NURS 120--Exam 3 (Modules 9 & 10)
A nurse is providing teaching for an inpatient support group meeting. Which group behavior indicates that the teaching was effective? A) The group members appear relaxed and interested in the topic. B) The group members are tentative in expressing their feelings. C) The group avoids discussion about their signs and symptoms. D) The group members appear self-conscious when asked questions about their condition.
A
A client diagnosed with a sexually transmitted infection reports having "no idea" how the illness was contracted. Which nursing diagnosis would be appropriate for the client at this time? A) Anxiety B) Deficient Knowledge C) Ineffective Coping D) Sexual Dysfunction
B
A nurse is working as the designated leader of a group of healthcare providers in a community clinic setting. The team members are working to decrease the number of adolescent pregnancies in the community. They have defined the problem and are now focusing on objectives and considering various viewpoints presented by the group. The nurse is tasked with helping the team stay focused in order to address the defined problem. Which of the competencies of collaboration does this describe? A) Decision making B) Mutual respect C) Trust D) Communication
A
A postoperative client is transferred to the medical-surgical unit from the intensive care unit (ICU). The client asks the assigned nurse why unlicensed assistive personnel (UAP) help with range-of-motion exercises. Which is the best response by the nurse? A) "Your condition has improved, so I delegated that part of your care to the UAP." B) "You do not need me to ambulate you." C) "The charge nurse made the decision to have the UAP assist you when walking." D) "I assigned all of your care to the UAP."
A
A staff nurse learns before reporting to work that a close family member has been diagnosed with terminal cancer. When receiving the shift report, the nurse finds that this family member has been assigned as a client. The nurse who cared for this individual on the outgoing shift states that the client is very demanding and complains a lot. Which action by the staff nurse who is assigned care for the oncoming shift is appropriate? A) Discuss the situation with the charge nurse. B) Resolve to refrain from reacting negatively to the client. C) Tell the client to change the behavior. D) Ask the healthcare provider to help control the client.
A
In arranging community services for a client who is diagnosed with schizophrenia, the nurse case manager discusses options with the assertive community treatment (ACT) team. Which team disciplines should the nurse expect will be part of the client's ACT interdisciplinary team? A) Psychiatrists, nurses, social workers, employment counselors B) Speech pathologists, occupational therapists, nurses, physicians C) Teachers, school administrators, psychiatrists, nurses D) Transportation providers, nurses, physicians, social workers
A
Nurse leaders in a local hospital created a neurotrauma (NT) unit healthcare team focused on improving outcomes for stroke clients. This team includes acute care nurses, physicians, other care partners (e.g., physical therapists, social workers, case managers, dietitians), and representatives from the NT outpatient clinic. The team is led by a physician who makes treatment decisions based on the treatment plans developed by individual team members who each communicate with the clients, asking the same or similar questions to obtain data needed For the treatment plan. Which type of communication and action is represented in this scenario? A) Parallel communication B) Parallel functioning C) Information exchange D) Coordination and consultation E) Co-management and referral
A
The nurse at a health fair is educating clients on risk factors associated with urinary incontinence. Which risk factor does the nurse include as a nonmodifiable risk factor for urinary incontinence? A) Age B) Obesity C) Smoking D) Diabetes
A
The nurse completes a teaching session on wound care for a client who will require dressing changes after discharge. The nurse then evaluates the effectiveness of the teaching session and determines that more education is required. Which statement by the nurse is appropriate in this situation? A) "Let me clarify again some of the steps that are required during wound care." B) "You didn't pay attention, did you?" C) "Here, let me do it for you." D) "I don't think you understood me correctly the first time."
A
The nurse delegated to an unlicensed assistive personnel (UAP) the task of assisting a client with a simple dressing change. The client was formerly able to do the procedure, but because of painful arthritis is now unable to perform the redressing. The UAP has done this procedure before. Which must the nurse emphasize to the UAP? A) Report to the nurse immediately anything unusual, such as bleeding or infection. B) The nurse should demonstrate the steps of the procedure. C) Make the client do most of the procedure and report the expected output. D) The UAP should do health teaching while performing the procedure.
