Nursing Sciences EAQ, Theory Communication, Nursing SBU
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."
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."
Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)
"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.
Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)
"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.
A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? "How do you feel about the voices, and what do they mean to you?" "You're the only one hearing the voices. Are you sure you hear them?" "The health team members will observe your behavior. We won't leave you alone." "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"
"I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you? Acknowledging that client is hearing voices and that the voices are very real to the client validates the presence of the client's hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self-injury or violence against others. The client's contact with reality is too tenuous to explore what the voices mean. Saying that the client is the only one hearing the voices and asking whether the client is sure the voices are being heard demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe the behavior and that the client won't be left alone is condescending and may impair future communication
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 school-aged child is brought to the clinic by the mother, who states, "Something is very wrong. My child never seems happy and refuses to play." When assessing this child for depressed behavior, what statement should the nurse initially begin with? "Tell me about yourself." "Let's talk about what you do after school." "Can you tell me what's making you so unhappy?" "Why does your mother think that you're unhappy?"
"Let's talk about what you do after school." A structured but nonthreatening question such as asking what the child does after school avoids beginning with the problem and may put the child at some ease, producing information that may be useful. The statement "Tell me about yourself" is too open and global; the child will probably not know how to answer this question or know where to begin. The child may not know the answer to the question "Can you tell me what's making you so unhappy?" Asking "Why does your mother think that you're unhappy?" will probably produce an "I don't know" response; the focus should be on the child, not the mother.
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."
Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?
"The medicine should be taken one hour before or two hours after meals."
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."
A client with schizophrenia reports having ongoing auditory hallucinations and describes them as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse? "Try to ignore the voices." "What are the voices saying to you?" "Do you believe what the voices are saying?" "They're only voices, so just try not to be afraid."
"Try to ignore the voices." Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices. Once it has been established by the nurse that the voices are not commanding the client to self-harm or harm others, focusing on the content of the hallucinations is not therapeutic. Asking whether the client believes what the voices are saying or encouraging the client not to be afraid of them is irrelevant to the situation; clients believe in and are frightened by hallucinations.
A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse?
"Untreated active tuberculosis is communicable."
A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?
"Wash used dishes in hot, soapy water."
A client with schizophrenia who has auditory hallucinations is withdrawn and apathetic. What should the nurse say to involve this client in an activity? "You'll get a reward if you go to the gym." "Would you like to participate in the group walk today?" "Those voices you hear would like it if you did a little exercise." "There's a positive relationship between exercise and good mental health."
"Would you like to participate in the group walk today?" is a declarative statement that invites the client to walk, and the client can comply without making a verbal decision. A client with schizophrenia is often ambivalent, rendering decision-making difficult. A withdrawn, apathetic client probably will not internalize or appreciate rationales for interventions. Saying that the voices want the client to exercise supports the client's hallucinations
A disturbed client says, "The voices are saying that I killed my husband." What is the best response by the nurse? "I just saw your husband, and he's doing fine." "Tell me more about your concerns for your husband." "We'll put you in a private room where you'll be safe." "You seem to be having very frightening thoughts right now."
"You seem to be having very frightening thoughts right now" demonstrates that the nurse understands the client's feelings; reflection opens a channel for communication. The nurse cannot talk the client out of her delusions by pointing out reality. Focusing on delusional content only reinforces false beliefs. "We'll put you in a private room where you'll be safe" does not reflect the content of the client's statement.
While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? "I don't mind it." "You seem upset." "This is part of my job." "Nurses get used to this."
"You seem upset." The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negates the client's feelings and presents a negative connotation.
Which pain scale would the nurse use to measure the intensity of pain in toddlers? 1 FACES scale 2 Visual analog scale 3 Numerical rating scale 4 Verbal descriptor scale
1
Which education would the nurse provide the parents of an infant with pyloric stenosis?
1 It is unlikely that surgery will be necessary. Correct 2 This is a condition with an excellent prognosis. 3 This condition results from an error of metabolism. Incorrect 4 Special feedings will be needed for a few weeks after surgery. answer is 2
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
What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? 1. A low-phenylalanine diet is required. 2. Phenylalanine is not necessary for growth. 3. Phenylalanine can be administered to correct the deficiency. 4. A substitute for phenylalanine is an increased amount of other amino acids.
1.A low-phenylalanine diet is requiredReducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There are no substitute for phenylalanine, which is one of the essential amino acids.
