Nursing Sciences EAQ

A nursing student is listing various stages of Lawrence Kohlberg's Theory of Moral Development. Which situation indicates that the individual has reached the Instrumental Relativist Orientation stage?

"An individual identifies that there is more than one right view."

A nurse is recalling Piaget's theory of cognitive development. What is the characteristic of the preoperational stage?

"An infant may learn to think with the use of symbols and mental images."

Inquisitiveness

acquiring knowledge.

RACE

RESCUE, ALARM, CONFINE, EXTINGUISH/EVACUATE. The acronym RACE stands for Remove all clients from immediate danger, Activate the alarm, Confine the fire by closing doors and windows, and Extinguish the fire with an appropriate fire extinguisher. The acronym does not include alerting the local fire department or releasing the pin from the fire extinguisher.

Evaluation

Reflecting on the nurse's own behavior

Self Regulation

Reflecting on your own experiences

Reminiscence

Reminiscence helps bring meaning and understanding to the present and resolve current conflicts by recollecting the past.

Which nursing intervention fosters the infant's development of trust?

Follow the parents' directions while providing care. Parents would provide the majority of the care when an infant is hospitalized. If the parents are away, the nurse would follow the parents' directions. This helps foster the infant's continuing development of trust.

When a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take?

Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

The school nurse conducts a class in nutrition planning for parents. What is the goal of school health nursing programs?

Health promotion

The nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which safeguard would the nurse take during this procedure?

Surgical asepsis

What information should the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply.

Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources

Which theories are relevant only to development in adults? Select all that apply. One, some, or all responses may be correct. Piaget's theory Erikson's theory Kohlberg's theory Stage-Crisis theory Life Span approach

Stage-Crisis theory Life Span approach

Which is an example of independent thinking in nursing practice?

Talking with other nurses to share ideas about nursing interventions

A nurse needs to provide preventive and primary care to adults during a health camp. Which of these actions should the nurse perform? Select all that apply.

The nurse should discuss vaccinations. The nurse should discuss family planning The nurse should instruct the health camp about road safety measures.

Delirium

The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

Evidence-informed nursing uses a variety of sources to support nursing practice. Which are sources of evidence-informed practice? Select all that apply.

Theory Research Clinical expertise

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often?

every 72 to 96 hours Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.

Arrange the stages of life in Erikson's theory of psychosocial development in the correct order

Trust versus mistrust Autonomy versus a sense of shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter?

Tubing injection port

Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct.

Using pincer grasp well Picking up small objects Showing hand preference

An older adult is experiencing emotional stress after a recent surgery. Which intervention would be most appropriate for the client?

Validation therapy

Validation therapy

Validation therapy is a communication technique that can help the client in a confused state.

Which goals of care are associated with the family health system model? Select all that apply. One, some, or all responses may be correct.

improve family health or well-being assist the family in managing the illness conditions achieve health outcomes related to the family's areas of concern.

Which statement is applicable to Watson's theory of transpersonal caring?

Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life.

Which action by the nurse is an example of a protective touch that may elicit negative feelings in a client?

Withdrawing from a client to escape the situation

Analysis

a critical thinking skill that requires open-mindedness while looking at the client's information

When ammonia is excreted by healthy kidneys, which mechanism usually is maintained?

acid-base balance

Which behavior by the client exhibits denial after a recent diagnosis?

attempts to minimize the illness

Which theory describes the phenomenon of grief or caring?

Descriptive theories

Interactive process

Family relationship

Explanation

Supportive findings and conclusions

The family health system

includes five realms, or processes, of family life. These realms are interactive, developmental, coping, integrity, and health. This approach is a method for family assessment used to determine areas of concern and strengths and to help develop an effective care plan. The component of integrity includes family rituals. Family relationships are a part of interactive processes. Family life stressors and daily hassles are considered components of coping processes. Health processes include family care takings and responsibilities.

Maturity

reflecting on one's own judgments and having cognitive maturity

open mindedness

respecting the rights of others and being tolerant of different viewpoints.

Anal Stage

second stage, from 12 to 18 months to 3 years of age.

Factors that can lead to nurses making medication errors

stress, overwork, and fatigue

nursing model of total client care

the RN is responsible for all aspects of client care; care can be delegated from the RN to other members of the health care team; and the RN works directly with the client, family members, and members of the health care team.

Which group benefits from Medicare?

People who are 65 years or older

Which of these is a part of health belief model?

Perception of susceptibility to an illness

Oral Stage

birth to 18 months

The nursing student is learning about the realms of family life. Which component would be included while learning about integrity processes?