A
The nurse is assessing an adult client in an urology clinic. The client reports that she has been having "accidents" and expresses frustration about this "normal part of aging." Which response by the nurse is the most appropriate? A) "Tell me more about the incontinence you are experiencing." B) "You may need to have surgery to manage this problem." C) "I understand you are frustrated about this occurrence." D) "Unfortunately, aging and incontinence go hand in hand."
A
The nurse is preparing to teach a class on the prevention of constipation. Which food choice will the nurse include as an example of a high-fiber food? A) Raw fruits B) Cooked vegetables C) White bread D) Cooked fruits
A
The nurse is providing care for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). In this scenario, which action by the nurse would be considered an example of therapeutic communication? A) The nurse asks appropriate questions about the client's medical history. B) The nurse closes the conversation with an anecdote about breathing. C) The nurse plans to tell the client about a COPD support group. D) The nurse bonds with the client by describing her own experiences living with COPD.
A
The nurse is providing care to a client who is diagnosed with hypertension. Which response by the nurse is an appropriate example of informational confrontation with the client? A) "I noticed you rubbing your head and your eyes. Are you hurting? Let's take your blood pressure." B) "I heard raised voices when I was coming down the hall to your room. Are you upset?" C) "It is 3 p.m. and time to take your blood pressure before I give you your medication." D) "Is the blood pressure medication making your head hurt?"
A
The nurse is providing care to a client who is experiencing constipation. The healthcare provider prescribes Metamucil, a bulk-forming laxative. Which is a nursing consideration when administering this medication to the client? A) Offering sufficient water B) Administering rectally C) Using to treat acute constipation D) Assessing for tardive dyskinesia
A
The nurse is working on a medical-surgical unit that is short staffed due to a callout. The manager of the unit was unable to replace the nurse, so the extra clients were assigned to the remaining nurses. The manager was able to get the help of unlicensed assistive personnel (UAP) from the house pool to help on the unit. Which action by the nurses would ensure effective care for the client? A) Delegate vital signs and weights to the UAP. B) Explain to the manager that care may be compromised if another nurse does not work the shift. C) Tell the clients their care will be sparse. D) Assign care of invasive lines to the UAP.
A
Which of the following is an example of covert conflict? A) Complaining to a friend about an assigned job task B) Yelling at a coworker who has insulted another coworker C) Telling a manager that you think she is being unnecessarily harsh D) Warning a client that inappropriate contact and comments will not be tolerated
A
Which of the following statements is true with regard to sexually transmitted infections (STIs) and older adults? A) Because pregnancy is no longer a concern, older adults may not use condoms, thereby increasing their risk of STIs. B) Normal age-related changes to the body put older adults at reduced risk of contracting STIs. C) STIs are rare among older adults because of decreased levels of sexual activity among the members of this population. D) Healthcare providers should avoid discussing STIs with older clients unless these clients initiate the conversation.
A
The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of therapeutic communication with this client? Select all that apply. A) "I am so happy today! I just found out that I got accepted into nurse practitioner school!" B) "Well, I guess your lifestyle finally caught up to you." C) "One of my cousins has AIDS. It is hard to watch him die." D) "Tell me your feelings about the diagnosis." E) "Would you like to talk about the new medications you've been prescribed?"
A, B, C
The nurse is sitting in on a meeting for clients on a behavioral health unit. Which of the following characteristics of the group indicate that the group is functioning effectively? Select all that apply. A) The expertise of group members is being used. B) The group atmosphere is positive. C) Members feel satisfied with their participation. D) The group listens to the ideas of certain group members. E) The discussion focuses on all issues brought by group members.
A, B, C
The nurse is providing training for the clinical staff of a skilled care facility that primarily treats elderly clients. The nurse wants to include information on functional incontinence. Which risk factors for functional incontinence will the nurse include in the training? Select all that apply. A) Limited mobility B) Impaired vision C) Lack of access to facilities D) Dementia E) Urinary tract infection
A, B, C, D
The nurse provides education and supportive assistance for the family of a preschool-age client diagnosed with encopresis. Which statement indicates parental understanding of appropriate care? Select all that apply. A) "We will establish a limited schedule of activities that has many breaks to provide opportunities to use the toilet regularly." B) "We will schedule an appointment with a play therapist to help our older child adjust to our new baby." C) "We won't change our child's diet because we were afraid it will be stress provoking." D) "We will work on regular elimination after morning and evening meals." E) "We will continue to punish our child for having accidents as the behavior is learned and attention seeking."