A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? Record your answer using a whole number. __________ mL/hr
150 ml/hr
A client presents with chief complaints of unexplained weight gain and back pain from a compression fracture of the vertebrae. On assessment, there is truncal obesity with excessively thin extremities, a moon-shaped face, a buffalo hump, thin hair, and adult acne. The symptoms described are suggestive of which disease? Addison disease Cushing disease Multiple sclerosis Kaposi sarcoma
2
When providing postoperative teaching, which rationale would the nurse give to explain the purpose of administering an opioid analgesic via epidural catheter? 1 Facilitates oxygen use 21Relieves abdominal pain 3Decreases anxiety and restlessness 4 Dilates coronary and peripheral blood vessels
2
Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food? 1 Mucositis 2 Dysgeusia 3 Dysphagia 4 Xerostomia
2
Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? 1 Massage 2 Effleurage 3 Acupressure 4 Counterpressure
2
How would the nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client's record Incorrect 4 By recording descriptive and objective information that he or she sees, hears, feels, and smells
2 By using exact measurements for each client's activity
A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood
3
How many levels of critical thinking exist for nursing judgment?
3
On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother's only comment to the nurse is, "My baby looks so fragile. Do you think my child will make it?" Which is the most appropriate response by the nurse? 1 "Many infants born as small as yours have done just fine." 2 "The staff is confident in your child's prognosis because preterm babies do look like this at first." 3 "Understandably, your baby looks fragile to you. What have you learned about the condition?" 4 "Your baby is not as fragile as it appears. Do you find it so frightening that you cannot touch your child?"
3 "It's understandable that your baby looks fragile to you. What have you learned about the condition?"
A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" Which is the nurse's most appropriate response? 1 "Do not tell your partner unless asked." 2 "This is a decision you alone can make." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."
3 "You are having difficulty deciding what to say."
Which age is considered the phallic stage according to Sigmund Freud's developmental theory?
3 to 6 years old
After surgery a client is to receive an antibiotic by intravenous (IV) piggyback in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtts/mL. The nurse should set the piggyback to flow at how many gtts/min? Record your answer using a whole number. __________ gtts/min
38
After abdominal surgery, a client reports pain. Which action would the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.
4
A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?
45-year-old woman with breast cancer
A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address? Safety Self-esteem Physiological Interpersonal
A call bell system enables the client to communicate with the staff and supports safety and security, which is a second-level need. Self-esteem involves intrapersonal needs, the fourth level of basic needs. Physiological needs include air, food, and water and represent the first level of needs. Interpersonal needs involve love and belonging, which are third-level needs.
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.
The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:
A decrease in CD4 T cells
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 patients are at risk of developing health care-associated infections (HAIs)? Select all that apply.
A patient with laryngeal cancer A patient with diabetes mellitus A patient with an indwelling urinary catheter
Which program is an example of a continuing education program?
A program on caring for the elderly with dementia offered by a university
antivenin
A serum that counteracts the effect of venom from an animal or insect.
A 2.5-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? Select all that apply. "Kids have to learn to be careful on the stairs." "Every time I turn around the kid is falling over something." "This child tends to be adventurous and doesn't understand about getting hurt on the stairs." "I can't understand it. This child didn't have a problem using the stairs without my help before this." "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid."
Abusive parents often have a poor understanding of the expected growth and development of children and tend to blame the child. Toddlers generally need supervision and some assistance when climbing stairs, but abusive parents have little understanding of toddlers' abilities. Although "Kids have to learn to be careful on the stairs" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs" is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. Although "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people usually do not have an understanding of children's needs in relation to growth and development.
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
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:
Administer the prescribed antipyretic and notify the charge nurse or primary health care provider
A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is:
Administering prescribed antibiotics
A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions?
Airborne precautions
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
A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? Asking about what type of foods the client usually eats Telling the client that the diet must be followed exactly as written Telling the client that the intake of foods on the list must be limited Asking about what the client knows about the diet that was prescribed
Asking about what the client knows about the prescribed diet may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.
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
Nursing Process
Assessment Diagnosis Planning Implementation Evaluation
A client receiving chemotherapy takes a steroid daily. The client has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client?
Avoid large crowds and persons with infections
A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has:
Been exposed to the tubercle bacillus
The health care provider prescribes peak and trough levels of an antibiotic for a client who is receiving the medication intravenous piggyback (IVPB). For peak levels the nurse should have the laboratory obtain a blood sample from the client:
Between 30 and 60 minutes after the IVPB
3 examples of objective data
Blood pressure Heart rate Respirations
What are the similarities between Medicare and Medicaid? Select all that apply.
Both programs assist older clients. Both programs pay for home care services
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
A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client?
