Nursing final practice test
The nurse is counseling a client undergoing chemotherapy. The client has shared with the nurse that the client does not have much of an appetite and is worried about not getting enough nutrients. Which of the following statements by the nurse addresses the client's concerns?
"Let me share information about high-nutrient-density foods to help you make choices."
Infertility in a woman is considered grounds for divorce and rejection among Arabs.
Although infertility is grounds for divorce in Arab cultures, it is not the best option for this question. Infertility as a punishment for unholy living may not be a generally accepted view, it is not the best option for this question. While the loss of status among other married Arab women may be true, it is not the best option for this question.
Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:
Show the unit staff proper student identification
You must always be aware of the client's need for rest. A lack of rest for long periods causes illness or worsening of existing illness.
Although the other options are appropriate concerns, they are not as immediate in nature as is the sleep problem.
Which of the following statements made by a nurse best reflects an understanding of the adaptation required of nursing to assure quality nursing care for the older adult client?
"My client is in her 90s, so I don't expect her to respond to the therapy like a 50- year-old does."
Which of the following statements made by a nursing student regarding responsibility for provided care requires immediate follow-up by the nursing instructor?
"My clinical instructor is ultimately responsible for the care I provide."
Which of the following assessment data provided by a client's family will have the greatest impact on the client's care while hospitalized?
"My husband doesn't like to let people know his arthritis is bothering him."
Which of the following nursing statements reflects the best understanding of the importance of appropriate nursing documentation regarding risk management?
"My notes are the proof that I provided the client with effective, appropriate care."
The daughter of an 88-year-old female client tells the nurse that her mother has recently quit going on walks in the neighborhood because of pain in her legs. Which of the following is the best response from the nurse?
"I would like to speak with your mother to get more information."
An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self- administration of medications?
"I'll be sure to read the inserts and ask the pharmacist if I don't understand something."
Which of the following questions will provide the nurse with the best understanding of a terminally ill client's spiritual needs?
"Are there any spiritual needs you have that I may help with?"
Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLS) to that client's activity tolerance?
"By washing and dresing himself he is building muscle strength that lets him actually walk a little better."
A client has reported to the nurse that his sprained ankle resulted from "a careless accident. I seem so clumsy and unfocused lately." Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms?
"Do you have any idea what is responsible for this lack of focus?"
The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse?
"Do you have any other gastrointestinal problems besides GERD?"
A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care?
"Do you have any suggestions on how we can minimize the pressure to her ankles?"
mother will receive after making the decision to institutionalize her. Which of the following statements made by the The son of a client diagnosed with moderately advanced Alzheimer's disease shows concern over the care his admitting nurse is most therapeutic in addressing the son's concerns?
"I hope that you will be able to visit your mother often and offer us suggestions on how best to meet her physical and emotional needs."
Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided?
"Pressure ulcer on left heel is no longer producing purulent drainage."
Which of the following statements made by ancillary personnel regarding the bathing of a 79-year-old client requires immediate follow-up by the nurse?
"She seemed to enjoy her morning bath; I'll bathe her again this evening after dinner."
A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client's care needs?
"She was sleeping when I checked 15 minutes ago. I'll go back in right now."
Which of the following statements made by a nurse reflects the best understanding of the legal safeguards of a DNR (do not resuscitate) order?
"The DNR order on the terminally ill client in Room 45 needs reviewed today."
Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?
"The client agreed to the consultation, so l'll have the chart sent over."
Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student?
"Think about several interventions that you could use with this client."
Which of the following statements made by a nurse caring for a client reporting severe pain expresses the most insight into how pain impacts a client's energy reserves?
"Trying to cope with pain is using up the energy that his recovery requires."
A terminally ill client shares with the nurse that he, "needs to tell someone what I want when the end comes." The nurse's most therapeutic response is:
"We can talk about that now if you want to. Let me close the door and pull up a chair."
The nurse on a postoperative care unit is assessing the quality of the client's pain. In order to obtain this specific information about the pain experience from the client, the nurse should ask:
"What does your discomfort feel like?"
Which of the following assessment questions is most likely to result in pertinent information regarding the client's expectations of the outcomes of a regular exercise program?
"What is your idea of a workable exercise program?"
Which one of the following individuals may legally give informed consent?
A 16-year-old for her newborn child
It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation?
A 45-year-old postoperative client up for the first time since knee surgery
Which of the following clients would most benefit from the case manager model of nursing care?
A client diagnosed with end-stage renal failure
A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior.
A cultural bias refers to interpreting and judging phenomena in terms particular to one's own culture while a universal truth is so overwhelmingly true that all mankind respects and acknowledges the validity of the statement. An individual preference is a personal choice.
If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure measurement may be a false high reading.
A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa.
A client's self-report of pain is the single most reliable indicator of the existence and intensity of pain and any related discomfort. Pain is individualistic.
A misconception about pain is that chronic pain is psychological. The belief that administering analgesics regularly will lead to drug addiction is a misconception. Another misconception about pain is that the amount of tissue damage is accurately reflected in the degree of pain perceived.
The nurse, in caring for this client, will coordinate the activities of other members of the health care client is less fatigued.
A nutritionist team. This client may reqyire the assistance of a nursing assistant to provide personal care until the may be necessary for diet evaluation, planning, and teaching. A nurse may provide education on the dialysis therapy and perform the skill necessary until the client is able to do so independently. The nurse may include patient teaching in the client's care, but more is required to meet the needs of this client. The nurse is not performing in the role of counselor. Clear communication will be necessary for the client to understand self-care measures regarding time. dialysis. The role of communicator does not, however, entirely meet the client's physical needs at this
A client has undergone intestinal surgery and now has an incontinent ostomy. The use of which of the following products by the client indicates that the discharge learning goals have been achieved?
