Nursing 224

12) An older client needs to access the Internet to complete a post hospitalization survey and update health information but the client does not have a computer and would not know how to use one. What should the nurse do? (Select all that apply.) 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction.

1,2

13) The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? (Select all that apply.) 1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care. 3. Client is unable to identify changes in skin around the stoma. 4. Client does not want to do the care. 5. Client asks the spouse to learn how to perform the care.

1,2

11) The nurse serves as an educator of other healthcare personnel. In what capacity will this nurse participate in education? (Select all that apply.) 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children

1,2,3

10) A school nurse is planning a program for adolescents about positive lifestyle choices. Which should the nurse keep in mind when planning content for this age group? (Select all that apply.) 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Accurate

1,2,3,5

14) The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this client's plan? (Select all that apply.) 1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content

1,2,3,5

25) The nurse is confident that a client has met the developmental guidelines for a preschooler. What did the nurse assess to make this clinical decision? (Select all that apply.) a. Can print her own name. b. Proudly announces, "I put my own toys away." c. Shares that, "I know I shouldn't hit, even when I'm mad." d. Effectively brushes her own teeth. e. Washes her hands after toileting without prompting.

1,2,4

8) An older client who has had a stroke is ready for hospital discharge. How should the gerontological nurse case manager support this client's independence? 1. Allow the client to be actively involved in all decisions made. 2. Make arrangements based on what the nurse feels is in the best interest of the client. 3. Work closely with the social worker and physician to make the decisions necessary for the client. 4. Set up a meeting with the family members so decisions can be made.

1. Allow the client to be actively involved in all decisions made.

6) The nurse is caring for a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days.

1. Client will be able to set up and administer a nebulizer treatment by the end of the day.

7) A nurse is presenting an educational session regarding psychosocial development to a group of middle-aged adults. According to Erikson's theory, what activity should the nurse select to best meet the needs of this stage? 1. Providing opportunities to mentor school-age children 2. Giving the group handouts regarding peer socialization 3. Helping the members of this group find appropriate civic responsibility 4. Assisting the group members to look at their life accomplishments

1. Providing opportunities to mentor school-age children

8) At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique 4. If the wound heals

1. Shared by the nurse and client

2) A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client's documentation? (Select all that apply.) 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client

2,3,4

9) The nurse is assessing a client's learning needs. On which elements should the nurse focus? (Select all that apply.) 1. Nurse's own knowledge 2. Client's age 3. Client's understanding of health problem 4. Sensory acuity 5. Learning style

2,3,4,5

4) During an educational session regarding physical changes of the middle-aged adult, a participant asks about typical weight changes. How should the nurse respond? 1. "Weight loss is no different during this time than at any other time of your life." 2. "Metabolism slows during middle age, which may result in weight gain." 3. "As long as you exercise appropriately, weight loss will be ensured." 4. "Weight loss is always a good idea, regardless of your age."

2. "Metabolism slows during middle age, which may result in weight gain."

3) The nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, which action is the nurse's highest priority? 1. Provide written instructions before discharge. 2. Address any healing beliefs the family has. 3. Make sure the child comes back for the follow-up appointment. 4. Make sure the parents can set up the treatments for their child.

2. Address any healing beliefs the family has.

3) An occupational health nurse is providing a hypertension screening at a local manufacturing plant. Among the employees, the nurse should focus on which population? 1. Males and females equally 2. African American males 3. Asian American females 4. Caucasian females

2. African American males

12) An older client being discharged has questions about medications and care at home. Which should the gerontological nurse do? 1. Inform the physician that the client needs to go to a nursing home 2. Assess the client's independence and ability to function in his own home before discharge 3. Tell the client not to worry about going home 4. Invite the client's family to come to the hospital so the nurse can explain the client's care to them

2. Assess the client's independence and ability to function in his own home before discharge

23) An adolescent reports feels pressure to participate in activities such as drinking parties and sexual explorations. What should the nurse do? 1. Tell the adolescent to stay away from "friends like that." 2. Be open to the concerns and provide accurate information about any questions. 3. Encourage the adolescent to accept psychosocial counseling. 4. Give the adolescent pamphlets on sexually transmitted diseases.

