questions for funds exam 1
extended family?
consists of a relative, such as aunts, uncles, and grandparents, who live in close geographic proximity to each other
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
contact
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:
decrease apical pulse
A client has smoked most of his life and has labored respirations. He is experiencing:
dyspnea
love and belonging needs:
including family and friends in care of patient establishing a trusting nurse-patient relationship referring patients to support groups
Examples of Surgical Asepsis (sterile technique)
inserting an undwelling urinary cath inserting an IV cath
Medical asepsis (clean technique)
involves procedures used to reduce and prevent the spread of microorganisms.
physiologic needs:
oxygen: most essential water food elimination temperature sexuality physical activity rest
Think back to Samuel Kaplan, the older man caring for his wife with Alzheimer disease at home. The nurse assesses the effect of providing this care on his activity, rest, and sleep patterns, thereby developing an appropriate plan of care for Mr. Kaplan to ensure that his needs are met as well. this fits under what level of hierarchy...
physiologic rationale: Physical activity and rest are also basic physiologic needs. Physical activity depends on intact and functioning neuromuscular and skeletal systems. Rest and sleep allow time for the body to rejuvenate and be free of stress. Individual requirements for rest and sleep vary widely, but the adverse health effects of deprivation have been well documented
what are maslows hierachy needs starting at lower level needs to higher level needs?
physiologic safety and security love and belonging self-esteem self-actualization
what needs must be met at least minimally to maintain life?
physiologic needs
Recall Rolanda Simpkins, the 16-year-old girl described at the beginning of the chapter requesting information about contraception. The nurse can use knowledge about Rolanda's sexuality and sexual practices to help determine the most appropriate method of contraception for her. this fits under what level of hierarchy...
physiologic needs rationale: Sexuality is an integral component of each person and may be affected by physical and emotional illnesses. Sexual practices depend on a variety of factors, such as a person's age, sociocultural background, self-esteem, and level of health.
what factors affect self-esteem?
role change body image changes respecting patient's values and beliefs encouraging patients to set attainable goals
HAND HYGIENE: USING AN ALCOHOL-BASED HANDRUB
Apply product to the palm of one hand, using the amount of product recommended on the package (it will vary according to the manufacturer but usually is 1 to 3 mL). Rub hands together, making sure to cover all surfaces of the hands, fingers, and in between the fingers. Also, clean the fingertips and the area beneath the fingernails. Continue rubbing until the hands are dry (at least 15 seconds).
The nurse takes a client's vital signs and notes a blood pressure of 88/56 mm Hg with a pulse rate of 60 beats/min. Which action should the nurse take first?
Assess the client for dizziness
The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?
Assess the client's ability to stand or sit.
when an alcohol-based handrub can be used to decontaminate hands (IHI, 2018):
Before direct contact with patients After direct contact with patient's skin After contact with body fluids, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly soiled After removing gloves Before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement Before donning sterile gloves prior to an invasive procedure (e.g., inserting a central intravascular catheter) If moving from a contaminated body site to a clean body site during patient care After contact with objects (including equipment) located in the patient's environment
four categories that are responsible for a majority of HAIs in the acute care hospital setting
Catheter-associated urinary tract infection (CAUTI) Surgical site infection (SSI) Central line-associated bloodstream infection (CLABSI) Ventilator-associated pneumonia (VAP)
The nurse is prioritizing nursing care for a pt in a long term setting. Which examples of nursing interventions help meet physiologic needs? Select all that apply. Preventing falls in the facility Changing a pts oxygen tank Providing materials for a pt who like to draw Helping a pt to eat his dinner Facilitating a visit from a spouse Referring a pt to a cancer support group
Changing a pts oxygen tank Helping a pt to eat his dinner
Describe each level of Maslow's hierarchy of basic human needs. Explain nursing care necessary to meet needs in each level of Maslow's hierarchy.
Chapter 4 objectives
The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?
Client stands at bedside, becomes pale, diaphoretic.
The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.
Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene. Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside.
A nurse is providing care based on Maslow's hierarchy of basic human needs. For which nursing activities is this approach useful? Making accurate nursing diagnosis Establishing priorities of care Communicating concerns more concisely Integrating science into nursing care
Establishing priorities of care
What is the most effective way to prevent the spread of infectious disease?