A, B, D
An experienced nurse is delivering a presentation to a group of nursing students about the importance of collaboration in the healthcare environment. The nurse wants to use evidence from the literature to support her argument. Which of the following are documented benefits of collaboration that the nurse should discuss in her presentation? Select all that apply. A) Improved client outcomes B) Reduction in duplication of healthcare services C) Increased overall cost of healthcare services D) Decreased client morbidity and mortality E) Higher level of job satisfaction
A, B, D, E
The nurse is caring for a client with chronic constipation. Which findings in the client's health history could be the cause of the current constipation? Select all that apply. A) Bedrest B) High-fiber diet C) Low-fiber foods D) Chronic laxative use E) Depression
A, C, D, E
A community hospital wants to implement a labor—delivery—recovery—postpartum unit to replace the labor and delivery and mother/baby units. The nurses who work on the mother/baby unit are concerned they will not be able to care for laboring mothers and may lose their jobs. The nurse manager for both units supports the plan for an integrated unit, reports that jobs will not be lost, and involves the team members in the planning process, which includes cross-training all nursing staff. Based on the information presented, what causes of conflict may occur despite the nurse manager's effort for a smooth transition? Select all that apply. A) Mistrust B) Miscommunication C) Ambiguous role expectations D) Resistance to change E) Ineffective leadership
A, D
A nurse-supervisor is encouraging nurses to delegate responsibilities whenever possible. Which criteria are used to determine tasks that can be delegated? Select all that apply. A) Does the delegate have the appropriate skills to perform the task safely? B) How busy are you? C) Is the client frequently complaining? D) Does the task require client education? E) Is the task unpleasant?
A, D
The nurse is providing education to sexual partners about the importance of treatment for a chlamydia infection. Which client statements indicate this teaching was effective? Select all that apply. A) "Chlamydia can cause inflammation of the tube that carries urine from the bladder to outside the body." B) "Severe vaginal itching can be a consequence of chlamydia." C) "Rashes commonly occur with this disease." D) "Chlamydia can spread to the uterus and fallopian tubes and result in infertility." E) "Chlamydia can result in pregnancy complications."
A, D, E
A case manager assembles a team of healthcare professionals, including a client's primary healthcare provider, physical therapist, and social worker, for the purpose of collaborative discharge planning and decision making. Which type of team did the case manager assemble? A) Intradisciplinary team B) Interdisciplinary team C) Interorganizational team D) Management team
B
A client with genital herpes asks the nurse how to manage pain when urinating and difficulty voiding. Which response by the nurse is correct? A) "Try to limit your fluid intake. That way, you won't have to void so often." B) "Pouring room-temperature water over your genitals may make it easier for you to start urinating." C) "Be sure to keep your genitals as dry as possible. Unnecessary exposure to water can worsen your infection and cause even greater pain upon urination." D) "Unfortunately, there's nothing you can do to eliminate your discomfort. It won't go away until your current herpes outbreak is over."
B
A client with type 1 diabetes mellitus has developed an open sore on the shin and is having trouble meeting daily goals for exercise. The client is scheduled for discharge in a couple of days. When planning for this client's continued care, who will the nurse notify regarding the client's post discharge needs? A) The pharmacy B) The case manager C) The occupational therapist D) The physical therapist
B
A college student is being treated for chlamydia. What should the nurse teach this student to decrease the risk of transmitting another sexually transmitted infection? A) Unprotected sex is acceptable if you know the partner well. B) Latex condoms should be used for all sexual activity. C) Birth control pills will help decrease the risk of pregnancy and STDs. D) Condoms should be used with petroleum jelly.