2. Be open to the concerns and provide accurate information about any questions.

5) A client prescribed new medications and a low-fat diet for a heart problem is concerned about understanding all of the new information. Which nursing diagnosis should be used to guide this client's care? 1. Health-Seeking Behavior 2. Deficient Knowledge 3. Noncompliance 4. Risk for Myocardial Infarction

2. Deficient knowledge

9) The nurse who works in a long-term care facility has noticed that one of the residents has been showing signs of impaired cognitive and self-care abilities over the last 2 weeks. Which should the nurse do? 1. Remember that memory loss is a normal, age-related change 2. Investigate for possible physiological problems 3. Instruct the staff to be extra attentive, as this person needs more assistance 4. Inform the resident's family that the resident probably has some form of dementia

2. Investigate for possible physiological problems

15) The nurse is preparing a teaching plan for a client. Which information should the nurse omit from the plan? 1. Content outline 2. Name of the nurse 3. Teaching methods 4. Learning outcomes

2. Name of Nurse

11) A client has had Alzheimer's dementia for a period of time and continues to live at home with the spouse. What would be one of the gerontological nurse's responsibilities? 1. Make sure the client is being prescribed appropriate medication. 2. Provide support for the spouse. 3. Assess the client early to ensure proper care. 4. Find a suitable long-term care facility for the client.

2. Provide support for the spouse.

1) The nurse explains the use, how it works, and the rationale for an incentive spirometer that a client needs to use after surgery. When mastering the use of this device, the client will demonstrate learning in which of Bloom's domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation

2. psychomotor

21) The nurse suspects that an adolescent is working through the stages of spiritual development. What observations did the nurse make to come to this conclusion? (Select all that apply.) a. Imitated behavior demonstrated by parents b. Conceptualized angels and devils with the use of imagination c. Compartmentalized differences between spiritual beliefs with friends d. Determined differences between spiritual beliefs as being right or wrong Met with the church priest to talk about the differences in spiritual beliefs

3,4,5

10) A client has been diagnosed with dementia. The family wants to know how to plan for the future. What is the best response by the nurse? 1. "Your family member's symptoms will get worse, but there are medications to stop the progress." 2. "You should plan right now on which long-term care facility you will want to utilize when the time comes." 3. "Dementia is a progressive deterioration. It's important for you to clearly understand what to look for in symptoms." 4. "Dementia can be treated once the cause is known."

3. "Dementia is a progressive deterioration. It's important for you to clearly understand what to look for in symptoms."

6) When consulting Erikson's developmental theory, the nurse determines that which older adult will have the least difficulty being successful with the task of this stage? 1. A client who felt success through her children's accomplishments 2. A client who held his job and work status as the defining feature of his life 3. A client who maintained a balance between work and home

3. A client who maintained a balance between work and home

5) A client comes to the clinic with a history of pain in his testicle. During the interview assessment, what information should be of concern to the nurse? 1. The client works as an auto-detailer. 2. He smokes half a pack of cigarettes per week. 3. He has not had a yearly exam for 5 years. 4. He does not perform testicular self-exams.

3. He has not had a yearly exam for 5 years.

7) A gerontological nurse is helping a potential home health client acquire the supplies that will be needed once the client is discharged from acute care. When considering these supplies, what should the nurse recall? 1. Medicare will cover supplies, but only with a physician's written order. 2. Between insurance supplements and Medicare, the older client shouldn't have any difficulty with coverage. 3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible. 4. Clients have to be responsible for their own supplies.

3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible.

