nurs233 quiz 1

the interdisciplinary health care team collectively developing plans of care

The case manager works in a facility that supports a participative leadership style. Which action should the nurse recognize as an example of democratic leadership style?

occupational therapist

The client is being discharged to the home setting following a stroke. The client requires assistance in relearning how to cook safely. To which home health care team member should the nurse refer the client?

"I want to understand what your desires are"

The home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. Which is the best response by the nurse when the family asks why those questions are being asked?

bathing a combative client

The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UAP). Which task is appropriate for the UAP to complete?

health education can benefit individuals and group

When educating clients in the community on health promotion and prevention of disease, it is important to stress:

validate the questionable data

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first?

providing accurate and complete communication to the new facility

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?

the change to shorter hospital stays

A hospital has begun to expand home health services to its clients. Which reason is the most likely cause for the expansion of these services?

gather information and complete admission database

A new client arrived on the unit while the nurse was obtaining the end-of-shift report from the night nurse. This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. The nursing assistant has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority nursing action is to:

assess whether the desired results have occurred

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

"dispose of the disconnected IV set"

In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant?

providing client education

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

the discharge home of clients who are more critically ill

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting?

assess the client's back visually

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action?

therapeutic communication

to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

whether the client has a document describing wishes for care when the client is not able to make decisions

On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine:

clients with high home care needs are being discharged into the community

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges?

-nurses should value technologies that support error prevention and care coordination -the use of informatics can help manage knowledge and mitigate error -utilization of information services helps to support decision making

Which statements are true about informatics in nursing practice? Select all that apply.

refer the client to a social worker to determine eligibility for assistance

A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that the client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client?

client states, "I don't see the point in trying anymore"

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

the opportunity for the oncoming nurse to ask questions

The nurse is met in the staff lounge by the nurse who has been caring for the client team on this shift. The off-going nurse says, "Sorry, but I have to get out of here." The nurse then gives a quick overview of each client on the team and says, "All the rest is in the chart if you need anything." Which essential part of the handoff is missing?

notify the health care provider immediately

A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak?

the charge nurse is providing support for the staff nurse in new responsibilities

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role?

secondary

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

subjective

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

empathy

A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting?

assess the client's blood pressure

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

the client's caregiver is absent whenever the nurse visits and the client is alone

A client is receiving home health services after having a stroke and being hospitalized. After a thorough assessment of the home environment and the client, what would indicate to the nurse that there is an impairment in the client's home management?

"the client and family are in control of the setting, not the nurse"

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate?

prioritize the nursing diagnosis

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?

make a referral to social services department

A nurse is caring for a 17-year-old pregnant client who is unable to afford health care. Which resources will the nurse access to obtain assistance for this client?

easy wrinkling of the skin and sunken eyes

A nurse is caring for a client admitted to the hospital for dehydration. Which physical findings should the nurse acknowledge as nonverbal communication concerning this diagnosis?

"I know this is hard for you. Is there anyway I could help?"

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

clearly defining the purpose and expectations of the admission

A nurse is covering all aspects of admission procedures for a client who is receiving home health services. The nurse explains what procedures will be covered during the nurse's visits. Which aspect of the admission process does this represent?

-discharge planning should begin upon admission to the facility to ensure continuity of care -the nurse ensures that the family members are taught the knowledge and skills needed to care for the client -preferably, the nurse who conducts the initial nursing assessment will determine the special needs of the client being discharged

A nurse is discharging a client from the hospital. Which nursing actions should occur when a client is discharged from a health care setting? Select all that apply.

-cue clustering -cluster interpretation -diagnostic validation

A nurse is involved in selecting the appropriate nursing diagnosis for a client. Which techniques would the nurse likely use? Select all that apply.

verbally report the finding immediately to the client's physician

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

the nurse prepares the room for the new client

A nurse is preparing for handoff communication for a client who is being discharged from the hospital to home health care. Which example is not an action performed during this process?

use broad, open statements to communicate with the client

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

transformational

A nurse is working as part of a group on developing strategies to meet the health care needs of the children being served by the facility. The nurse identifies the need for expanded play therapy programs. The nurse works to motivate others in the group and promote a common vision. The nurse and the group communicate openly and honestly with the others involved, focusing on the process as well as the outcomes. The nurse is exhibiting which style of leadership?

laissez-fairre

A nurse leader on a unit allows the staff to make all decisions and direct themselves, including filling out the work schedule. The nurse leader is practicing which leadership style?

resource management

A nurse manager must provide care to the unit's clients and employees under the constraints of the resources. This involves maintaining the financial constraints of the division. What term best describes this scenario?

performance appraisal

A nurse manager reviews an employee's contribution to the nursing division annually. This process is:

hold a unit meeting to discuss how the changes will benefit staff

A nursing facility has recently implemented new policies regarding nurse-to-client ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change?

-giving a bed bath to a client -taking routine vital signs -transferring a client to another floor

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply.

encourage active participation of the client and family in health care decisions

A registered nurse is providing community-based health care for a client diagnosed with early onset dementia. Which strategy is best for the nurse to employ to facilitate the family participating in the client's care?

cognitively understand how to care for the children

A single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which?

"i collaborate with health care teams to promote client care"

A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader would be appropriate?

democratic

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

coordinator

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success?

support system

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?

time-lapsed assessment

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

closed question

During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "Have you been hospitalized this year for your back pain?" This is an example of which type of question?

inform the client of the maintenance of confidentiality

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

review as much information as possible

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

prepare the client for home care

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to:

provides health care for the community

Public health nursing is the branch of nursing that:

reflective practice

Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:

encourage the client and family to contact appropriate community resources

The community-based nurse is assessing a new client and the home environment. What is a responsibility of the community-based nurse at this initial visit?

functional assessment

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

administer a dose of digoxin that is two hours behind schedule

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first?

repositioning the client

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

provide the teaching

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self-care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated?

objective

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

suicide-attempt risk

The nurse is assessing a client in an outpatient setting. The client states, "I do not want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing concern for this client?

have the client sign the AMA form

The nurse is assigned to care for a middle-aged client who is agitated and wants to go home. The client states that the client does not have time to waste in the hospital, and no one is doing anything anyway. Which action by the nurse is most appropriate if the client insists on leaving the hospital against medical advice (AMA)?

analyze the data and create an individualized nursing diagnosis

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

assess the need for assistance with ambulation

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

administer a high calorie diet, excluding wheat, rye, and oats

The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?

time-lapsed assessment

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

A need for a safer intravenous therapy pump is identified. New intravenous therapy pumps are purchased and training for staff nurses is provided. Intravenous therapy pumps are placed on the nursing unit for client care.

The nurse is conducting an in-serve on change theories. Which example should the nurse include in the presentation illustrating Lewin's three stages of change?

assessment

The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

both during the collection and at the end of the collection

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

the nurse

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the health care provider?

complete an exam of all body systems

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to:

explain the nurse will need to touch the client during the assessment

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

administer prescribed pain medication prior to conducting the interview

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

refer the client to social services for assistance

The nurse is providing care to a homeless client who presents to the emergency department with a foot wound. Which is the priority nursing intervention prior to discharge?

better client outcomes

The nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on client care?

collaborating

The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which conflict resolution style does the nurse manager display?

Enlist volunteers to help develop a community outreach project that will educate adolescents on methods to prevent pregnancy

The nurse manager is concerned about the large number of adolescent mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?

"the care will be divided and the registered nurse will have a licensed practical/vocational nurse and unlicensed assistive personnel to provide care together"

The nurse manager of the acute care unit has decided to implement a team nursing approach for client care. One of the staff members asks, "Will we each take care of our own clients?" What is the appropriate response by the manager?

the new mother attempts to breastfeed the infant again using the new techniques and is successful

The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstrates various positions in which to hold the infant while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the infant again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing?

providing continuity of care that is goal directed

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as:

watching client walk into the room

The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment?

the initial comprehensive client assessment

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

identify actual and potential health problems

The purpose of obtaining a nursing history is to:

the nurse practice act or facility's policies and procedures

The registered nurse (RN) wants to delegate a task to an unlicensed assistive personnel (UAP) but is unsure if the task can be delegated. What is the best resource for the RN to use in determining if the task is appropriate?

the stability of the client's condition, potential for harm, and complexity of the activity

The registered nurse (RN) wants to delegate measuring a client's urinary output to an unlicensed assistive personnel (UAP). Which factors should the nurse consider before delegating the task?

The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution?

a regular employee who is a natural leader

Two nurse managers working on different units in a hospital are planning for a major change to occur on both units. One nurse manager reports to the other having identified a key power player on the unit. Which description most applies to a key power player in this context?

conflict resolution

Two staff nurses on a unit disagree with one another over certain key aspects of providing client care. The nurse manager of the unit arranges a meeting with the charge nurse and the two staff nurses at a mutually agreed-upon time to discuss this situation. This activity is most accurately described as what?

as soon as possible after a client presents for care

When is the best time for a nurse to take a client's health history?

provide for the coordination and continuity of care by health care providers

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to:

decide whether to continue, modify, or terminate client care

Which action exemplifies the purpose of evaluation in the nursing process?

demonstrating how to suction the oropharynx

Which activity by the nurse exhibits the role of family educator?

self-aware, honest, persistent, and authentic

Which are characteristics of one who has developed critical thinking skills?

-anxiety -light-headedness -nausea

Which are examples of subjective data? Select all that apply.

collection, validation, and communication of client data

Which group of terms best defines assessing in the nursing process?

obtaining intake and output on a client with a foley catheter

Which is a task that the nurse can delegate to the unlicensed assistive personnel (UAP)?

client

Which is the best source of information for the nurse when collecting data for an assessment?

palpating a mass in the lower right quadrant of the abdomen

Which is the most appropriate example of the assessment phase of the nursing process?

staff nurses are developing innovative solutions to problems

Which of these statements reflects the expected functioning at a hospital that has achieved Magnet status?

consult with another nurse for that colleague's description of the assessment or observations

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?

clarity

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?