NU271 EAQ Evolve Elsevier NU271 HESI Prep: Fundamentals - Fundamental Skills
Arrange the events of communication throughout the nursing process in chronological order. o Assessing the medical records and diagnostic tests o Intrapersonal analysis of the assessment findings o Documenting expected outcomes o Performing verbal, visual, auditory, and tactile health-teaching activities o Identifying the factors affecting the outcomes
o Assessing the medical records and diagnostic tests o Intrapersonal analysis of the assessment findings o Documenting expected outcomes o Performing verbal, visual, auditory, and tactile health-teaching activities o Identifying the factors affecting the outcomes · The first step of communication throughout the nursing process is assessment, which involves assessing medical records and diagnostic tests. The second step is nursing diagnosis, which involves the intrapersonal analysis of assessment findings. The third step is planning, which involves the documentation of expected outcomes. The fourth step is implementation, which involves performing verbal, visual, auditory, and tactile health-teaching activities. The final step is evaluation, which involves identifying the factors affecting the outcomes.
A client with a disturbed state of mind is under observation. Which indicates the client is suffering from dementia? Select all that apply. One, some, or all responses may be correct. o Signs of depression o Difficulty making decisions o Continuously mentioning past failures o Inability to complete purposeful work o Disturbed sleep/wake cycle
o Difficulty making decisions o Inability to complete purposeful work · A client with dementia may not be able to make decisions because dementia affects thinking ability. The client with dementia may suffer from apraxia, in which the client is not able to perform purposeful work. In depression, the client will remain depressed but in dementia, the mood is affected superficially. A client with depression may tell about his or her failures, but in dementia, the client may or may not be able to recollect details of life. In dementia, the sleep/wake cycle of the client is a bit fragmented, but in depression it is completely disturbed.
Which nursing actions best promote communication when obtaining a nursing history? Select all that apply. One, some, or all responses may be correct. o Establishing eye contact o Paraphrasing the client's message o Asking "why" and "how" questions o Using broad, open-ended statements o Reassuring the client that there is no cause for alarm o Asking questions that can be answered with a "yes" or "no
o Establishing eye contact o Paraphrasing the client's message o Using broad, open-ended statements · Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication.
The nurse is communicating with a deaf client. Which intervention by the nurse is beneficial to promote communication? Select all that apply. One, some, or all responses may be correct. o Giving the client a chance to speak o Assuming the client is being uncooperative o Chewing gum while talking to the client o Making sure that the client knows you are speaking o Keeping the communication concise
o Giving the client a chance to speak o Making sure that the client knows you are speaking o Keeping the communication concise · When communicating with an older adult who has a hearing disability, the nurse would give the client a chance to speak, make sure that the client knows the nurse is talking, and keep the communication concise. The nurse would not assume that the client is uncooperative if she or he does not reply or gives a delayed response. The nurse would also not chew gum while talking because this action may garble the nurse's language.
According to Benner, the nurse passes through five levels of proficiency when acquiring and developing generalized or specialized nursing skills. Arrange the order of level of proficiency from lowest to highest. o Novice o Advanced beginner o Competent o Proficient o Expert
o Novice o Advanced beginner o Competent o Proficient o Expert · A novice is the beginning nursing student who doesn't have any previous level of experience. An advanced beginner is the nurse who has had some level of experience. The nurse is said to be competent if she or he has been in the same clinical position for 2 to 3 years. The nurse is said to be proficient after 3 years of experience in the same clinical position. An expert is the nurse with diverse experience and who has an intuitive grasp of an existing or potential clinical problem.
While reviewing a client's prescriptions, the nurse finds that one of the prescribed medications is redundant and notifies the primary health care provider. Which attitude of critical thinking does the nurse exhibit? o Curiosity o Risk taking o Thinking independently o Responsibility and authority
o Risk taking · If the nurse questions a health care provider's prescription by applying his or her knowledge, then this attitude is considered risk taking. If the nurse explores and learns more about a client to make appropriate judgments, then the attitude is curiosity. Thinking independently is indicated when the nurse reads nursing literature that provides multiple viewpoints on the same subject. The responsibility and authority of the nurse are shown by asking for help, reporting problems immediately, and following proper procedures.