4) An older client comes to the clinic reporting gastrointestinal problems, including frequent constipation and indigestion, but denies any recent weight loss. What should these symptoms indicate to the nurse? 1. Could be caused by cancer 2. The need for an upper and lower GI x-ray series 3. Normal changes in muscle tone and activity 4. A gastric ulcer or colitis

3. Normal changes in muscle tone and activity

8) The nurse is providing assistance at a community health fair for middle-aged clients. Which information should the nurse use when working with this group of clients? 1. The middle-aged person has decreased intellectual and cognitive abilities as a result of the normal aging process. 2. Adults make the transition into this stage easily and without problems. 3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life. 4. Cognitive and intellectual abilities are somewhat decreased due to slower reaction time, loss of memory, and changes in perception and problem solving.

3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life.

7) A client needs discharge teaching regarding the use of a walker before going home however the client's room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do? 1. Wait until just prior to discharge, then do the teaching in the hospital lobby. 2. Close the door to the client's room and make sure there is no clutter on the floor before the teaching session begins. 3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client's room. 4. Make sure a physical therapist is available to do the teaching and can see the client before discharge.

3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client's room.

4) The nurse is working with a group of older clients through a community senior citizens center. In which way should the nurse support these clients' health literacy? 1. Provide information written at a third-grade level. 2. Use a variety of approaches when teaching 3. Provide information with pictures. 4. Ensure ample time for teaching.

4. Ensure ample time for teaching

) The nurse is providing education regarding early detection of breast cancer to a group of women between the ages of 30 and 40. According to recommendations from the American Cancer Society, which should the nurse instruct the clients to do? 1. Monthly breast self-exams - 2. Yearly mammogram 3. See a physician if there is a strong family history of breast cancer 4. Have an annual breast exam performed by a healthcare provider.

4. Have an annual breast exam performed by a healthcare provider.

1) A client reports that an adult child has moved back home, which is causing issues in the family. Which factor should the nurse identify that is least likely contributing to this trend? 1. Maladaptive behavior 2. High unemployment rate 3. High housing costs 4. High incidence of chronic disease

4. High incidence of chronic disease

2) A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. "It's going to take time for me to understand this whole thing." 2. "Let's make sure my spouse is around before you start explaining." 3. "I wish my doctor would have explained this more in depth." 4. "I'm feeling nauseous but go ahead and start anyway."

4. I'm feeling nauseous but go ahead and start anyway

9) The nurse is preparing information for a community health education seminar. Which statement should the nurse include regarding disease for the middle-aged adult? 1. Cancer is the leading cause of death in the age group from 25 to 64 years. 2. Coronary heart disease is the leading cause of death. 3. Leading causes of death include suicide and motor-vehicle crashes. 4. Injuries and chronic disease are the leading causes of death in this age group.

4. Injuries and chronic disease are the leading causes of death in this age group.

) An older male client is upset because of a lack interest in sexual intercourse. What should the nurse explain about decreased sexual interest in older clients? 1. It does decrease and gradually disappears. 2. It should not be taken as seriously as it would be if the client were a younger person. 3. It is caused by decreased hormone activity and there is little that can be done about it. 4. It decreases but does not disappear.

4. It decreases but does not disappear.

2) In the review of an older client's chart, the nurse reads that the client has sarcopenia. What should the nurse expect the client to report? 1. Weight loss and nausea 2. Hair loss and thin skin 3. Bleeding and bruising tendencies 4. Lack of strength and tiring easily

4. Lack of strength and tiring easily

3) The school nurse is bringing a group of students to a nursing home for a social exchange project. Before the students arrive, the nurse reminds them to do what when speaking to the residents? 1. Speak as loud as they can. 2. Speak into the residents' ears. 3. Write out what they want to say on a piece of paper. 4. Speak distinctly, while facing the residents.

4. Speak distinctly, while facing the residents.

14) The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? (Select all that apply.) a. Growth involves physical change and increase in size. b. Skills and function increase with growth. c. Most humans experience a similar pattern of growth. d. Being able to adapt to one's environment is an indicator of growth. e. Children's growth is monitored by height, weight, bone size, and dentition.

