NURS 314 - PrepU Ch 3, 15, 41-43

After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply? a. Use silence and allow the husband to express his emotions. b. Leave the room and do not be part of this situation. c. Call the pastor into the room to speak with the husband. d. Tell the husband to think before saying anything negative.

a. Use silence and allow the husband to express his emotions.

The husband of a client who died of breast cancer is still grieving for his wife 2 years later. What type of grief is he experiencing? a. situational b. unresolved c. inhibited d. maturational

b. unresolved

A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education? a. to ensure the client will return for follow-up care b. to implement ordered teaching and counseling c. to help the client develop self-care abilities d. to facilitate complete recovery from the disease

c. to help the client develop self-care abilities

The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion? a. Jehovah's Witnesses b. Jewish c. Christian Scientist d. Roman Catholic

d. Roman Catholic

When the nurse informs a client's employer of the client's autoimmune deficiency disease, the nurse is committing the tort of: a. assault. b. battery. c. invasion of privacy. d. breach of contract.

c. invasion of privacy.

The nurse is caring for a client who is dying. The nurse overhears the client saying, "God, if you will only let me live to see my daughter get married, I promise I will start going to church again." The nurse understands that the client is in which stage of grief according to Kübler-Ross? a. bargaining b. acceptance c. depression d. denial

a. bargaining

A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity? a. Criminal b. Civil c. Private d. Public

a. Criminal

Which statement made by the client indicates a need for further teaching regarding stress management? a. "I manage my stress with occasional alcohol and alprazolam." b. "I manage my stress by going out with friends for an occasional drink." c. "I manage my stress by taking antianxiety medication." d. "I manage my stress by exercising once a week."

a. "I manage my stress with occasional alcohol and alprazolam."

A 65-year-old client has experienced the death of a parent and a family pet in the span of 1 month. Which action is a coping mechanism that demonstrates adaptation? a. deciding to no longer attend his family reunion picnic b. buying a new car c. joining the local garden club d. visiting a psychic

c. joining the local garden club

A client scheduled for complex heart surgery has been reading the Bible for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client? a. Family members live far away and the client is lonely. b. These behaviors are expected before major surgery. c. The client is naturally emotional and reactive. d. These behaviors are signs of spiritual distress.

d. These behaviors are signs of spiritual distress.

The nurse is caring for a hospice client who states worry about how the client treated a younger sibling. The client asks the nurse how to make things right. Which is the nurse's best response? a. "It seems as though you feel bad about how you treated your sibling. Can you tell me more about your feelings?" b. "Just call your sibling and tell him or her that you are sorry." c. "Do you want me to talk to your sibling on your behalf?" d. "Do not worry about your sibling. Your sibling will come around eventually."

a. "It seems as though you feel bad about how you treated your sibling. Can you tell me more about your feelings?"

The nurse is caring for a client who has just died after a long diagnosis of dementia. Which nursing assessment is the priority for documentation? a. "No breathing and no pulse at 0840." b. "Body transported to morgue." c. "Notified the patient's daughter." d. "Postmortem care completed."

a. "No breathing and no pulse at 0840."

The nursing instructor has been discussing spirituality with a group of nursing students. Which statement by a student would indicate a need for further education? a. "Spiritual beliefs and practices do not give strength when a person is in crisis." b. "A person's daily living habits can be guided by their spiritual beliefs." c. "Spiritual beliefs and practices give healing strength and support." d. "Spiritual beliefs can help give a person meaning in their life."

a. "Spiritual beliefs and practices do not give strength when a person is in crisis."

The nurse visits a client in the home who is at the end stage of life from stage IV colon cancer and observes that the client is in obvious pain. The nurse asks the spouse when the client last had medication for pain and the spouse reports withholding the pain medication, fearing the client will become addicted. How should the nurse respond to the spouse? a. "The fear of addiction should not prevent the client from obtaining adequate pain relief so let us discuss the schedule of medication." b. "How would you feel if you had cancer and were unable to receive enough pain medication for relief?" c. "It will not make any difference if the client becomes addicted during the end stage of life." d. "My parent died of cancer and I would like to think that I did everything possible so that my parent did not suffer from pain."

a. "The fear of addiction should not prevent the client from obtaining adequate pain relief so let us discuss the schedule of medication."

The maternal health nurse is caring for a client following an uncomplicated caesarean birth. The nurse asks the client about religious practices for the neonate. The client tells the nurse, "I am an atheist. I do not believe in a higher power." How will the nurse integrate this information on the client's plan of care? a. Be supportive and respect the client's religious beliefs b. Write the diagnosis of "Spiritual Distress" on the plan of care c. Document "no circumcision" on the neonate's plan of care d. Consult the ethics committee regarding baptism of the neonate

a. Be supportive and respect the client's religious beliefs

The nurse cares for a client of the Islamic faith. Which lunch will the nurse recommend to the client? a. Broiled chicken sandwich with skimmed milk b. Barbecued pork sandwich with a milkshake c. Sliced ham and cheese sandwich and 2% milk d. Salad with crumbled bacon and cheese with a cup of tea

a. Broiled chicken sandwich with skimmed milk

The hospice nurse is caring for a group of clients with terminal illness. Which is the highest care priority for a client in the process of dying? a. Pain management b. Skin care c. Hygiene d. Hydration

a. Pain management

A terminally ill client states to the nurse, "My situation is hopeless; I have no control over anything." The nurse implements which interventions to enable hope for the client? Select all that apply. a. Sit in a chair next to the client. b. Hold the client's hand. c. Encourage the client to discuss feelings. d. State to the client, "We have explored all treatment options." e. Withhold information about disease progression.

a. Sit in a chair next to the client. b. Hold the client's hand. c. Encourage the client to discuss feelings.