Hand hygiene
Examples of medical asepsis(clean technique)?
Hand hygiene using clean gloves cleaning the environment routinely
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?
Hand hygiene is needed after contact with objects near the client.
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?
Incentivizing health care workers to utilize hand hygiene
A nurse is practicing community-based nursing in a mobile health clinic. What would be the central focus of this nurse's care? Individual and family health care needs Populations within the community Local health care facilities Families in crisis
Individual and family health care needs rationale: In contrast to community health nursing, which focuses on populations within a community, community-based nursing is centered on individual and family health care needs. Community-based nurses may help families in crisis and work in health care facilities, but these are not the focus of community-based nursing.
A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?
Inflate the blood pressure cuff while palpating the client's brachial artery.
During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110 mmHg. Why is this finding particularly significant?
It deviates from normal and is significant.
The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?
Lightly compress the client's radial artery using the first, second, and third fingers.
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds
When do we perform Hand hygiene?
Moment 1 - Before touching a patient Moment 2 - Before a clean or aseptic procedure Moment 3 - After a body fluid exposure risk Moment 4 - After touching a patient Moment 5 - After touching patient surroundings
A visiting nurse performs a community assessment in an area of the city in which the nurse will be working. What is one element of a healthy community? Meets all the needs of its inhabitants Has mixed residential and industrial areas Offers access to health care services Has modern housing and condominiums
Offers access to health care services
An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?
Perform surgical hand scrub using detergent.
The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?
Pour the liquid into a sterile container within the sterile field.
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure.
The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?
Remove the thermometer and assess the blood pressure and heart rate.
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled.
The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field?
Separate the sealed flaps and drop contents onto field.
A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?
She should place her three fingers just below the wrist on the outside of the arm with the palm up.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?
The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
A nurse who focuses attention on the strengths and abilities of patients rather than their problems is helping them to achieve which of Maslow's basic human needs? A. Self-actualization B. Self-esteem C. Love and belonging D. Safety and security E. Physiologic
self actualization Rationale: To meet patient self-actualization needs, nurses provide a sense of direction and hope, and maximize patient potential. Self-esteem needs are met by respecting patient values and beliefs and setting attainable goals for them. Love and belonging needs are met by including family and friends and establishing caring relationships with patients. Safety and security needs are met by encouraging spiritual practices and independent decision making. Physiologic needs are needs that must be met to maintain life.
During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.
True
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?
Use the Doppler ultrasound device
Surgical asepsis is defined as:
absence of all microorganisms.
An ultrasonic Doppler is used for:
auscultating a pulse that is difficult to palpate.
During a clinic visit, a diabetic patient expresses difficulty with his prescribed dietary recommendations but also recognizes that he needs to be more careful or "I'll end up losing a leg or having trouble seeing because of this disease." A nurse coach recognizes that the patient is the best expert about his own health and listens carefully as he reviews his eating habits and discusses what he thinks he needs to do differently. Based on assessment data and the patient's desire to change his behavior, the nurse and patient together create an action plan to begin the process of change and move toward the optimal way for him to achieve his goals. this fits under what level of hierarchy...
self-actualization
blended family?
when parents bring unrelated children from previous relationships together to form a new family
multigenerational family?
which several generations or age groups live together in the same household
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
"Dizziness when you change position can occur when fluid volume in the body is decreased."
The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state which of the following? -"The nurse is the handmaiden of the physician." -"Pets can help heal clients." -"Everything in nature is alive with invisible forces." -"The physician is viewed as a god-like figure."
"Everything in nature is alive with invisible forces"
The nurse instructs a mother of young children how to properly use a nonmercury glass thermometer. Which statement made by the client indicates a need for further instruction?
"I will clean the thermometer in the dishwasher."
The nurse is attempting to provide anticipatory guidance for parents of an eighteen-month-old boy. Which of the following would be the best statement for the nurse to make? -"Do not give the child a bottle now" -"Does he have nightmares often?" -"Keep all medications in a locked cabinet." -"He is in the 95th percentile for weight."
"Keep all medications in a locked cabinet."
