nurse evaluates the plan and revises it with input from other healthcare providers, as necessary. 4 The nurse identifies an ethical dilemma. 5 The nurse identifies possible solutions or actions to resolve the dilemma. 6 The nurse reviews the medical record, including entries by all healthcare professionals, to gather information relevant to this client's situation. 7 The nurse states the problem.

Nurse identifies dilemma, Nurse reviews med record, Nurse examines issue, Nurse states prob, Nurse identifies poss solutions, HCPs use negotiation, Nurse evaluates

The nurses on an acute care medical floor notice an increase in pressure injury formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure injury risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career?

Nurse researcher

Many older homes in a neighborhood are undergoing a lot of restoration. Lead paint was used to paint the homes when they were built. The community clinic in the neighborhood is initiating a lead screening program. This activity is based on which social determinant of health?

Physical environment

The examination for RN licensure is the same in every state in the United States. This examination:

Provides the minimal standard of knowledge for an RN in practice

Which ethical Provision does this statement represent?: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 1

Which ethical Provision does this statement represent?: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 2

Which ethical Provision does this statement represent?: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 3

Which ethical Provision does this statement represent?: the nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

Provision 4

Which ethical Provision does this statement represent?: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

Provision 5

Which ethical Provision does this statement represent?: The nurse, through individual and collective effort, establishes, maintains, and improves the ethicalenvironment of the work setting and conditions of employment that are conducive to safe, quality healthcare.

Provision 6

Which ethical Provision does this statement represent?: The nurse in all roles and settings advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 7

Which ethical Provision does this statement represent?: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Provision 8

Which ethical Provision does this statement represent?: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Provision 9

The nurse manager meets with the registered nursing staff about an increase in urinary tract infections in patients with a Foley catheter. The staff work together to review the literature on catheter-associated urinary tract infections (CAUTIs), identifies at-risk patients, and establishes new catheter care practices. This is an example of which QSEN competency?

Quality improvement

Which component of SMART is this?: Set an outcome that a patient can meet based upon physiological, emotional, economic, and sociocultural resources.

Realistic

What are 5 major components of Provision 1?

Respect for human dignity, relationships w/ clients, the nature of health, the right to self-determination, and relationships w/ colleagues and others

A home health nurse completes a home safety assessment. The data reveal that the patient is 71 years old with bilateral cataracts that are causing blurred vision and sensitivity to bright lights. The patient is recovering from a stroke that has caused left-sided weakness of the leg, with an unsteady gait. When talking with the patient, the nurse learns the patient lives alone and fell in the bathroom 4 months ago. Rooms in the home are in disrepair. The nurse identifies nursing diagnoses of Impaired Vision, Impaired Mobility, and Risk for Fall. Which diagnosis is the nurse's priority? Give a rationale.

Risk for Fall

What is the term for this definition?: Conditions in which people are born, grow, live, work, and age

Social determinants

Which component of SMART is this?: Be sure an outcome addresses only one patient behavior or response.

Specific

Which publication describes the competence level of nursing practice using critical thinking, has 6 standards, and uses the nursing process?

Standards of Practice

Which publication describes expected behaviors of the registered nurse and includes 12 standards?

Standards of Professional Perfomance

Which component of SMART is this?: Include when an outcome is to be met.

Timed

Match the term to its definition: Factor that shapes how people perceive others and how they relate to reality

Worldview

What are the domains of transcultural assessment model? (8)

a. Culturally unique individual b. Communication—voice quality, pronunciation, use of silence, nonverbal, touch c. Space - degree of comfort, distance in conversations, definition of space d. Social organization - normal state of health, marital status, number of children, parents live or deceased e. Time - orientation, view of, physicochemical reaction to time f. Environmental control -locus-of-control, value orientation g. Biological variations - physical assessment h. Nursing assessment - cultural assimilation, incorporate data into nursing plan

Identify the areas to focus on in conducting a comprehensive cultural assessment.

a. health beliefs and practices b. faith-based influences and special rituals c. language and communication d. parenting styles and family roles e. sources of support beyond the family f. dietary practices

A nurse inspects a patient's sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter with inflammation. The nurse gently applies pressure around the wound, with the patient acknowledging pain. The nurse asks the patient to rate the level of pain on a scale from 0 to 10. A final assessment includes reviewing the electronic health record for how frequently the patient was turned in the last 12 hours. Fill in the spaces below to identify the following concepts: assessment activity or cue. The nurse inspects (a. _____) a patient's sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter (b. _____) with inflammation (c. _____). The nurse gently applies pressure (d. ____) around the wound, with the patient acknowledging pain (e. _____). The nurse asks the patient to rate the level of pain on a scale (f. _____) from 0 to 10. A final assessment includes reviewing the electronic record (g. _____) for how frequently the patient was turned in the last 12 hours.

a: assessment activity b: cue c: cue d: assessment e: cue f: assessment g: assessment:

Which professional core value does this demonstrate?: The nurse arrives for the shift to discover that two nurses are out sick and have not been replaced. The nurse contacts the supervisor for additional help caring for clients.

accountability

Which professional core value does this demonstrate?: The client does not want to receive a blood transfusion that has been prescribed, so the nurse contacts the healthcare provider.

advocacy

Which ethical principle is this?: Mr. Smith refuses to take a narcotic for pain, stating the medication makes him too sleepy. The nurse ensures that the client has all the information necessary to make this decision and accepts the client's choice.