A nursing instructor is preparing a class presentation on spiritual care. What would the instructor include as an essential component? Select all that apply. a. Trust b. Narrow definition of spirituality c. Limited verbal communication d. Empathy e. Self-awareness

a. Trust, d. Empathy, e. Self-awareness

The nurse is assisting a client and family with the death and dying process. Which is the first thing the nurse does to prepare to provide culturally competent care? a. Understand the client's beliefs. b. Contact the hospital chaplain. c. Explain the stages of grief. d. Leave the family to grieve alone.

a. Understand the client's beliefs.

The hospice nurse is caring for a client with lung cancer. The client's daughter states, "My mom isn't happy with anything I do for her. She is constantly yelling at me." The nurse understands that the client is in which stage of grief according to Kübler-Ross? a. anger b. bargaining c. depression d. denial

a. anger

When asked about his religious preference, the client becomes very upset with the nurse. Which response is appropriate for this situation? a. "You need to understand that I am just doing my job here." b. "I can see that this question upsets you. Do you have any questions about this?" c. "There is nothing to be upset about. This is part of my assessment." d. "I can see that this upsets you. Let me come back later when you are feeling better."

b. "I can see that this question upsets you. Do you have any questions about this?"

The nurse is performing the intake assessment for a 16-year-old adolescent in the emergency department. Which question by the nurse will assist in understanding the adolescent's spirituality? a. "What religion do you practice?" b. "What are your spiritual beliefs?" c. "How many times per week do you attend religious services?" d. "What religion do you want me to write down in your medical record?"

b. "What are your spiritual beliefs?"

A nurse is caring for a young client who is diagnosed with chronic renal failure. Which is an effective strategy to help the client cope with the diagnosis? a. Offer the client a brochure about hemodialysis and renal transplantation. b. Encourage the client to join a local support group of young people with renal disease. c. Suggest that the client get affairs in order and identify a health care proxy. d. Tell the client that the client's older adult parents will be able to help with home tasks.

b. Encourage the client to join a local support group of young people with renal disease.

The nurse is caring for a client who is preparing to undergo a left mastectomy. As the nurse performs the physical assessment, the client informs the nurse that she is unable to accept blood products as treatment due to her religion. The nurse interprets this as a belief of which religion? a. Buddhism b. Jehovah's Witnesses c. Baha'i International Community d. Latter Day Saints

b. Jehovah's Witnesses

The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply. a. Encourage forgetting of the deceased. b. Provide for stability and safety. c. Encourage expression of feelings. d. Talk openly about death and the feelings associated with it. e. Praise stoicism.

b. Provide for stability and safety. c. Encourage expression of feelings. d. Talk openly about death and the feelings associated with it.

What would be an example of the nurse practicing fidelity? The nurse: a. regulates visitors. b. stays with a client during death as promised. c. provides continuity of care. d. withholds information as requested.

b. stays with a client during death as promised.

A client that is dying yells at the nurse, "I put my light on a long time ago and you do not even care enough to see what I need!" How should the nurse respond? a. "I was with another client that had pain which was a priority for me at that time." b. "I do not appreciate that you are speaking to me in that tone and would like you to lower your voice." c. "I apologize for not responding more quickly and would be glad to help with whatever you need now." d. "You have not had the light on for long and I got here as quickly as I could."

c. "I apologize for not responding more quickly and would be glad to help with whatever you need now."

The nurse is performing the initial assessment on a client admitted with pneumonia. The client tells the nurse, "Last time I was here, the nurse gave me the wrong medication!" Which statement by the nurse will help establish trust with the client? a. Reply that the nurse is not the nurse last time and will not make a mistake. b. Call and report the client's behaviors to the hospital's legal team. c. Actively listen to the client and allow expression of negative feelings. d. Tell the client the nurse has no control over what happened last time.

c. Actively listen to the client and allow expression of negative feelings.

Which group of terms best defines spiritual distress? a. Forgiveness, purpose b. Spirituality, religion c. Alienation, despair d. Faith, prayer

c. Alienation, despair

The nurse cares for a client diagnosed with end-stage AIDS. The client states not having seen the parents for years because the parents cut off all contact upon "coming out." The client states, "I do not understand why God is punishing me this way." Which is the best intervention to use to meet the client's spiritual needs? a. Avoid any discussion of religion or spirituality. b. Remind the client that nurses are not ministers. c. Offer a compassionate presence. d. Refer all questions to a spiritual advisor.

c. Offer a compassionate presence.

A nurse interviews a client and finds that, because of religious beliefs, the client's view on health care does not involve blood transfusions. How can the nurse best handle this client situation? a. Praise the client for sticking to religious beliefs. b. Explain to the client that there are times when a blood transfusion may be necessary. c. Record this information in the client's chart. d. Recommend that the client be transferred to another health care facility.

c. Record this information in the client's chart.

Which statement about religion and spirituality is most accurate? a. Spirituality is the behavioral manifestation of religious beliefs. b. Spirituality is a recently developed alternative to traditional religious belief. c. Religion is an organized system of spiritual beliefs and practices. d. Religion and spirituality are synonymous.

c. Religion is an organized system of spiritual beliefs and practices.