A 48-year-old client was just diagnosed with type 2 diabetes mellitus. The client has a BMI of 35 and leads a sedentary lifestyle. The nurse informs the client of risk factors for the diagnosis and the need to change diet and exercise behavior. Which client statement indicates a need for further teaching?
"There is nothing that can be done anyway; chronic diseases cannot be prevented"
The nurse is explaining to a nursing colleague why there should be only one entry into the profession. What is the best statement by the explaining nurse? -"Increasingly, there is opportunity for educational advancement." -"Multiple methods of preparation are confusing to consumers." -"Multiple methods of preparation increase the number of nurses." -"State laws recognize both the LPN and RN as nursing credentials."
"multiple methods of preparation are confusing to consumers."
Friedman and associates identified the importance of family-centered nursing care, based on four rationales. First, the family is composed of interdependent members who affect one another. If some form of illness occurs in one member, all other members become part of the illness. Second, a strong relationship exists between the family and the health status of its members; therefore, the role of the family is essential in every level of nursing care. The third rationale is that the level of health of the family and, in turn, each member can be significantly improved through health-promotion activities. Finally, illness of one family member may suggest the possibility of the same problem in other members; through assessment and intervention, the nurse can assist in improving the health status of all members.
*****
The nurse is preparing to create a plan of care for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse understands that the client's self-actualization needs can be met by implementing which interventions? (Select all that apply.)
- Educating the client about the course of the disease process - Creating a treatment and prevention plan to decrease readmissions - Teaching the client about the COPD diagnosis
A nurse is performing health promotion activities for clients at a local health care clinic. Which nursing actions exemplify the focus of secondary preventive care? Select all that apply.
- Scheduling a mammogram for a client - Referring a client to family counseling - Screening clients for hypertension
Nurses understand the importance of adopting healthy behaviors so that they can better care for clients. What are some examples of healthy self-care behaviors everyone should adopt? Select all that apply.
- Sleeping 7 to 8 hours each night - Eating regular healthy meals - Maintaining an ideal body weight
Which clients, at risk for health disparities, may require additional assistance from the nurse in order to access healthcare services? (Select all that apply.)
- migrant farm workers - older adult clients in a senior citizen complex - clients who have been unemployed for several months
In what time period did nursing care as we now know it begin?
18th to 19th century
A nurse is prioritizing care for patients in a hospital setting. Place the following examples of interventions to meet human needs in order from highest-level needs to lower-level needs based on Maslow's hierarchy. 1- A nurse prepares a room for a clerical visit requested by a patient. 2 - A nurse places a No Smoking sign on the door of a patient who is receiving oxygen. 3 - A nurse helps a patient focus on her strengths following a diagnosis of breast cancer. 4 - A nurse provides nutrition for a patient through a feeding tube. 5 - A nurse includes family members in the care of a patient.
4, 2, 5, 1, 3
Which of the following is the best example of a nurse in the role of counselor? -A nurse allowing a client to verbalize their fears of death -A nurse ensuring that a client has follow-up care at a free clinic -A nurse telling a client the side effects of a medication -A nurse providing the physician a client's test results
A nurse allowing a crying client to verbalize their fears of death
A nurse is demonstrating collegiality in professional practice. What behaviors practiced by the nurse correlate with this standard of practice? Select all that apply. -A nurse helps a colleague write a journal article -A nurse encourages a colleague to join the hospital journal club -A nurse encourages a colleague to join the American Nurses Association (ANA) -A nurse helps a colleague complete a bed bath on a client -A nurse encourages a colleague to quit smoking
A nurse helps a colleague write a journal article, a nurse encourages a colleague to join the hospital journal club, and a nurse encourages a colleague to join the American Nurses Association (ANA)
A nurse is describing the role of the nurse entrepreneur. Which of the following statements best describe this role? -A nurse who teaches in a clinical setting -A nurse responsible for administration of resources -A nurse who manages personnel involved in client care -A nurse who manages a health-related business
A nurse who manages a health-related business
Which advance nurse practitioner is best qualified to provide prenatal care for a pregnant client?
A nurse-midwife
A 32-year-old construction worker is admitted to the emergency department after suffering a heat stroke. Which of the following IV solutions would the nurse expect the physician would order?