Cleansing the wound with soap and water
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 who has participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the infant's discharge comes to the unit on the last hospital day with an alcohol odor on her breath and slurred speech. What is the most appropriate action for the nurse to take at this juncture? Speak with the mother about her condition and assess her willingness to participate in an alternate discharge plan. Request that the mother wait in the hospital lobby and call the primary healthcare provider to cancel the discharge order. Speak to the mother about her condition and have her see a social worker about the infant's discharge to a foster home. Continue with the discharge procedure and alert the home health nurse that the mother needs an immediate follow-up visit.
Confrontation regarding the active substance abuse and the mother's diminished ability to care for the infant safely at this time is necessary to help the mother obtain help and to protect the infant. Decisions should not be made without input from the mother. Continuing with the discharge procedure and alerting the home health nurse that the mother needs an immediate follow-up visit is unsafe; the mother may not be capable of caring for the infant.
The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? Tachycardia Hypotension Rigid abdomen Nausea and vomiting Back and shoulder pain
Correct1 Tachycardia Correct2 Hypotension Correct3 Rigid abdomen Correct4 Nausea and vomiting Correct5 Back and shoulder pain
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
Which medication is used in the treatment of a client with intervertebral disc disease?
Cyclobenzaprine
A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain one week later. What does the nurse identify as the cause of the post therapeutic neuralgia?
Damage to the nerves
Which theory describes the phenomenon of grief or caring?
Descriptive theories
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.
A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Which questions does the nurse ask? Select all that apply. "What brought you here for treatment today?" "What do you believe is the cause of your depression?" "Does religion have a role in your perception of health and wellness?" "Do you have insurance that includes coverage of mental health issues?" "Have you ever sought treatment for a mental health problem previously?"
Determining the client's perception of the problem is an appropriate question that allows cultural factors to be included. Encouraging the client to discuss the problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.
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)
When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response?
Document the presence of the lesions, describing their size, location, and color
A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client?
Eliminate chemical, mechanical, and thermal irritation.
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.
A primary health care provider prescribes airborne precautions for a client with tuberculosis. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a glass of juice from the kitchen. The most effective nursing intervention is to:
Explore what the precautions mean to the client
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
A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse?
Finding the client's contacts
The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. Which fetal development time period would the nurse respond? 1 First 12 weeks 2 Third trimester 3 Second 16 weeks 4 Implantation phase
First 12 Weeks
4 Agonal breaths
Gasping
A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug?
Give the medication an hour before milk products are ingested.
A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? (Select all that apply.)
Gloves Hand hygiene
A nurse is caring for a client with a diagnosis of acute salpingitis. Which condition most commonly causing inflammation of the fallopian tubes should the nurse include when planning a teaching program for this client?
Gonorrhea
A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:
Has a CD4+ T lymphocyte level of less than 200 cells/µL
The school nurse conducts a class in nutrition planning for parents. What is the goal of school health nursing programs?
Health promotion
2 Tachycardia
Heart rate over a 100
A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? (Select all that apply.)
Hyperthermia Splenomegaly
Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what?
Identify personal attitudes and feelings about homosexuality
A mother with the diagnosis of acquired immunodeficiency disease (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?
If the baby is breastfeeding
During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement?
Ignorance related to correct condom use
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
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
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
A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse teach this client?
It can produce sterility.
What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)?
It provides temporary care for 96 hours or less.
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.
What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? (Select all that apply.)
Joint pain Facial rash Pericarditis
A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?
Keep skin lubricated with lotion
The parent of a 4-year-old client states, "My child gets so upset when I ask her to stop talking so that I can answer a work phone call. I don't understand why this happens." Which response by the nurse is most appropriate? "School is a source of stress for many children at this age." "Worrying is a source of stress for many children at this age." "Attention is a source of stress for many children at this age." "Belongings are a source of stress for many children at this age."
Lack of attention is often a stressor for the 4-year-old preschool-age client; therefore, the nurse should provide education about this stressor to the parent. The child's reaction is not due to the stressors of school, worrying, or belongings
Which would the nurse discuss with new parents to assist them in preparing for infant care?
Learning specific behaviors involving states of wakefulness to promote positive interactions
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
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 client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria?
Mosquito bites
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.
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
A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site nine months ago. The site is healed and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present?
Obtain a prescription to culture the client's blood
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 important intervention would be included in the nursing care provided immediately after a sexual assault? 1. Obtaining the assault history from the client 2. Reporting the assault to the police before the client is examined 3 Having the client void a clean-catch urine specimen 4 Testing the client's urine for seminal alkaline phosphatase
Obtaining the assault history from the client
What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?
Occurred in conjunction with treatment for an illness
An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. The primary reason that the nurse pursues more information about the roommate is because:
Older adults with chronic illness are affected adversely by tuberculosis
A chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case finding?
