Interactive Review Questions: Exam 1

Which health care team member is most accountable for an initial assessment and ongoing evaluation of client care? A. Client B. RN C. LPN D. UAP

B

Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship? A. The self and desire to help B. Knowledge and psychopathology C. Advanced communication skills D. Years of experience in psychiatric nursing

A The nurse brings an understanding of self and the basic principles of therapeutic communication

The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which activities are considered in the BADLs assessment? (Select all that apply.) 1. Brushing teeth or dentures 2. Dressing oneself in the mornings 3. Washing, drying, and folding laundry 4. Counting own pulse and taking heart pill 5. Taking the bus to the park 6. Calling family members

1,2 BADLs include actions related to self-care and mobility and also include eating, personal hygiene, and grooming activities. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, using the telephone, taking medications, and using transportation.

The nurse is performing a skin assessment of a client which findings were indicate a risk of skin cancer? 1. Lesions 2. Lumps. 3. Rashes. 4. Bruising 5. Dryness

1,2,3 Lesions on the skin that take a long time to heal may indicate skin cancer. Lumps and rashes on the skin or characteristics of skin cancer.

The nurse should recognize which attributes and criteria are concepts of spirituality? (Select all that apply.) 1. Spirituality is universal. 2. Physical illness does not impact the spirit. 3. Spirituality manifests whether a person acts on personal beliefs or not. 4. Family and culture impact spiritual beliefs. 5. Nurses should be aware of local community-based religious organizations.

1,4,5 Spirituality is universal. All individuals, even those who profess no religious belief, are driven to derive meaning and purpose from life. The nurse needs to be aware that specific spiritual beliefs and practices are impacted by family and culture. Community-based religious organizations can provide supportive care to families and patients and nurses need to be aware of these resources.

The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which interventions should be included in the plan of care? (Select all that apply.) 1. Increasing oral fluids 2. Placement of an oral airway at the bedside 3. Monitoring for Chvostek's sign 4. Implementing seizure precautions 5. Hyperactive reflex assessment 6. Observation for muscle weakness

1,6 Serious complications of hypercalcemia include severe muscle weakness, dehydration, loss of deep tendon reflexes, paralytic ileus, and electrocardiographic changes. Early manifestations of hypercalcemia include fatigue, loss of appetite, nausea, vomiting, constipation, and polyuria (increased urine output)

Which services to community health centers provide in preventative in primary care services? 1. Daycare 2. Health Screenings 3. Physical assessment 4. Disease management 5. Acute and chronic care management

2,3,4 Health screenings, physical assessments and disease management services are provided by community health centers and preventative and primary care services

The nurse is completing a health history on a Mexican-American patient who works odd jobs as available and lives with multiple family members ranging from infant to older adults. One motor vehicle is shared between the family members, and the family shares a two-room apartment with one bathroom. What likely health disparities should the nurse investigate for this patient? (Select all that apply.) 1. Comprehensive insurance 2. Low income 3. Lack of self-grooming 4. Inadequate sleep 5. Educational level

2,3,4,5 Based on the patient's living arrangements and job status, the nurse should investigate possible health disparities such as low income, lack of grooming (only one bath available), inadequate sleep, and low educational level. Comprehensive insurance is not a health disparity but is an asset to ensure adequate health care.

The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which activities are considered in the IADLs assessment? (Select all that apply.) 1. Feeding oneself 2. Preparing a meal 3. Balancing a checkbook 4. Walking 5. Toileting 6. Grocery shopping

2,3,6 IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care. IADLs are more complex skills that are essential to living in a community.

A patient who has recently moved to this country states he is frustrated about the pressure to give up his original identity and develop a new cultural identity. Which term best describes this type of cultural change? 1. Biculturalism 2. Acculturation 3. Assimilation 4. Ethnicity identification

3 Assimilation is a process by which a person gives up their original identity and develops a new cultural identity by becoming absorbed into the more dominant cultural group.

The nurse is triaging a Latin-Caribbean patient who is behaving hysterically in the emergency room. The patient is crying, has uncontrollable spasms, and is trembling and shouting. What cultural bound syndrome should the nurse recognize these behaviors demonstrate? 1. henjing shaijo 2. Loco de la cabeza 3. Ataque de nervios 4. Neurasthenia

3 Ataque de nervios is a Latin-Caribbean culture-bound syndrome that usually occurs in response to a specific stressor and is characterized by dissociation or trance-like states, crying, uncontrollable spasms, trembling, or shouting.

Which information emphasizes the importance of values in nursing practice? 1. People may consider strong values as opinions 2. Evaluate a client's values and beliefs in terms of your own values 3. Values vary among clients and develop and change over time 4. The values that an individual holds reflect cultural and social influence 5. To discuss differences in opinions and values, the nurse would be clear about their own values

3,4,5 The nurse knows that values differ among people and change/develop over time. An individual's values reflect cultural and social influences. A nurse be clear of their own values before discussing differences in values/opinions

The RN is communicating with the health care team regarding the delegation of tasks. Which factors can determine the quality if communication between the RN and health care team? 1. Accuracy 2. Effectiveness 3. Responsiveness 4. Meaningfulness 5. Understandability

3,5,6 Effectiveness determines the quality of communication when delivering appropriate information. The communication should be meaningful to improve quality of communication. Communication should be understood by all team members so they can perform a task properly

Which action would the nurse take for an older adult resident with Alzheimer disease who often talks about the good old days at the ranch? A. Allowing the resident to reminisce about the past and listening with interest. B. Involving the resident an interesting diversional activities with a small group. C. Reminding the resident that those times are in the past and should focus on the present. D introducing the resident to other residence with the same diagnosis to share past experiences

A Allowing the resident to reminisce about the past and listening with interest encourages verbalization, gives the resident a feeling of security, and decreases the residence sense of isolation.

An older adult client states "Disease occurs when supernatural elements enter the body." Which variable influences the client's health belief in this scenario A. Spiritual factors B. Emotional factors C. Intellectual background D. Perception of functioning

A A client's spirituality, beliefs, and response to illness influence how the nurse will provide support. The client's statement indicates that spiritual factors are at play

Which nurse statement reflects positive cultural sensitivity to help reduce potential health disparities? A. Which type of food do you usually eat at home? B. You need to ask your family to bring food of your choice C. The hospital staff will not be able to cook food with your requirements D. You need to eat the food that the hospital provides

A Asking a patient what food they eat at home shows cultural sensitivity and that the nurse respects the client's culture

The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern the nurse should address? A. Promoting at least 6 hours of sleep a night B. Encouraging an oral intake of 1200 calories per day C. Managing the patient's pain from arthritis D. Supervising medication administration

D Safety is the priority concern for the cognitively impaired patient; safely taking medication addresses safety needs for the patient.

The nurse is working with a patient who has undergone transgender transformation to become a male. Which are some Western cultural masculine attributes the nurse should emphasize to the patient?

Some societies, such as Western societies, place a greater value on masculine attributes such as achievement, material success, and recognition than on more feminine attributes such as harmonious relationships, modesty, and taking care of others.

For a client admitted to the hospital after the accident the nurses uses the Glasgow coma scale. The client is alert and opens eyes when there is a sound or when somebody talks. When asked questions to client answered in a confused matter. The client obeys command, such as being asked to move your leg, which total client score would the nurse document.

13 The score for opening eyes on sound, or speech is a three, the score for confuse verbal responses of four, a score of six is assigned to the motor response of obeying commands

A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When the family asks the nurse about the behavior, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A. Delirium B. Dementia C. Alzheimer disease D. Sundowner syndrome

A Delirium, which occurs over hours to a few days, is the most frequent complication of hospitalization in the elderly population.

A patient does not make eye contact with the nurse and is folding his arms at his chest. Which aspect of communication has the nurse assessed? A. Nonverbal communication B. A message filter C. A cultural barrier D. Social skills

A Eye contact and body movements are considered nonverbal communication. There are insufficient data to determine the level of the patient's social skills or whether a cultural barrier exists.

Which therapeutic communication technique would be useful for a client with major depressive disorder? 1. Reflecting 2. Offering self 3. Using silence 4. Paraphrasing 5. Asking open-ended questions 6. Encouraging comparison

1-6 Reflection- helps understand own thoughts/feelings Offering self- nurse is interested and desires to understand Silence- gives time to collect thoughts Paraphrasing- gives content in fewer words Open-ended- opening up of pt Encouraging comparison- recurring themes and similarities/differences

The nurse is assessing learning needs for a patient who has coronary artery disease. The nurse finds that the patient has recently made dietary changes to decrease fat intake and has stopped smoking. Which is the best initial response by the nurse? 1. "You did an excellent job of changing your eating habits and quitting smoking. This is so important for your heart health. Nice work!" 2. "Although the changes you made are important, it is essential that you make other changes, too." 3. "Which additional changes in your lifestyle would you like to implement at this time?" 4. "Are you having any difficulty in maintaining the changes you have already made?"

1 The perceived behavioral expectations (normative beliefs) of family, friends, coworkers, and healthcare providers influence an individual's motivation to comply with the perceived social pressures from these groups (subjective norm) to behave in a certain way. Responses B, C, and D are appropriate, but A is the best initial response.