A solution of normal saline
When admitting an adolescent to the hospital, the nurse anticipates that the client will respond to questions about his health beliefs based primarily on his:
Age and developmental stage.
A 90-year-old woman has a Staphylococcus infection in her decubitus ulcer. Staphylococcus is the:
Agent Explanation: The agent is any factor that leads to illness.
The first nursing journal owned, operated, and published by nurses was:
American Journal of Nursing
Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?
American Nurses Association
A nurse is considering relocating to another state to practice nursing. Which of the following is the most appropriate action by the nurse to ensure ability to practice in the new state?
Applying for a reciprocal license in the new state
The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?
Art of nursing
Which nursing intervention is an example of tertiary preventive care?
Assisting with speech therapy for a client with a traumatic brain injury
The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification?
Associate degree
An elderly patient has been recently diagnosed with vascular dementia. Because he lives alone and has poorly controlled hypertension, he has begun to receive home healthcare. This new aspect of his care is characteristic of which stage of illness?
Assuming a dependent role
A nurse mentoring second-year nursing students from a community college plans clinical experiences for them. These students will most likely graduate in which time frame?
At the end of the year
Which of the following is the best example of a nurse attending an inservice program? -Attending a conference on cultural diversity -Taking an online course at a local university -Attending a continuing education program by a national organization -Attending a hospital program on how to use a new IV pump
Attending a hospital program on how to use a new IV pump
A student is choosing her educational path and desires a nursing degree with a tract that contains community nursing and leadership, as well as liberal arts. The student would best be suited in which type of program?
Baccalaureate program
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
The nurse is caring for a client who is on a ventilator. The nurse is bathing the client and talking to him as she is carrying out care, as well as telling the client what is going to happen next. The nurse speaks to the client in a soothing manner. The nurse is acting in which role? Select all that apply. -Caregiver -Decision-maker -Communicator -Educator -Client advocate
Caregiver, communicator, and educator
An exacerbation refers to the reactivation of a disease. Which condition is associated with exacerbation?
Chronic illness
What is a misconception about chronic disease?
Chronic illnesses cannot be prevented.
A nurse is planning to continue her education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which of the following expanded career roles is the nurse preparing?
Clinical nurse specialist
Which of the following statements accurately describes the formulation of a nursing diagnosis? -Collection of assessment data provides the basis for identifying nursing diagnoses -A nursing diagnosis is first assigned by the physician and modified for the patient by the RN -Nursing care is directed by the nursing diagnosis but there are no legal ramifications for the RN providing care -A member of the healthcare team evaluates the patient and identifies an approved nursing diagnosis -Although the registered nurse assigns the nursing diagnosis, the patient is ultimately the responsibility of the physician
Collection of assessment data provides the basis for identifying nursing diagnoses
During the course of any given day of work in the acute care setting, the nurse may need to perform which of the following roles? Select all that apply. -Communicator -Teacher -Statistician -Financer -Counselor
Communicator, Teacher, and Counselor
A client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. The remission state is characterized by:
Disappearance of signs and symptoms associated with the disease.
The nurse is developing a plan of care for a client. Which of the following is a nursing care activity/intervention? Select all that apply. -Educating clients -Starting an IV -Reading an X-Ray -Holding the client's hand
Educating clients, starting an IV, and holding the client's hand
The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation fo each step?
Educator
The nursing student who has diarrhea before every test and every clinical understands that this is not a healthy behavior. The student is aware that this negative effect can impact overall health. The nurse manager recognizes that this student needs to focus on which dimension of health?
Emotional dimension Explanation: - How the mind affects body functions and responds to body conditions also influences health. Long-term stress affects body systems, and anxiety affects health habits. - Intellectual dimension encompasses cognitive abilities and past experiences - Physical dimension includes things like genetics, gender, and race. - Sociocultural dimensions relate to a client's economic level, lifestyle, family, and culture.
What is the best nursing intervention to promote health in a client at risk for heart disease?
Emphasizing a client's strengths to encourage weight loss
Which of the following actions should the nurse implement when working with a medically homeless client? -Encourage the client to utilize the emergency room when ill -Assist the client in finding a job -Assist the client in finding housing -Encourage client to utilize the free healthcare clinic
Encourage client to utilize the free healthcare clinic
A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, a problem that was accompanied by a random blood glucose reading of 575 mg/dLm (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomena?
