Nursing Exam 2 Practice

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse?

"Tell me what you know about these tests."

Which client would a nurse correctly refer to Medicare services?

A 66-year-old client with diabetes

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program?

Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting.

A new nurse is considering getting a job in either an acute care setting or a home care setting. Which statement about these care settings is most accurate?

Clients play a large role in helping themselves in the home care setting.

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?

Cognitively understand how to care for the children

A nurse is helping clients access the health insurance marketplace. What is the goal of this health insurance coverage concept?

Comparison of available health care plans

A nurse is providing supportive care to a client diagnosed with a terminal illness who is not expected to live past the next 3 months or so. The nurse is likely working in which setting?

Hospice care

Which step of the nursing process involves setting long-term goals and short-term expectations?

Planning

A client is admitted to the health center with chronic diarrhea. When should the nurse begin imparting health teaching about the benefits of proper diet to the client so that the risk of diarrhea is minimized?

When admitting the patient

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by:

asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate

A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse:

creating an atmosphere for discussion of feelings.

Continuity of care for a particular client is most important to prevent:

fragmentation of services.

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

health education can benefit individuals and groups.

Which six trends in health care reflect the Institute of Medicine's (IOM) focus?

The system should be safe, effective, efficient, patient centered, timely, and equitable

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity and rest

The nurse is caring for an underweight 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?

Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

Orientation Phase

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Reflection

Which statement accurately describes the concept of feedback as it pertains to the process of communication?

The sender and the receiver use one another's reactions to produce further messages.

A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long-term plan can be formed?

Enroll the client in Meals on Wheels.

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply.

Impaired mobility Imbalanced nutrition Ineffective coping

Which is the primary criterion for admission to a long-term care facility?

Inability to provide self care

The community health nurse is preparing a campaign to educate the public about heart health. Which forms of verbal communication would be effective to use in this campaign? Select all that apply.

Radio, a public speech, television

The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurolgoical checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed?

Recommendation

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client?

Arrange for a sign language interpreter

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective?

Demonstrate and explain the procedure and then have the daughter perform it.

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process?

Dynamic

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request?

Identify and recommend some credible websites appropriate to the spouse's learning needs.

Which is the largest single source of reimbursement for home health care services?

Medicare

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

The nurse has completed teaching. Which client behavior demonstrates understanding within the affective domain?

States, "I feel comfortable using my walker"

Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge?

Teach the client how to administer insulin

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete the postoperative assessment.

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education?

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

A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client states not having time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You are taking too long and it is hurting a little bit. Just pull them out and get it over with." Which statement is an example of appropriate therapeutic response?

"It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them."

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect?

Coordinator of care

The nurse is using nonverbal communication when caring for a group of clients. Which situation(s) reflects nonverbal communication? Select all that apply.

The nurse is maintaining eye contact when changing a client's dressing. The nurse has a smile when being thanked for caring for a family member. The nurse assess a client is in pain from a grimace.

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy?

"Just take your time. I am listening."

An 18-month-old child is ventilator-dependent due to infantile scoliosis. This is the first time the child has been home since birth and the parents are very concerned about providing care. What is this family's priority need for assistance?

Emotional Bonding

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?

Empathy

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?

Refer the client to a social worker to determine eligibility for assistance.

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care?

Asking only the client's parents to be present at the education session

A nurse is evaluating a client's care. During this phase of the nursing process, which behavior by the nurse indicates critical thinking?

Outcome attainment

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:

whether the client has a document describing wishes for care when the client is no longer able to make decisions.

The nurse is caring for a 70-year-old client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught?

Ask the client to recall after approximately 15 minutes.

A school nurse is discussing bike and outdoor safety measures with a group of Boy Scouts. What type of health education and counseling is the nurse providing to this group of children?

Preventing Illness

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?

Providing client education

A client, eager to go home from an acute care facility, calls out to have discharge education completed. The nurse is not able to get to the client's room until an hour later, and finds the client asleep. The client's significant other states, "She will be out for a couple hours after that pain medication." Which of the following best describes what must happen with the education session?

The client demonstrates not being ready to learn

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?

The discharge home of clients who are more critically ill

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.

The nurse fails to accept that clients have the right to change their minds. The nurse uses medical jargon frequently when discussing the teaching plan. The nurse ignores the restrictions of the client's environment.

The nurse is caring for a client who demonstrates a health literacy concern. The nurse adjusts client teaching in which way?

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