B
A group of nurses are in a staff meeting on a medical-surgical unit headed by the new unit nurse manager. The manager announces that nurses should not criticize and make fun of other nurses or there will be repercussions. Several nurses at the meeting suggest that the nurse manager talk to the individual nurses who are exhibiting this behavior. When assessing the staff's group dynamics, which action by the nurse manager is appropriate? A) Insist that this is an appropriate new policy. B) Recognize that the group already has defined behavioral norms. C) Discipline the staff nurses who spoke out. D) Request a transfer to another unit.
B
A home health nurse is planning care for an adult client who is being discharged from the hospital after experiencing complications of diabetes mellitus. The client requires an extensive dressing change twice per day, help with activities of daily living, and comprehensive education. To ensure these needs are met, the nurse is coordinating home visits from aides and therapists. Which role is the nurse assuming by coordinating this client's care? A) Health educator B) Case manager C) Client advocate D) Health promoter
B
A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication? A) When a client's family member is making inappropriate comments to the nurse B) When an upset spouse is alone and the client has just expired C) When speaking to a client with a history of physical abuse D) When a young male client asks a young student nurse for a hug
B
A nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." Which skill associated with the working phase of the nurse-client relationship does the nurse's statement best reflect? A) Confronting B) Respect C) Concreteness D) Genuineness
B
A school-age client is admitted to the pediatric intensive care unit (PICU), unconscious and with multiple traumatic injuries, after a skateboard accident that included a closed head injury. Many health professionals are involved in the client's care, and the scene is chaotic. The client's parents are extremely anxious and want to know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the client's parents. Which is the rationale for this meeting? A) To allow for each specialty to practice independently B) To share and evaluate information for care planning and implementation, and to prevent priority conflicts, redundancy, and omissions in care C) To allow the primary healthcare provider to make all decisions regarding the client's care D) To prevent the client's parents from trying to change the plan of care
B
An experienced delegator is mentoring a newly appointed nurse in the hospital. The new nurse states, "I am hesitant to delegate tasks to unlicensed assistive personnel (UAP) because I am afraid they will not be done correctly." Which response by the experienced delegator is appropriate? A) Tell her not to delegate any tasks unless she is completely confident. B) Tell her to clearly identify the task and expectations and then to monitor the delegate's progress. C) Tell her that delegation often results in a decrease in job satisfaction. D) Tell her that her job responsibility requires that she do everything herself.
B
The nurse is caring for a client who will be discharged with an indwelling catheter. The nurse has provided education to the client and family in regard to catheter care once the client is discharged. Which client or family action indicates a correct understanding of the information presented? A) Hanging the drainage bag on a towel rod B) Taking a shower each day instead of taking a tub bath C) Restricting the amounts of fluids per day D) Emptying the drainage bag twice a day
B
The nurse is planning care for a client with gonorrhea who also has a history of prior sexually transmitted infections (STIs). What is the priority nursing action for this client? A) Instruction about the need to avoid all future sexual contact B) A plan for the client to contact sexual partners regarding the diagnosis C) Recommendation that the client increase fluids and rest D) Teaching regarding the importance of adequate nutrition
B
The nurse is planning care to address pain in a client with genital herpes. Which intervention would most be appropriate for this plan of care? A) Do not submerge lesions in water. B) Clean lesions two or three times a day with warm water and soap. C) Dry lesions with a hair dryer turned to the hot setting. D) Wear tight cotton clothing.
B
Which of the following conflict-related communication styles involves attempting to satisfy the concerns of others while neglecting the self? A) Compromising B) Accommodating C) Avoiding D) Competing
B
Which of the following individuals would be included on an interdisciplinary healthcare team but not on an interprofessional healthcare team? A) Nurse practitioner B) Laboratory technologist C) Pharmacist D) Physical therapist
B
Which of the following is a primary barrier to effective nurse-physician collaboration that has persisted over time? A) The view among the general population that nurses' contributions to client care are less important to health and well-being than physicians' contributions B) Nurses' and physicians' perceptions of inequity in their roles, with nurses assuming a subservient role and physicians assuming leadership and a superior role in healthcare settings C) A general lack of education among health professionals about the ways in which nurse—physician collaboration improves healthcare quality D) A lack of published evidence regarding the effectiveness of collaborative efforts among and between nurses and physicians E) A lack of support at the federal level for efforts to improve healthcare among the general population through increased nurse-physician-client collaboration
B
Which of the following statements is true with regard to monopolizing in the group setting? A) Group members who engage in monopolizing behavior do so intentionally. B) When one member of a group engages in monopolizing behavior, the other group members may become angry or frustrated with the group's leader. C) Monopolizing behavior may be motivated by anxiety or a need for attention, recognition, and approval. D) One useful strategy for dealing with monopolizing is to simply and directly interrupt the individual who is engaging in this behavior.