The client is terminal and has unrelieved and intractable pain. The nurse is administering hydromorphone intravenously. The client states, "I want you to give me additional medication so I will die. I can't go on any longer." What action would the nurse take? a. Contact the health care provider to request additional intravenous medication to honor the client's request. b. Obtain additional medication from the automated medication system that would hasten the client's death. c. State, "This is not something I or any of the nurses can do." d. Ignore the client's statement, and limit any contact with the client.

c. State, "This is not something I or any of the nurses can do."

The nurse is caring for a client with terminal illness and congestive heart failure. Which documentation on the client's medical record supports eligibility for hospice care? a. The client's blood pressure is 85/60 mm Hg. b. The client has a cardiac ejection fraction of 20%. c. The client has 6 months or less to live. d. The client income is 200% below the national poverty level.

c. The client has 6 months or less to live.

The home health nurse is visiting a client who has been living alone for the past 5 years following the death of the spouse. Which behavior suggests the client may be experiencing abnormal grief? a. The client's living environment is extremely clean and neat. b. The client becomes teary when talking about the deceased spouse. c. The client talks as if the loss just happened. d. The client reports attending church on a weekly basis.

c. The client talks as if the loss just happened.

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. The nurse informs the parents that the development of a child's spirituality is best accomplished by: a. educating the child about God. b. educating the child about religion. c. educating through parental behaviors. d. educating through religious-based schools.

c. educating through parental behaviors.

A hospital owned by a Catholic order of nuns will not allow tubal ligations to be performed. This is considered to be: a. legal obligation. b. personal values. c. institutional policy. d. personal morality.

c. institutional policy.

Mrs. Jones is an 81-year-old client who can no longer live alone safely and is being admitted to a long-term-care facility. She had to leave her elderly cat, Baby, with neighbors. She tells the nurse that her cat was the only family she had and that she misses her. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people? a. need for meaning and purpose b. need for basic necessities of life c. need for love and relatedness d. need for forgiveness

c. need for love and relatedness

A client is informed of the diagnosis of leukemia based on recent testing results. The client states, "I do not have leukemia." Which additional statement indicates the client is experiencing denial? a. "Leukemia does not have to be a death sentence." b. "I do not want a bone marrow transplant!" c. "If I start going to church again, God will heal me." d. "Mistakes are made with laboratory tests all the time."

d. "Mistakes are made with laboratory tests all the time."

The nurse is caring for a woman with terminal breast cancer. Which statement made by the client reflects the bargaining stage of grief? a. "I do not care about anything. Just let me sleep." b. "Why is this happening now? I will never see my grandchild." c. "I may not see my grandchild here on Earth, but I will in the afterlife." d. "Please, let me live long enough to see my grandchild."

d. "Please, let me live long enough to see my grandchild."

A nurse is caring for a client who is upset after being told about a diagnosis of cancer. The client asks the nurse to stay a minute to pray. Which is the nurse's most respectful and appropriate behavior? a. Tell the client that there are medications to be given to other clients. b. Tell the client that praying will not help the cancer go away. c. Inform the client that someone else of the same religion would be better to pray with. d. Agree to pray with the client and stand in silence by the bed.

d. Agree to pray with the client and stand in silence by the bed.

The nurse is assessing a client who was diagnosed with metastatic prostate cancer. Which information from the client's medical record indicates the client is experiencing depression? a. Confused as to time and place, oriented to person b. Threw water pitcher on the floor stating, "That is not cold enough!" c. Family at bedside talking about grandchild's success in college d. Appears sullen, shakes head "yes" or "no," refuses visitors

d. Appears sullen, shakes head "yes" or "no," refuses visitors

While admitting a client who is having elective surgery tomorrow, the nurse asks if he has a preferred religion or faith. The client indicates that he does not believe in a higher power and therefore has no preferred religion. The nurse knows that which term describes the client's feelings about religion? a. Jehovah's Witness b. Spiritualist c. Agnostic d. Atheist

d. Atheist

Which illness has been associated with long-term stress? a. Fractures b. Bacterial infections c. Renal disease d. Cardiovascular disease

d. Cardiovascular disease

A nurse is caring for an infant who requires a treatment procedure. What would be most important for the nurse to do to help support the infant's spiritual needs? a. Tell the infant that it will be over within a minute. b. Provide the infant with soft toys or a feeding bottle. c. Ask a child specialist to be present during the treatment. d. Encourage parents to be present during the treatment.

d. Encourage parents to be present during the treatment.

A terminally ill client told her family, "I am ready to die." Her family is very upset that she has given up and wants the nurse to intervene. Which nursing intervention is most appropriate? a. Explain to the family that giving up is expected with terminal illness. b. Explain to the client that she cannot give up because her family needs her. c. Encourage the client to think about living instead of dying. d. Explain to the family that acceptance is part of the grieving process.

d. Explain to the family that acceptance is part of the grieving process.

A nurse caring for a client of the Jewish faith knows the importance of asking about any food preferences when discussing diet. This is important for which reason? a. Religious practices and beliefs are not that important in relation to the client's illness. b. Religious practices and beliefs make caring for clients interesting. c. Religious practices and beliefs are difficult to understand. d. Religious practices and beliefs can directly influence a client's self-care practices.

d. Religious practices and beliefs can directly influence a client's self-care practices.