The nurse in an acute care setting is caring for a patient experiencing pain and a pain management plan of care has been implemented. What is the minimal interval of time and/or instance when the nurse should reassess the patient's pain? (Select all that apply.) 1. With each new report of pain 2. Before and after administration of analgesics 3. Every 10 minutes 4. Every shift 5. Daily

1,2 Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. At a minimum, pain should be reassessed with each new report of pain and before and after administration of analgesics.

The nurse leader teaches the nursing staff about developing objectives. Which statement by a member of the nursing staff indicates effective learning? 1. I will specify the target to be achieved 2. I will not include unrealistic and unattainable goals 3. I will provide the level of accomplishment for the end result 4. I will include statements such as 'in the future' in the objective 5. I will not indicate specific teams working toward the goals

1,2,3 An effective objective should be specific, measurable, agreed upon, realistic, and time-bound. It is important to include statements that specify the target that needs to be achieved

Which nursing assessment questions assess the faith, belief, fellowship, and community aspect of a client's spirituality? 1. What gives meaning to your life? 2. What is your source of power, hope, and belief during difficult times? 3. In what way do your beliefs help or strengthen you for coping with illness? 4. How has the illness affected your capability to express what os essential in life? 5. How do you feel the changes caused by the illness are affecting you or your life?

1,2,3 The nurse can assess this aspect of spirituality by asking these questions.

Which comment would the nurse say to the client who is not fluent in the language the nurse is speaking to initiate appropriate communication? 1. Please tell me about the healthcare practices and beliefs of your community 2. Let me bring in an interpreter to help you understand the medical procedures better 3. I would like to know your personal beliefs regarding healthcare traditions and practices 4. Please let me explain our traditions and cultural practices to help you understand our health care practices 5. I have read up extensively about the health care practices of your community and have designed a care plan accordingly

1,2,3 The nurse would try to understand the client's beliefs, traditions, and values and the effect of these dimensions on the client's healthcare beliefs and practices. An interpreter should be used to explain medical procedures. The nurse would try to find out about the client's traditions, beliefs, and values to provide individualized care

The nurse determines a patient has not been taking antihypertensive medication as prescribed. How should the nurse proceed? (Select all that apply.) 1. Evaluate the teaching plan to determine if there is a need to reeducate the patient. 2. Assess the patient's perception and attitude towards the risks associated with missing doses of medication. 3. Review and reinforce the need to take the medication as prescribed. 4. Ask the provider to prescribe a different medication because the patient does not want to take this medication. 5. Emphasize the risk of stroke or heart attack if the patient does not adhere to the treatment plan.

1,2,3 The patient may need additional information. Assessing what the patient's perceptions are will provide the nurse with insight on how to proceed next. Reviewing and reinforcing will reaffirm the importance of taking the medication which leads to adherence. The nurse should first explore why the patient is not taking the medication before requesting a different medication order from the provider. Scare tactics may cause the patient to become defensive and may lead to non-adherence.

Which statements made by the client would the nurse consider as an influence of spirituality on health beliefs? 1. My faith prohibits use of donor sperm 2. Dont administer nasal drops now because it will break my fast 3. I do not believe in surrogacy because this is not permitted in our community 4. I am not worried about my surgery because I have undergone several surgeries in the past 5. I am not able to meet my basic needs. How do you expect me to buy these costly medications?

1,2,3 The reason against the use of donor sperm, nasal drops, and surrogacy are examples of spiritual factors influencing health beliefs and practices

A patient is admitted to the long-term care setting. The nurse notes that the patient does not read or write well. Which nursing actions are priority while developing a teaching plan to increase adherence? (Select all that apply.) 1. Determine the patient's motivation and readiness to learn. 2. Assess what the patient knows about their health issues. 3. Include the family in the orientation to the unit and include them in the teaching process. 4. Assess what grade level the patient can read and write and tailor teaching strategies accordingly. 5. Give the patient brochures with more pictures and explanations with short sentences.

1,2,3,4 It is most important to determine the level at which the patient will understand so the nurse can avoid teaching over the patient's level of understanding. Motivation is an important component to learning new information. Assessing what the patient does know will help determine what areas still need to be addressed. Including the family will aid in the teaching process. The patient may not be able to read even short sentences. The priority is to assess the patient's reading level first, then choose appropriate teaching tools.

A 15-year-old pregnant patient asks the nurse how she can take care of herself and her baby at home. What education should the nurse include in this patient's teaching plan? (Select all that apply.) 1. Healthy diet 2. Physical activity 3. Taking prenatal vitamins 4. Avoiding alcohol 5. Infant bathing

1,2,3,4 Regular prenatal care helps to inform women about the steps they can take to ensure a healthy pregnancy. These include: consuming a safe and healthy diet, taking a prenatal vitamin with minimum daily folic acid requirements, getting regular exercise, avoiding an exposure to harmful environmental substances, avoiding alcohol and drugs, and managing pre-existing conditions. Knowledge of infant bathing does not enhance or hinder the patient from experiencing a healthy pregnancy and is not relevant at this time.

The nurse is planning care for the spiritual needs of a patient who has been newly diagnosed with a chronic illness. Which are appropriate nursing interventions for the spiritual care of this patient? (Select all that apply.) 1. Shared laughter Correct 2. Shared tears Correct 3. Listening to the patient Correct 4. Administering medication 5. Praying with the patient Correct 6. Ambulating the patient

1,2,3,5 Spiritual care involves recognizing and honoring the religious beliefs and practices of those in our care but it can also be shared laughter or tears or remembering a patient's birthday. It can be a shared prayer or religious reading that has special meaning to the patient. Spiritual care cannot be boxed in and narrowly defined. Spiritual care is not limited to those who believe a certain way or who define God according to a specific doctrine.

Which factors should the nurse recognize put a patient diagnosed with diabetes at risk for inadequately self-managed blood glucose levels? (Select all that apply.) 1. Obesity 2. Desk job 3. New car 4. Busy lifestyle 5. Regular exercise

1,2,4 Effective self-management of diabetes is essential for patients to avoid complications. Several factors that put a client at risk for inadequately controlled blood glucose levels include: being overweight, sedentary lifestyle (desk job), and non-compliance with medication and self-monitoring. A busy lifestyle could hinder a patient from regularly checking blood sugar levels and attending office appointments. Important factors in the successful self-management of diabetes include regular visits to a provider, medication adherence, and setting realistic goals for engaging in health-promoting lifestyle behaviors (i.e., exercise and healthy diet). A new car indicates this patient has transportation to attend regular provider appointments.

A patient being treated for tuberculosis (TB) with a standard four-drug regimen continues to have positive sputum smears for acid-fast bacilli. Which actions should the nurse implement? (Select all that apply.) 1. Assist the patient with short-term goals and plan teaching according to these goals. 2. Provide the patient with all the educational materials about drug-resistant TB. 3. Refer the patient to a pulmonary specialist, who can assist the patient with the treatment regimen. 4. Ask the patient about any barriers to obtaining medications. 5. Ask the patient whether medications have been taken as directed.

1,2,4,5 The first action should be to determine whether the patient has adhered to the treatment plan and if not identify any barriers to completing the drug therapy regimen. If the TB bacillus is susceptible to the medications and the medications have been taken correctly, negative sputum smears (not positive) would be expected. Obtaining medications may be a factor in whether the client is taking medications as prescribed. Depending on whether the patient has adhered to the medication regimen, goals should be established and different medications or directly observed therapy may be indicated. The nurse is responsible and capable of providing education to patients regarding medication regimens and illness pathology. Referring the patient to a pulmonary specialist will not help with determining compliance.

Which interventions are priorities in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? (Select all that apply.) 1. Promoting rest and sleep 2. Promoting a diet rich in protein 3. Promoting exercise and ambulation 4. Assisting the patient with ADLs 5. Limiting visitors and social contacts

1,3 It is important to promote independence in ADLs early in the plan of care to increase independence in general. Promoting rest and sleep will promote well-being. Ambulation and exercise promote well-being and increase healing by circulating oxygen to the brain. Protein promotes healing in postsurgical patients but is not a main focus in stroke patients. Assisting the patient does not promote independence. Limiting visitors will isolate the patient, which can lead to depression.

Patients who are immobile often experience which emotions? (Select all that apply.) 1. Helplessness 2. Hunger 3. Anger 4. Anxiety 5. Increased communication 6. Improved self-worth

1,3,4 Patients who experience immobility often have psychological issues such as helplessness, anger, and anxiety

Which results are the benefits of providing culturally competent care? 1. Increased client safety 2. Limits number of visitors 3. Reduced health disparities 4. Increased client satisfaction 5. Ensure adequate interpreters

1,3,4 Cultural competence is the ability to understand, appreciate, and work with individuals from cultures other than one's own and involves awareness and acceptance of differences

Which factor may help in providing excellent health care services to the client? 1. Cultural sensitivity 2. High client literacy 3. Competent health care 4. One-way communication 5. Interprofessional teamwork

1,3,5 Cultural sensitivity helps provide excellent health care while keeping in mind the client's cultural background and attitude. Excellent health care services can be provided through competent health care that helps in reaching the client's goals. Interprofessional teamwork helps provide comprehensive care to the client

Which of the following processes have the strongest links to intracranial regulation? (Select all that apply.) 1. Cognition 2. Mobility 3. Oxygenation 4. Perfusion 5. Hormonal regulation

1-5 Cognitive function is dependent on an optimally functioning brain. Mobility is frequently affected by intracranial regulation problems. Perfusion and oxygenation are intimately involved with intracranial regulation, and without adequate perfusion and oxygenation, the brain cannot function. Hormonal regulation is dependent on normal intracranial regulation because of the location of the hypothalamus and pituitary glands within the brain.