B
The nurse is providing care to a client who is diagnosed with stress incontinence. Which data would nurse expect to collect during the client's health history and physical assessment? Select all that apply. A) Urine leakage while talking B) Urine leakage while coughing C) Urine leakage while laughing D) Skin breakdown on the buttock E) A urinary catheter
B, C, D
The nurse is conducting a history and physical assessment of a sexually active teenage client. Which findings should the nurse identify as consistent with genital herpes? Select all that apply. A) Low blood pressure B) Headache C) Fever D) Dysuria E) Vaginal discharge
B, C, D, E
The nurse is caring for a client who is experiencing intermittent constipation. The client has been advised to increase the amount of dietary fiber. Which food selections by the client indicate that teaching has been effective? Select all that apply. A) Rice B) Carrot slices C) Spinach salad D) Bananas E) Peas
B, C, E
The nurse is caring for a client with functional incontinence. Which conditions are factors in the development of this type of incontinence? Select all that apply. A) Fecal impaction B) Dementia C) Confusion D) Prostate surgery E) Impaired mobility
B, C, E
A client in the ambulatory care clinic tells the nurse about experiencing frequent constipation. The nurse inquires about the client's diet. Which statement from the client would be of greatest concern for the nurse? A) "I like to eat a bran muffin and applesauce every morning for breakfast." B) "I like to eat popcorn for an afternoon snack." C) "I like to eat cheese, a banana, and a turkey sandwich for lunch." D) "I like to eat baked chicken, whole grain rolls, and a small salad for dinner."
C
A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, because my mother has the same illness."
C
A nurse is discussing the plan of care with a client who is preparing for discharge. The client has a strong objection to portions of the plan of care. The nurse recognizes that there is a conflict. Which response by the nurse indicates an understanding of the client's position and a willingness to collaborate regarding the discharge plan? A) "You are not being cooperative in your plan of care." B) "This plan of care was ordered by the physician." C) "Let's talk about your objections and possible solutions or alternatives." D) "I will ask your family to help convince you that this plan of care is best."
C
A nurse manager overhears two staff nurses talking about a third nurse, who has the day off. The two nurses are making unflattering comments regarding the third nurse in front of several other nurses who work on the unit. The nurse manager discreetly asks to speak to the two nurses in private and states, "This behavior isn't OK, especially in a hospital like ours with a "zero-tolerance policy." If you have an issue with another nurse, please deal with that nurse directly. If you'd like me to help you with this, please let me know, and the four of us can meet." The nurse manager's behavior modeled strategies for dealing with which type of workplace conflict? A) Intergroup conflict B) Sexual harassment C) Horizontal violence D) Intrapersonal conflict
C
A public health nurse is educating a group of adults about the incidence and prevalence of sexually transmitted infections (STIs). Which statement should be included? A) "Males have higher rates of gonorrhea and chlamydia, whereas women have higher rates of syphilis." B) "Men are disproportionately affected by STIs as compared to women and infants." C) "Women often experience few early manifestations of infection, which causes them to delay diagnosis and treatment." D) "The incidence of STIs is highest among young Caucasian females"
C
A staff nurse at a hospital calls a long-term care facility that has just received transfer of care for a client. The hospital nurse reports the physician's medication orders to a nurse at the receiving facility. The hospital nurse does not have prescribing privileges. What is the responsibility of the nurse at the receiving facility in order to reduce the fear of liability? A) Withhold medications until the facility's physician can assess the new client B) Administer medications to the client immediately C) Verify the order with the prescribing physician D) Submit the medication order to the on-site pharmacy as soon as possible
C
Four groups of nurses are attempting to determine which methods are most effective for teaching patients about proper self-care. Which of these groups is least likely to arrive at a successful decision in a timely manner? A) The group that launches a pilot project to determine which teaching methods are most effective B) The group that uses scenario planning to evaluate the potential results of various teaching methods C) The group that uses trial and error to gauge the effectiveness of various teaching methods D) The group that uses a decision tree to visualize the potential results of various teaching methods
C
The nurse conducts education for a client who is experiencing urinary incontinence. Which statement by the client indicates the need for further education? A)"Relaxation of pelvic muscles may be a factor in incontinence." B) "Reduced urethral resistance can be a cause of incontinence." C) "Incontinence is normal with aging." D) "A disturbance of my bladder is a factor in the development of incontinence."