A powder for a yeast infection
After the x-ray confirmation, the next best method involves testing the pH of the feeding tube aspirate and observing the appearbnce of the aspirate.
A properly obtained pH of 0 to 4 is a good indication of gastric placement. Placing the end of the tube in water and observing for bubbling is not an accurate method of checking for tube placement. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus can transmit a sound similar to that of air entering the stomach. Asking the client to speak as a method of checking for tube placement has a high degree of inaccuracy. There have been cases reported in which clients have been able to speak despite placement of feeding tubes in the lung.
Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles.
ADLS require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The remaining options do not explain the reason for the additional activity tolerance as does the answer.
Throughout the nursing process communication is used. During the evaluation phase, communication is specifically used by the nurse to:
Acquire both verbal and nonverbal client feedback
Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Generally, violations of civil laws cause harm to an individual or property and damages involve payment of money.
Administering an incorrect dosage of morphine sulfate would fall under civil law because it could cause harm to an individual. Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). Common law is created by judicial decisions made in courts when individual legal cases are decided (1.e., informed consent). Administrative law is created by administrative bodies, such as state boards of nursing when they pass rules and regulations (i.e., the duty to report unethical nursing conduct)
Health teaching is an example of a nurse-initiated intervention.
Administering medication is a physician- initiated intervention. Ordering a CAT scan is a physician-initiated intervention. Referring a client physical therapy is a collaborative intervention.
A sterile specimen can be obtained through the special port found on the side of the indwelling catheter The nurse clamps the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube.
After the nurse wipes the port with an antimicrobial swab, a sterile syringe needle is inserted, and at least 3 to 5 mL of urine is withdrawn. Using sterile technique, the nurse transfers the urine to a sterile container. The catheter should not be disconnected from the drainage tubing. The system should remain a closed system to prevent infection. A urinometer is a device used to determine the specific gravity of urine. It is not a sterile device and should not be used for obtaining a sterile urine specimen. Urine should not be obtained from a drainage bag for a specimen, because the urine would not be fresh and would be contaminated from microorganisms in the drainage bag.
An emancipated minor, one who is below the age of 18 but who is a parent, can legally give informed consent for the care of her newborn.
An emancipated minor can also be someone below the age of 18 who is legally married. A person who has been sedated cannot legally give informed consent. Consent should be obtained before a sedative is administered. If the 84-year-old client were unable to give consent, then the client's wife would be the person legally authorized to do so on the client's behalf. In order for a friend to be legally able to give consent, he or she would have to possess power of attorney or legal guardianship of the client. If a client does not understand the proposed treatment plan, the nurse must notify the physician or nursing supervisor and must make certain that clients are informed before signing the consent.
An unintentional tort is an unintended wrongful act against another person that produces injury or harm.
An example of an unintentional tort would be leaving the side rails down and the client falls and is injured. Restraining a client who refuses care would be an example of assault and battery. Taking photos of a client's surgical wounds without the client's permission is an example of invasion of privacy. Talking about a client's history of sexually transmitted diseases would fall under the category of invasion of privacy. Personal information should be kept confidential.
An older Chinese client experienced a stroke that left him with right-sided weakness and now refuses to participate in physical therapy until his son is present. The nurse should initially interpret this behavior as:
An illustration of cultural collectivism
When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion of feces located higher in the color seeps around the impacted mass.
An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate. The digital examination should be performed after it has been determined that the client has been without a normal bowel movement for several days. Although the remaining options are not inappropriate, they would not be the initial intervention.
The benefit of anticipatory grief is that it allows time for the process of grief (i.e., to say good-bye and complete life affairs).
Anticipatory grief allows time to grieve in private, to discuss the anticipated loss with others, and to "let go" of the loved one. Anticipatory grief can help a person progress to a healthier and dealing with loss. It is not most beneficial for grieving to take place emotional state of acceptance only in private. It is important for grief to be acknowledged by others, and to be able to receive the support of others in the grieving process. Anticipatory grieving can be discussed with others in most circumstances. However, there may be times when anticipatory grief is disenfranchised grief as well, meaning it cannot be openly acknowledged, socially sanctioned, or publicly shared, such as a partner circumstances, as this discussion dying of AIDS. The benefit of anticipatory grieving is not so much that it can be discussed in most can also occur with normal grief when the actual loss has occurred. Anticipatory grief is the process of disengaging or "letting go" that occurs before an actual loss or death has occurred. The benefit is not the separation of the ill client from the family as much as it is the process of being able to say good-bye and to put life affairs in order, and as a result, it can help a client or family to progress to a higher emotional state.
When reaching over the side rails to take a client's blood pressure, he draws back. To promote effective communication, the nurse should first:
Apologize for startling the client and explain the need for touching the client
Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than quickly and carelessly forming quick solutions.
Asking for staff input regarding interventions shows critical thinking. While Answer 1 may be true, it is knowledge or experience, not critical thinking, that brought about this conclusion. Although Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. While Answer 4 may be true and an example of an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion.
The client's vital signs are consistent with the client being in pain. It would be safe and appropriate for the nurse to give the pain medication.
Asking if the client is anxious is not the most appropriate action. most appropriate action is for the nurse to administer pain medication. Rechecking would not be the The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action. The nurse should medicate the client for pain.
The nurse most effectively addresses the protection of a terminally ill, incontinent client's skin from irritation and breakdown by:
Assessing the client's bed frequently for wetness and assuring clean, dry linens and clothing
Family and friends can make important observations about the client's health status, changes, and needs that can affect the way care is delivered.