A client is discussing with the nurse concerns about their unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is "lets go back to what we were talking about." Which therapeutic communication technique did the nurse use? A. Focusing B. Restating C. Exploring D. Accepting

A Focusing directs a client back to the original topic of discussion

When providing nutritional education for a Mexican-American patient with newly diagnosed hypertension, the nurse notes that the patient is nodding "yes" to everything that is being said. Which action by the nurse is appropriate? 1. Write everything down for the patient to refer to later. 2. Prompt the patient further to elicit additional questions or concerns. 3. Call the recognized elder for this patient. 4. Call the patient's oldest male relative for help with decision making.

2 - The patient is nodding "yes" because it is a polite way of indicating that the power distance is too close for the patient. - Acknowledging power distance is the way in which a less powerful member of an organization or institution (such as a family) accepts and indicates that power is being distributed unequally. - In cultures that endorse a high power distance, less powerful persons accept power relations that are more autocratic and paternalistic, and are subordinate to the higher ups - When a nurse provides nutritional education for a patient who is from a culture that values a greater power distance, it might appear that the patient is willing to accept all that the nurse suggests; further prompting would elicit additional questions or concerns.

An array of assessment tools has been developed to assess activities of daily living (ADLs) as an indication of a person's functional ability. Some of these tools include the 24-Hour Functional Ability Questionnaire (24hFAQ), Long Term Care Minimum Data Set (MDS), Functional Status Scale (FSS), and the Edmonton Functional Assessment Tool. What is a disadvantage of these specific tools? 1. The measurement of efficacy and reliability of the instruments are used to assess activities of daily living (ADLs). 2. The variations in assessments and responses may be subjective because of self-reporting of functional activities. 3. The instruments do not show a true measure of ability because of a lack of interactivity during the assessments. 4. The information contained in the instruments is insufficient to make a determination about the functional status of these populations.

2 A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) instruments is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.

A nursing instructor evaluates that a nursing student understands the concept of spirituality in nursing practice when the student makes which statement? 1. A lack of spirituality theories has contributed to the omission of this aspect of care. 2. A lack of spirituality assessment can have a negative impact on patient care. 3. Spirituality assessment is not part of professional nursing care but should be included in holistic care. 4. There are currently no nursing diagnoses addressing spirituality to include in the plan of care.

2 Professional organizations have incorporated spirituality into holistic care and developed mandates to provide spiritual care because the lack of addressing spirituality may negatively impact patient care.

Why is it important for nurses to have a broad understanding of cultural influences on health care? 1. Disability entitlements 2. Requirements of the Health Insurance Portability and Accountability Act (HIPAA) 3. Increasing global diversity 4. Litigious society

3 Culture is an essential aspect of health care because of increasing global diversity.

A family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. Which action would the nurse take to handle the situation? 1. Wait for the court's order to give blood 2. Proceed with the transfusion to save the client's life 3. Inform the primary healthcare provider and not give blood to the client 4. Explain to the family member that the client needs this transfusion

3 The client of client's family has the right to refuse treatment, and the nurse should value their beliefs and traditions

Which nursing interventions would help a terminally ill client cope with feelings of death? 1. Providing medications and therapies for pain management 2. Teaching the client about the importance of complementary medications 3. Helping the client find meaning and purpose in life by listening to concerns 4. Allowing time for religious readings, spiritual visitations, or attendance to religious services 5. Encouraging the client to pray if desired by facilitating privacy and a proper environment

3,4,5 Feelings of connectedness are important for the client who is terminally ill, so the nurse would listen to their concerns. Prayer and devotion can help a client cope with feelings related to death.

The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? (Select all that apply.) 1. Can feed herself and prepare meals but cannot drive to the store 2. Lives on a fixed income and can balance her checkbook 3. Experiences stress incontinence 4. Cannot participate in activities at the senior center 5. Lives alone and has no nearby relatives 6. Has no transportation to the oncology clinic

3,5,6 The patient will not be able to get treatment if she has no transportation or no relatives who live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.

Which therapeutic communication technique is used when the nurse and client have a conversation and the client begins to repeat the conversation to self? A. Focusing B. Clarifying C. Paraphrasing D. Summarizing

A Focusing is a technique that is useful when clients begin to repeat conversations to themselves

Which statement by a student nurse demonstrates understanding of managing patient care for a patient with a chronic disease? 1. "Chronic disease management is best handled with one expert provider taking the lead role in the treatment plan." 2. "A care giver-centered approach is best for managing the complexities of chronic disease care." 3. "Current healthcare trends are evolving toward the paternalistic approach to care of the patient with chronic illness." 4. "The patient and family should develop a partnership when developing a plan of care for a loved one with a chronic illness."

4 Data show that approximately 90% of all healthcare expenditures are for the prevention and treatment of chronic disease, with 12% of the population accounting for more than 40% of healthcare spending. This shift toward chronic disease care has required healthcare systems to revamp their approaches to medical treatment. The paternalistic approach, which views the provider as "expert" and the patient as "passive recipient" of medical advice, works well in acute illness but is largely ineffective at treating chronic diseases that require daily management by patients and their caregivers. Rather, evidence suggests that patient-centered approaches, which emphasize patient-provider partnerships where patients are active participants in their care, are most effective for addressing chronic disease.

Which patient would benefit most from a plan of care that includes self-management? 1. Patient hospitalized with femur fracture 2. Patient diagnosed with pulmonary embolus 3. Patient experiencing chest pain 4. Patient with chronic heart failure

4 Patients diagnosed with a chronic disease who are not suffering acute exacerbations are the best candidates for self-management. A patient with chronic heart failure can be educated about signs/symptoms and the treatment plan to manage the condition outside of the hospital. Patients with a femur fracture need acute care and assisted rehabilitation. Pulmonary embolism and chest pain are emergent conditions that require skilled, acute care.

As the profession of nursing evolved to incorporate evidence-based practice, which statement is true about spirituality? 1. Evidence-based care focuses solely on the physical effects of health and illness. 2. An emphasis was placed on spirituality as nursing education moved into colleges and universities. 3. Spirituality was incorporated back into care when a concrete definition had been established. 4. Spirituality commonly encompasses a concept or belief about God and the inner person.

4 The definitions of spirituality encompass the following: a principle, an experience, attitudes and belief regarding God, a sense of God, the inner person.

A patient tells the nurse, "I am not a religious person. I believe things happen in life out of pure coincidence." Which evaluation of this patient's spirituality is true? 1. This patient is not a spiritual person. 2. This patient is more likely to suffer from depression. 3. This patient will experience difficulty coping with life changes. 4. This patient experiences emotions and should be asked about the effects of health changes

4 This patient will still experience emotions and the effects of health changes even though he does not identify himself as spiritual. Patient still has spiritual nature (as does everyone) even if they do not believe it

A 10 yo child who has head lice tells the school nurse "I'm mad because my parents said I got lice because I don't keep myself clean." Which would the nurse communicate to initiate therapeutic communication about this subject? A. It sounds as if you feel that your parent is putting you down B. There is a relationship between cleanliness and lice infestation C. You must be having problems getting along w/ your parent D. People who don't keep themselves clean are more likely to get lice

A Asking whether the child feels put down focuses on the child's perceptions and promotes further communication

Which is a priority for the nurse to include in a teaching plan for a patient who desires self-management and alternative strategies for pain management? A. Body alignment and superficial heat and cooling B. Patient-controlled analgesia (PCA) pump C. Neurostimulation D. Peripheral nerve blocks

A Body alignment and thermal management are examples of nonpharmacological measures to manage pain. They can be used individually or in combination with other nondrug therapies. Proper body alignment achieved through proper positioning can help prevent or relieve pain. Thermal measures such as the application of localized, superficial heat and cooling may relieve pain and provide comfort

Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? A. "It is okay to cry; mourning the loss of your breast is important for getting past this." B. "I know this is hard, but chances of survival are greatly improved now." C. "Would you like to talk to someone who also has had a mastectomy?" D. "How have you coped with difficult situations in the past?"

A Cancer surgery can involve the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy response to adapting or adjusting to a new image

Which condition causes impaired speech coordination? A. Cranial nerve lesion. B. Occipital lobe lesion. C. Parietal cortex lesion D limbic lobe lesion

A Cranial nerve lesions cause a lack of coordination in articulating speech because the cranial nerves are responsible for speech coordination

A patient recently admitted to the hospital has been diagnosed with delirium. The family of the patient asks the nurse to explain what delirium is. How should the nurse respond? A. Delirium is reversible with treatment of the underlying cause. B. Delirium is progressive and has no known cure. C. Delirium affects a specific area of cognitive functioning. D. Delirium indicates the onset of a cerebrovascular accident.