Which statement made by a senior citizen who has taken a class on stress reduction would indicate to the nurse the need for further instruction? a. "As one grows older, their stress decreases." b. "Adults draw on coping skills learned throughout life." c. "Stress may be positive or negative." d. "Family members can be supportive during stress."

a. "As one grows older, their stress decreases."

Which documentation example best reflects the complexity of client teaching by the nurse? a. "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal." b. "Client return demonstrated how to use glucometer." c. "Told client to take antibiotic as ordered." d. "Taught client about peak flows; client verbalized understanding."

a. "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

An adolescent expresses concern that a friend is under "a lot of stress" with home life, classes, clubs, community service, and part-time work. The adolescent asks the nurse what medication the friend should take to "calm down." Which response by the nurse will be supportive of the client? a. "Do you think your friend would be willing to sit down and talk with me? I would like to get to know your friend better so I can suggest some healthy alternatives." b. "It sounds like your friend is in too many extracurricular activities. Can you convince your friend to drop out of some of those clubs?" c. "What medication is your friend taking now? I can recommend something, but we need to make sure there will not be an interaction with something else." d. "Is your friend passing classes? Did you tell your friend's parents this was happening?"

a. "Do you think your friend would be willing to sit down and talk with me? I would like to get to know your friend better so I can suggest some healthy alternatives."

A nurse is caring for a slightly overweight client whose lipid panel revealed elevated cholesterol levels. The client was prescribed a statin by the health care provider. Which statement by the client would indicate a health literacy level that would enable the client to make appropriate health decisions to lower cholesterol levels? a. "In addition to this cholesterol medication, I plan to reduce my consumption of red meat and other saturated fats and start walking again." b. "I am going to switch from using butter to using margarine to flavor my food." c. "I am going to take this new medication whenever I eat fatty foods." d. "Since I am going to be taking this cholesterol medication, I do not need to worry about what I eat."

a. "In addition to this cholesterol medication, I plan to reduce my consumption of red meat and other saturated fats and start walking again."

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate? a. "Tell me about what signs of infection you will report to the health care provider." b. "I notice that you do not have the dressing secured. Place a piece of tape on the wrap." c. "Let's see how you irrigate the wound with saline." d. "I would like you to demonstrate how to change the dressing on your leg."

a. "Tell me about what signs of infection you will report to the health care provider."

A client who is recently divorced reports sleeping during the day and an inability to adapt to the life change. Which teaching by the nurse will promote healthy adaptation? a. "Try making a list to prioritize what needs to be done." b. "Save tasks until evening so you can conserve your energy." c. "Thinking about the past will help you move forward." d. "You should get a dog so you will feel needed."

a. "Try making a list to prioritize what needs to be done."

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response? a. "When 15 minutes have passed, I will ask your mother to show me how to instill the drops." b. "We can never be completely sure that your mother understands instructions." c. "After I demonstrate it once, your mother will be able to do it." d. "I will have you bring your mother back next week to see how things are going."

a. "When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

A nurse caring for clients in a skilled nursing facility assesses client motivation to participate in care. Based on the health belief model, which clients would be most motivated? Select all that apply. a. A client who believes there are actions that will reduce the probability of contracting the disease b. A client who believes that doing nothing is preferable to painful treatments c. A client who believes that noncompliance is not an option d. A client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself e. A client who views a disease as a serious threat f. A client who does not view oneself as susceptible to the disease

a. A client who believes there are actions that will reduce the probability of contracting the disease d. A client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself e. A client who views a disease as a serious threat

A nurse is caring for a pregnant client in labor. Which intervention will the nurse initiate to assist the client in managing her stress? a. Deep breathing b. Thought stopping c. Biofeedback d. Low-intensity exercise

a. Deep breathing

A nurse is caring for a client with diabetes and foot gangrene who is scheduled for surgery that involves amputation of the affected foot. What would be most effective in helping the client cope with the fear and pain of surgery? a. Explain the surgery and its importance to the client. b. Have the client practice with the walking device suggested by the health care provider. c. Inform the client about the complications of a gangrenous foot. d. Refrain from telling the client about the disability before surgery.

a. Explain the surgery and its importance to the client.

A nurse working on a busy medical-surgical unit does not take the vital signs of client who is preparing for discharge but instead documents the same vital signs obtained for this client earlier in the morning. For which tort would the nurse be potentially liable? a. Fraud b. False imprisonment c. Assault d. Battery

a. Fraud

When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized? a. Include educational strategies that encourage clients to be active participants. b. Be sure that clients are formally engaged. c. Administer tests to evaluate learning. d. Have the clients read material after client education.

a. Include educational strategies that encourage clients to be active participants.

Which strategy might a nurse use to increase compliance with education? a. Include the client and family as partners. b. Use short, simple sentences for all ages. c. Maintain a clear role as the authority. d. Provide verbal instruction at all times.

a. Include the client and family as partners.

A nurse is caring for a client with hypertension whose blood pressure has increased from 154/78 mmHg to 196/98 mmHg with a heart rate of 110 beats per minute during the past hour. The nurse goes to lunch without reporting the change to the health care provider, and the client experiences a cardiac arrest. What tort has the nurse likely committed? a. Negligence b. False imprisonment c. Invasion of privacy d. Battery

a. Negligence

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse? a. Obtain a medical order. b. Get written consent. c. Notify the family. d. Sedate the client.

a. Obtain a medical order.