Which clinical finding demonstrates to the nurse that the client can use a standard walker? o Weak upper arm strength and impaired stamina o Weight bearing as tolerated and unilateral paralysis o Partial weight bearing on the affected extremity and kyphosis o Strong upper arm strength and non-weight bearing on the affected extremity
o Strong upper arm strength and non-weight bearing on the affected extremity o A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.
The nurse is caring for a client with a temperature of 104.5°F (40.3°C). The nurse applies a cooling blanket and administers an antipyretic medication. Which is the correct rationale for the nurse's interventions? o To promote equalization of osmotic pressures o To prevent hypoxia associated with diaphoresis o To promote integrity of intracerebral neurons o To reduce brain metabolism and limit hypoxia
o To reduce brain metabolism and limit hypoxia o Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.
When the nurse is making a home visit to a family with a toddler, which finding indicates a need for education about home safety? o Fire extinguishers o Unlocked cabinets o House built in 2000 o Front-facing car seat
o Unlocked cabinets · The presence of unlocked cabinets in the home can place the toddler at risk for injury due to accidental poisoning. This finding requires parental education about home safety. The presence of fire extinguishers indicates adequate safety for fire prevention. Houses built before 1978 may have lead paint which can place the toddler at risk for neurological deficits. Front-facing car seats are appropriate for toddlers.
Once an infant is stabilized after a choking incident, which statement made by the parents indicates a need for teaching? o "The baby is always buckled into the stroller or infant seat." o "The spaces between the slats of the crib are only 2 inches wide." o "The pacifier is never placed on a string around our baby's neck." o "The crib is filled with many small stuffed animals with button noses."
o "The crib is filled with many small stuffed animals with button noses." o The infant could choke on small toys with removable pieces such as buttons. The statement indicates the parents need further teaching. The parents are being safe by buckling the baby in the stroller or infant seat. The space between the slats of the crib should be no wider than 2 3/8 inches apart to prevent injury. The parents are minimizing the risk for injury by never placing the pacifier on a string around the baby's neck to prevent injury.
When assessing a client who is receiving palliative care, which question regarding spiritual health is correct? o "Are you afraid of death?" o "After hearing about your condition, didn't you lose faith?" o "What is your source of spiritual strength during hard times?" o "May I ask the chaplain to visit you to help you cope? "
o "What is your source of spiritual strength during hard times?" · When assessing a client who is receiving palliative care, it is appropriate for the nurse to ask about the client's source of spiritual strength during hard times. This helps the nurse understands the client's spiritual practices, facilitating quality care. The nurse would not ask the client if he or she is afraid of death because this is not supportive. Assuming a client has lost his or her faith on diagnosis is inappropriate and unsupportive. Because not all clients identify with a religion, it is not appropriate to ask to call the hospital chaplain unless the client requests this.
Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions. o Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist. o Apply either a surgical mask or a respirator around the mouth and nose. o Apply eyewear or goggles snugly around the face and eyes. o Apply clean gloves within the gown. o Bring the glove cuffs over the edge of the gown sleeves.
o Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist. o Apply either a surgical mask or a respirator around the mouth and nose. o Apply eyewear or goggles snugly around the face and eyes. o Apply clean gloves within the gown. o Bring the glove cuffs over the edge of the gown sleeves. · When preparing to enter an isolation room, the nurse first needs to apply a cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist. The nurse would wear either a surgical mask or a respirator around his or her mouth and nose. If necessary, apply eyewear or goggles snugly around the face and eyes. Next, the nurse would wear gloves within the gown and pull the glove cuffs over the gown sleeves.