A Delirium can be reversible with treatment of the precipitating problem and control of predisposing factors.

A client with newly diagnosed bronchitis tells the home health nurse about continuing to smoke 1-2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is the best? A. Tell me about your typical day before you were diagnosed with chronic lung disease B. Smoking and not doing the exercises will make your lung disease continue to get worse C. I can't make you stop what you are doing, and it is your choice to be sick or well D. Your shortness of breath is probably from the smoking and not doing your exercises

A More data is needed about the client's usual activities of daily living so the care plan can be adapted to the client's preferences

The ability to receive and interpret stimuli is a priority for what human need? A. Safety B. Socialization C. Nutrition D. Mobility

A Safety is the highest priority of the needs listed.

The nurse is surveying the assisted living facility regarding safety features for patients with sensory deficits. Which are the most appropriate accommodations? A. Fire and smoke alarms with sound and flashing lights B. Colorful throw rugs to designate the purpose of various rooms C. Alarms on all exit doors D. Steps painted with dark colors

A Sound and flashing lights for alarms are helpful for both visual and auditory deficits.

The RN while teaching a group of new nurses about the characteristics of a good team player states, "A good team player should work with determination and refuse to stop until accomplishing the goal." Which characteristic is the RN describing? A. Tenacity B. Selflessness C. Dependibility D. Collaboration

A Tenacity means giving your all with determination and refusing to stop until your goal has been accomplished

Which approach would the nurse take for an older adult client who was confused, does not recognize family members, and often soils clothing with feces and urine? A. Toileting, the client every two hours. B. Placing the client in orientation therapy. C. Supervising the clients bathroom activities closely. D explaining to the client how offensive the behavior is to others

A The client needs toileting, every two hours to prevent soiling, physically sitting the client on the toilet often prevent accidents and negates the need for disposable pads or underwear

Which member of the interprofessional team in palliative care setting serves as a client's advocate, evaluating the physical, emotional, and spiritual needs of the client? A. Nurse B. Pharmacist C. Music therapist D. Primary health care provider

A The nurse evaluates the physical, emotional, and spiritual needs of the patient and advocates for the client and provides referrals to other members of the team.

Which therapeutic technique is demonstrated when the nurse says, "I'm confused about exactly what is upsetting you. Would you go over that again please?" A. Clarifying B. Structuring C. Confronting D. Paraphrasing

A The nurse is asking for clarification to better understand the intended message

Which members of the interprofessional team in palliative care setting serves as the client's advocate, evaluating the physical, emotional, and spiritual needs of the client> A. Nurse B. Pharmacist C. Music therapist D. Primary health care provider

A The nurse on the team evaluates the physical, emotional, and spiritual needs of the client, along with advocating for the pt and making referrals

Which nursing action establishes the nurse as a caregiver for a client in spiritual distress? A. Provide therapeutic treatment to the client B. Teaches the client about signs of spiritual distress C. Communicates the wishes of the client to family members D. Collaborates with the agency chaplain to pursue the best treatment

A The nurse serves as a caregiver by meeting all health care requirements of the client by providing measures that restore a client's emotional, spiritual and social well-being

When preparing a client for a diagnostic procedure, which action would the nurse take if the client is wearing a religious symbol dangling from a necklace? A. Ask the client about the religious symbol and the significance of removing it B. Explain to the client that the religious symbol must be removed immediately C. Call the radiologist performing the procedure to obtain an order to keep the necklace in place D. Say nothing to the client, remove the necklace, and give it to. family member for safekeeping

A The nurse would ask the client about the religious symbol, and if client safety is a concern, the nurse would explain why removal is necessary

A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A. Older male adults with diabetes B. Older female adults who are overweight C. Young adults living in school dormitories D. Adolescents attending summer camps

A The primary risk factor for cognitive impairment is advancing age; males with a history of stroke or diabetes are at significant risk.

Which statement is important to include in the teaching for a patient who has received an injection of iodine-131? A. "Do not share a toilet with anyone else for 3 days." B. "You need to save all your urine for the next 7 days." C. "No special precautions are needed, because this is a weak type of radiation." D. "You need to avoid contact with everyone except family members until the radiation device is removed."

A The radiation source is an unsealed isotope that is eliminated from the body mainly through urine and feces. This material is radioactive for about 48 hours after instillation. The patient should not share a toilet with others for 3 days to ensure the isotope has been completely eliminated and is no longer radioactive.

What priority intervention will the nurse employ to prevent injury to the patient with bone cancer? A. Using a lift sheet when repositioning the patient B. Positioning the patient so the heels do not touch the mattress C. Providing small, frequent meals rich in calcium and phosphorus D. Applying pressure for a full 5 minutes after intramuscular injections

A The resultant bone destruction from bone cancer can cause pathologic fractures by grasping or pulling on a patient by the extremities or trunk of the body during re-positioning. The use of a lift sheet evenly distributes the patient's weight, lessening the chance of fractures occurring.

Which approach would the nurse take for an older adult client who is confused, does not recognize family members, and often soils clothing with feces and urine? A. Toileting the client every 2 hours B. Placing the client in orientation therapy C. Supervising the client's bathroom activities closely D. Explaining to the client how offensive the behavior is to others

A This client needs toileting every 2 hours to prevent soiling, physically seating the client on the toilet prevents accidents and negates the need for disposable pads/underwear

Which response would the nurse say to an older adult client whose spouse has died and who says, "I'm all alone, no one has any use for me"? A. You seem upset. Let's talk about what's bothering you. B. We need to be alone sometimes. It helps us get to know ourselves better C. Try doing something to avoid feeling lonely. I think you should socialize more D. Let's focus on ways to change this. How about playing some games to improve your morale?

A This response indicates an awareness of the client's feelings and encourages verbalization.

A man who has dementia is admitted to a long-term care facility. His wife, who appears tired and angry says in a sarcastic tone, "Let's see what you can do with him." Which response is therapeutic? A. It sounds like it's been difficult for you B. I don't understand what you mean C. I have experience with all types of clients D. It's too bad you didn't admit him sooner

A When the nurse acknowledges the problems faced by the caregiver without a hint of blame, it opens the channel of communication

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? A. Gait and balance B. Speech and hearing C. Mental alertness D. Ability to follow directions

A When the patient is walking, the nurse is assessing for gait and balance (mobility).

Which information would the nurse include in the explanation of a pap test? A. The Pap smear screens for cancer of the cervix B. Vaginal bleeding like a period is expected after a Pap smear. C. Colonoscopy will be used to visualize the cervix. D. Scraping a cervix is the most uncomfortable part

A pap smears a screening test for cancer the cervix

Which assessment is a component of the primary survey? A. Disability B. Abdomen and flanks C. Head, neck, and face. D history of the illness or injury

A Assessing disability, by conducting, a brief neurological examination is a component of the primary survey which aims to identify life-threatening conditions, so appropriate interventions can be started

Which of the four older clients who is clinical features are shown in the accompanying chart may have dementia? A. Normal psychomotor behavior, normal attention and misperceptions absence. B. Hypokinetic, psychomotor behavior, impaired attention, difficult to distinguish between reality in perceptions. C. Hyperkinetic, inattentive, hallucinations. D psychomotor retardation, easily distractible, illusions present

A Client one has normal psycho motor behavior. The attention of the client is also indicated to be normal. Moreover, misinterpretations are absent, client one may likely have dementia.

Which respect her with the nurse discuss with a Loco women's group as indicating the need for breast cancer screening at it earlier age? A. Family history of breast cancer B. History of tobacco use C. Obesity D. Early onset menopause

A Family history of breast cancer increases one's risk the screening should be done earlier

Oral contraceptives are prescribed for a client who smokes heavily, which is a major immediate risk to the client? A. Blood clots B. Cervical cancer. C. Ovarian cancer. D. Risk of coronary heart disease later in life.

A Heavy smoking as a major risk factor for an increased risk of thrombosis or blood clot

Which primary objective of nursing interventions with the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders? A. Safety within the environment. B. Enhancement of psychological faculties. C. Participation in educational activities. D face-to-face contact with other clients

A Safety within the environment is the primary objective of nursing interventions. Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately or diminished.

Which nursing intervention would be the priority action during the whole history portion of the secondary survey in an emergency assessment? A. Determining medication, allergies. B. Note general appearance C. Examining neck for stiffness. D isolating for heart and lung sounds

A The priority, nursing action during the health history portion of the assessment, is a determine medication allergies

Which technique would be appropriate for clients who exhibit mild neurocognitive impairment? A. Reality orientation. B. Behavioral confrontation. C. Reflective communication D reminiscence group therapy

A We all orientation is a technique to use with clients with mild neurocognitive impairments. These clients are aware of their impairment and orientation, then reduces anxiety.