Upon entering the hospital system, the nurse discusses the rights and responsibilities that the client is entitled to in the institution. The information the nurse discusses is commonly referred to as: a. Patient's Bill of Rights. b. Standards of Clinical Nursing Practice. c. The Code of Ethics for Nurses. d. The Bill of Rights for Registered Nurses.

a. Patient's Bill of Rights.

A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief? a. Personal moral b. Professional value c. Legal obligation d. Ethical principle

a. Personal moral

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall? a. Psychomotor b. Affective c. Cognitive d. Interpersonal

a. Psychomotor

Nurses must maintain the privacy of clients. Which example is a breach in privacy and would pose an ethical problem? a. Taking a picture of a client with the nurse's cell phone b. Talking to the family when they visit the client c. Documenting the care in the client's record d. Participating in a hand-off report at the end of the shift

a. Taking a picture of a client with the nurse's cell phone

The principle of autonomy by a client is applied in which situation? a. The client has decided to stop chemotherapy treatments. b. An order for an antibiotic is being written in the chart. c. The family of a client is discussing care with the physician. d. A hospice consult is ordered by the nurse.

a. The client has decided to stop chemotherapy treatments.

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report? a. The client was found lying on the floor. b. The client was not aware that the client had fallen. c. The client was trying to lower the side rails. d. The client was trying to get out of the bed.

a. The client was found lying on the floor.

While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind? a. The nurse and client relationship is based on mutual sharing and negotiation. b. Nurses are experts who generously bestow knowledge upon clients. c. Nurses barter knowledge of medication with the client for compliance. d. Nurses have control over the client because of their knowledge and expertise.

a. The nurse and client relationship is based on mutual sharing and negotiation.

A nurse gives the 400 IU of a vitamin supplement that was in the client's medications instead of the 200 IU that was prescribed. The dosage was given when the unit was busy admitting three clients and another client was in crisis. Which action(s) by the nurse demonstrate the professional value of integrity? Select all that apply. a. The nurse documents the dose given. b. The nurse blames the pharmacy for the error on the prescription. c. The nurse says, "This is not fair, we are so busy." d. The nurse dismisses the dose difference, because it is not critical. e. The nurse completes a variance or incident report.

a. The nurse documents the dose given. e. The nurse completes a variance or incident report.

A nurse is using the teaching-learning process to teach new parents how to care for their infants. Which nursing actions reflect recommended steps of this process? Select all that apply. a. The nurse relates new learning material to clients' past life experiences to help them to assimilate new knowledge. b. The nurse identifies general long-term goals for client learning when developing learning objectives. c. The nurse assesses the learning needs and readiness of the parents. d. The nurse formulates a verbal or written contract with clients. e. The nurse does not allow time constraints, schedules, and the physical environment to influence the choice of education strategies. f. The nurse includes group teaching and formal teaching in every education plan.

a. The nurse relates new learning material to clients' past life experiences to help them to assimilate new knowledge. c. The nurse assesses the learning needs and readiness of the parents. d. The nurse formulates a verbal or written contract with clients.

The nurse is providing education to a client recently diagnosed with diabetes. Which action should the nurse take first to address the client's educational needs? a. creating a plan with the client based upon needs b. teaching spontaneously and assessing the result c. showing enthusiasm when the client states correct information d. instructing the client to read a booklet and make notes

a. creating a plan with the client based upon needs

A nurse observes another nurse place an unused dose of an opioid in the nurse's pocket. If caught, the nurse could be charged with which type of crime? a. felony b. misdemeanor c. tort d. negligence

a. felony

A client's body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as: a. homeostasis. b. fight-or-flight response. c. stress. d. self-regulation.

a. homeostasis.

A nurse does not assist with ambulation of a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? a. negligence b. fraud c. battery d. assault

a. negligence

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response? a. "I will contact the hospital social worker to come and discuss the development of an advance directive with you." b. "It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition." c. "It is a document created by you and your attorney naming a beneficiary to handle your estate if you become terminally ill." d. "It is an agreement that authorizes the hospital to make decisions on your behalf, if you become incapacitated."

b. "It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate? a. "I am going to sign you up for a support group." b. "What do you know about support groups?" c. "I am sure you would feel better if you joined a support group." d. "Support groups are for people like you who are depressed."

b. "What do you know about support groups?"

The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client? a. At the time of pain medication administration b. As the client is sitting quietly, reading a book c. Immediately before discharge to home d. When the meal tray arrives

b. As the client is sitting quietly, reading a book

A nurse is sitting with friends in a coffee shop while working on a plan of care for a client. The client's name is written at the top of the plan. Which ethical responsibility is the nurse violating? a. Accountability b. Confidentiality c. Informed consent d. Trust

b. Confidentiality

A nurse is designing an education program for individuals who have recently immigrated from Iraq. Which consideration is necessary for culturally competent client education? a Use all visual materials when teaching content. b. Develop written materials in the client's native language. c. Use a lecture format to teach content with few questions. d. Use materials developed previously for citizens.

b. Develop written materials in the client's native language.