Being aware of the client's reluctance to discuss his pain will impact the frequency and way his pain is assessed. While this information will affect the way the staff prepares the client for sleep, it does not have priority over pain assessment. While this information will allow the staff to meet the client's morning coffee need, it does not have priority over pain assessment. While this information will affect the way the staff address the client's emotional needs, it does not have priority over pain assessment.
This reaction prepares a person for action by increasing heart rate; diverting blood from the intestines levels.
Body temperature and oxygen saturation are not typically affected by fight or flight. to the brain and striated muscles; and increasing blood pressure, respiratory rate, and blood sugar
Spiritual priorities do not need to be sacrificed for physical care priorities. For example, when a client is in acute distress, focus care to provide the client a sense of control, but when a client is terminally ill, spiritual care is possibly the most important nursing intervention.
By arranging for the PT treatment at a time that will not interrupt the client's prayers, the nurse is showing attention to the client's spiritual needs most therapeutically. While the other options may be appropriate, they do not address the facilitation of the client's expressed need regarding prayer.
Regarding a client who is an Orthodox Jew and maintains a Kosher diet, the nurse will make sure that the client's menu does not include:
C. Shellfish
A case manager follows up with the client after discharge home.
Case managers do not always provide direct care, but instead they work with and supervise the care delivered by other staff members. Case availability of services and resources, and assisting the client in choosing cost-efficient health care managers actively coordinate client discharge planning by identifying health care needs, determining the options. The client dealing with end-stage renal failure would most benefit from this model of care because the client's case is the most complex and will require extension discharge support.
After a Navajo child's delivery, the umbilical cord is taken from the newborn, dried, and buried near a place that symbolizes what parents want for the child's future.
Catholics do not have special care of the umbilical cord after delivery. They may want their newborn baptized if there is any chance of the newborn not surviving. Shintos have no special rituals related to birth, including the umbilical cord. Hindus have no special rituals related to birth, including the umbilical cord.
Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client?
Changing soiled dressings
Which source of law best addresses a situation where nurse accidentally administers an incorrect dosage of morphine sulfate to the client?
Civil law
and exercise, can slow the process of Alzheimer's disease considerably.
Clients may live years after the Alzheimer's disease usually progresses gradually with a deterioration in function. Medications, not diet diagnosis of Alzheimer's disease. There is no cure for Alzheimer's disease but medications can be given to slow the progression of symptoms.
It is necessary for the nurse manager to delegate tasks to the staff. Which of the following is a requirement of the delegation process?
Communicating the work assignment in understandable terms
Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.)
Condition of surrounding tissue. Depth of damage. Length and width. Description of drainage. Presence of drainage.
Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care.
Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client.
The client appears to be breathing faster than before. The nurse should:
Count the client's rate of respirations
The daughter of a terminally ill client is grieving the inevitable death of her parent. The expression and depth of her grieve is most likely impacted by her: (Select all that apply.)
Culturally influences. Past experiences with loss. Spiritual beliefs.
The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurse's initial intervention for this client is to:
Determine if the client has been eating sufficiently, especially fiber-rich foods
The correct option best describes ageism since it identifies discrimination towards a person based solely on the person's age.
Devaluing is one aspect of ageism but this option failed to identify discrimination as the goal. While perception of a person's worth is a criteria used to judge, it is not the most complete description of the term. Bias and discrimination are the outcomes of ageism.
The nurse defines ageism most accurately
Discrimination based on an individual's increasing age
The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure?
Discuss the pre- and postprocedure care that will be provided.
Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions.
Do the datareveal what you believe is true, or are there other options? Although pain may be the cause of this clients tears, there are other possible reasons, so making an assumption is not appropriate. Although Answer 3 shows the nurse's intention to analyze the client's needs, the delay is not appropriate. While the client may be experiencing some depression, there are other possible reasons for the tears and so the nurse should not assume.
The nurse educator is asking the student to synthesize to examine alternatives to meet the client's unique needs critical thinking skills by encouraging the student within the context of the nursing process.
Drawing inferences is a specific critical thinking competency used in diagnostic reasoning. The educator who tells the student not to draw inferences is not allowing the student to practice competencies necessary for specific critical thinking in clinical situations. The critical solution to a problem. Intuition develops as one's clinical experience thinker will look beyond a single should examine increases. The nursing student rationales in order to make good decisions.
Implement a comprehensive skin care program to prevent skin breakdown in all clients, from neonates to older adults.
Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turn the client at least every 2 hours). Keeping the skin dry is very important in preventing skin breakdown, range-of-motion exercises will help prevent contractures from occurring, lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers.
An 8-month-old infant is hospitalized with severe diarrhea. The nurse knows that the major problem associated with severe diarrhea is:
Electrolyte and fluid loss
A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when:
Elevating an affected part that is bleeding
Which of the following is likely to result in damage to the client's skin? (Select all that apply.)
Elevating the bed to 85 degrees so the client can easily watch a movie on TV Removing the tape when discontinuing a heparin lock Dry shaving a client in preparation for discharge Frequently positioning the client on her favorite right side
There are issues concerning death and dying may influence nursing practice which the nurse recognizes. Concerning the legalities of death and dying issues, which of the following is true?
Feedings may be refused by competent individuals who are unable to self-feed.
A nursing care assistant fails to report in a timely male client who is recovering from a stab wound. The nurse's initial action is to evaluate the care assistants: manner a request for pain medication from an African-American
Feelings regardikg this particular client
Good nutrition for older adults includes a limited intake of refined sugars.
Fiber should not be reduced as it has benefits of aiding bowel elimination and lowering cholesterol. Protein should not be reduced. Protein intake may be lower than recommended if older adults have reduced financial resources or limited access to grocery stores. Difficulty chewing meat may also limit protein intake. Vitamin A does not need to be reduced in the older adult. Vitamin intake may be less than recommended if shopping for fresh fruits and vegetables is difficult.