Family rituals

Which basic concept associated with rehabilitation would the nurse consider when formulating discharge plans for clients?

Immediate or potential rehabilitation needs are exhibited by clients with health problems.

Which intervention by the home health care nurse conforms to the use of safety competency while providing health care?

The nurse ensures the furniture does not obstruct the client's movement.

A new toy is shown to a baby, and after his or her attention is drawn, the parent hides the toy under the bed. Then the baby tries to find the toy, which is hidden. Which stage of cognitive development does the child belong, according to Jean Piaget?

Sensorimotor

The Institute of Medicine (IOM) identified five interrelated competencies for all health care workers in the twenty-first century. What should the nurse do to provide patient-centered care?

Share decision-making and management.

Which developmental changes require the nurse's assessment in a 12-year-old female?

Skeletal think scoliosis

A nurse is working in a health care organization that has Magnet status. What specific responsibility does the nurse have in this organization?

The nurse must collect data for comparison against a national level.

What is the duty of a nurse while caring for a client?

The nurse should determine the client's care preferences.

How is a SOAP progress note different from a PIE progress note? Select all that apply.

In a SOAP progress note, the P stands for plan; in a PIE progress note, the P stands for problem. SOAP progress notes originate from medical records; PIE progress notes have a nursing origin. SOAP progress notes include assessment information; PIE progress notes do not include assessment information

nursing model of team nursing

In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

Latency stage

6-12 years

alternative family

grandparents caring for grandchildren

A nursing instructor asks a student to describe Betty Neuman's theory. Which statement by the student indicates the need for further education?

"Betty Neuman's theory outlines that the external environmental factors act as stressor."

Which questions would the nurse ask when gathering a client's physical and developmental health history?

"Do you have any marital problems?" "Are you able to complete your activities of daily living?"

A nurse is recollecting Sigmund Freud's psychoanalytical model of personality development. What are the characteristics of the phallic stage, as per this model? Select all that apply.

"In this stage, a child may develop an oedipal complex." "In this stage, a girl may experience 'penis envy' feelings." "In this stage, the genital organs are the focus of pleasure.

A registered nurse is teaching a student nurse about a rapid-improvement event (RIE), a quality improvement model. Which statement by the student nurse indicates effective learning?

"It is a very intense, usually week-long, event."

A nurse conducting a research study is obtaining informed consent from a research subject. Which statement made by the nurse to the client needs correction?

"Let me explain all the details about the research and why it is the best available method of treatment."

A nurse is evaluating situations based on the responses of several clients. Which client's statement confirms that he or she has reached the Integrity versus Despair stage according to Erikson's theory of psychosocial development? Select all that apply.

"Looking back at my entire life, I find that I have actually achieved nothing." "In the twilight of my life, I regret not fulfilling the promises I made to my wife." "Now that I am at the end of the road, I think I am the luckiest person on the earth because God has given me everything that I had asked for."

A registered nurse is teaching a nursing student about Nightingale's theory, which is an initial model for nursing. Which statements of a nursing student indicate an understanding of the theory? Select all that apply.

"Nightingale's theory deals with visionary principles that include areas of practice, research, and education." "Nightingale's theory deals with descriptive theories that provides nurses with a way to think about clients and their environment." "Nightingale's theory focuses on the fact that nursing is caring through the environment and helping the client deal with symptoms related to illness."

A registered nurse is teaching a student nurse about Gesell's theory of biophysical development. Which statement by the student nurse indicates the need for further teaching? Select all that apply.

"Proximodistal growth describes the sequence in which growth is fastest from the head down." "In the cephalocaudal pattern, growth starts at the center of the body and moves toward the extremities."

A nursing student is listing the steps that need to be followed for applying developmental theory when caring for chronically ill older adults with depression. Which step listed by the nursing student needs correction?

"The nurse should recognize the need to identify depression so that heart failure can be prevented."

The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and the health care provider should be notified. I

Which complication would the nurse monitor for in a client on strict bed rest for 3 days?

Atelectasis Hypotension Constipation Pressure injuries Urinary tract infection

Authority

Authority refers to the legitimate power to give commands and make final decisions specific to a given position.

What are the similarities between Medicare and Medicaid? Select all that apply.

Both programs assist older clients. Both programs pay for home care services

Which activity demonstrates fine motor skills in infants aged 2 to 4 months?

Bringing objects from hand to mouth

How does a nurse prepare a "factual" record when performing a client documentation?

By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

How does a nurse incorporate the quality of accuracy into client documentation?

By using exact measurements for each client's activity

Phallic or Oedipal stage

Children between the ages of 3 and 6 years are considered to be in the phallic or oedipal stage.

