NUR168 ECPI

A nurse is in charge of a large group of employees on a busy surgical floor. Today's care must be completed early due to a special event involving most of the employees. Which management style would work best in this situation?

Correct response: Authoritarian Explanation: With authoritarian, or autocratic, leadership, the leader determines, dictates, and directs the activities of the group, with no input from the followers on decisions. It is particularly effective when decisions for a large group need to be made quickly and efficiently, as in this scenario. Coercion--involving forcing actions upon the staff--is not a recognized leadership style and, in any case, would not be an advisable approach as it would likely trigger resistance in the group and be counterproductive. Democratic leadership is appropriate when the task, or decision at hand, is not one that requires urgent action, when subordinates can be expected to make meaningful contributions, and when their input can be taken into account. Laissez-faire management provides little or no direction; coworkers develop their own goals, make their own decisions, and take responsibility for their own management.

A nurse manager of a hospital unit is working within a decentralized management structure. Which nursing action best exemplifies this type of system?

Correct response: Decisions are made by those who are most knowledgeable about the issue. Explanation: The best example of a nurse manager of a hospital unit working within a decentralized management structure would be that decisions are made by those who are most knowledgeable about the issue. Nurses would be greatly involved in decisions involving client care. Senior managers would not make all the decisions within a decentralized management structure. Nurse managers could be accountable for clients, staffing, supplies, and/or budgets.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

Correct response: ptosis. Explanation: Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.

A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale?

Correct response: 15 The Glasgow Coma Scale (GCS) evaluates three key categories of behavior: eye opening, verbal response, and motor response. Within each category, each level of response is given a numerical value. The maximal score is 15, indicating a fully awake, alert, and oriented client.

The nurse is having difficulty managing time while caring for a group of clients with complex needs. Medications are several hours behind schedule and several nursing procedures have not be performed. How should the nurse resolve the time management issue? Place the following steps in order.

Identify which nursing interventions are priority. Evaluate the potential to successfully complete the nursing interventions. Identify which nursing interventions can be delegated to other members of the health care team. Establish a timeline to get the nursing interventions completed.

The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis?

Risk for Falls

A nurse manager best demonstrates effective leadership characteristic by which action?

Sharing a vision for the unit and enlisting support

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code?

Correct response: Autocratic leadership Explanation: Autocratic leadership will be most effective in this scenario. Autocratic leadership involves the leader assuming control over the decision and activities of the group. During code blue, a leader is needed to direct the actions needed and make quick decisions to positively affect the client. Laissez-faire leadership would ultimately lead to the demise of the client. Democratic leadership could possibly delay the client receiving life-sustaining measures and would be less effective than autocratic leadership. Transactional leadership would involve a reward system which would be unethical in this situation.

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

Correct response: Decreased cardiac output Explanation: Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse. Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses.

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?

Correct response: Hepatitis Explanation: Jaundice is a yellow color of the skin resulting from liver or gallbladder disease, some types of anemia, and hemolysis. Hepatitis, inflammation of the liver, is a potential cause of jaundice. Appendicitis and diverticulitis do not typically result in changes in skin color, but will manifest as severe abdominal pain. Cellulitis would not result in yellowing of the skin, but as red and swollen legs.

The nurse testing a client's eyes asks the client to focus on a finger from 60 cm away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing?

Correct response: III: Oculomotor IV: Trochlear VI: Abducens Explanation: The oculomotor, trochlear, and abducens nerves control the motor function of the eye structures, which can be assessed through movement of the eyes through the six cardinal positions of gaze. The optic nerve controls the sense of vision. The trigeminal nerve controls the jaw movements of chewing and mastication (motor), and sensation on the face and neck (sensory). The facial nerve controls the muscles of the face (motor) and the sense of taste on the tongue (sensory).

The nurse is advising a client about health problems related to being overweight. The client acknowledges the need to lose weight. The nurse provides education on how to count calories in food and the importance of daily exercise. The client states an intention to begin counting calories with the next meal. The client also states an intention to begin an exercise program with friends. Which statement associated with this scenario illustrates Lewin's stage of unfreezing?

Correct response: The client acknowledges the need to lose weight. Explanation: In unfreezing, one recognizes the need for change. The client's acknowledgment of the need to lose weight is the only example provided of unfreezing. The nurse providing education on how to count calories in food and the importance of daily exercise is an example of moving, in which change is initiated after a careful process of planning. The client's intentions to begin an exercise program with friends and to begin counting calories with the next meal are examples of refreezing, which involves making a change operational, or a part of one's everyday life.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature?

Correct response: The dorsum Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

Correct response: Tuning fork Explanation: Rinne and Weber tests are performed in order to assess sound conduction; both require a tuning fork. A Rinne test evaluates hearing loss by comparing air conduction to bone conduction. The nurse strikes a tuning fork and places it on the mastoid bone behind one ear. When the client can no longer hear the sound, they signal to the nurse. The nurse then moves the tuning fork to the ear canal. When the client can no longer hear that sound, they once again signal the nurse. The nurse records the length of time the client hears each sound. In the Weber test, the nurse strikes a tuning fork and places it on the middle of the client's head, and the client indicates where the sound is best heard: the left ear, the right ear, or both equally. A Snellen chart is an eye chart that can be used to measure visual acuity. An otoscope is an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses. An ophthalmoscope is an instrument for inspecting the retina and other parts of the eye.