Knowing who clients are helps you select caring approaches that are most appropriate to the clients' needs.
For that reason, focus on building a relationship that allows you to learn what is important to your clients. While arranging for clergy to visit may be comforting to some clients, the nurse must first 'know the client to determine if it would be appropriate and then ask the client if they wish clergy to visit. While asking someone why the client is crying may get to the root of the crying, it does not aid directly in the nurse-client relationship that will help in the development of a caring relationship built on the nurse knowing' the client. While offering to answer questions may help minimize the client's fear, it will be effective only after the nurse knows' the client well enough to determine that the crying is a result of an insufficient understanding of the proposed procedure.
The general goal of exercise and activity for all clients is to: (Select all that apply.)
Foster personal independence. Minimize social isolation
The client's apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the:
Fourth to fifth intercostal space
The correct sequence for attaining the resolution of an ethical problem is:
Gather facts, verbalize the problem, and consider actions
A nurse is about to administer pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurse's most appropriate action is to:
Give the medication
The nurse is counseling a 64-year-old client that is important to eat plenty of fruits and vegetables, but the client should avoid which of the following because it can inhibit the absorption of some drugs?
Grapefruit
One of the benefits of anticipatory grieving to a client or family is that it can:
Help a person progress to a healthier emotional state
topics would present the greatest learning challenge for this developmental group? The nurse is preparing an educational program for members of the local senior center. Which of the following
Importance of the human touch
It would be important to know the time frames of the employer's malpractice coverage.
In other words, is the nurse only covered during the times he or she is working within the institution? It would be important to know the individual liability. For example, if sued, what financial responsibility would the nurse have? The nurse should be aware of Good Samaritan laws, but this would not be sufficient coverage for most nursing practice. Therefore it is not the most importance factor in determining whether to purchase private malpractice insurance. The amount of malpractice insurance provided by the employer is not the most important factor in deciding whether to carry private insurance. Generally, the employer's malpractice insurance coverage is much greater than private insurance coverage. The area of nursing in which the nurse is employed is not the most important factor in deciding whether or not to carry malpractice insurance. Lawsuits can occur anywhere.
A nursing diagnosis focuses on a client's actual or potential response to a health problem rather than on the physiological event, complications, or disease.
In the case of the diagnosis deficient knowledge regarding surgery, the nurse will best minimize anxiety by providing information regarding pre- and postoperative routines so as to facilitate the client in formulating realistic expectations. Although the other options are appropriate, they are limited in scope and do not have as much impact on anxiety.
What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift?
Include the client's request in the shift report.
Nurses need to be aware of current trends in the health care delivery system in order to respond in educational preparation and practice. A major trend that is influencing nursing practice today is:
Increased incidence of chronic disease processes
Excess loss of colonic fluid because diarrhea can result in serious fluid and electrolyte or acid-base imbalances.
Infants and older adults are particularly susceptible to associated complications. Pain from abdominal cramping may occur with diarrhea, but it is not the major problem associated with severe diarrhea. Excessive flatus is not the major problem associated with severe diarrhea. Because repeated passage of diarrhea stools exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage are needed to prevent skin breakdown. The greatest danger of severe diarrhea is a fluid and electrolyte or acid-base imbalance.
To determine the quality of the client's pain the nurse might say, "What does your discomfort feel like?" It is more accurate to have clients describe the pain in their own words whenever possible.
Inquiring about what activities make the pain worse is a type of question directed at determining the pain pattern. Having the client rate his or her pain on a pain scale is a method of measuring the intensity of pain. To determine the client's expectations, the nurse may ask the client, "How much discomfort are you able to tolerate?"
Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: "Client will lose 10 pounds in 3 months?"
Interview the client to identify reasons why the goal was not met.
The client's admission has no acute physical needs and so the emotional need of familiarization with the environment has priority.
Inventory of clothes and other personal belongings does not reflect a priority because it does not relate directly to a physical need, and there are other emotional needs of higher priority. Interview regarding medications currently being taken does not reflect a priority because it does not relate directly to a physical need, and there are emotional needs of higher priority. Although assessment of body systems for presurgery checklist reflects a needed nursing action, it is not a priority because it does not relate directly to physical need, and there are other emotional needs of higher priority.
disposable gloves helps protect the susceptible host.
Isolating client's articles is an intervention to Covering the mouth and nose when sneezing is an intervention to control a portal of exit. Wearing articles that become contaminated with infectious material such as in changing soiled dressings. fluids, drainage, or solutions that might harbor microorganisms. The nurse also To control or eliminate reservoir sites for infection, the nurse eliminates or controls sources of body carefully discards control transmission.
A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that:
It usually progresses gradually with a deterioration of function
The health care provider has ordered a stool specimen for ova and parasites from the 43-year-old male client. The nurse knows that when collecting the specimen the stool must be:
Kept warm
Jewish clients who follow a
Kosher diet will avoid meat from carnivores, pork products, and fish without scales or fins. Therefore shellfish should not be included in the menu of a client who is an Orthodox Jew and maintains a Kosher diet. Beef may be included in a Kosher diet. Eggs may be included in a Kosher diet. Milk may be included in a Kosher diet.
Which one of the following actions is example of an unintentional tort?
Leaving the side rails down and the client falls and is injured
The nurse realizes that an individual client's value system is most affected by:
Life experiences
for the promotion of respiratory Positioning the client upright is an independent nursing intervention function in a terminally ill client.