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws? a. A negligent act performed in an emergency situation b. Emergency care for a choking victim in a restaurant c. Any emergency care given when consent is obtained d. Medical advice given to a neighbor regarding a child's rash

b. Emergency care for a choking victim in a restaurant

During a health teaching session, the nurse notes that the client is not attentive and loses concentration easily. Which of the following techniques is most appropriate to grab the attention of the client during the education? a. Repeat directions several times. b. Involve the client in an active way. c. Use verbal and visual modes of instruction. d. Show the relevance of teaching.

b. Involve the client in an active way.

A nurse has a duty of nonmaleficence. Which action would be considered a contradiction to that duty? a. Assisting the client with activities of daily living b. Refusing to administer pain medication as prescribed c. Providing comfort measures for a terminally ill client d. Providing all information related to procedures

b. Refusing to administer pain medication as prescribed

Which strategy should the nurse use when providing education to the older adult client? a. Teach from books only and remain calm. b. Remain calm and conduct the teaching session in a quiet environment. c. Avoid the use of colorful materials and keep the session short. d. Teach in a monotone voice in a quiet environment.

b. Remain calm and conduct the teaching session in a quiet environment.

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class? a. Panel discussion b. Role-playing c. Role modeling d. Programmed instruction

b. Role-playing

A pediatric nurse provides education to numerous clients. Which group of children benefits most from being involved in the teaching-learning process? a. Toddlers b. School-age children c. Preschoolers d. Infants

b. School-age children

Several nurses on the same hospital unit communicate on the same social networking site. A nurse posts the following statement to the social networking page, "The lady in room 34 with heart failure was a train wreck!" In which manner has the nurse failed to apply the principles of confidentiality? a. The nurse did not fail to apply the principles of confidentiality because the hospital's name was not mentioned. b. Sharing information about a client beyond the area of client care is unacceptable and breaches the client's confidentiality rights. c. The nurse did not fail to apply the principles of confidentiality because the client's name was not used. d. Sharing information about the client's diagnosis is unacceptable because it is viewed by the general public and not just other nurses.

b. Sharing information about a client beyond the area of client care is unacceptable and breaches the client's confidentiality rights.

A 7-year-old child has been the victim of abuse. The child appears stoic and disconnected while being interviewed by the nurse. Although the child currently has a painful injury, the child does not cry or flinch when the area is touched. Which explains the child's stoic behavior? a. The child is refusing to cooperate with the interview. b. The child has learned to cope by shutting off feelings. c. The child has a mental health disorder. d. The abuse is likely short-lived.

b. The child has learned to cope by shutting off feelings.

A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the nurse's actions? a. The head nurse b. The nurse c. The hospital d. The physician

b. The nurse

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is: a. a license. b. an advance directive. c. a will. d. a standard of care.

b. an advance directive.

A nurse shows client advocacy by: a. sending a client home with verbal discharge instructions. b. offering a hospice consultation to a client who is terminally ill. c. insisting that a medication be taken. d. refusing to allow a spouse to stay by the bedside.

b. offering a hospice consultation to a client who is terminally ill.

A young adult who has just started college has several tests and assignments due in approximately 3 days. The client has developed a sore throat and fever. Which teaching would the nurse provide to the client to combat the effect intense stress has on the development of illness? a. "Caffeine will help you stay awake so that you can study more, which will relieve study-induced stress." b. "Take vitamins to counteract the effect stress has on your immune system." c. "Be sure that you get enough sleep and eat well during these stressful times." d. "Whenever you feel stressed, go out and run a couple of miles."

c. "Be sure that you get enough sleep and eat well during these stressful times."

The nurse is readmitting a client who was discharged 1 week ago with complications from diabetes mellitus. The client states, "I really did not understand what I was supposed to do to care for myself from those papers that I was sent home with." What question will the nurse ask to promote the client's self-esteem? a. "You understand that if you are not able to care for yourself, will you'll continue to be admitted?" b. "What was so difficult about the discharge instructions?" c. "How do you learn best and what can we do to provide you with that information?" d. "Do you have a problem with reading?"

c. "How do you learn best and what can we do to provide you with that information?"

A nursing student is preparing for the first time to insert an indwelling catheter in a client. The client asks the student if he or she has have performed the procedure before. What is the best response by the student? a. "There is no need to be concerned, I have done this several times." b. "This is a simple procedure and there will be no issues." c. "I have practiced the skill in the lab and my instructor will be present during the procedure." d. "I am a little nervous because I have never done this before."

c. "I have practiced the skill in the lab and my instructor will be present during the procedure."

The nurse is providing education for a client who will be providing self-care at home. The client states, "I just do not think I can do all of this. It is too much to learn." What is the best response by the nurse? a. "I understand that you are frustrated and a bit overwhelmed with all of the information, but it is not difficult information; this is why I am providing education." b. "I understand that you are frustrated and a bit overwhelmed with all of the information, but if you do not learn how to do it, who will take care of you?" c. "I understand that you feel overwhelmed with all of the information. Tell me what I can do to help." d. "I understand that you feel overwhelmed with all of the information, but you will be just fine."

c. "I understand that you feel overwhelmed with all of the information. Tell me what I can do to help."

The nurse has been working with a client for several days during the client's recovery from a femoral head fracture. How should a nurse best evaluate whether client education regarding the prevention of falls in the home has been effective? a. "In light of what we've talked about, why is it important that you remove the throw rugs in your house?" b. "Do you think that the safety measures I taught you are clear and realistic?" c. "What changes will you make around your house to reduce the chance of future falls?" d. "Do you have any questions about the fall prevention measures that we've talked about?"

c. "What changes will you make around your house to reduce the chance of future falls?"

Which nursing student would most likely be held liable for negligence? a. A nursing student completes an incident report after administering a medication to a client who then experienced an adverse reaction to the medication. b. A nursing student reports that insulin was not administered to the client by the nurse on the previous shift. c. A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home. d. A nursing student performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound.

c. A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf? a. A best friend b. A church-appointed guardian c. A surrogate decision maker d. A significant other

c. A surrogate decision maker

Which word is best described as protection and support of another's rights? a. Paternalism b. Ethics c. Advocacy d. Autonomy

c. Advocacy

An oncology nurse is caring for a client suffering from metabolic encephalopathy and end-stage kidney disease. The client has no known family and no advance directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration. What is the priority action the nurse should take? a. Contact the physician. b. Call the coroner. c. Begin CPR. d. Notify the charge nurse.

c. Begin CPR.

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching? a. Giving stickers as a reward for task completion b. Ensuring the client's parents are present c. Blocking 30 minutes of time for skill teaching d. Using dolls to demonstrate psychomotor skills

c. Blocking 30 minutes of time for skill teaching

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory? a. Behavioral learning theory b. Developmental learning theory c. Cognitive learning theory d. Adaptive learning theory

c. Cognitive learning theory

A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However, the client asks the nurse not to put on vest restraints. What would be the best nursing action? a. Apply restraints after giving a sedative. b. Apply wrist restraints instead of vest restraints. c. Contact the physician and obtain necessary orders. d. Restrain the client with vest restraints.

c. Contact the physician and obtain necessary orders.

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? a. Fully discuss the rationale for using the walker. b. Tell the client how to move the walker as the client ambulates. c. Describe how the walker can improve the client's quality of life. d. Explain how the walker supports the client's lower extremities.

c. Describe how the walker can improve the client's quality of life.

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse? a. Give written materials to the client and administer pain medication. b. Assess the client's understanding of self-care and administer medication. c. Have the client rate pain level, and reschedule the teaching session. d. Redirect the client to learning about self-care and begin education.

c. Have the client rate pain level, and reschedule the teaching session.

A client informs the nurse that the client wants to discontinue treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation? a. Restrain the client until medical treatment is over. b. Warn the client that the client may not be able to access health care again. c. Let the client go after signing a document stating that the client is going against medical advice. d. Call the physician and get the discharge paper signed.

c. Let the client go after signing a document stating that the client is going against medical advice.

A nurse knows that the expression "Do not cause harm" refers to which ethical principle? a. Fidelity b. Justice c. Nonmaleficence d. Beneficence

c. Nonmaleficence

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? a. Formal religious beliefs b. Orthopedic surgical history c. Personal perception of health and aging d. Floor plan of the client's dwelling

c. Personal perception of health and aging

The nurse completed education with a client. Which documentation entry represents the most complete teaching plan? a. Written and oral instructions given. Return demonstration performed accurately. b. Start warfarin therapy initiated as prescribed; instructed to return to clinic for testing in 2 weeks. c. Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled. d. Discussed "Therapeutic Lifestyle Changes," printed materials reviewed, follow-up scheduled.

c. Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled.

A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? a. Administer the medication based on the order. b. Refuse to administer the medication. c. Question the order for the medication. d. Document concerns about the order.

c. Question the order for the medication.

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client? a. Oral test b. Written test c. Return demonstration d. Simulation

c. Return demonstration

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse says that the surgeon is rude and that the surgeon's clients always end up with infections. The nurse is at risk of being accused of which? a. Libel b. Negligence c. Slander d. Assault

c. Slander

What governing body has the authority to revoke or suspend a nurse's license? a. The Supreme Court b. The National League for Nursing c. The State Board of Nurse Examiners d. The employing health care institution

c. The State Board of Nurse Examiners

A nurse is caring for a client who is a celebrity in the area. A person claiming to be a family member inquires about the medical details of the client. The nurse reveals the information but later comes to find out that the person was not a family member. The nurse has violated: a. fidelity. b. autonomy. c. confidentiality. d. veracity.

c. confidentiality.

An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's: a. physical demonstration. b. emotions or feelings. c. critical thinking. d. muscular movements.

c. critical thinking.

A client has been diagnosed with breast cancer. Which will the nurse suggest to the client to assist her in engaging in a healthy lifestyle during treatment? a. Going to happy hour every day after work b. Missing a chemotherapy appointment to attend a wedding c. Giving away personal possessions d. Participating in a cancer survivors 5K walk/run

d. Participating in a cancer survivors 5K walk/run

A middle-age woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are: a. illnesses. b. stimuli. c. stressors. d. demands.

c. stressors.

A competent adult client is scheduled for surgery. Who signs the informed consent form to allow the surgery? a. the physician b. a nurse c. the client d. a relative

c. the client

A client has just been diagnosed with a brain tumor after recurring headaches prompted the health care provider to prescribe a computed tomography (CT) scan. Which statement by the client indicates to the nurse that the client is not coping well with the diagnosis? a. "I had a coworker whose spouse had a brain tumor and the spouse managed to recover." b. "With medical advances, I am sure there are really promising treatments out there." c. "I am going to do everything I can to beat this thing." d. "I really need to get back to my job because I am falling behind on a lot of tasks."

d. "I really need to get back to my job because I am falling behind on a lot of tasks."