autonomy

Which ethical principle is this?: Nurse Johnson offers to help a coworker who is overwhelmed with a new admission. This action ensures that the client is cared for as quickly as possible.

beneficience

Ethics is _____ than the law.

broader

Term?: Process of drawing conclusions from related pieces of evidence and previous experience

clinical inference

Term?: Visual representation of a client's problems and interventions that shows their relationship to one another

concept map

Which professional core value does this demonstrate?: A healthcare provider who is not caring for the client calls and requests information about the client's neighbor. The nurse refuses to provide information.

confidentiality

What is the term for this definition?: conducting a self-exam of one's own biases toward other cultures

cultural awareness

What is the term for this definition?: Health care must be culturally sensitive and appropriate to the needs of the patient

cultural competence

What is the term for this definition?: the motivation of the professional to "want to" engage in the process

cultural desire

What is the term for this definition?: the process that encourages professionals to engage in face-to-face cultural interactions directly

cultural encounter

What is the term for this definition?: the professional seeks and obtains a sound educational base about culturally diverse groups.

cultural knowledge

What is the term for this definition?: ability to conduct a cultural assessment of a patient to collect relevant cultural data and conduct a culturally based physical assessment

cultural skill

What is the term for this definition?: Transcultural care

culturally congruent when it fits a person's life patterns, values, and system of meaning

What is the term for this definition?: Learned and shared beliefs, values, norms, and traditions of a particular group

culture

Term?: Moves from reviewing general knowledge to the specific pieces of evidence

deductive reasoning

Term?: Analytical process for determining a client's health problems

diagnostic reasoning

Provision 1 affirms health through relationships of ____ and ____.

dignity and respect

Provisions 1-3 address what?

direct client care and describe the most fundamental values and commitments of the nurse

What is the term for this definition?: Insider perspective

emic

ethical dilemma or moral distress?: When two opposing but justifiable options are presented, often using the nursing process will identify more options for the nurse. Nurses also use the code of ethics to guide their professional moral compass.

ethical dilemma

What do Provisions 4-6 focus on?

ethical environment, the individual nurse's responsibility and accountability in nursing practice, and the promotion of safe, quality healthcare.

What is the term for this definition?: Outsider perspective

etic

What do Provisions 7-9 focus on?

expanded duties of the nurse and the profession in advancing nursing and healthcare nationally and globally.

Which ethical principle is this?: Nurse Chen promises the client to return in 30 minutes to assist with bathing and dressing. At the appointed time, the nurse returns to help the client.

fidelity

___ are broad statements that describe a desired change in a client's condition.

goals

What is the term for this definition?: the degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make health decisions.

health literacy

Who, what, where, when, why or how for this situation in the scope of nursing practice?: A registered nurse uses the nursing process to care for each client.

how

Term?: Moves from reviewing specific data elements to making a conclusion about the related pieces of evidence

inductive reasoning

What is the term for this definition?: Research and policy model to study the complexities of people's lives and experiences

intersectionality

Which ethical principle is this?: Nurse Miller provides excellent care to two clients, one of whom is very wealthy with health insurance and the other who is experiencing homelessness.

justice

What are the 5 components of critical thinking?

knowledge base, experience, nursing process competencies, attitudes, standards

What is the term for this definition?: the ability to communicate effectively and convey information in a manner that is easily understood by diverse audiences.

linguistic competence

What is the term for this definition?: Have poorer health outcomes because of complex interactions due to behaviors, environment, and clinical care received

marginalized groups

With _____ ______, often the environment contributes to the problem. Discussing the situation with another person may be helpful. Working together with a supervisor or manager may best address the factors contributing to moral distress. Nurses also use the code of ethics to resolve ethical issues.

moral distress

Which ethical principle is this?: Ms. Martin is at risk of falling after surgery. The nurse puts fall prevention protocols into place to avoid injury to the client.

nonmaleficence

What is the term for this definition?: A formal and informal system of advantages and disadvantages tied to a membership in social groups

oppression

_____ are measurable changes that must be achieved by the client to reach the goals

outcomes

Which professional core value does this demonstrate?: The nurse agrees to provide the client with pain medication in 15 minutes. The nurse returns to the client's room at the designated time with the medication.

responsibility

What is the term for this definition?: Assumed belief regarding a particular group

stereotype

What is the term for this definition?: an ongoing process of asking patients for feedback thru explanation or demonstration and presenting information in a new way until you feel confident that you communicated clearly and that your patient understands the information presented.

teach-back method

Who, what, where, when, why or how for this situation in the scope of nursing practice?: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that the person would perform unaided given the necessary strength, will, or knowledge.

what

Who, what, where, when, why or how for this situation in the scope of nursing practice?: A registered nurse cares for clients on weekends, holidays, and in the middle of the night.

when

Who, what, where, when, why or how for this situation in the scope of nursing practice?: A registered nurse is caring for clients in an urgent care clinic in Texas.

where

Who, what, where, when, why or how for this situation in the scope of nursing practice?: A registered nurse working who has a BSN and works in a cardiac intensive care in the state of Montana.

who

Who, what, where, when, why or how for this situation in the scope of nursing practice?: A registered nurse understands that medicine and the needs of society change frequently, and they will be lifelong learners to improve outcomes.

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