Which activities with the nurse initiate for a client with Alzheimer's disease who is admitted to a long-term care facility? A. Weighing the patient once a week. B. Having specialized rehab equipment available. C. Keeping the client in pajamas and robe most of the day. D. Establishing a schedule with periods of rest after activities. E. Reviewing a clients weekly budget and use of community resources F. Setting up a plan for weekly entertainment through a senior citizens travel group.

A,B,D Monitoring weight is an objective way to assess nutritional status, specialized rehab equipment can facilitate the clients participation in self care, incorporating rest periods into the clients day prevent fatigue and energizes the client for the next period of activity

According to Piaget, which cognitive skills would the nurse expect from a school-age child? A. Classifying objects B. Understanding reversibility C. Having theoretical thoughts D. Describing a process. without actually doing it E. Believing personal actions are constantly being scrutinized

A,B,D These actions would be expected of a school-age child according to Piaget's cognitive developmental theory

Which intervention would be implemented by a nurse is caring for a community dwelling, older adult who is suffering from confusion? A. Provide a protective environment. B. Assist the personal hygiene C. Educate the client about correct body mechanics. D promote activities that reinforce reality E. Teach the clients caregiver proper feeding techniques.

A,B,D When caring for an older adult who is in the confuse state, the nurse would provide a protective environment, assist with hygiene and promote activities that reinforce reality

The nurse is having a therapeutic conversation with a patient newly diagnosed with hypertension. Which communication techniques will most likely prove effective for this patient? (Select all that apply.) A. The nurse presents a laminated poster to the patient that depicts pictures of foods that would be on the low sodium diet. B. The nurse and patient engage in a humorous conversation about the top ten "what not to eat when you are being treated for hypertension." C. The nurse gives the patient a sheet full of information and asks the patient to read the information and let the nurse know if they have any questions. D. The nurse states the risk factors and statistics of patients who do not take their medications as prescribed. E. The nurse helps the patient identify weight loss goals that are reasonable. F. The nurse waits until the patient has been awake for a few hours before beginning the teaching plan.

A,B,E,F Engaging techniques such as humor, visual props, and waiting for the patient to be more alert will increase the therapeutic interaction. Providing the patient with written materials is important; however, there is no way to gauge the effectiveness of the teaching and does not guarantee that the patient has read the information. It would be useful to implement the teaching plan and supplement the teaching with a handout at the end of the session to reinforce the teaching.

A nurse mentor is explaining the benefits of collaborative practice to a nurse new to a facility. Which research-based benefits should the nurse identify as likely positive outcomes of collaboration? (Select all that apply.) A. Decreased length of stay for patients B. Decreased staff resignations C. Decreased use of pain medications D. Increased reimbursement from insurance carriers E. Increased patient follow-up appointments after discharge F. Increased job satisfaction of the staff

A,B,F Documented positive outcomes from collaboration include a shortened length of stay, increased job retention and decreased staff turnover, increased job satisfaction for registered nurses, and improved problem-solving skills

Which is a normal finding during the regular checkup of an older adult? A. Loss of turgor B. Urinary incontinence C. Decreased night vision D. Decreased mobility of the ribs E. Increased sensitivity to odors

A,C,D In older adults, skin loses its elasticity and there is fat loss in the extremities. Visual acuity declines with age. Decreased mobility of the ribs is found in older adults due to calcification of costal cartilage

Which component of the Glasgow coma scale assessment tool would the nurse recall when performing a neurological assessment on a client? A. Best verbal response. B. Best pupillary response. C. Best motor response. D. Best eye-opening response. E. Best cognitive response.

A,C,E The GCS is a common way of determining and documenting level of consciousness that scores verbal response, motor response and eye-opening response

Which education would the nurse provide the parent of a toddler about expected sleep patterns? A. Total sleep average 12 hrs a day B.Toddlers normally take several naps during the day C. It is uncommon for toddlers to awake during the night D. In the waking period, the toddler may engage in sleepwalking E. During this period, the toddler may be unwilling to go to bed at night

A,E The nurse tells the parent that toddlers sleep 12 hours a day. During this period, toddlers may be unwilling to go to bed at night because they need autonomy or because they fear separation from their parent

Which nutrients are critical for the musculoskeletal development during infancy, childhood, and adolescence? A. Vitamins and minerals B. Protein and calcium C. Fats and carbohydrates D. Zinc and potassium

B Adequate stores of protein and calcium allow the developing musculoskeletal system to grow properly.

The nurse manager of a neuro-medical surgical unit reviewing potential manifestations of seizures with an orientee should become concerned if the new nurse included which of the following dysfunctions as a manifestation? A. Autonomic B. Family C. Motor D. Sensory

B Although family dysfunctions can result from long-term stress, this would not be a manifestation of a seizure

A victim of a car crash tells the nurse "I don't believe in God anymore now that I am paralyzed." The nurse asks the client to discuss how the condition has affected the client's ability to express what is important. Which aspect of spiritual assessment would this question address? A. Faith B. Vocation C. Connectedness D. Life and self-responsibility

B By asking how the client's condition has affected the ability to express what is important, the nurse is addressing the vocation aspect of spirituality

After the nurse teaches a client about self-management techniques for smoking cessation, which client statement indicates the need for further teaching? A. I should list the reasons why I should stop smoking B. I should visit all the places where I started smoking C. I should remove all ashtrays and lighters from my home D. I should try replacing tobacco with sugarless mints and gum

B Clients may be tempted to smoke if they visit the places where they started smoking

Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? A. Is able to obtain pulse oximeter reading B. Demonstrates use of a metered-dose inhaler C. Knows the health care provider's office hours D. Can identify triggers that may cause wheezing

B Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack, this is an important skill to have

During a new nurse' orientation to the unit, a nurse explains why collaboration is valued. Which outcome is a key patient care outcome that occurs when collaboration is correctly used? A. Governmental accrediting agencies give more favorable reviews to the agency. B. There are fewer errors that occur in patient care. C. Agencies can offer higher salaries due to the cross-training of staff. D. Ongoing education is not needed, because other specialties contribute to care decisions.

B Collaboration results in fewer errors in patient care due to the interactions between health providers of all disciplines and patient involvement in planning

Intracranial regulation should be a priority concern for the nurse caring for a patient with which admitting diagnosis? A. Failure to thrive B. Traumatic brain injury C. Upper respiratory infection D. Urinary tract infection

B Intracranial regulation would be a concern for a patient who suffered a traumatic brain injury.

Which communication term can be applied to this statement: How messages are received and interpreted would include personal states such as mood disturbance, environmental stimuli related to the setting of the communication, and contextual variables? A. Therapeutic communication B. Metacommunication C. Vigor communication D. Internal noise

B Metacommunication is a term which means how messages are received and interpreted would include personal states such as mood disturbance, environment stimuli related to the setting of the communication, and contextual variable.

A retired schoolteacher is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Based on her expressed wishes, which options should the nurse suggest for her plan of care? A. Using a stationary exercise bicycle and free weights and attending a spinning class B. Using music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy C. Drinking chamomile tea and applying icy/hot gel D. Receiving acupuncture and attending church services

B Mind-body therapies are designed to enhance the mind's capacity to affect bodily functions and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others.

A woman fell while sweeping her driveway and sustained a tissue injury. She describes her condition as an aching, throbbing back. Which term best describes this type of pain? A. Neuropathic pain B. Nociceptive pain C. Chronic pain D. Mixed pain syndrome

B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as dull or aching, and it is poorly localized.

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? A. Restrict client's fluid intake B. Regulary offer the client a urinal C. Apply incontinence pants D. Insert an indwelling urinary catheter

B Regularly offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void which increases bladder muscle tone and creates a conditioned response

Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? A. Sharing hope B. Sharing humor C. Sharing empathy D. Sharing Observations

B Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps nurse/client adjust to stress

The nurse is reviewing skin care for immobilized patients with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? A. "Proper care of the skin is important because the immobilized patient does not want to smell bad." B. "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." C. "Proper care of the skin is important because the immobilized patient will have many visitors." D. "Proper care of the skin is important because the immobilized patient will be incontinent."

B Skin care is important for an immobilized patient because the patient is prone to skin breakdown from pressure and body fluids.

Which member of the health care team acts as a team leader by developing clients' plans of care and coordinating care among team members? A. Charge nurse B. RN C. LPN D. UAP

B The RN works directly with the client, family, and health care team members

Which factor is associated with culture-bound syndrome? A. Traits are inherited and genetically linked B. Etiology may be mystical or spiritual C. Signs and symptoms have no organic cause D. Illness respond only to culture-bound treatments

B The cause of illness may seem mystical (imbalance of harmony) or spiritual (evil spirits or loss of the soul)

A client says, "None of the medications will work on me because I am away from my holy land." Which course of action would the nurse take to comply with teamwork and collaboration competency according to QSEN? A. Provide care the client with respect to diversity, values and beliefs B. Approach the agency chaplain to discuss the spiritual needs of the client C. Conduct thorough research on the effect of emotional distress on the client's health D. Use the flow chart data to provide the best care and monitor the outcome of care processes

B The nurse complies with teamwork and collaboration competency to function within the nursing and interprofessional teams, which would include approaching the agency chaplain.