A,C,E

11) The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? (Select all that apply.) a. Intact and dry skin b. Intact oral mucous membranes c. Bowel sounds present in all four quadrants d. Nasal congestion e. Urinary retention

ABC

10) A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. a. Pad bony prominences on the wrist. b. Apply the padded portion of the restraint around the wrist. c. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. d. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

ABCD

9) A client diagnosed with an infectious disease asks the nurse how the infection "got inside" her body. Which responses would be appropriate for the nurse to make? (Select all that apply.) a. "It depends on the number of organisms present to cause a disease." b. "It depends on how aggressive the organisms are to cause a disease." c. "It depends on how the organisms get inside the body to cause a disease." d. "It depends on where the person is at the time the disease is present." e. "It depends on where the person works."

ABCD

13) The nurse is caring for an older client living in the community. Which nurse actions demonstrate an understanding of the prevalent health concerns specific to the older adult client? (Select all that apply.) 1. Discusses the need for proper lighting-especially at night-to minimize the risk of falls 2. Assesses amount and frequency of the client's alcohol consumption patterns 3. Assesses the client's orientation to time, place, and person as well as short-term memory 4. Discusses the client's views on long-term residential care if the need arises 5. Asks the client to name and provide the reason for each medication he is currently taking

ABCE

2) The nurse working in a community health office that is often frequented by young adults is assessing clients for suicide. Which factors should the nurse identify as indicating a problem in this area? (Select all that apply.) 1. Decreased interest in work 2. Weight loss 3. Depression 4. Brain dysfunction, including tumors 5. Sleep disturbances

ABCE

10) The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? (Select all that apply.) 1. Selecting a mate 2. Rearing children 3. Achieving civic responsibility 4. Finding a congenial social group 5. Developing adult leisure-time activities

ABD

11) The nurse is completing a spiritual assessment with a middle-aged client. What should the nurse recognize as expected characteristics of moral development in this client? (Select all that apply.) 1. Uses religion for comfort 2. Seeks religious explanations for death 3. Compares characteristics of various religions 4. Questions the purpose of religion in one's life 5. Relies upon spiritual beliefs to help with illness

ABE

1) The nurse is planning care for an older adult client. On what should the nurse focus if following the Functional Consequences Theory on aging? (Select all that apply.) 1. Promote safety. 2. Promote mental health. 3. Improve quality of life. 4. Promote spiritual health. 5. Promote growth and development.

AC

13) The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? (Select all that apply.) a. Triclosan b. Chlorine (bleach) c. Isopropyl alcohol d. Hydrogen peroxide

CE

14) The nurse needs to apply personal protective equipment before entering a client's room. In which order should the nurse perform the following actions? Place the steps in the order in which they should be performed. a. Apply gloves. b. Apply eyewear. c. Apply the gown. d. Apply the face mask. e. Perform hand hygiene.

ECDBA

15) The nurse is preparing a teaching session for a group of parents with newborn children. What should the nurse include about Bowlby's attachment theory during this presentation? (Select all that apply.) a. Use the attachment figure as security b. Desire to be near the attachment figure c. Plan to separate from the attachment figure d. Return to the attachment figure when threatened e. Express anxiety when the attachment figure is absent

a,b,d,e

16) The school nurse determines that a 14-year-old student has reached an expected level of cognitive development. What did the nurse assess to come to this conclusion? (Select all that apply.) a. Thinks logically b. Thinks about the future c. Makes rational statements d. Uses a trial-and-error process e. States things as they could be

a,b,d,e

19) The parents of a school-age child are concerned about the child learning right from wrong. In which order should the nurse explain that moral development will develop in the child? a. Punishment and obedience b. Law-and-order orientation c. Instrumental—relativist orientation d. "Good boy—nice girl" stage

a,d,b,c

15) The nurse is assessing an older client. Which finding should cause the nurse to be concerned about the client's safety? a. Alteration in olfactory status b. Blood pressure 138/88 mm Hg c. Applies medication for a skin rash d. Ambulates without assistive devices

a. Alteration in olfactory status

6) The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? a. Always pull a plug at the plug-in from the wall outlet. b. Keep plants in the home. c. Use overloaded outlets when necessary. d. Remove labels from containers and refill for recycling.

a. Always pull a plug at the plug-in from the wall outlet.