Exacerbation
A nurse is caring for a client with end-stage liver failure. Which healthcare agency should the nurse recommend for continuity of care?
Extended care
A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?
Facilitating coping
A client is admitted to the mental health centre with attempted suicide. Which of the client's problems is priority for the nurse to manage?
Freedom from harm
An woman 80 years of age has had a cerebrovascular accident. She has flaccidity of her right side with aphasia. For this client, which of the following activities constitutes tertiary prevention?
Gait training and speech therapy
When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by his personal expectations in relation to health and illness. The nurse is demonstrating understanding of which health model?
Health belief model
The nursing instructor is teaching the students about health and wellness and identifies which definition of health as the best?
Health is a state of complete well-being.
A student nurse understands that the primary aim of the Healthy People 2020 initiatives is..?
Health promotion
A community health nurse arranges for a dental checkup camp for the local children in the school district. Which of the following would most likely be the nurse's goal for this health camp?
Health promotion Explanation: - The education on lifestyle choices is part of health promotion activity, which focuses on protecting the person's health. - The goal of the prevention of illness is to detect and prevent the illness. - High-level wellness focuses on maximizing the person's highest potential for functioning. - Reversal of self-care deficits would involve therapeutic interventions that are directed at contributing factors.
When chronic illnesses and disabilities are present, individuals benefit most from activities that:
Help them maintain independence.
The recognition of health as an ongoing process toward a person's highest potential of functioning is defined as:
High-level wellness
The body's attempt to restore balance through self-regulatory mechanisms is termed:
Homeostasis
The nurse is caring for a client admitted for the third time in 90 days with a diagnosis of heart failure. What nursing activities on a tertiary level will the nurse educate the client regarding to prevent readmission?
Importance of adhering to a low sodium diet
A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?
In-service education
The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention Which activity performed by the nurse is classified as tertiary prevention?
Instructing a client how to use crutches
The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?
It focuses on what people believe to be true about their health.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?
It has a gradual onset and lasts for a long time.
A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role? -It is the role of the physician, not the nurse, to assist clients in understanding their health problems -It is the role of nursing to provide a caring relationship that facilitates health and healing -Nursing is a profession dependent upon the medical community as a whole -The essential components of professional nursing care are strength, endurance, and cure..
It is the role of nursing to provide a caring relationship that facilitates health and healing
What was one barrier to the development of the nursing profession in the United States after the Civil War?
Lack of educational standards
A prospective nursing student desires a career that will allow him to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
Licensed or vocational nursing program
A class of nursing students is studying the history of nursing. The class learns that the founder of public health nursing is:
Lillian Wald
A nurse wishes to pursue a degree as a nurse practitioner. What is the minimal degree needed by the nurse?
Masters
The nurse is giving a talk to a local community group on the harms of smoking. The nurse tells the group that a risk factor is something that increases a person's chances for illness or injury. What type of risk factor is smoking?
Modifiable
Which of the following is a characteristic of nursing practiced from early civilization to the 16th century?
Most early civilizations believed that illness had supernatural causes
A nurse understands that for nursing to be considered a profession, many things need to be in place. Which of the following is not part of those considerations? -Well-defined body of knowledge -Multidisciplinary approach -Ongoing research -Strong service orientation -Code of ethics
Multidisciplinary approach
Nurses must use multiple mechanical devices in the workplace to assess their patients. The data collected from these devices supply what type of information?
Objective
The student nurse is changing the bed linens of a hospitalized patient. While placing the contaminated materials into the laundry bag, the outside of the bag is touched by the material. What should the student nurse do next?
Obtain another laundry bag and place the contaminated bag inside while in the patient's room
What might a nurse need to do to ensure the continuation of his/her nursing license?
Obtaining continuing education credits
A client states, "I must be in poor health because I am a senior citizen. That's what my neighbor says and she is older than I am." This statement is based on which of the following factors?
Peer influence
Teaching a woman about breast self-examination is an example of what broad aim of nursing?
Preventing illness
A nurse is explaining A1C diagnostic testing to a client with diabetes. What level of healthcare delivery does this test suggest?