Older adults with chronic illness are more susceptible to tuberculosis
Which nursing theory focuses on the client's self-care needs?
Orem's theory
3 examples of subjective data
Pain, Dizziness, Exhaustion
A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?
Penicillin therapy
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
PPE -
Personal Protective Equipment
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.
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? Express disbelief about the client's delusion. Divert the client's attention to unit activities. React to the feeling tone of the client's delusion. Respond to the verbal content of the client's delusion.
Reacting to the feeling tone of the client's delusion helps the client explore underlying feelings and allows the client to see the message that the verbalizations are communicating. Expressing disbelief about the client's delusion denies the client's feelings rather than accepting and working with them. Attempting to divert the client rather than accepting and working with the client denies the client's feelings. Responding to the verbal content of the client's delusion focuses on the delusion itself rather than on the feeling that is causing the delusion.
Which actions contribute to the transmission of human immunodeficiency virus (HIV) infection from an infected to a healthy person? Select all that apply.
Receiving blood transfusions Having sexual intercourse
A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:
Reschedule administration of the vaccine for the next month
RACE -
Rescue, Activate alarm, Confine the fire, Evacuate/Extinguish
A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.
Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions
A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.)
Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions
A nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurse's best way to handle this situation is to:
Review transmission-based precautions with the UAP
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
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.
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
SMART goals
Specific, Measurable, Attainable, Realistic, Timely
SOP
Standard Operating Procedure (defined in Queensland mining legislation)
Which activity of the registered nurse is included in supervision? Performing the given task Allocating a portion of the work Providing information to the delegator Providing guidance and oversight in delegating a task
Supervision is defined as "provision of guidance and oversight of a delegated nursing task." It includes open lines of communication between the delegator and the delegatee to provide guidance. Responsibility is the activity of performing a given task. Delegation is the activity of allocating a portion of work. Authority is the activity of providing information to the delegator.
The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? (Select all that apply.)
Tachypnea Increased pulse rate
A reasonable short-term outcome for clients who are functioning below the optimal level of mental health is to help them become better able to do what? Understand the dynamics behind their inadequate interpersonal relations. Confront their inadequacies in interpersonal relations and be more sociable. Discuss feelings regarding their life experiences and their significant others. Take actions that will increase their satisfaction with their relationships with others.
The ability to discuss feelings about others and life situations is necessary for positive mental health. Understanding interpersonal dynamics, confronting inadequacies, and taking actions to increase satisfaction in relationships are all long-term, not short-term, outcomes.
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
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.
A 16-year-old girl has been admitted to the pediatric eating disorders unit with a diagnosis of anorexia and is undergoing behavioral therapy. Unit privileges are based on weight gain and have been explained to the client. What is the most appropriate intervention for the nurse to use when taking the lunch tray to the client's room? Setting the tray down and saying nothing Reminding the client that eating will be rewarded Commenting on the client's thinness and need to gain weight Threatening the client that if she doesn't eat she won't gain any privileges
The client uses eating/weight gain as a means of controlling the environment. The client has been told the rules of the unit and must make the personal decision to try to win privileges. The nurse needs to take the focus away from eating. The client knows that gaining weight will be rewarded and does not need reminders. The client is used to everyone commenting on her weight. Although the client appears thin to others, the client's self-perception is that she needs to lose a little bit of weight. Threats should not be used in any circumstance.
The parents of a 6-year-old boy tell the nurse in the pediatric clinic that their son has recently started to wet the bed at night. What is the most helpful response by the nurse? "How's your son doing in school?" "Have there been any changes in his life recently?" "You should arrange to see the doctor, because there may be a physical problem." "When children are angry at their parents, they may use bed-wetting to punish them."
The collection of more information is essential before the nurse can intervene further. Asking a general question opens the lines of communication. Asking specifically about school might be appropriate later in the discussion. Suggesting a medical consultation is premature; more information is needed. Enuresis is usually not a behavioral response precipitated by anger; this statement may cause the parents to feel guilty or become defensive.
What is the incubation period for an infectious disease?
The interval between entrance of pathogen into body and appearance of first symptoms
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 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.
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.
After a week on the mental health unit, a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are." What is the best response by the nurse? "We're here to protect you." "No one wants to hurt anyone." "You're having very frightening thoughts." "Tell me more about their wanting to kill you."
The observation that the client is experiencing frightening thoughts is a reflection of the client's feelings; it leaves the line of communication open. Telling the client that the staff is there to protect the client does not provide security, because the client may believe that the nurse is one of the people plotting. Telling the client that no one wants to hurt anyone discounts the client's thoughts and may increase the agitation. Asking the client to detail the plot supports the client's delusion.