C
The nurse is caring for a client with a history of chronic urinary tract infections. The nurse is planning care for this client based on the priority nursing diagnosis of urinary retention related to scarring. Based on this data, which treatment does the nurse anticipate from the healthcare provider? A) Antibiotic therapy B) An anticholinergic medication C) Intermittent straight catheterization D) Removal of bladder stones
C
The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client? A) Facilitating and taking action when needed B) Maintaining a proper social distance when speaking with the client C) Leaning toward the client during conversation D) Being concrete about actions that need to be taken during client care
C
The nurse is caring for an older adult client. The client tells the nurse that he is constipated. What is the nurse's initial action? A) Encourage the client to increase fluid intake and activity. B) Assess the client's intake of fiber and fluids. C) Determine what the client means by constipation. D) Obtain an order for a laxative and an enema from the physician.
C
The nurse is caring for several medical-surgical clients. The nurse has delegated skin care of an incontinent client to new unlicensed assistive personnel (UAP) on the unit. Which action by the nurse will improve effectiveness of the client care provided? A) Ask the client if the care was appropriate. B) Ask the UAP if the care was given. C) Demonstrate the appropriate care needed and have the UAP give a return demonstration. D) Closely observe the UAP each time the care is given.
C
The nurse is discussing follow-up care with a client who is being discharged. The client and his family cross their arms and state angrily that the care team's suggestions are not acceptable. Which response by the nurse is appropriate? A) "We will leave you alone to discuss your options." B) "We only want what's best for you." C) "Let's discuss other options that might work well for you and your family." D) "Perhaps you did not understand the recommendations."
C
The nurse is preparing for the discharge of a client who will require physical therapy (PT) for rehabilitation following a total knee replacement. After reading the healthcare provider's order for PT, what should the nurse do next? A) Set up outpatient appointments for the client with the hospital's PT department B) Call home health and schedule a therapist to visit the client's home for PT C) Inform the client about the settings in which PT may occur and have the client choose the venue D) Teach the client's family the exercises that will be included in the client's PT regimen
C
The nurse is preparing to discharge a client with diarrhea. The healthcare provider prescribes loperamide to manage the client's diarrhea. After providing the client with information on this medication, which client statement indicates the need for further education? A) "If my diarrhea does not get better within 2 days, I will need to call my healthcare provider for further advice." B) "I will need to take the medication after each loose stool." C) "I should continue to take this medication daily until my stools are firm and dry." D) "If I start to have a fever, I need to contact my healthcare provider about continuing to take this medication."
C
The nurse is providing care to a client who ignores the urge to defecate when at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which response by the nurse is the most appropriate? A) "This is a common practice, and it will strengthen the reflex later." B) "You will get the urge later, so you should not worry about it." C) "If you continue to ignore the urge to defecate, it can lead to problems." D) "It is better to suppress the urge than to suffer embarrassment at work."
C
The nurse is reviewing discharge instructions with the mother of a toddler who was hospitalized for constipation. Which statement made by the toddler's mother indicates the need for further education? A) "I should recognize that when my child walks stiffly on his tiptoes, this could indicate withholding." B) "Rocking and crossing the legs could be a sign of withholding." C) "I need to make sure my child eats a low-fiber diet." D) "Soiling could be a sign of withholding because of involuntary overflow."