10) A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? a. Anxiety b. Acute Pain c. Social Isolation d. Low Self-Esteem

a. Anxiety

1) The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? a. Burns b. Drowning c. Poisoning d. Suffocation

a. Burns

7) The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? (Select all that apply.) a. Client is receiving intravenous fluids. b. Client has an indwelling urinary catheter. c. Client is recovering from surgery. d. Client is receiving pain medication. e. Client is ambulating twice a day with assistance.

a. Client is receiving intravenous fluids. b. Client has an indwelling urinary catheter. c. Client is recovering from surgery

12) While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do? a. Flush the nose and eyes for 5-10 minutes with water or normal saline. b. Begin HIV high-risk exposure prophylaxis within 24 hours. c. Wash the areas with soap and water. d. Have blood drawn for hepatitis B antibodies.

a. Flush the nose and eyes for 5-10 minutes with water or normal saline.

) A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? a. Have the client wear a mask when coming from admission. b. Stock the supply cart at the beginning of each shift. c. Wash the hands only after leaving the room. d. Wear a mask when exiting the room.

a. Have the client wear a mask when coming from admission.

9) The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? a. Place the leg band on the client with the leg in a straight horizontal position. b. Place the sensor under the mattress near the shoulder region. c. Set a time delay for 30 seconds. Connect the sensor pad to the control unit.

a. Place the leg band on the client with the leg in a straight horizontal position.

16) The nurse is creating a teaching poster about the most recent National Patient Safety Goals. Which information should be included to reduce the risk of healthcare-associated infections? a. Post the guidelines for hand hygiene b. List the chemicals used to clean the floors c. Identify when the client rooms are cleaned each day d. Explain the different types of transmission-based precautions

a. Post the guidelines for hand hygiene

17) The nurse is planning care for a client with urinary frequency. Which action should be taken to reduce the client's risk of falling when walking to the bathroom? a. Provide a bedside commode b. Raise one side rail on the bed c. Assess for activity intolerance d. Provide slippers with nonskid soles

a. Provide a bedside commode

3) A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children? a. Temperament b. Physical characteristics c. Environment d. Culture

a. Temperament

27) The nurse is assessing the cognitive development of an adolescent. Which finding indicates that the client is in the formal operations stage of cognitive development? a. Thinks abstractly b. Spends times with peers c. Engages in organized sports d. Decides differences are wrong

a. Thinks abstractly

20) The school health nurse is identifying education programs for high school students besides the dangers of unprotected sex or drug and alcohol abuse. Which class topic should the nurse present to these students? a. Warning signs of depression for peers to identify among their classmates b. Injury prevention c. Early signs of cancer and heart disease d. Normal physiological changes of this age group

a. Warning signs of depression for peers to identify among their

15) The nurse asks unlicensed assistive personnel (UAP) to help a client off of a bedpan. Which action should the UAP take first? a. Wash hands b. Apply gloves c. Apply a gown d. Apply a face mask

a. Wash hands

22) An adolescent spends large amounts of time with friends, causing the parents to have concern. What should the nurse respond to the parents? a. "You should really keep better track of your child. It's hard to tell what kinds of trouble she may be getting into." b. "Independence is really important for this age group. Try to be extra attentive when your child does spend time at home." c. "Use stricter guidelines for curfew and punishment if curfew is broken." d. "Is it possible that your child might be taking drugs?"

b. "Independence is really important for this age group. Try to be extra attentive when your child does spend time at home."