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? a. "I can monitor my caloric intake by measuring portions." b. "Osteoarthritis in my knees may be because of my weight." c. "I can lower my blood pressure by losing weight." d. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

d. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

A nurse is working with the Red Cross to assist a family whose home was destroyed by fire. Which statement is most appropriate to assist with this situational crisis? a. "You have lost everything. I guess family will be taking you in for a while." b. "I cannot believe the destruction. I would not know where to begin to rebuild." c. "Over time this will all just be a memory. You will adjust to the changes." d. "You have had a tremendous loss. What are your plans for shelter tonight?"

d. "You have had a tremendous loss. What are your plans for shelter tonight?"

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall? a. Psychomotor b. Affective c. Interpersonal d. Cognitive

d. Cognitive

The nurse is caring for a 65-year-old widower whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with him about his spouse. Which is the nurse's priority intervention for this client? a. Refer the client to a religious support group b. Refer the client to an encounter group c. Refer the client to a consciousness-raising group d. Refer the client to a support group

d. Refer the client to a support group

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain? a. Explaining what to do if hypoglycemia occurs b. Describing the signs and symptoms of low blood sugar c. Reviewing with the client appropriate foods to eat d. Demonstrating the technique for insulin self-injection

d. Demonstrating the technique for insulin self-injection

A nurse refers a client with a new colostomy to a support group. This nurse is practicing which aim of nursing? a. Preventing illness b. Promoting health c. Restoring health d. Facilitating coping

d. Facilitating coping

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics? a. Nonmaleficence b. Justice c. Autonomy d. Fidelity

d. Fidelity

A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients? a. Focus mainly on the mother; ask the child a couple of simple questions. b. Separate the mother and the child; teach the mother and then let the mother teach the child. c. Provide the mother with written materials; teach the child about keeping the cast dry. d. Include the child in the education; ask questions of both the mother and the child.

d. Include the child in the education; ask questions of both the mother and the child.

An older adult woman is receiving Medicare benefits only and her source of income is Social Security. She has limited literacy skills and no family support. What is the major issue that puts her at risk for an alteration in health maintenance? a. Family values b. Lack of motivation c. Unpleasant past experience d. Knowledge deficit

d. Knowledge deficit

What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women? a. Test taking b. Demonstration c. Role play d. Lecture/discussion

d. Lecture/discussion

The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action? a. Have family members translate. b. Request other health care providers who speak the client's language to care for the client. c. Use a translating application for cellular phone to aid in communication. d. Obtain a medical interpreter.

d. Obtain a medical interpreter.

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response? a. Tell the client to take the antibiotic until symptoms subside. b. Proceed with teaching about the decongestant. c. Ask the client to restate the teaching that was provided. d. Reteach the length of time to take the prescription.

d. Reteach the length of time to take the prescription.

A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction? a. The client has a short attention span. b. The client is a passive learner. c. The client is not interested. d. The client belongs to a different culture.

d. The client belongs to a different culture.

A client gets out of bed following hip surgery, falls, and re-injures the hip. The nurse caring for the client knows that it is the nurse's duty to make sure an incident report is filed. Which statement accurately describes the correct procedure for filing an incident report? a. The physician in charge should fill out the report. b. The reports are used for disciplinary action against the staff. c. The names of the staff involved should not be included. d. The report should contain all the variables related to the incident.

d. The report should contain all the variables related to the incident.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report? a. To initiate litigation b. To document the need for disciplinary action c. To document everyday occurrences d. To improve quality of care

d. To improve quality of care

Ethical distress is: a. supporting the rights of a client during hospitalization. b. being aware of the principles of right and wrong. c. having trouble deciding which of two conflicting ethical principles to follow. d. knowing the correct action but being unable to perform it due to constraints.

d. knowing the correct action but being unable to perform it due to constraints.

A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a (an): a. adjustment. b. threat. c. concern. d. stressor.

d. stressor.

A nurse is driving on a back country road when a man flags the nurse down and yells that his wife is having a baby. The registered nurse is eager to help. The nurse recalls being covered under the Good Samaritan law. This law states: a. that the nurse is not allowed to help this couple and should instead call 911. b. that the nurse's license is at risk and the nurse would face criminal prosecution if an error was made. c. that the nurse is required to assist this couple because of knowledge and abilities. d. that the nurse's license is protected if the nurse acts in a reasonable manner given the circumstances.

d. that the nurse's license is protected if the nurse acts in a reasonable manner given the circumstances.

A nurse has been assigned to the ICU by her supervisor because there is an emergency there. However, the nurse is not aware of the setup and workings of the ICU. What would be the appropriate action by the nurse? a. to report to the ICU and take leave on the pretext of some illness b. to refuse to go to the ICU and keep working in the previously assigned unit c. to call the lawyer and seek her advice regarding the sudden change. d. to report to the nurse-in-charge for duty and tell her the tasks she can help with

d. to report to the nurse-in-charge for duty and tell her the tasks she can help with

The nurse is caring for a client who demonstrates a health literacy concern. The nurse adjusts client teaching in which way? a. uses medical terminology to help the client feel smarter b. gives instructions in multiple ways so the client will understand c. provides general teaching instead of specificity regarding diagnosis d. uses videos, diagrams, and pictures rather than focusing on verbal teaching

d. uses videos, diagrams, and pictures rather than focusing on verbal teaching