Limiting fluids may not promote respiratory client is on a fluid-restricted diet, the nurse should not do so. Reducing nurse-initiated activity to promote respiratory function. A respiratory rate should be assessed before narcotic analgesic use is not a function, and unless a administering narcotics to prevent further respiratory depression. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician's order. It is not an independent nursing activity.
return you to the optimum level of self-care A nurse is caring for a client who has chronic renal failure. The nurse states, "We will do everything possible to possible." In coordinating an approach to best meet the needs of this client, the nurse is fulfilling the role of:
Manager
A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons form tampering with records.
Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is not a true statement. Authorized health care providers from any department can access and use the data.
Which of the following would the nurse expect as a normal change in the bowel elimination as a person ages?
Mastication processes are less efficient.
A nasogastric tube is inserted in order for the client to receive intermittent tube feedings. An initial chest x-ray examination is done to confirm placement of the tube in the stomach. After the x-ray confirmation, the most reliable method of checking for tube placement is for the nurse to:
Measure the pH of the secretions aspirated
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced.
Medications that cause dizziness and prolonged immobility also affect balance. Although all the options represent a potential risk for falling, the postoperative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk.
Nursing education programs in the United States may seek voluntary accreditation by the appropriate accrediting commission council of the:
National League for Nursing
The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the child's birth for the clients who are:
Navajo
When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy.
Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.
The nurse observes a client scheduled for an invasive procedure crying while discussing the procedure with a family member. Which of the following therapeutic nursing interventions would be the most caring?
Offering to "sit and talk" if the client has any questions
adults are lifelong learners, but concrete rather than abstract material appears to be a better choice for Of the available topics, "Importance of the human touch" is possibly the most abstract in nature.
Older in nature and so a better choice for the in nature and so a better choice for the learning style of most older adults. This option is concrete learning style of most older adults. This option is concrete the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults.
The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority?
Orientation to the nursing unit and individual room
The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are:
P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg
To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have:
Periodic changes in staff passwords
The belief that all life is sacred and must be preserved regardless of the quality of that life is an example of:
Personal value
Acute pain seriously threatens a client's recovery by resulting in prolonged hospitalization, increased risks of complications from immobility, and delayed rehabilitation.
Physical or psychological progress is delayed as long as acute pain persists because the client focuses all energy on pain relief. A pain rating of 4 reflects tolerable pain, which may be a realistic expectation in some cases of chronic pain.
In the acute care setting, the change-of-shift report is the way for nurses from one shift to communicate client's wishes above the bed is not appropriate because there is no client's condition, response to treatment, or current appropriate for inclusion in the nursing notes because it does information to nurses on the next shift Documenting the request in the nursing notes is not health status.
Placing the instructions regarding the not reflect information regarding the guarantee that staff will see the wishes being respected, it is not the most the unit clerk of the client's request may result in the client's posting, but more importantly there are confidentiality issues being ignored. While verbally informing effective option.
A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to:
Position the client upright
Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive.
Postmenopausal women have a greater problem with osteoporosis than older men. Muscle fibers are reduced in size with aging. Muscle strength diminishes in proportion to the decline in muscle mass.
Assessment includes depth of tissue involvement in wound bed, wound dimensions, exudate description, and condition of surrounding skin.
Presence of (staging), type and approximate percentage of tissue pain is not a component of this charting.
Foods are sometimes described according to their nutrient density, the proportion of essential nutrients to the number of kilocalories. High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. The client did not express a concern about weight loss but is asking about nutrition.
Protein provides energy, but because of protein's essential role in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. Each gram of carbohydrate produces 4 kcal and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. When there is sufficient carbohydrate in the diet to meet the energy needs of the body, protein is spared as an energy source.
Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse- initiated intervention is:
Providing client teaching
An example of a cognitive nursing skill
Recognizing the potential complications of a blood transfusion
When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a:
Referral
The nurse is presenting an information session on nutritional guidelines at a senior living center. Incorporated into the discussion are the recommendations for nutritional intake for individuals of this age-group, which include a reduction in:
Refined sugars
After measuring the client's vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg. pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should:
Retake the blood pressure
The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to:
Schedule the client's physical therapy treatments to avoid being an interruption
Cultural groups consist of units of social organization delineated by kinship, status hierarchy, and appropriate roles for their members. Sensitivity to social organization is the recognition of the client's status and role in the family.
Sensitivity to communication patterns would be the recognition of the client's language usage. Cûlture is the framework used in defining social phenomena such as when a person is considered to be healthy or in need of intervention. The way an individual defines health and health practices needs to be understood by the nurse to best meet the needs of the client. Sensitivity to social organization is not met by recognizing the definition of health for an individual. Psychological characteristics and coping mechanisms may be expressed in a variety of ways across cultures. Sensitivity to social organization is not demonstrated by the recognition of psychological characteristics and coping mechanisms of a particular culture.
A client is admitted for a CAT scan (diagnostic test) of the cranium. As the nurse explains this diagnostic test, the client moves away from the nurse. This is an example of what influencing factor in communication?
Space and territoriality
To thrive, organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light.
Space does not generally affect microorganism growth.
The nurse recognizes which of the following client outcomes as being a result of ineffective pain management? (Select all that apply.)
Stage 1 pressure ulcer development on coccyx and left hip. Inability to self-ambulate distance from bed to bathroom Client expressing feelings of despair and hopelessness. Postponement of discharge because of the inability to perform activities of daily living. Postponement of physical therapy because of client's inability to tolerate knee flexion.
Within transcultural nursing, sensitivity to social organization is the recognition of the client's:
Status and expected role in the family
When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.)
Stress management. Improved bone integrity. Enhanced cardiac output. Increased musculoskeletal flexibility. Facilitation of weight control.
The first action the nurse should take is to assess the client's respiratory rate. The nurse can then determine if the client is breathing faster than before.