Following a myocardial infarction (heart attack), a client begins to recognize the need to increase exercise, eat a low-fat diet, and implement relaxation techniques. According to Lewin, this client is in which stage of the change process?

Correct response: Unfreezing Explanation: Unfreezing is stage in the change process in which the person recognizes the need for change and the dissolution of previously held patterns of behavior. Unfreeze, move (or change), refreeze, also known as the Kurt Lewin Change Model, is a method for managing change within a client or organization. For a client to change, the client must be melted (unfreeze), poured into a mold (move), and frozen again in the new shape (refreeze). Prizing is not a component of the model.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

Correct response: Verify that the procedural consent form is signed. Explanation: Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.

Which nursing model results in the greatest continuity of care? a.) Primary nursing b.) Total client care

Correct response: a.) Primary nursing Explanation: Primary nursing results in increased continuity of care because the same nurse is assigned to provide care for a given client over an extended period of time. The other approaches listed involve multiple nurses providing care to the client at the same time.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment? a.) auscultation b.) percussion

Correct response: a.) auscultation Explanation: Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.

After a nurse manager implements a solution to the problem of delays in obtaining supplies, the first task for the manager is to:

Correct response: assess whether the desired results have occurred. Explanation: The nurse manager must evaluate the results of the efforts to determine whether the desired results have occurred. The nurse manager should solicit input from staff members about potential solutions before, not after, implementing a solution. Monitoring the supply cabinets would be more appropriate if the problem were suspected drug diversion by staff but would be unnecessary for evaluating for improvement in delays for obtaining supplies. Making an appointment with the chief nursing officer is not necessary and would not help the nurse manager evaluate the change in procedure related to obtaining supplies.

A nurse is assessing the abdomen of a newly admitted client. What are the order of steps of assessing the abdomen?

Inspection Auscultation Percussion Palpation

The chief nursing officer (CNO) wants to encourage nurses in the hospital to become clinical nurse leaders (CNL) and is reviewing a roster of nurses working on the medical-surgical unit. Which nurse should the CNO recognize as being qualified to take the CNL examination? a.) An with a BSN who is a case manager; has 16 years of nursing experience, is trustworthy, and provides compassionate client care b.) An RN with an MSN who is a nurse manager, has 7 years of nursing experience, is supportive, and is engaged in community service activities

Correct response: b.) An RN with an MSN who is a nurse manager, has 7 years of nursing experience, is supportive, and is engaged in community service activities Explanation: The RN with an MSN who is a nurse manager, has 7 years of nursing experience, is supportive, and is engaged in community service activities is the only nurse qualified to become a CNL. The American Association of Colleges of Nursing requires an RN to have at least a master's degree to be eligible to become a CNL.

Conflict has emerged on a nursing unit because new graduates have found that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict? a.) Gather evidence over the next several weeks in order to determine if the practice is indeed happening. b.) Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible.

Correct response: b.) Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. Explanation: Open, explicit, and participatory conflict resolution that is based on collaboration is an effective strategy for the management of conflict. Gathering evidence does not directly address the conflict that currently exists and reassurance may be unwarranted and false. Allowing the new graduates to create the client assignment may perpetuate selfish practices and does not resolve animosity between the two camps.

A staff nurse works on a medical unit where staff retention is very high. There is a sense of equality between the leader and the staff nurses. The unit decisions and activities are shared between the leader and the group. The designated nurse leader practices which leadership style? a.) Transformational b.) Democratic

Correct response: b.) Democratic Explanation: The democratic leadership style is characterized by a sense of equality among the leader and other participants and shared decision making. The autocratic leader assumes complete control over the decisions and activities of the group. Transformational leaders create intellectually stimulating practice environments, and challenge themselves and others to grow personally, to grow professionally, and to learn. In laissez-faire leadership, also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group.

A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving? a.) The client's tongue remains midline when it protrudes from the mouth. b.) The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows.

Correct response: b.) The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Explanation: Bell's palsy is usually a temporary condition that presents with left or right facial weakness or paralysis. Cranial nerve VII controls the muscles of the face. Normal results would be symmetrical appearance and movement as the client smiles, frowns, and raises the eyebrows. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.

A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding? a.) A uniform yellow reflex b.) Dark-red arteries and light-red veins c.) A reddish retina

Correct response: c.) A reddish retina Explanation: Normal findings of the internal eye structures include a uniform red reflex; round white or pink optic nerve disc; reddish retina; and bright-red arterioles and dark-red veins.

The nurse conducts a health history on a client who has experienced a 15-pound (7-kilogram) weight loss in the past 3 weeks. Which information would the nurse gather to determine the client's nutrition pattern? a.) Inspect the clients abdomen. b.) Examine the hygiene of the client's teeth. c.) Ask the client for a 24-hour diet recall.

Correct response: c.) Ask the client for a 24-hour diet recall. Explanation: Interview questions that will focus on nutrition might include asking the client to disclose what the individual has eaten in the last 24 hours. Weighing the client would not provide good nutrition information because the nurse already knows the client has experienced a significant weight loss. A 24-hour diet recall would provide better information about the total nutritional pattern than merely examining the client's teeth or inspecting the abdomen for symmetry.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?

Correct response: circumoral cyanosis when the client is at rest Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider.