Nurs 4 - RN EAQ's -QSEN: Patient Centered Care

Which skin infection is caused by bacteria? 1 Folliculitis 2 Candidiasis 3 Herpes zoster 4 Dermatophytosis

1 - Folliculitis Folliculitis is caused by bacteria. Candidiasis is a skin infection caused by a fungus. Herpes zoster is caused by a virus. Dermatophytosis is caused by a fungus.

A nursing student is citing examples of situations that constitute invasion of privacy. Which examples are accurate? Select all that apply. 1 "A nurse states in a press conference that a famous singer is suffering from throat cancer." 2 "A nurse informs a woman's husband that she has had a miscarriage without consulting with the client." 3 "A nurse tells the parents of a 19-year-old that their child is addicted to drugs without waiting for consent." 4 "A nurse informs the primary healthcare provider that the client has cancer without waiting for consent." 5 "A nurse falsely enters in a client's electronic health record that he or she has a sexually transmitted infection (STI)."

1 - "A nurse states in a press conference that a famous singer is suffering from throat cancer." 2 - "A nurse informs a woman's husband that she has had a miscarriage without consulting with the client." 3 - "A nurse tells the parents of a 19-year-old that their child is addicted to drugs without waiting for consent." All medical information of clients is confidential and should not be revealed to unauthorized personnel; a violation of this confidentiality is considered to be an invasion of privacy. Revealing information about a client's illness to media personnel is considered to be invasion of privacy. The nurse should not inform the client's husband about the miscarriage without consulting with the client. In addition, divulging information about an adult client's drug abuse to his or her parents without consent is an invasion of privacy. Informing the primary healthcare provider about the client's illness without waiting for the client's consent is not considered to be an invasion of privacy, because the information is being shared for the purpose of medical treatment. Entering false information in the client's electronic health recording may damage the reputation of the client. This is considered to be libel.

What is the similarity between the preoperational period and the formal operations period? 1 Both periods reflect egocentrism in the individual. 2 Both periods demonstrate animism in the individual. 3 Both stages outline play as a means for fostering development. 4 Both periods are characterized by an individual's capacity to reason with respect to all possibilities.

1 - Both periods reflect egocentrism in the individual. Both the preoperational and the formal operations period show that there is a prevalence of egocentric thought in the individual. The preoperational period demonstrates animism in an individual. The preoperational period also demonstrates play as a means of fostering development in the child. During formal operation period, the individual has the capacity to reason with respect to possibilities.

When a client who has a bipolar mood disorder is hyperactive, it is difficult to entice her to sit still long enough to eat a complete meal. The plan of care states, "Provide finger foods such as carrots, celery, and cheese sticks at 10 am, 2 pm, and 7 pm." Recent assessment of this client indicates that all of the food provided at mealtimes is being eaten but that snacks have been refused. What should the nursing staff do? 1 Change the plan, depending on evaluation findings. 2 Ask the client whether the finger foods should still be provided. 3 Continue the current plan so the client's nutritional status will improve. 4 Reassess the client's nutritional status in 1 week so changes can be made.

1 - Change the plan, depending on evaluation findings. Because the plan does not meet the client's needs, it should be changed. The client has already let the staff know that finger foods are not wanted. Continuing the plan will be frustrating for the client and the staff, because the client's behavior indicates that snacks are not wanted. When the client's needs are not being met, the plan should be changed immediately.

What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate? 1 Encouraging more frequent breastfeeding during the first 2 days 2 Instituting phototherapy for 30 minutes every 6 hours for 3 days 3 Substituting formula feeding for breastfeeding on the second day 4 Supplementing breastfeeding with glucose water during the first day

1 - Encouraging more frequent breastfeeding during the first 2 days More frequent breastfeeding stimulates more frequent evacuation of meconium, thereby preventing resorption of bilirubin into the circulatory system. Phototherapy is the treatment for hyperbilirubinemia, and it is maintained continuously; it does not prevent the development of hyperbilirubinemia. It is not necessary to feed the infant formula. Early breastfeeding tends to keep the bilirubin level low by stimulating gastrointestinal activity. Increasing water intake does not limit the development of hyperbilirubinemia, because only small amounts of bilirubin are excreted by the kidneys.

The nurse is caring for a client who is in the taking-in phase of the postpartum period. What area of health teaching will the client be most responsive to? 1 Perineal care 2 Infant feeding 3 Infant hygiene 4 Family planning

1 - Perineal care During the taking-in phase a woman is primarily concerned with self-care needs and being cared for. The taking-in phase generally occurs during the first 24 hours after delivery and may last up to 2 days. Infant feeding and infant hygiene are best taught during the taking-hold phase of postpartum adjustment. Family planning is not a primary concern during the immediate postpartum period.

The nurse develops a goal that makes a client feel as if the client is engaging in a competition. Which type of motivation is the nurse using in this situation? 1 Power motivation 2 Affiliative motivation 3 Avoidance motivation 4 Achievement motivation

1 - Power motivation People who tend to be motivated by power generally have more assertive and aggressive behavior. Therefore the nurse designs goals in such a way that makes these clients feel like they are in a competition even though the clients are only competing against themselves. Individuals who tend to be motivated by affiliative motivation are generally nonassertive and more dependent on others. Therefore the nurse can design the goal according to their mental behavior. Avoidance motivation requires the nurse to consider the client's anxiety, fear of failure, and other phobias. People who are motivated by achievement are not characterized by aggressive behavior with a need to engage in competition.

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply. 1 Resting tremors 2 Flattened affect 3 Muscle flaccidity 4 Tonic-clonic seizures 5 Slow voluntary movements

1 - Resting tremors 2 - Flattened affect 5 - Slow voluntary movements Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

The urinalysis report of a client reveals cloudy urine. What does a nurse infer from the client's report? 1 The client has a urinary infection. 2 The client has a biliary obstruction. 3 The client has diabetic ketoacidosis. 4 The client has been on a starvation diet.

1 - The client has a urinary infection. The urine becomes cloudy when an infection is present due to the presence of leukocytes. Therefore the nurse concludes that the client has a urinary infection. In cases of biliary obstruction, the urine contains bilirubin. The presence of ketones in the urine indicates diabetic ketoacidosis or prolonged starvation.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. 1 The nurse keeps the newborn covered in warm blankets. 2 The nurse keeps the newborn under the radiant warmer. 3 The nurse places the newborn on the mother's abdomen. 4 The nurse measures the newborn's temperature regularly. 5 The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1 - The nurse keeps the newborn covered in warm blankets. 2 - The nurse keeps the newborn under the radiant warmer. 3 - The nurse places the newborn on the mother's abdomen. Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

The emergency department nurse is called to care for a client with a snake bite. What are the nursing interventions performed by the nurse in the order of priority? 1. Removing the client's clothing 2. Moving the client to a safe area 3. Calling for emergency assistance 4. Taking photographs of the snake 5. Immobilizing the affected area with splint

1. - Moving the client to a safe area 2. - Removing the client's clothing 3. - Immobilizing the affected area with splint 4. - Calling for emergency assistance 5. - Taking photographs of the snake While providing prehospital care for a client with a snake bite, the nurse should first move the client to a safe area away from the snake and encourage rest to reduce venom circulation. Next, the nurse should remove constricting clothing and jewelry before swelling worsens. Then, the nurse should immobilize the affected area using a splint to limit the spread of venom. The nurse should then call for immediate emergency medical assistance. Lastly, digital photographs are taken at a safe distance to help in identification of the snake.

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

2 - Evaluation Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? 1 Spiritual belief 2 Family practices 3 Emotional factors 4 Cultural background

2 - Family practices Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care. The client is not influenced by spiritual beliefs in this instance. An individual's spiritual beliefs and religious practices may restrict the use of certain forms of medical treatment. Emotional factors such as stress, depression, or fear may influence an individual's health practice; however, this client does not show signs of being affected by emotional factors. The client is said to be influenced by cultural background if he or she follows certain beliefs about the causes of illness and uses customary practices to restore health.

A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? 1 Sweating 2 Hyperpnea 3 Bradycardia 4 Hypertension

2 - Hyperpnea Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.

To which assessment findings should the nurse give the highest priority when caring for a client with symptomatic sinus tachycardia? Select all that apply. 1 Anxiety 2 Orthopnea 3 Restlessness 4 Lightheadedness 5 Decreased blood pressure

2 - Orthopnea 4 - Lightheadedness 5 - Decreased blood pressure The assessment findings having the highest priority for clients with symptomatic sinus tachycardia are orthopnea (shortness of breath while lying flat), lightheadedness, and decreased blood pressure because these assessments can help to quickly identify the client's condition and the most effective treatment for it. Anxiety and restlessness are frequently observed in a client with symptomatic sinus tachycardia, but they are not the nurse's highest priority.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family? 1 Orem's theory 2 Peplau's theory 3 Leininger's theory 4 Henderson's theory

2 - Peplau's theory Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

What is the action of vasopressin? 1 Promotes sodium reabsorption 2 Reabsorbs water into the capillaries 3 Promotes tubular secretion of sodium 4 Stimulates bone marrow to make red blood cells

2 - Reabsorbs water into the capillaries Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).

Which point is included in the World Professional Association for Transgender Health (WPATH) document regarding core principles of care for transgender clients? 1 Designating unisex or single-stall restrooms 2 Seeking informed consent before providing treatment 3 Posting the patient's bill of rights and nondiscrimination policies visibly 4 Reflecting the client's choice of terminology in communication and documentation

2 - Seeking informed consent before providing treatment The nurse must seek informed consent before providing treatment for a transgender client. This is one of the core principles for health care professionals who care for transgender clients as per the document published by the World Professional Association for Transgender Health (WPATH). As per The Joint Commission recommendations for creating a safe and welcoming environment for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients, the nurse should designate unisex or single-stall restrooms, post the patient's bill of rights and nondiscrimination policies visibly, and use the client's choice of terminology in communication and documentation.

A nurse is educating the caregivers of an elderly adult with advanced Parkinson's disease about continuing care. What information should the nurse provide? Select all that apply. 1 "Home care is a type of continuing care in which the primary objectives are health promotion and education." 2 "Continuing care is necessary for clients who are recovering from an acute or chronic illness or disability." 3 "Adult day care centers are ideal for clients whose caregivers have to be away from home during the day." 4 "Hospice care is a continuing care system that allows clients to live at home with comfort, independence, and dignity." 5 "Nursing centers provide 24-hour custodial care in order to help residents achieve and maintain their highest level of functioning."

3 - "Adult day care centers are ideal for clients whose caregivers have to be away from home during the day." 4 - "Hospice care is a continuing care system that allows clients to live at home with comfort, independence, and dignity." 5 - "Nursing centers provide 24-hour custodial care in order to help residents achieve and maintain their highest level of functioning." Adult day care centers are ideal for providing continuing care to clients whose caregivers have to be away from home during the day. Hospice care is a type of continuing care that provides palliative care to clients within the comfort, dignity, and independence of their homes. Clients also go to nursing centers to receive continuing care. Nursing centers provide 24-hour custodial care. They help clients achieve and maintain their highest level of functioning. The primary objectives of providing restorative home care are health promotion and education. Clients recovering from chronic or acute illnesses or disabilities require restorative care. Continuing care is necessary for clients who are suffering from a terminal disease, who are disabled, or who were never functionally independent.

An adolescent with terminal cancer tells the home care nurse, "I'd really like to get my general education development (GED) certificate. Do you think that's possible?" What is the best approach for the nurse to take in response to the adolescent's question? 1 Refocusing the conversation on things the adolescent has already accomplished in life 2 Trying to help the adolescent understand that this goal is too taxing and slightly unrealistic 3 Arranging a conference with the school and encouraging the adolescent to prepare for the test 4 Suggesting to the adolescent that this energy should be directed toward expressing feelings about the illness

3 - Arranging a conference with the school and encouraging the adolescent to prepare for the test Passing the high school equivalency test is the client's desire, and the nurse should do everything possible to help the client fulfill the goal. Refocusing the conversation on things that the adolescent has already accomplished in life is not therapeutic; the client has an unmet need, and the nurse should not try to refocus the client away from the stated objective. The client should be encouraged, not discouraged; mental activity is not too taxing and is not unrealistic if the client wishes to engage in it. There are no data supporting the conclusion that the client needs to work through feelings about the illness.

A 6-year-old boy is hospitalized with an exacerbation of nephrotic syndrome. The mother asks the nurse what she should bring for her son to play with during the hospitalization. What should the nurse suggest? 1 Plastic bat, cloth ball, and a hula hoop 2 Stuffed animals, large puzzles, and blocks 3 Checkers, simple card games, and crayons 4 Children's magazines, a model plane kit, and laptop computer

3 - Checkers, simple card games, and crayons School-aged children enjoy competition, have manipulative skills, and are creative. A bat, ball, and hula hoop require too much expenditure of energy for a child in the acute phase of nephrotic syndrome. A stuffed animal, large puzzle, and blocks are appropriate for the toddler who is developing fine motor skills. Magazines, a model plane kit, and a laptop are appropriate for a child older than 6 years. Six-year-old children are not proficient readers.

During a critical incident stress debriefing (CISD) session conducted by the nurse for clients affected by a natural disaster, a client says, "The worst thing that happened on that day was that my child was severely injured and I was not in a position to help. I would like to forget that day as soon as possible. It was the most painful experience of my life." Which phase of CISD does this indicate? 1 Reentry phase 2 Thought phase 3 Reaction phase 4 Symptom phase

3 - Reaction phase In the reaction phase, CISD participants talk about the worst thing of the incident - what they would like to forget and what was most painful. In the reentry phase, participants review materials discussed, ask questions, and discuss how they would like to bring closure to the debriefing. In the thought phase, participants discuss their first thoughts of the incident. In the symptom phase, participants describe their physical, cognitive, emotional, or behavioral experiences that happened at the incidence scene.

The parents of an infant with tetralogy of Fallot ask a nurse about the problems involved with this disorder. When answering, what must the nurse consider? 1 Overriding aorta, aortic stenosis, patent ductus arteriosus, and mitral insufficiency are the components of this defect. 2 Tricuspid atresia, ventricular septal defect, atrioventricular canal, and coarctation of the aorta are the components of this defect. 3 The disorder consists of right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. 4 The disorder consists of right ventricular hypertrophy, atrial septal defect, patent ductus arteriosus, and mitral insufficiency.

3 - The disorder consists of right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. Tetralogy of Fallot consists of right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and an overriding aorta.

A nurse is educating the mother of a one-year-old baby about an adequate child's diet plan. Which statement made by the mother indicates the need for further education? 1 "I should limit the intake of milk to two to three cups per day." 2 "I should serve finger foods in small and reasonable amounts." 3 "I can start supplementing milk with solid food items such as vegetables and fruits." 4 "I should give low-fat or skimmed milk to the child until he or she is two years old."

4 - "I should give low-fat or skimmed milk to the child until he or she is two years old." Children under two years of age should not be given low-fat or skimmed milk because fat is important for physical and intellectual growth. Milk intake should be limited to two to three cups per day because the consumption of more than a quart of milk per day will decrease a child's appetite for essential solid foods and result in inadequate iron intake. Serving finger foods to toddlers allows them to eat by themselves and to satisfy their need for independence and control. Small, reasonable servings allow toddlers to eat all of their meals. By the age of six months, the mother should start supplementing milk with solid food items, ensuring a balanced diet for an adequate growth of the child.

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. What is the best response by the nurse? 1 "That client is not on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 "The client has requested that no information be given out. You'll need to call the client directly." 4 "It is against the hospital's policy to provide you with any information."

4 - "It is against the hospital's policy to provide you with any information." The response "It is against the hospital's policy to provide you with any information." is a factual statement, without indicating whether or not the client is in the hospital. The response "That client is not on our unit. Thank you for calling." is a lie and should be avoided. HIPAA (Canada: FOIPOP) laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others.

A nurse concludes that a client is using displacement. Which behavior has the nurse identified? 1 Ignoring unpleasant aspects of reality 2 Resisting any demands made by others 3 Using imaginative activity to escape reality 4 Directing pent-up emotions at someone other than the primary source

4 - Directing pent-up emotions at someone other than the primary source When acting out against the primary source of anxiety creates even further anxiety or danger, the individual may use displacement to express feelings toward a "safer" person or object. Ignoring unpleasant aspects of reality is an example of denial. Resisting any demands made by others reflects an inability to mature and accept responsibility. Using imaginative activity to escape reality is fantasy.

The nurse is caring for a neonate who is undergoing phototherapy. What specific care should the nurse plan for this infant? 1 Applying mineral oil to the skin to prevent excoriation 2 Covering the infant's head with a cap to minimize heat loss 3 Regulating radiant heat to maintain optimum skin temperature 4 Discontinuing therapy during feeding to meet the infant's emotional needs

4 - Discontinuing therapy during feeding to meet the infant's emotional needs Discontinuing therapy during feedings is necessary to ensure psychosocial contact. Mineral oil may block light rays from acting on bilirubin deposits; cleansing after each voiding and defecation will prevent skin excoriation. All parts of the body may contain bilirubin deposits and should be exposed to the light. Radiant heaters are not used; a fluorescent light source is used.

A 4-year-old child is restricted to 600 mL/24 hr. What nursing intervention will best help the child cope with this limitation? 1 Dividing the fluids equally throughout the 24 hours 2 Allowing the child to drink fluids as desired until the 600-mL limit is reached 3 Providing the 600 mL from 7 AM to 7 PM and then withholding fluids again until 7 AM 4 Offering the child at least 1 oz (30 mL) of fluid, served in a 1-oz (30-mL) medicine cup each waking hour

4 - Offering the child at least 1 oz (30 mL) of fluid, served in a 1-oz (30-mL) medicine cup each waking hour Providing at least 1 oz (30 mL) of fluid per hour, served in a 1-oz (30-mL) medicine cup, allows the child to drink 30 mL of fluid (1-oz medicine cup) without long periods between drinks. This approach will provide a total of 480 mL with leeway to offer another ounce four times during waking hours, either at meal or snack times or if the child awakens during the night. When fluid is limited, a smaller amount should be apportioned to the sleeping hours. If the child is allowed to drink as much as is desired until the limit is reached, 15 to 20 hours might elapse before fluids will be permitted again. Although fluids can be limited more easily during sleeping hours, 12 hours without fluid is too long for a young child to tolerate.

The nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do to prevent retinopathy of prematurity (ROP)? 1 Cover the neonate's eyes with a shield 2 Place the neonate in an elevated side-lying position 3 Assess the neonate every hour with a pulse oximeter 4 Support the neonate's oxygen saturation while providing minimal FiO2

4 - Support the neonate's oxygen saturation while providing minimal FiO2 ROP is a complex disease of the preterm infant; hyperoxemia is one of the numerous causes implicated. Oxygen therapy is maintained at the lowest level necessary to support respiratory status. If the oxygen concentration needs to be increased to maintain life, ROP may not be preventable. Using a shield over the neonate's eyes will not prevent the development of ROP; nor does positioning or assessment of the neonate every hour with a pulse oximeter alone. If the pulse oximetry results are within an acceptable range, the oxygen concentration may be reduced.

A client has decided to become a total vegetarian (vegan) and wishes to plan a diet to ensure adequate protein quality. What should the nurse recommend to the client? 1 Add milk to grains to provide complete proteins 2 Use eggs with plant foods to provide essential amino acids 3 Add cheese to beans to provide a balance of different proteins 4 Use a mixture of plant proteins to provide the essential amino acids

4 - Use a mixture of plant proteins to provide the essential amino acids Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents. A vegan does not consume flesh, milk, milk products, or eggs.