Stress may increase an individual's respiratory determine if it is within normal limits and will be able to compare it to the previous measurement to findings the nurse may or may not need to take the client's pulse. Assessing the pulse will not verify if implementing any nursing measures. The nurse should count the respiratory rate. Based on these down may decrease a client's respiratory rate, but the nurse should first assess the client before rate. The nurse should first make the objective measurement of the client's rate. Having the client lay the client is breathing faster.
foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her to her bath while she was in the tub. The nurse should do which of the following?
Suggest that the temperature of the hot water heater be lowered.
The nurse recognizes that a client experiencing anxiety related to a traumatic injury and the resulting pain is likely to experience the fight or flight response, which would cause which of the following assessment findings? (Select all that apply.)
Systolic blood pressure 26 mm Hg above baseline. Fasting glucose level of 118 mg/dL. Heart rate greater than 100 beats per minute. Respirations of 30 breaths per minute.
A spouse assists the nurse evaluating the measurement of the client's blood pressure. The nurse feels additional teaching is required if the spouse is observed:
Taking the blood pressure after the client comes back from a walk
A nurse caring for the Arab community observes a client crying. The woman was recently informed that her radiation treatments may affect her ability to become pregnant. The nurse recognizes that the client is most likely reacting to a cultural attitude regarding:
The Arab view that infertility is grounds for divorce
The National League for Nursing (NLN) is the professional nursing organization concerned with nursing education.
The NLN provides accreditation to nursing programs that seek and meet the NLN accreditation requirements. The American Nurses Association (ANA) is concerned with the nursing profession and issues affecting health care, including standards of care. The Congress for Nursing Practice is the part of the ANA concerned with determining the legal aspects of nursing practice, the public recognition of the importance of nursing, and the impact of trends in health care on nursing practice. The International Council of Nurses (ICN) is concerned about issues of health care and the nursing profession, including the provision of an international power base for nurses.
In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists.
The absence of purulent drainage indicates successful nursing interventions while the other options either fail to provide measurable data regarding the wound or indicate no improvement.
Hot water from the tap should not have the potential to scald, because it is a safety hazard.
The client had a plausible explanation for the incident without other signs to indicate abuse. There is no reason that the client should not be able to continue to take tub baths if the water temperature is within a safe range. The client has no other indications that she is in any danger of caring for herself; thus Answer 4 is not appropriate.
Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance.
The client is less likely to be able to pay attention and comprehend instruction when in pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning.
space at the left midclavicular Fifth to sixth is not the correct placement for auscultating a client's apical pulse. the third to fourth is incorrect.
The client is not identified as being a child. auscultating a client's apical pulse. The PMI is higher and more medial in children under 8 years old, thus line. Second to third intercostals space is not the correct placement for An apical pulse should be assessed at the client's PMI. The PMI is located at the fourth to fifth intercostal
Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct?
The client is the best authority on the pain experience.
The client's blood pressure should not be measured after the client has exercised, smoked, or ingested caffeine.
The client should wait 30 minutes before assessment of the blood pressure. The cuff should be deflated at a rate of 2 mm Hg per in a chair. The blood pressure should be assessed at the same time each day. second. When possible, the client should be sitting
Territoriality is the need to gain, maintain, and defend one's right to space.
The client who moves away from the nurse during a conversation is demonstrating the influence of space and territoriality on communication. This not an example of gender influencing communication. This is not an example of environment influencing communication. Noise, temperature extremes, distractions, and lack of privacy are examples of environmental factors that may influence communication. Although people do maintain varying distances between each other depending on their culture, this is not an example of sociocultural background influencing communication, as cultural orientation is not mentioned in this situation.
An older adult client diagnosed as being in the early stage of Alzheimer's disease shares with the nurse that her sleep is interrupted by "the noises I hear all through the night." The nurse explains that the most likely reason for this problem is:
The client's age
Student nurses are expected to perform as professional nurses, that is, as an RN would in providing safe, appropriate client care.
The clinical instructor is responsible for proper instruction, supervision, and guidance but the student is responsible for their own acts. The remaining options do reflect misconceptions, but the issue of responsibility has priority.
The nurse is caring for a 35-year-old father of three young children who has experienced a compound fractured femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again. This has affected both his emotional status and his sleeping patterns. The nurse's most immediate concern is that:
The lack of appropriate rest will affect his healing process
Progressive disease and decreased level of consciousness can result in both urinary and fecal incontinence.
The most effective means of protect skin from irritation or breakdown is by maintaining dry linens and clothing. The remaining options are not inappropriate, but a client may not be able to respond to the need to urinate or defecate. While adult diapers and an indwelling catheter are viable interventions, the client must still be provided with care that ensures that skin will be clean and dry.
These are expected findings of a 10-year-old client.
The normal pulse range for a 10-year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure range for a 7- year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected values of a 10-year-old client.
When delegating, the nurse should always provide unambiguous and clear directions by describing a task, the desired outcome, and the time period within which the task should be completed.
The nurse manager does not necessarily have to work alongside staff to evaluate their care. The nurse manager can often evaluate staff performance in client outcomes. A laissez-faire style of leadership is not a requirement for delegation. Tasks should be delegated to those who are capable, not necessarily to those who are willing.
Nurses often have to enter a client's personal space to provide care.
The nurse should convey confidence, gentleness, and respect for privacy. This response demonstrates respect and provides information so the client can understand the need for personal contact. Telling the client that the blood pressure can be taken at a later time does not promote effective communication. Rotating the nurses who are assigned to take the client's blood pressure impedes the nurse's ability to form a therapeutic, helping relationship. Continuing to perform the procedure quickly and quietly may send a negative nonverbal message. It also does not promote effective communication.
The normal blood pressure reading is s120/80 mm Hg. This client's blood pressure is significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions).