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse?

Clinical nurse specialist

A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing?

0.9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

A healthcare facility is using the "plan, do, study, act (PDSA)" cycle model for performing a quality improvement. Arrange the order in which quality improvement takes place based on this model.

1. Review available data. 2. Choose the appropriate intervention. 3. Evaluate the outcomes. 4. Incorporate new practices in daily performance

Arrange in order the items of personal protection equipment (PPE) removed after seeing a client in droplet precautions.

1. Gloves 2. Face Shield 3. gown 4. Mask

Genital stage

12-adulthood. he genital stage is the sixth stage; it starts in puberty and continues to adulthood.

How many levels of critical thinking exist for nursing judgment?

3

Which age is considered the phallic stage according to Sigmund Freud's developmental theory?

3 to 6 years old

A nurse is examining different situations that represent the superego component of human personality, as per Sigmund Freud. Which situations accurately represent superego? Select all that apply.

A client controls the urge to eat candy because he or she knows that it will affect the blood sugar levels. A client having a craving for fruits does not steal them from the next client because that client needs it more. A client experiencing a stomachache refrains from stealing medications from a friend because it is illegal.

A nurse is evaluating different situations related to Maslow's hierarchy of needs. Which situations come under the second level of needs? Select all that apply.

A client tells the nurse that he or she is taunted by his or her boss every day. A client tells the nurse that his or her spouse belongs to a criminal gang. A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals.

Validation therapy

A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation.

A nursing student is taking down notes about paradigm. Which point noted down by the nursing student needs correction?

A paradigm is the perspective of a profession.

Which program is an example of a continuing education program?

A program on caring for the elderly with dementia offered by a university

The nurse finds that a client with bilateral oral swelling, pain, and trismus had undergone a surgical extraction of an impacted tooth five days ago. What type of nursing diagnosis does the documentation of acute pain refer to?

Actual nursing diagnosis

Which professional standard is important for critical thinking?

An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

What is the order of evidence-based practice that a nurse should follow while caring for a client?

Ask a question Collect evidence Appraise the evidence Make a decision Evaluate changes Share outcomes

Which intervention by the nurse is an important aspect of client-centered care according to the survey conducted by the Picker Institute?

Asking the client if the family should be involved in his or her care

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. Which nursing intervention is correct regarding restraints?

Assess the clients condition per hospital protocol A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown.

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and would be performed first?

Assess the patency of airway.

The nurse is caring for a client whose mobility is restricted to a wheelchair after a motor vehicle accident. The client has been prescribed physiotherapy as a part of rehabilitation care. Which interventions would the nurse consider when the client is discharged from the health care facility?

Assist the family in identifying community support systems. Encourage the primary caregiver to set a routine time for respite. Consider the primary caregiver's experience in the discharge plan

Gross motor skills in an 8-10 month old infant

Crawling Pulling up to standing or sitting

According to Watson's theory, in which practice is the nurse least likely to engage?

Curing the disease before engaging in care of the client

A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction?

Descriptive theories help direct specific nursing activities.

Which degree does The American Association of Colleges of Nursing (AACN) recommend as terminal practice degree for all advanced practice registered nurses (APRNs)?

Doctor of Nursing Practice (DNP)

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with client care, remove the gown first and then remove the gloves

Don an N95 respirator mask before entering the room. An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions, are required. When finished with care, gloves would be removed first because they are the most contaminated.

Which nursing interventions are examples of the nurse as a caregiver? Select all that apply.

Encouraging the client to exercise daily Setting goals for the client to reduce weight Arranging for the client to meet a spiritual advisor

While teaching a nursing student, a registered nurse says "This is a study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable." Which type of research is the above statement?

Experimental research

The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply.

Explain the need for referral to the client and family. Provide the referral with adequate client information. Determine what the referral recommends for client care.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?

Explanation explanation requires knowledge and experience for choosing strategies for care for clients.

A nurse is heading a performance improvement team. The nurse collects records of needlestick injuries due to improper needle recapping techniques used during medicine administration. What is the next step to be followed by the nurse, if he or she is using the "plan, do, study, act model

Facilitate a training program for all nurses to teach the proper technique of recapping needles

Coping process

Family life stressors and daily hassles

Integrity process

Family rituals

Which is the first sign that would assist the nurse in suspecting malignant hyperthermia in a client?

Increased expired carbon dioxide increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles.

A hospital organization plans to conduct a study on the effect of dried plums for lowering the risk of colon cancer. After selecting the subjects, a nurse researcher provides adequate information about the research and then inquires about the preference of the subjects to associate with the research. What does this procedure indicate?