2) During a wellness visit, the nurse notes that a 16-month-old child is unable to move from a sitting to a standing position. In which process should the nurse identify that this child is lagging? a. Growth b. Development c. Height d. Behavior

b. Development

7) A client with a terminal diagnosis collects pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task? a. Body transcendence versus body preoccupation b. Ego transcendence versus ego preoccupation c. Ego differentiation versus work-role preoccupation d. Integrity versus despair

b. Ego transcendence versus ego preoccupation

4) The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? a. Becoming ill with tetanus and receiving tetanus toxoid b. Having chickenpox c. Receiving a rabies shot after being bitten by a rabid dog d. Receiving an injection of gamma globulin

b. Having chickenpox

26) The nurse is assessing a preschool-age child. Which behavior indicates that the client is successfully in the stage of initiative versus guilt? a. Becomes upset with failure b. Imitates a parent's behavior c. Cries when the mother leaves the room d. Argues about spending time with friends

b. Imitates a parent's behavior

11) A client is prescribed seizure precautions. What can the nurse safely assign to assistive personnel (AP) to complete when implementing the precautions? a. Placing a tongue blade at the head of the bed b. Padding the client's bed c. Installing oxygen d. Checking the oral suction apparatus

b. Padding the client's bed

4) The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? a. Assign this client to the farthest room from the nurses' station. b. Place a rocking chair in the client's room. c. Pull up all of the side rails on the bed. d. Wedge pillows against the side rails on the bed.

b. Place a rocking chair in the client's room.

8) A child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase? a. Intuitive thought phase b. Preconceptual phase c. Concrete operations phase d. Formal operations phase

b. Preconceptual phase

5) The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? a. The client will demonstrate an understanding of all limitations. b. The client will establish a buddy system. c. The client will make uninformed choices when addressing health issues. d. The client will take his medication as desired.

b. The client will establish a buddy system.

11) A client with an acute, serious illness is observed praying. With which theorist should the nurse associate this client's behavior? a. Fowler b. Westerhoff c. Gilligan d. Kohlberg

b. Westernhoff

1) The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the children's health is the nurse assessing? a. Development b. Health c. Growth d. Bone size

c growth

17) The parents of a toddler are concerned that the child is messy during eating and feed the child instead. What should the nurse respond to the parents? a. "That's probably best. I'm sure it makes your mealtime more pleasant." b. "At least you're sharing meals as a family. That's the most important." c. "Motor skills keep improving with age. Try not to get frustrated with the mess." d. "Your child will never learn if you don't let him experience."

c. "Motor skills keep improving with age. Try not to get frustrated with the mess."

3) As a member of the safety committee, the nurse's task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? a. Display the phone number to the nurses' station. b. Keep electrical cords under the bed. c. Keep the environment tidy. d. Read label directions.

c. Keep the environment tidy.

9) The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information? a. Vygotsky b. Skinner c. Kohlberg d. Piaget

c. Kohlberg

5) A toddler shows fear and begins to cry when left at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting? a. Building wholesome attitudes toward oneself b. Learning to get along with age-mates c. Learning to relate emotionally d. Achieving personal independence

c. Learning to relate emotionally

14) The nurse visits the home of a client recently hospitalized. Which finding indicates to the nurse that the client is at risk for injury in the home environment? a. Handrails on all stairs b. Nonskid shower surface c. Outdoor lightbulbs burned out d. Smoke alarms throughout the home

c. Outdoor lightbulbs burned out

7) The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? a. Keep clutter to a minimum in the client's room. b. Have the client wear terry-cloth slippers. c. Provide adequate lighting. d. Turn off alarms to reduce noise.

c. Provide adequate lighting.