The nurse should retake the blood pressure. The client's temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5° C. The nurse should repeat the blood pressure measurement to confirm the reading before reporting the findings. The blood pressure reading is not within normal limits. The pulse rate, respiratory rate, and temperature are within normal limits.
This option reflects an understanding of the importance to understand the various aspects of the medication and its effects on the client.
The older adult should be encouraged to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. Although this option reflects an understanding of potential risk for side effects, it is not the best option because it focuses on only one aspect of self-medication. This option appears to have the client delegating responsibility to the daughter. This option appears to have the client minimizing the importance of informed self- administration.
Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information.
The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information.
In collectivistic cultures that value group reliance and interdependence, such as traditional Asians, Hispanics, and Africans, caring behaviors require actively providing physical and psychosocial support for family or community members.
The other options may be true; however, the more likely interpretation is the client's cultural inclination toward group reliance and family support systems.
Development of values begins in childhood, shaped by experiences within the family unit, especially dramatic events during the formative years.
The other options may influence the value system, but not to the same extent.
If a yeast infection occurs, thorough cleansing should be performed, followed by patting the area dry and applying a prescribed topical agent, such as triamcinolone acetonide (Kenalog) spray or nystatin (Mycostatin), to the affected region.
The peristomal skin should be cleansed gently with warm tap water using gauze pads or a clean washcloth. An ostomy deodorant may be placed into the pouch, not around the stoma. Alcohol should not be used to clean the stoma. The area may be cleaned with warm tap water.
The nurse should ask relevant questions and collect relevant history and physical assessment data related to the client's presenting health care needs in order to produce the most inclusive, effective nursing care plan.
The questions "How long have you been dealing with GERD?" and "Are you currently taking any medications for your GERD?" as well as "Do you follow a particular diet to help manage your GERD?" are directed towards the GERD itself and not towards conditions that might be related to the presence of GERD.
Effective pain management improves quality of life, reduces physical discomfort, promotes earlier mobilization and return to work, results in fewer hospital/clinic visits, and shortens hospital stays, thus reducing health care costs.
The remaining option does not involve a client who is normally dealing with pain.
The nurse's documentation is often the evidence of care received by a client and serves as proof that the nurse acted reasonably and safely.
The remaining options are not incorrect but do not identify the primary importance to the nurse.
Weakening of the epidermis occurs by scraping or stripping its surface (e.g., use of dry razors, tape removal, or improper turning or positioning techniques).
The remaining options are not likely to cause skin damage
With aging, sleep becomes more fragmented, and a person spends more time in lighter stages that are easily disturbed by noise.
The remaining options may be a factor but not to the degree of normal aging.
When goals are not met, the nurse should identify the factors that interfere with goal achievement.
The remaining options reflect actions to be taken after the interview to further determine how the care plan will be modified.
A living will is an advance directive, prepared when the individual is competent and able to make and communicate personal decisions, regarding specific instructions about end-of-life care.
The remaining options represent motivation for implementing a living will.
It is important to avoid delays in sending specimens to the laboratory. Some tests such as measurement for ova and parasites require the stool to be warm.
The specimen need not be collected using sterile technique, because the laboratory will not be testing the sample for bacteria, but it should be collected good sanitation practices. Likewise, a small amount of urine should not alter the test results.
Which of the following is the most important factor in a nurse deciding whether or not to carry malpractice insurance?
The time frames and individual liability of the employer's malpractice coverage
An expected change in bowel elimination is decreased chewing and decreased salivation, resulting in less efficient mastication.
There is decreased nutrient absorption of the small intestine in the older adult. Esophageal emptying slows, as a result of reduced motility, especially in the lower third of the esophagus. With decreased peristalsis and weakened musculature, the older adult is more prone to constipation. Duller nerve sensations may place the older adult at increased risk for fecal incontinence.
Competent clients have the right to refuse treatment.
This includes life-saving hydration and nutrition. This is not a true statement. Furthermore, physician-assisted suicide is legal in the state of Oregon. In 1997 the Supreme Court ruled that there is no fundamental constitutional right to assisted suicide. Organ donation does not have to be attempted to save a recipient's life.
In asking if there are any spiritual needs that the client might need help with, you collect information about life goals, values, anH religious practices; part of a client's spirituality.
This option provides the client with an opportunity to discuss his needs if indeed he has any while reaffirming the nurse's wish to meet his needs. Asking simply is a client has a religious preference is a closed-ended question and provides little encouragement to discuss spiritual needs. While asking if the client has given thought to their spiritual needs provides an opportunity to discuss any client needs, it does not allow for the nurse to be of help with attending to these needs. Inquiring about a particular clergy is a closed-ended question and provides little encouragement to discuss spiritual needs.
The nurse and client deterinine whether the plan of care has been successful by evaluating the client communication outcomes established during planning.
This process involves acquiring verbal and nursing process. Delegation is more likely to be used in the implementation phase of the nursing nonverbal feedback. Delegation is not the purpose of communication in the evaluation phase of the and planned interventions is part of the planning phase of the nursing process, not the evaluation are gathered during the assessment phase of the nursing process. Documenting expected outcomes evaluation phase of the nursing process. Validation of the client's needs is often determined when data process. Validation of the client's needs is not why the nurse specifically uses communication in the phase.
Given the increasing number of older adults in health care settings, cultivation of positive attitudes toward older adults and specialized knowledge about aging and the health care needs of older adults are priorities for nurses.
This statement reflects that the nurse understands that older client's may respond differently than younger adults to certain therapies
Discussing the client's follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in:
Timing and relevance
adult client up in bed. Before moving The nurse and a nursing assistive personnel (NAP) are going to move an older the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is:
To avoid shearing the client's skin
The greater the surface area of the object that is moved, the greater the friction. A larger object produces greater resistance to movement.