Which factor can interfere with the nurses ability to actively listen to a 15 yr old client who has a history of drug abuse, stealing, truancy and a general disregard for others? A. clients age and disease process B. Nurse's personal cultural beliefs C. Limited time to complete care D. Professional need to secure information

B The nurse may unconsciously stop listening if the client's actions and beliefs contradict the nurses.

One week after an above-knee amputation a client refuses going to PT and tells the nurse "I'll never be a whole person again!" Which response would the nurse provide? A. You're the same person you have always been, just relax B. You've lost a part of yourself, that must be difficult for you C. You may feel that way, but I'm sure your family considers you a whole person D. You must go to PT everyday or you will develop muscle contractures

B This response acknowledges and reflects the client's feelings and encourages further communication

After being medicated for anxiety, the client says to the nurse "I guess you are too busy to stay with me." Which response by the nurse is correct? A. I'm so sorry but I need to see other clients B. I have to go now, but I will come back in 10 minutes C. You'll be able to rest after the medicine starts working D. You'll feel better after I've made you more comfortable

B This response demonstrates that the nurse cares about the client and will have time for the client's special and emotional needs

A pregnant client says "abortion is banned in our community because it interferes with God's creative work. Which variable influences the client's health belief? A. Emotional factors B. Cultural background C. Socioeconomic factors D. Perception of functioning

B This statement is an example of the influence of cultural background on health beliefs

Which action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? A. Assess the client's ability to understand the nurse B. Evaluate how well the nurse uses active listening C. Reinforce to the client the importance of sharing D. Review the nurse's use of questioning techniques

B effective listening is critical to the development of meaningful, therapeutic communication between the nurse and the client. Lack of effective communication on the nurse's part results in superficial, ineffective communication.

Which statement by the client indicates a need for further learning about skin cancer prevention? A. I should use sunscreen before going outside. B. I should limit sun exposure between 7 AM and 12 PM. C. I should wear a hat and opaque clothing when going out. D. I should have regular examinations of precancerous lesions.

B And prevention of skin cancer the client should not be out in the sun at mid day

Which intervention would the nurse implement for an infant with increased intracranial pressure? A. Weighing daily before feelings. B. Elevating the head higher than the hips. C. Check the reflexes at regular intervals. D monitoring alertness with frequent stimulation

B Elevation of the head helps decrease intracranial pressure by way of gravity

Which statement would the nurse say to an older adult, accompanied by family members who is admitted to a long-term care facility with symptoms of neurocognitive disorder? A. You're a little disoriented now, but don't worry you'll be fine in a few days. B. I'm your nurse and the staff is here to help you. C. I will be on duty today. You're in a long-term care facility. Your family can say about 30 minutes. D. In a little while I'll get you acquainted to our unit routine.

B Familiarity with the environment and self introduction may help promote security and feelings of trust

When a client who is in charge of the diagnosis of lung cancer and pneumonectomy, becomes withdrawn after being discharged home, which action by the home health nurse will be best? A. Suggest that an antidepressant may be helpful. B. Ask the client to describe the current emotional state. C. Reassure the client that depression is a normal reaction. D ask the healthcare provider to make a mental health referral

B Further assessment of a client is needed before developing a care plan

A client with stomach cancer expresses a lack of interest in food and consumes only small amounts which nursing intervention is best for meeting the dietary needs for this client? A. Smaller portions more frequently B. Nutritional supplements between meals. C. Supplementary vitamins to stimulate appetite. D only food the client likes in small portions at meal times

B Nutritional supplements provide more adequate calories and nutrients

When providing care for a client with traumatic brain injury in increased intracranial pressure which healthcare provider prescription with the nurse question? A. Continue anticonvulsants. B. Teach isometric exercises. C. Continue osmotic diuretics D keep head of bed at 30°

B The nurse should question the prescription for isometric exercises due to the increase of the basal metabolic rate and intracranial pressure from these exercises

Which action would the nurse take for an older resident in a nursing home with Alzheimer's disease who holds leftover food and other seemingly valueless articles and stuff some of the pockets so others won't steal them? A. Remove the residence on safe and soiled articles during the night. B. Give the resident a small bag in which to place a selected personal item articles of food. C. Explain to the resident where the nursing homes policy for cleanliness and safety must be followed.

B This action allows client to exercise the right to decide which articles to keep. It helps ensure safety and cleanliness.

The nurse advice as a client to refrain from eating salty food as a way to prevent high blood pressure which healthcare services this? A. Tertiary care. B. Primary care C. Preventative care. D. Restorative care

B When the nurse provides nutrition counseling to the client it qualifies as primary care

Which intervention with the nurse take to ensure the well-being of a community dwelling older adult with dementia? A. Obtain the clients medication history and educate the older adult about safe medication storage. B. Foster human dignity and maintain the best possible functioning, protection, and safety. C. Teach the client to be cautious of fake advertisement that promise a cure for disease. D show the caregiver techniques to dress feed and toilet the older adult E protect clients rights

B, C, E When caring for a community dwelling, older adult with dementia, the nurse would maintain the best possible functioning, protection, and safety in addition to fostering human dignity the nurse would demonstrate to the caregiver techniques to feed dress and toilet the client and protect the clients rights and provide support

Which similarities would the nurse expect between a preschooler and a school-age child A. Both have imaginary playmates B. Both are curious to know about their surroundings C. Both are able to relate the events and their causes D. Both understand that one object can exist in 2 shapes E. Both believe that inanimate objects have lifelike qualities

B,C Both preschoolers and school-age children are curious to know their surroundings. This behavior is evident as they explore the environment and ask questions. Both are able to relate the things based on their casual relationship

Which nursing diagnoses for patients with sensory perceptual variances may be included in a plan of care? (Select all that apply.) A. Knowledge deficit for nutrition B. Risk for injury C. Impaired mobility D. Altered nutrition that is less than the body requirements E. Decreased cardiac output

B,C,D Multiple sensory deficits can contribute to injury, and visual, auditory, and tactile changes can lead to injury. Likewise, mobility may be impaired by both tactile and visual changes.

Which terms represent different patterns of physical development and maturation of neuromuscular functions in a child A. Sensorimotor B. Proximodistal C. Differentiation D. Cephalocaudal E. Undifferentiated

B,C,D Proximodistal development refers to near-to-far development in the infant. Cephalocaudal is the head to toe growth seen in a child. Differentiation refers to the development from simple operations to more complex functions

Which expected sensory loss associated with aging would a nurse recall when designing a plan of care for an 85 year old client admitted to a nursing home? A. Difficulty swallowing B. Diminished sensation of pain C. Heightened response to stimuli D. Impaired hearing of high frequency sounds E. Increased ability to tolerate environmental heat

B,D Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age, they experience atrophy of corti and cochlear neurons, loss of sensory hair, and degeneration of stria vascularis causes diminished ability to hear high pitch sounds.

The mother of a 2-year-old asks the nurse about her child's cognitive development. The best response of the nurse is that her child A. is beginning to think intuitively. B. is using magical thinking. C. can solve concrete problems. D. is using abstract thinking.

B. The expected stage of development for a 2-year-old is one with magical thinking, where a child begins to engage in make-believe play. Intuitive reasoning occurs by the end of the preoperational period (at 2 to 7 years of age). The ability to solve concrete problems occurs with the period of concrete operations (at 7 to 11 years of age). The formal operational period (at 11+ years of age) is when individuals use thinking that is logical and can consider abstract ideas.

The geriatric nurse practitioner preparing to assess an 84-year-old whose daughter is concerned about her ability to live alone would complete a A. developmental assessment. B. functional assessment. C. life experiences survey. D. recent life changes questionnaire.

B. The nurse would complete a functional assessment of an individual's ability to carry out activities of daily living (ADLs) such as basic activities of daily living (BADLs) or instrumental activities of daily living (IADLs). The focus of the assessment to address the daughter's concern should be function, not overall development. The life experiences survey is aimed at identifying those in need of guidance relative to stress and coping, as is the recent life changes questionnaire.

Lack of mobility in a child may interfere with which developmental milestone? A. Physiological bonding and growth B. Speech and hearing development C. Intellectual and psychomotor function D. Childhood play interaction

C A child must experience mobility so he or she can explore and learn about the world. Immobility can cause intellectual and psychomotor deficits because children need to experience mobility to explore the world

Which findings during a female breast examination should the nurse report as suspicious for breast cancer? A. Multiple nodules of round, lumpy, tender tissue in both breasts B. A single soft, mobile, lobular nodule that is nontender C. A poorly defined, firm lump that is nontender and nonmovable D. A single soft lump that is well-defined and tender

C A poorly defined, firm lump that is nontender, nonmovable, and fixed to the skin is characteristic of breast cancer.

The nurse is teaching a parenting class. Which suggestion would the nurse make about managing the behavior of a young school-age child? A. Avoid answering questions B. Give the child a list of expectations C. Be consistent about established rules D. Allow the child to plan the day's activities

C Because of a child's short attention span/distractibility, consistent limit setting by parents is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflict

A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is necessary. What is the nurse's best response? A. "Your cancer is widespread and requires more than the usual amount of radiation treatment." B. "The cost of larger doses of radiation for a shorter period of time is justified by the results." C. "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." D. "It is less likely your hair will fall out or you will become anemic if radiation is given in smaller doses over a longer period of time."