The nurse leader is giving a speech on leadership skills to followers. Which questions enable the nurse leader to evaluate the understanding level of the followers? Select all that apply. "Are you getting my points?" "Would you all like a break?" "Can I change the topic in a little while?" "How can you solve a conflict at the workplace?" "What did you 'hear' in the process of this communication?"
The question such as "what did you 'hear' in the process of this communication?" cannot be answered by a "yes" or "no" and requires a detailed explanation of the things that are taught. The questions starting with "how" are usually open-ended and require the person to answer in detail. Therefore these questions can help the nurse leader evaluate the understanding level of the followers. The questions such as "are you getting my points?", "would you all like a break?", and "can I change the topic in a little while?" can be answered by a "yes" and "no." Therefore these questions do not help the nurse leader to evaluate the understanding level of the followers.
A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? "Did you forget to take your medication?" "You are worried about having more seizures?" "You must be under a lot of stress right now." "Don't be too concerned
The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be too concerned because your medication needs to be increased" negates the client's feelings and discourages communication.
A nurse stops by the room of a newly admitted depressed client and offers to walk with the tearful client to the evening meal. The client looks intently at the nurse but says nothing. What is the best response by the nurse? "I'll be at the desk if you need me." "You must tell me what you're feeling now." "We'll walk together to dinner when you calm down." "It must be very difficult for you to be on a psychiatric unit."
The statement "It must be very difficult for you to be on a psychiatric unit" lets the client know that the nurse realizes that the client is having difficulty without asking direct questions or focusing on specific behavior. The response "I'll be at the desk if you need me" connotes avoidance. Saying "You must tell me what you're feeling now" sounds more like an order than an opportunity to express feelings. Saying "We'll walk together to dinner when you calm down" negates the client's feelings. The nurse should talk to the client without any expectation that the client will "calm down."
As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join and says, "I have nothing to talk about." What is the best response by the nurse? "Maybe tomorrow you'll feel more like talking." "Could you start off by talking about your family?" "A person like you has a great deal to offer the group." "You feel you won't be accepted unless you have something to say?"
The statement about the client's feelings of acceptance is a reflective statement that allows the client to either validate the statement or correct the nurse. Postponing the conversation delays addressing the problem and avoids exploring feelings. Asking the client to start talking about her or his family is a response that gives advice and does not allow the client to explore feelings. Stating that the client has a lot to offer the group denies the client's statement and does not allow the exploration of feelings.
The nurse as a leader provides feedback to a newly recruited nursing student after checking the student's progress report. Which action of the registered nurse is most closely aligned with the application of two-factor theory during the feedback session? Creating enthusiasm for practice Ignoring negative behaviors of the student nurse Promoting job enrichment by creating job satisfaction Providing specific feedback about positive performance
The two-factor theory of leadership indicates that motivating factors such as promoting job enrichment by creating job satisfaction inspire the work performance of the staff. Creating enthusiasm for staff practice characterizes the transformational theory of leadership. Ignoring the negative behaviors of student nurses indicates an application of the Organizational Behavior Modification theory of leadership. Providing specific feedback about positive performance indicates the application of the Expectancy theory of leadership.
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
A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?
Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine
A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?
Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.
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
A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan?
Two to six weeks
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?
Use standard precautions.
A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is a:
Viral infection characterized by convulsions and difficulty swallowing
The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in:
Vitamins A, C, E, and selenium
A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?
Wash used dishes in hot, soapy water."
A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for:
Water-soluble forms of vitamins A and E
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.
A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?
Wear a particulate respirator mask
Clinical judgment
a judgment based on experience in observing and treating patients
ABCS
airway, breathing, circulation
dysphagia
condition in which swallowing is difficult or painful
Dyspnea
difficult or labored breathing
dysgeusia
distortion of the sense of taste
antihypertensive
drug that lowers blood pressure
xerostomia
dryness of the mouth
Palliative care
hospice care; taking care of the whole person—body, mind, spirit, heart and soul—with the goal of giving patients with life-threatening illnesses the best quality of life they can have through the aggressive management of symptoms
glomerulonephritis
inflammation of the glomeruli of the kidney
Objective data
information that is seen, heard, felt, or smelled by an observer; signs
A female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection in the future?" The nurse evaluates that the teaching is understood when the client states, "My best protection is to:
insist that my partner use a condom."
pyloric stenosis.
narrowing of the opening of the stomach to the duodenum
mucositis
painful inflammation of oral mucous membranes
hematuria
presence of blood in the urine
Etiology
the study of the causes of diseases
Subjective data
things a person tells you about that you cannot observe through your senses; symptoms
Debillitated
weakened