18) An older client is agitated and confused after relocating to a new facility. Which action should the nurse take to ensure for this client's safety? a. Apply a vest restraint b. Medicate with a sedative c. Take the client for a walk d. Place in a chair with a locked tray

c. Take the client for a walk

13) The nurse is assessing a client's risk for injury. Which finding should the nurse categorize as a lifestyle factor? a. Language barrier b. Chronic insomnia c. Diminished balance d. Access to illicit drugs

d. Access to illicit drugs

2) The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? a. A client in the emergency department with abdominal pain b. A 19-year-old woman in her first trimester of pregnancy c. A 72-year-old male client with COPD d. An 86-year-old female client on steroid therapy

d. An 86-year-old female client on steroid therapy

12) After ambulating a client to the bathroom, the assistive personnel did not reattach the client's bed safety-monitoring device, and the client fell out of bed. What should the nurse document? a. Client fell out of bed; bed safety-monitoring device malfunctioning. b. Client fell out of bed; client removed leg band of bed safety-monitoring device. c. Client fell out of bed; no observable injuries. d. client fell out of bed; bed safety-monitoring device not activated.

d. Client fell out of bed; bed safety-monitoring device not activated.

24) The school nurse is implementing a program to promote psychosocial development among adolescent teens at a high school. Which activity should the nurse include? a. Career planning b. Establishing peer groups c. Playing musical instruments d. Determining a value system

d. Determining a value system

13) A community health nurse is planning adult health education classes. According to Erikson's stages of development, the nurse should address which task with this age group? a. Industry versus inferiority b. Identity versus role confusion c. Intimacy versus isolation d. Generativity versus stagnation

d. Generativity versus stagnation

18) The nurse is addressing the developmental needs of grade school students according to Erikson's theory of industry versus inferiority. Which activities should the nurse suggest? a. Providing time for running and playing sports, such as basketball, to increase gross motor skills b. Allowing "pretend" time during their classes, such as for dress-up or role-playing activities c. Presenting diversity in culture and practices as part of classroom study d. Helping them develop skills needed in the adult world, such as allowance budgeting

d. Helping them develop skills needed in the adult world, such as allowance budgeting

6) A client is being seen in the mental health clinic for antisocial behavior. According to Erikson's stages of development, the nurse realizes that this client is experiencing which task of development? a. Initiative versus guilt b. Industry versus inferiori c. Intimacy versus isolation d. Identify versus role confusion

d. Identify versus role confusion

10) The nurse is completing a spiritual assessment with an adult client. In which stage of Fowler's theory of development should the nurse expect for this client? a. Mythic-lyrical b. Intuitive-projective c. Universalizing d. Individuating-reflexive

d. Individuating-reflexive

8) A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the client's medications? a. Nothing, as the medications all need to be reordered at the long-term care facility. b. Have the client's medication prescriptions filled before going to the long-term care facility. c. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. d. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

d. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

4) The nurse explains that development is based on in-born timetables and a child will be most likely able to meet this milestone at a specific time. Which theory is the nurse explaining? a. Havighurst's theory b. Task theory c. Psychosocial theory d. Maturational theory

d. Maturational theory

16) A client is having a lumbar puncture at the bedside. Which action should the nurse assign to unlicensed assistive personnel (UAP) to complete? a. Apply sterile gloves b. Clean a work surface c. Open the sterile package d. Transport samples to the lab

d. Transport samples to the lab

6) The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown? a. Grasp the sleeve of the dominant arm and remove it with a gloved hand. b. Release the neck ties of the gown and allow the gown to fall forward. c. Untie the strings at the neck first. d. Untie the strings at the waist first.

d. Untie the strings at the waist first.

5) The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper handwashing technique with this client? a. Allow the water to splatter forcibly when it is turned on. b. Clean the faucet after use. c. Hold the hands upward under the faucet. d. Use approximately a teaspoon of soap.

d. Use approximately a teaspoon of soap.

1) The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? a. Administering parenteral medications b. Changing a dressing c. Performing a urinary catheterization d. Using personal protective equipment

d. Using personal protective equipment

3) The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms? a. Heavy smoking b. Moisturizing the skin c. Breakdown of skin d. Voiding quantity sufficient

d. Voiding quantity sufficient

28) The nurse observes a child ask a parent a "why" question about a social issue. For which age should the nurse plan teaching for the parent? a. Toddler b. School-age c. Adolescent d. Preschool-age

d. preschool-age