C Because of the varying responses of all the cancer cells within a given tumor, smaller doses of radiation given on a daily basis for a set period of time provide multiple opportunities for the destruction of cancer cells while minimizing damage to normal tissues.

Which behavior by a nurse indicates the effective strategy for collaboration with other professionals? A. Strongly defends own professional role B. Avoids conflict C. Negotiates with others D. Aggressively presents a personal view of a situation

C Conflicts may arise during collaboration, requiring the skill of negotiation

Which developmental task is characteristic of young adulthood? A. Mastering his environment B. Identifying with the male role C. Developing meaningful relationships D. Differentiating himself from the environment

C Developing meaningful relationships is the young adult's developmental task associated with intimacy versus isolation

When performing an assessment of the clients reproductive system, which finding in the past medical history indicates the client is at risk for cervical cancer? A. Vaginal discharge. B. Ovarian dysfunction. C. Human papilloma virus infection D hematuria and urinary incontinence

C HPV infection increases the risk of cervical cancer

Which mental process would be recognized by the nurse as associating with deterioration that accompanies aging? A. Judgment B. Intelligence. C. Creative thinking D short term memory

D During the aging process, there's a progressive atrophy of the convulsions of the brain, with a decrease in its blood supply which may produce a tendency to become forgetful, a reduction in short-term memory , and susceptibility to personality changes

Which statement by a nursing student demonstrates an understanding of collaboration? A. "Collaboration is a new way of interacting with physicians." B. "Collaboration means that the care team can make all of the decisions for the patient." C. "Collaboration with patients has been used by nurses throughout the history of nursing." D. "Collaboration is an outdated concept that has been replaced by managed care"

C History shows that from the time of Florence Nightingale, nurses have worked with patients to assess their needs and wants. Collaboration with fellow care providers such as physicians is not a new concept; it is becoming more prevalent.

A client who sustained a head injury, reports bland taste of food upon examination. The nurse finds that there's a loss of taste perception from the interior 2/3 region of the tongue which origin of the brain is associated with the involves nerve? A. Medulla B. Midbrain. C. Inferior pons. D cerebrum

C Loss of taste perception from the interior 2/3 of the tongue indicates injury to the facial nerve which originates from the inferior pons

A patient voices an understanding of instructions about furosemide (Lasix) when he makes which statement? A. "I will report any blurred vision." B. "I expect that this will cause me to have increased sensitivity to saltiness." C. "If I notice ringing in my ears, I will call the doctor." D. "I know that I need to monitor my feet for possible skin changes."

C One of the side effects of furosemide is ringing in the ears (tinnitus)

Which degenerative disease of the brain can disrupt intracranial function? A. Encephalitis B. Meningitis C. Parkinson's disease D. Brain tumors

C Parkinson's disease is an exemplar of the degenerative diseases that can affect intracranial regulation

Which consideration would the nurse incorporate when planning care regarding the past experiences of clients who have immigrated? A. Inherited traits are more important than past experiences B. Immigrants can acculturate if past experiences are minimized C. It is important to first assess immigrants' values and beliefs D.. Immigrants' interactional patterns are permanently established

C Past experiences are important and must be recognized because they help see an individual's values and beliefs throughout life

An older woman has lived alone since the death of her husband, 10 years ago and she has a long list of a complaints which assessment is a priority for the home health nurse to perform? A. Assessed for feelings of loneliness and isolation. B. Determine if the client has unresolved grief C. Determine if there any safety issues. D ask about availability of support systems

C Safety as a priority, and the client has several risk factors

Which physiological change occurs in older adults and warrants the nurse teaching the client about safety tips to prevent falls? A. Slowed movement B. Cartilage degeneration C. Decreased bone density D. Decreased range of motion

C Teaching safety tips to prevent falls would best help a client with decreased bone density

Which team is most likely to show effective and positive outcomes based on the information in the table? A. Team 1: leader (kindness in communication), team members (few members dominating) B. Team 2: leader (autocratic/rigid), team members (overly stiff/formal) C. Team 3: leader (keeps promises and fulfills commitments), team members (communicate openly and through ample discussion) D. Team 4: leader (treat others fairly but not the same), team members (uncomfortable and hide resentment)

C Team 3 will likely achieve positive outcomes because the leader sets the tone by keeping promises and fulfilling commitments on time. Team members communicating openly with one another openly resolves disagreements in a civil manner.

Which statement indicates family understanding of age-related changes and required care after family members received discharge instructions for an older adult male recovering from a UTI? A. I place a small glass of water at his side to ensure sipping before bedtime B. I respond immediately with the urinal whenever he indicates a need to void C. I provide privacy and standby assistance to help him void D. I encourage him to use the urinal at least every 2 hours during the day

C The family must help the client while he voids and provide privacy to encourage voiding without embarrassment. These measures will promote voiding and prevent urinary retention

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Knowing the most common complication of this type of surgery, what clinical manifestations should the nurse instruct the home caregivers to monitor for at home? A. Excessive fluid accumulation in the abdomen B. Eyes with sclera visible above the irises C. Fever accompanied by decreased responsiveness D. Violent involuntary muscle contractions

C The most common complication of surgery would be infection as evidenced by fever and decreased responsiveness.

Which QSEN competencies does the nurse comply with when asking a client from another country about healthcare traditions? A. Safety B. Informatics C. Patient-centered care D. Teamwork and collaboration

C The nurse who provides compassionate and coordinated care to clients based on their preferences, values, and needs is providing patient-centered care. Asking about the health care traditions followed in the client's country is an example of patient-centered care

Which purpose is served by establishing a therapeutic nurse-client relationship? A. Modifying and improving nonverbal communication B. Presenting an outlet for suppressed hostile feelings C. Assisting the client in acquiring more effective behavior D. Providing the client with someone who can make decisions

C The therapeutic nurse-client relationship provides an opportunity for the client to try out different behaviors in an accepting atmosphere and ultimately to replace pathological responses w/ more effective responses

When assessing a client who is receiving palliative care, which question regarding spiritual health is correct? A. Are you afraid of death? B After hearing about your condition, didn't you lose faith? C. What is your source of spiritual strength during hard times? D. May I ask the chaplain to visit you to help you cope?

C This helps the nurse understand the client's spiritual practices, facilitating quality care

Which cranial nerve is responsible for the clients equilibrium? A. Vagus B. Trochlear. C. Vestibulocochlear D glossopharyngeal

C Vestibulocochlear nerve located in the pons medulla junction is responsible for equilibrium of the body

Which statement made by parents about the psychosocial changes of adolescence indicates an adequate learning? A. Adolescence search for personal identity. B. Adolescents establish close-peer relationships. C. Adolescent love their parents in every situation. D adolescent, wish to be independent will keep in good family ties

C Adolescents tend to love or hate their parents depending on the situation

During an assessment, which client may indicate to the nurse that the client is experiencing spiritual distress? A. I want to find out whether any divine force truly exists in this world B. I am sure that God is with me, otherwise I could have suffered a lot more C. I deserve a better life than this, I don't understand why God decided to make me ill" D. I wish I didn't need help with daily activities, but I am grateful the universe gave me a support system

C Spiritual distress is a disturbance in a client's belief system that can cause a loss of faith and an inability to experience and integrate life's meaning/purpose.

26-year-old woman who sister recently had a lumpectomy for breast cancer, calls a local women's health center asked for an appointment for a mammogram. Which guidance would the nurse provide the client? A. Mammograms are not done before the age of 40. B. Genetic testing is required before evaluation when there's a family history of breast cancer. C. An appointment should be given for history assessment, and indicated imaging D. MRI scan would be recommended imaging.

C The client would be advised to have an appointment that would include detailed family history, including genetic testing done on clients sister, examination and counseling

Which priority parameter would the nurse assess when caring for an older adult client with neurocognitive disorder who demonstrated disorientation in numerous unmanageable behaviors? A. Orientation of time, place, and person. B. Ability to perform daily activities without assistance from others. C. Stressors that appear to precipitate the clients disruptive behavior. D cognitive impairments until complete adjustments are accomplished

C The nurses priority assessment would be to assess for stressors that appear to precipitate the clients disruptive behavior

Which factor would the nurse consider when planning care for a nursing home client to demonstrate numerous disorganized behaviors related to disorientation and cognitive impairments? A. Level of interest in unit activities. B. Orientation to time, place, and person. C. Ability to perform tasks without becoming frustrated. D cognitive impairment, which will increase until adjustment to the home is accomplished

C When the client is unable to perform a task, frustration occurs in result in more disorganized behavior

The nurse is admitting a new patient to the psychiatric unit. Which factors will most likely contribute to a positive outcome of the interaction? (Select all that apply.) A. The patient is in a bad mood. B. The patient states that he or she is in pain. C. The unit is quiet. D. The patient has been admitted to the facility in the past. E. The patient is awake, alert, and oriented to person, place, and time. F. There are various interactive sessions going on in the unit today.