C
The nurse is working on a unit with unlicensed assistive personnel (UAP). One nurse refuses to use the UAP and is consistently leaving nursing tasks for the next shift that have yet to be completed. Which is the most likely reason the nurse is not using the UAP to assist with client care? A) Avoidance of responsibility B) Overdependence on others C) The belief that no one else can perform a task as well as the nurse can D) The state nurse practice act
C
The nurse managers in a community hospital have been charged with reviewing the job descriptions of unlicensed assistive personnel (UAP), and they have questions about the delegation of certain client care activities to UAP by nurses. To which group, organization, or individual would the committee members direct their questions to obtain definitive answers about the parameters of nurse delegation to UAP? A) The hospital's Chief Nursing Officer B) The hospital's Chief Executive Officer C) The state board of nursing D) The American Nurses Association
C
The nurses in the emergency department (ED) and the staff nurses on the neurology unit are experiencing conflict. The ED nurses are not pleased with the amount of time it takes for the neurology unit's admitting nurse to receive face-to-face handoff communication for clients who are being admitted to that unit. Which type of conflict is being experienced by these nurses? A) Intrapersonal conflict B) Interpersonal conflict C) Intergroup conflict D) Interorganizational conflict
C
Urge incontinence is the involuntary loss of urine associated with a strong urge to void and an increased rate of urination. Which condition can contribute to urge incontinence? A) Weakness of the urethra and surrounding tissue leading to decreased urethral resistance B) Disruption to neuronal control of the sacral micturition centers due to tissue damage C) An overactive detrusor muscle leading to increased pressure within the bladder D) Outlet obstruction leading to the overfilling of the bladder and increased pressure
C
What is the first phase in the therapeutic nurse-client relationship? A) Introductory phase B) Working phase C) Preinteraction phase D) Anticipatory phase
C
________ occurs when two or more individuals show or feel honor or esteem toward one another, and it is an important element of successful collaborative practice. A) Trust B) Conflict management C) Mutual respect D) Effective communication
C
A home healthcare nurse is planning care for an older adult client. Which interdisciplinary program would best support the needs of an older adult client within the community? Select all that apply. A) Assertive community treatment (ACT) B) YMCA C) Programs of All-Inclusive Care for the Elderly (PACE) D) Outpatient clinic E) Meals on Wheels
C, D
A client is experiencing dysuria, urinary frequency, and vaginal discharge. For which sexually transmitted infection(s) should the nurse prepare the client for testing? Select all that apply. A) Syphilis B) HIV C) Chlamydia D) Human papillomavirus (HPV) E) Gonorrhea
C, E
A client presents with acute constipation for the second time in two months. The physician orders a diagnostic barium enema. Based on the testing order, the nurse understands that the client's condition is likely associated with: A) rectal muscle contractions. B) completeness of bowel elimination. C) the efficiency with which the food moves through the gastrointestinal tract. D) the structure of the bowel or the presence of tumors or diverticula.
D
A nurse who is caring for an adult client in the intensive care unit (ICU) is given a verbal prescription by a first-year medical resident. The nurse determines that the best course of action is to check with the attending healthcare provider before implementing the prescription. What is the most likely reason why the nurse is experiencing conflict regarding this situation? A) The resident seems unsure of the prescription. B) The nurse only takes prescription orders from attending healthcare providers. C) The nurse does not like first-year residents. D) The nurse may not trust the resident to make the best care decisions.
D
Fecal impaction is a mass or collection of hardened feces in the folds of the rectum or colon as a result of prolonged retention and accumulation of fecal material. Which clinical manifestation is common in cases of fecal impaction? A) No passage of stool or fecal material of any kind B) Passage of soft, formed stools C) Passage of lumpy stools that are hard and dry D) Passage of liquid, foul-smelling fecal material in the absence of formed stool
D
Nurses who demonstrate mindsight are able to A) focus on being "in the moment" so that they can dedicate their full attention to the events and emotions they are currently experiencing. B) predict events that will occur in the future with reasonable certainty. C) interpret events and emotions from another person's perspective. D) recognize their personal triggers to stress that result in conflict, then retrain their brain to respond differently.