To decrease surface area and reduce friction when clients are unable to assist with moving up in bed, nurses use an sling. It mechanically lifts the client off the surface of the bed, thereby shearing of the client's delicate skin. The client may also be frightened by the use of the equipment. It is on and what the client can expect to experience when using any ergonomic assistive device, such as a full body preventing friction, tearing, or important to explain what will be going piece. Lift policies are put in place to protect both clients and staff; however, the nurse should not be as concerned with being "written up" as with protecting himself or herself, the NAP, and the client from harm. The most important reason for using the lift equipment is to protect the client and staff from harm.
DNR orders are not necessarily maintained throughout the client's stay because a client's condition may warrant a change in DNR status.
To ensure client safety, the attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. If there is no living will or durable power of attorney appointed, members of the family will be consulted regarding a DNR order. Although not all family members need to agree, an order will usually not be written if some family members express strong opposition to the status change. If no family can be located, the attending physician has the legal right to write the order. There is no legal requirement for a terminally ill client to be required to assume DNR status.
The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to:
Turn the client a minimum of every 2 hours
Cognitive skills involve the application of nursing knowledge.
Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring that is an interpersonal skill. The nurse who provides a soothing bed bath is also using a psychomotor skill in performing the bed bath correctly. Communicating with the client and family is an example of an interpersonal skill. Giving an injection to the client is a psychomotor skill.
When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should:
Use a syringe to withdraw urine from the catheter port
A loss of REM sleep leads to feelings of confusion and suspicion.
Various body functions (e.g, mood, motor performance, memory, and equilibrium) are altered when prolonged sleep loss occurs. Research estimates that traffic, home, and work-related accidents caused by falling asleep are often a result of sleep loss. This answer is the best question because it directly opens up the opportunity for the client to discuss possible sleep problems if they exist. The other questions are not inappropriate but are less likely to reveal the possible cause of the accidents.
For infectious organisms to grow and multiply enough to cause illness, they need an environment that has appropriate amounts of: (Select all that apply.)
Water. Oxygen. Darkness. Food. Warmth.
There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age:
Weight-bearing exercise reduces the loss of bone mass
If a client is bleeding, the nurse applies direct pressure and elevates the affected part.
When a penetrating object is present, it is not removed. Removal could cause massive, uncontrolled bleeding. Vigorous cleaning can cause bleeding or further injury. Abrasions and minor lacerations should be rinsed with normal saline and lightly covered with a dressing. Puncture wounds are allowed to bleed to remove dirt and other contaminants.
The decision to institutionalize a family member and the aftermath of that decision cause emotional distress and are a threat to family members' psychological well-being.
When their role shifted from primary caregiver to advocate for the patient, the family members felt empowered. Previous studies showed that institutionalized residents have a better quality of life when family members are involved. By encouraging frequent visits and including them in the client's care, the family's concerns will be best managed.
Avoid communication barriers such as denying the client's grief, providing false reassurance, or avoiding discussion of sensitive issues.
When you sense that a client wants to talk about something, make time right then, if at all possible.
The general goal related to exercise and activity is to improve or maintain the client's motor function and independence.
While the other options are not inappropriate, they do not reflect the general goals for all clients.
A reduction in protein, carbohydrates, and fats as a result of illness, inadequate diet, or debility increases a client's susceptibility to infection and delays wound healing.
While the other options are not incorrect, they are not as directly related to the cause of the client's poorly healing, infected wounds.
In assessing the client's expectations concerning activity and exercise, first determine the client's perception of what is normal or acceptable in regard to physical fitness.
While the remaining options are not incorrect, they are not as likely to provide as much pertinent information regarding expectations.
In recent decades, there is a higher incidence of chronic, long-term illness.
With shortened hospital stays, client acuity has increased, not decreased. Hospital stays have decreased, not increased. Lengths of stay have shortened with a trend toward home care, and health promotion and illness prevention. With increased public awareness and rising health care costs, greater emphasis has been placed on health promotion and illness prevention.
A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the client's nutritional history is of primary importance since:
Wound healing and infection prevention are negatively impacted by poor nutrition
A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant:
Wraps the cuff too loosely around the arm
Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs.
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Grief is the emotional response to a loss, manifested in ways unique to an individual, based on personal experiences, cultural expectations, and spiritual beliefs. The remaining options have minimal effect on individual grieving
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Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.
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The correct sequence for resolving ethical problems is recognizing the dilemma, gathering facts, examining one's own values, verbalizing the problem, considering actions, negotiating the outcome, and evaluating the action.
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The presence of pain in an older adult requires aggressive assessment, diagnosis, and management. Pain is not an inevitable part of aging.
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Which of the following client outcomes reflect the positive aspects of effective pain management? (Select all that apply.)
a. A client with knee replacement surgery returning to his job as a mail carrier. C. A client with terminal cancer going home on outpatient chemotherapy. A client who has undergone surgery ambulating to the bathroom on the first postoperative day. A client rating his chronic back pain as a 3 on a scale of 0 to 10 .The client with arthritis in both hands knitting for pleasure.
Which of the following statements made by a terminally ill client reflects the best understanding of the purpose of a living will?
b. "I can make my wishes known while I still have the ability to express them."
Bathing removes excess body secretions, although if excessive, it causes dry skin.
scented soaps is often discouraged. The remaining options do not require follow-up.
nursing care. While all the options are appropriate, the nurse's Personal bias and prejudices when acted upon may interfere with the delivery of appropriate, effective initial action is to determine the cause of is to determine the cause of the care assistant's negligent behavior.
the care assistant's negligent behavior. Although all the options are appropriate, the nurse's initial action