C,D,E Positive outcomes for interactions include factors such as the relationship between participants, internal mood states, mental and physical condition, experience and education, and external noise emanating from the environment.

Which characteristic develops in an adolescent according to Piaget's theory of cognitive development? A. Animism B. Ability to understand the process of reversibility. C. Ability to reason with respect to possibilities. D action patterns for dealing with the environment E. Feelings and behaviors characterized by self consciousness.

C,E According to Piaget's theory of cognitive development, during the formal operational stage and adolescent develops the capacity to reason with respect to possibilities, and also show egocentrism and demonstrate feelings and behaviors characterized by self consciousness

A nurse working in a free clinic has recognized the need for health promotion for pregnant teenagers. The nurse works to develop a consortium of healthcare experts from several disciplines across the region to work toward improving the nutrition of pregnant teenagers. This is an example of what type of collaboration? A. Nurse-patient collaboration B. Nurse-nurse collaboration C. Intraprofessional collaboration D. Interorganizational collaboration

D Interorganizational collaboration occurs between regional, national, or international organizations to achieve a common goal.

Which of the following statements made by a mother would raise concerns about a developmental delay? A."My 3-month-old raises her head and chest when lying down." B."My 7-month-old transfers blocks from one hand to the other." C. "My 7-month-old never seems to smile." D."My 1-year-old seems shy or anxious with strangers."

C. A 7-month-old who never seems to smile would be a concern. The lack of smiling could be related to a number of developmental issues, including vision and hearing. By the end of 3 months, a child begins to develop a social smile, and by the end of 7 months, a child enjoys social play. A 3-month-old is expected to raise her head and chest when lying down. A 7-month-old is expected to be able to transfer blocks from one hand to the other. By the end of 1 year, a child is often shy or anxious and may experience what is referred to as separation anxiety.

A child uses two- to four-word sentences. The nurse interprets this data as expected development for a child the age of A. 2 months. B. 1 year. C. 2 years. D. 3 years.

C. A child of 2 years is expected to say several single words and use simple phrases and two- to four-word sentences. A child of 2 months may begin to babble and imitate some sounds. A child of 1 year is paying increasing attention to speech, babbles with inflection, and usually says "dada" and "mama". A child of 3 years is expected to understand most sentences and use four- to five-word sentences.

An older client is able to perform activities of daily living, but has vague physical complaints and has experienced multiple deaths of friends and family and has lost their special roles. Which question is the most therapeutic? A. Can you cope with being alone? B. Have you considered assisted living C. What is the main problem today? D. How do you feel about your life right now?

D An open-ended question is the most therapeutic invitation to encourage the patient to discuss hopes and frustrations without being threatening/probing

The nurse is teaching a family about sensory alterations. The nurse needs to provide additional teaching if a family member makes which statement? A. "I am going to wear earplugs when I mow the lawn." B. "If I stop smoking, I might enjoy eating more!" C. "So grandpa's stroke is why he thinks his left arm and leg aren't there any more." D. "My cousin has autism, and I am going to hug him more so he understands how much I care."

D Autistic individuals tend to have touch disturbances, and hugging would be overwhelming for them.

Which communication technique is part of therapeutic communication? A. Asking for explanations B. Showing sympathy to the client C. Asking personal questions of the client D. Providing relevant info to the client

D Clients have the right to know about their health status, so nurse will provide them with all the relevant information

A client is admitted to the hospital because of multiple chronic health problems. Which is the priority intervention at this time? A. Advising the client to join a support group immediately after discharge B. Assuring the family that staff members will take care of the client's needs C. Reminding the client to keep medical follow-up appointments after discharge D. Conducting a multidisciplinary staff conference early during client's hospitalization

D Collaboration of all team members involved in the client's care early during hospitalization will allow for efficient planning of care and help prepare for discharge

When completing a Health assessment, the nurse identifies tremors of the clients hands when discussing this assessment the client reports being nervous, having difficulty sleeping and feeling as if the collars of the shirts are getting tight. Which additional assessment findings with the nurse report immediately? A. Increase appetite. B. Recent weight loss C. Feelings of warmth D fluttering in the chest

D Palpations may indicate cardiovascular changes requiring prompt interventions

The RN is delegating tasks for the care of a vulnerable population. Which health care team would be appropriate for the delegation of tasks? A. CN, CNO, RN B. LPN, UAP, CN C. CNO, RN, and UAP D. RN. LPN, and UAP

D Proper care assistance can be provided by this team.

When caring for a patient on the neuro-trauma unit, the nurse should assess for which signs and symptoms of increased intracranial pressure? A. Dehydration B. Hunger C. Nausea D. Vomiting

D Symptoms of increased intracranial pressure include headache, decreased consciousness, and vomiting without nausea. Signs may include cranial nerve VI palsies, papilledema, periorbital bruising, and the late sign of Cushing's triad

After assigning a specific task, the RN observes that the delegatee is unable to perform the task adequately. Which statement made by the RN is appropriate? A. It's better if I do the work myself B. We will do the task some other time C. You can't do even this work properly D. Just follow my steps and you can do it

D The RN lowers expectations and helps delegates accomplish the task. Following the nurse's example to do the work provides encouragement

Which intervention with the nurse include in the nursing home plan of care for an older adult with Alzheimer disease who has nighttime wandering? A. Order a vest restraint for the client to be applied at night. B. Obtain a prescription for a sedative so the client will sleep better at night. C. Request that the family provide a companion to stay with the client at night. D assign the client to a room near the nurses station for closer supervision at night

D The nurse would assign the client to a room near the nurses station for closer supervision at night because the client has nighttime wandering

The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A. Keep a radio on all the time to provide sound for the patient. B. Decrease patient confusion by limiting verbal interactions. C. Limit family visits to one person for 30 minutes per day. D. Provide a quiet environment in a private room.

D The patient experiencing dementia needs a quiet environment with a minimum of unfamiliar stimulation from a roommate.

Which action would the nurse leader take to promote a health care climate embracing curiosity, reflection, and change? A. Serving as a coach/guide B. Maintaining a good relationship w/ team C. Working to solve process problems w/ team D. Empowering staff to be lifelong learners/risk takers

D This nurse leader is promoting a health care environment where questioning the status quo, reflecting on processes and advocating for change when appropriate are welcome and encouraged.

Which need would be essential to clients who have dementia? A. To relate to consistent manner to staff. B. To learn that the staff cannot be manipulated. C. To accept controls that are concrete in fairly applied. D to have seamless and inconsistency in the environment

D To have sameness and consistency in the environment is needed that is essential and clients with dementia. A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented

Unless contraindicated, postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course? A. Antihistamine B. Local anesthetic C. Opioids D. Nonsteroidal anti-inflammatory drug (NSAID)

D Unless contraindicated, all surgical patients should routinely be given acetaminophen and an NSAID in scheduled doses throughout the postoperative course

Which description of symptoms is consistent with dementia of the Alzheimer type? A. Symptom onset is fairly rapid. B. Symptoms will subside periodically. C. Symptoms are triggered by personal crisis. D symptoms reflect progressive disintegration

D Dementia results from pathological changes of the central nervous system cells producing deterioration that is long-term and progressive

Which action would the nurse take when caring for an older adult with a history of recent memory loss? A. Instruct the client to move slowly when changing positions. B. Remind the client to look where he or she places the feet while walking C. Adjust the daily schedule to accommodate sleep patterns. D employ electronic devices that provide alerts

D Providing electronic devices that give alerts can help an older adult who has developed a recent memory loss

Which information would the nurse include as part of the teaching plan for an anxious client about to have her first Pap smear? A. pastor to six on the incidence of cervical cancer. B. Description of the early symptoms of cervical cancer. C. Explanation of why there's a small risk for cervical cancer D. Information on how we Pap smear screens for pre-cancerous and cancer cells of the cervix.

D Providing verbal information about what Pap smear is used for decreases fear, and fosters further communication

Which statement with the nurse make when educating parents about how to communicate with her 14-year-old? A. You should ask your child closed, ended questions. B. You should avoid involving other individuals and resources. C. You should avoid discussing sensitive issues with your child. D you should look for the meaning behind your child's words or actions

D The nurse will tell parents to search for the reasons or meanings behind their child's words or actions

An exemplar of a social/emotional developmental delay is A. developmental dyspraxia. B. fragile X syndrome. C. mental retardation. D. separation anxiety disorder.

D. Separation anxiety disorder is an exemplar of a social/emotional developmental delay. Developmental dyspraxia is an exemplar of an adaptive developmental delay. Fragile X syndrome is an exemplar of a physical developmental delay. Mental retardation is an exemplar of a cognitive developmental delay.

What is the Glasgow coma scale for a client who, after a trauma has difficulty opening their eyes to pain, has an abnormal flexion motor response and speaks inappropriate words?

Eight The client having pain opening the eyes scores two points, abnormal flexion motor response scores three points, inappropriate words scores three points

Which health care team member is familiar with all the needs of the individual client? A. Orderly B. Social worker C. Charge nurse D. UAP

The charge nurse is the only person familiar with all the needs of any individual client under care.