D
The charge nurse is observing a newly licensed nurse catheterize an older adult client admitted with an enlarged prostate. Which action by the newly licensed nurse requires intervention from the charge nurse? A) The newly licensed nurse injects 10 mL of 2% lidocaine gel into the client's urethra. B) The newly licensed nurse inserts a 16 French coudé-tipped catheter. C) The newly licensed nurse uses sterile technique to place the catheter. D) The newly licensed nurse clamps the catheter after draining 800 mL.
D
The nurse delegates vital signs and daily weights of assigned clients to the unlicensed assistive personnel (UAP) on duty. Which is the reason for the nurse to assess each client throughout the shift? A) The UAP cannot report to the next shift. B) The UAP is not trustworthy. C) The nurse maintains the authority to care for the clients. D) The nurse remains accountable for the clients' care.
D
The nurse is assessing a client who presents with an open sore on his penis. Which question by the nurse best elicits additional data related to this finding? A) "Do you think you have a disease?" B) "Have you had sexual intercourse recently?" C) "Are you promiscuous?" D) "When did you initially notice this open area?"
D
The nurse is caring for a client with rheumatoid arthritis who expresses the desire to remain active as long as possible. In order for the client to meet this goal, what should the nurse prepare to do? A) Teach the client about nutrition and joint exercises. B) Ask the client about the reasons for this goal. C) Tell the client that activity limitations are inevitable with rheumatoid arthritis. D) Provide referrals to other professionals who can help the client meet this goal.
D
The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic? A) "Would you like some toys from the playroom?" B) "I'm going to go get the doctor." C) "You shouldn't cry. You are not in pain." D) "It is okay to cry. I know this is scary."
D
The nurse is planning care for a newly admitted bed-bound older adult client. Which nursing diagnosis would be most appropriate for this client? A) Risk of Bowel Incontinence B) Disturbed Body Image C) Risk for Diarrhea D) Risk for Constipation
D
The nurse is reviewing discharge instructions for a client diagnosed with urinary incontinence resulting from a urinary tract infection. Which statement made by the client indicates the need for further education? A) "I should drink plenty of water to prevent damage to my kidneys while I am on the antibiotics for the infection." B) "Drinking cranberry juice will decrease the risk for developing urinary tract infections." C) "I will contact the healthcare provider prior to taking over-the-counter medications while on my antibiotic." D) "I will continue to hold my urine while in public so that I do not get another infection."
D
The nurse is working in a urology clinic and is providing care for a client with stress urinary incontinence. The nurse has chosen the diagnosis of Stress Urinary Incontinence related to sphincter incompetence. Which is the desired outcome for a client with this diagnosis? A) The client will stop the flow of urine when voiding. B) The client will improve her incontinence within 1 month. C) The client will empty her bladder every time she voids. D) The client will perform 4-5 squeezes (Kegel exercises) for 10-15 seconds.
D
Which of the following actions on the part of the nurse is most appropriate when treating an 8-year-old client who is exhibiting the symptoms of a sexually transmitted infection (STI)? A) Immediately perform a detailed examination and collect relevant specimens B) Assume that the child acquired the infection during the perinatal period C) Initiate presumptive treatment of the STI as soon as possible D) Anticipate the need to follow mandatory reporting guidelines
D
Which of the following situations is an example of countertransference in the group setting? A) After failing at an assigned task, the members of a group place all blame for this failure on a single group member. B) A group member reveres the group's leader, largely because the leader possesses many similarities to the member's mother, whom he adores. C) The members of a group become so caught up in the group's current beliefs and actions that they fail to recognize simple changes that would greatly improve the group's efficiency. D) The leader of a group distrusts one of the group members solely because the member reminds him of his ex-wife.
D
Which of the following statements by the nurse is an example of the therapeutic communication technique of offering self? A) "Would you like to talk with me about your emotions right now?" B) "I'm not sure I understand. Please tell me more about the situation." C) "I don't know the answer to your question, but I will check with the physician." D) "I'll stay here with you until your family arrives."
D