Informed consent

Which internal variable influences health beliefs and practices?

Intellectual background

Interpretation

Interpretation involves clarifying any data about which the nurse is uncertain.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error?

Interpreting

Which action is appropriate when caring for an elderly client admitted to a health care facility?

Invite a family member to join the conversation

What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)?

It provides temporary care for 96 hours or less.

When meeting the preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning?

It requires continued reinforcement. Neurological aging causes forgetfulness and slower response time; repetition increases learning.

The nurse uses evidence-based practice while providing nursing care to clients. What distinguishes research-based practice different from evidence-based practice?

It uses knowledge based only on research studies.

While caring for a group of clients from different ethnicities, the nurse observes that a client from Ireland is stoic and not complaining about pain. Which theory should the nurse follow in this situation?

Leininger's Theory

Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be correct.

Lifestyle Occupation Frequent traveling

A nurse is completing the Resident Assessment Instrument (RAI) for a resident at the nursing center. What should the nurse consider while completing the RAI? Select all that apply.

Minimum Data Set (MDS) Resident Assessment Protocols Utilization guidelines of the state

A pregnant woman complains, "I have had morning sickness for one week, which caused me to eat less. I am experiencing irritability because of weakness." The nurse taught the client relaxation and distraction techniques to overcome this problem. During a follow-up visit, the nurse evaluates the client's response and determines if the condition is resolved. Which model is the nurse using in this situation?

Neuman systems model

A registered nurse is teaching a nursing student about Nightingale's theory of nursing. Which statements have been correctly stated by the nursing student as a result of the teaching? Select all that apply.

Nightingale's theory states that the focus of nursing is caring through the environment. Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness.

Do alcohol based hand scrubs kill C.Diff?

No. Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs.

Which are the core roles for an advanced practice registered nurse (APRN)? Select all that apply.

Nurse practitioner Clinical nurse specialist (CNS) Certified nurse midwife (CNM) Certified registered nurse anesthetist (CRNA)

What kind of health service does the nurse offer in a health promotion or primary care program?

Nutrition counseling

Which steps are taken by a nurse during the implementation phase of drug research? Select all that apply.

Obtaining necessary approvals Recruiting subjects and collecting data obtained from the study

Which concept refers to respecting the rights of others?

Open-mindedness

Arrange the stages of Freud's psychoanalytical model of personality development in the correct order.

Oral Anal Phallic Latency Genital

Which nursing theory focuses on the client's self-care needs?

Orem's theory

Systematicity

Organized and focused

A nursing student is listing the goals of theoretical nursing models. Which goal listed by the nursing student needs correction?

Provide knowledge to validate nursing interventions

How is public health nursing different from community health nursing?

Public health nursing focuses on population.

Which information must be clearly documented in the medication administration record (MAR) before administering a medication? Select all that apply. One, some, or all responses may be correct.

Required information includes the medication dosage and route, the client's full name, the time the medication is to be administered, the frequency of administration, and the full name of the prescribed medication.

Responsibility

Responsibility refers to all duties and activities the nurse is employed to perform.

While reviewing a client's prescriptions, the nurse finds that one of the prescribed medications is redundant and notifies the primary health care provider. Which attitude of critical thinking does the nurse exhibit?

Risk Taking questioning the provider is risk taking

Client A is recovering from heart surgery and needs to adapt to his or her environment. Client B is at the last stage of cancer. Which of these theories may the nurse use for better health maintenance of both the clients?

Roy's theory for client A and Henderson's theory for client B

According to Piaget's theory, what are the cognitive or moral developmental changes in children aged 6 to 12 years? Select all that apply.

The child develops logical thinking. The child is in the concrete operations period

Which assessment finding is associated with dementia?

The client has impaired recent and remote memory.

Which assessment finding is associated with depression?

The client has islands of intact memory.

A middle-aged client says, "I have been unsuccessful in raising my kids." Which stage should the nurse expect the client to have reached, according to Erikson's theory of psychosocial development?

The client has reached the Generativity versus Self-Absorption and Stagnation stage.

Which is the most important skill of the nurse leader?

The most important leadership skill for the nurse leader is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.

How would the nurse prevent footdrop in a client with a leg cast?

To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion.

Why would the nurse establish "moderately hard" client-centered goals?

To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal

A client who has sustained an accident says, "I have a dream of conquering the world's highest mountain range." To which level of need does the given scenario refer to, according to Maslow's hierarchy of needs?

Toddler Preschool

Touch

Touch is a therapeutic tool that helps induce relaxation, provide physical and emotional comfort, and communicate interest