Primary Explanation: Primary care delivery is provided by the first healthcare provider or agency a person contacts and includes teaching and basic care.
A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent?
Primary prevention
What level of prevention is noted when the nurse educates a group of mothers of school-age children on self breast examinations?
Primary prevention Explanation: Primary prevention focuses on the health of a person with the goal of preventing disease or illness.
Cardinal signs of infection are?
Redness Heat Swelling Spike in fever Pain loss of function
Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?
Refer the mother for a home care visit
Which is an example of tertiary health promotion?
Rehabilitation Explanation: - Tertiary health promotion and disease prevention begin after an illness is diagnosed and treated to reduce disability and to help rehabilitate clients to a maximum level of functioning. Therefore, rehabilitation is an example of tertiary health promotion. - Family counseling and Pap tests are examples of secondary health promotion. - Water treatment is an example of primary health promotion.
The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated?
Science of nursing
The nurse is holding a cholesterol screening at a local pharmacy this Saturday morning. What level(s) of health promotion is this screening an example of?
Secondary
A client experiencing symptoms of cold is referred to the specialist for diagnosis and consultation. Consultation and diagnostic tests are included in which level of the health care system?
Secondary care Explanation: - Consultation and diagnostic tests are included in the secondary level of health care. - The first contact with a general physician is the primary care - The reference to a highly specialized facility for desensitization is the tertiary care level. The secondary and tertiary care facilities are equipped to provide highly specialized care. - Extended care is care provided to clients who no longer require acute hospital care.
A woman over the age of 40 years has an annual mammogram. What level of prevention does this represent?
Secondary prevention
Research has shown that the incidence of chronic conditions is increasing. Which lifestyle factor is associated with chronic diseases?
Smoking
Nurses promote the needs of clients as an integral part of each person's human dimension. Which needs are being met when a nurse recommends a senior citizen community centre for an older client who is living alone?
Sociocultural needs
The nurse recognizes that the client who makes the decision to accept a new diagnosis and follow the prescribed treatment plan is in which stage of an illness?
Stage 3-Assuming a dependent role
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
Surgical asepsis
A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:
Survival adaptation
A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness?
Symptoms are not experienced.
The nurse is preparing a plan of care for a client with nutritional deficits. Which is the priority intervention for this client?
Teaching about intake of food and vitamins
Which of the following are examples of a RN participating in illness prevention for a client with hypertension? Select all that apply. -Administering ordered medication -Reporting low blood pressure to the physician -Performing risk screenings for hypertension -Providing literature on heart-healthy diets -Teaching lifestyle modifications
Teaching lifestyle modifications, Providing literature on heart-healthy diets, and perform risk screenings for hypertension
Which of the following are the best examples of the role of the nurse as a communicator? Select all that apply. -Telling a client their blood pressure -Calling a physician about a client's blood pressure -Telling a friend about something that happened to a client that day -Informing the physical therapist that client's therapy was discontinued
Telling a client their blood pressure, calling a physician about a client's blood pressure, and informing the physical therapist that client's therapy was discontinued
The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?
Temporal artery
A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care?
Tertiary
A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?
Tertiary prevention
Which explanation differentiates the Registered Nurse (RN) from the Licensed Practical Nurse (LPN)?
The LPN should work under the supervision of an RN
The registered nurse communicated with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?
The RN coordinates care delivery
The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented? -The RN educates about preventing falls -The RN promotes a safe environment -The RN identifies client outcomes -The RN develops a plan of care
The RN promotes a safe environment
The definition of implementation would include which of the following? -The use of assessment skills to develop a nursing diagnosis -The action phase of the nursing process in which nursing care is provided -The development of outcome criteria -The proper documentation of the nursing assessment -The inclusion of the patient in establishing outcome goals
The action phase of the nursing process in which nursing care is provided
The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?
The client is covered with a couple of thick blankets
A nurse is providing care for clients in a long-term facility. Based on the definitions of nursing in the textbook, what should be the central focus of this care?
The client receiving the care
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
Which of the following is the best example of client-centered approach to care? -The nurse asks the client about his health goals -The nurse asks the client what he would like to order from the menu -The nurse helps a client ambulate -The nurse drawing a blood sample from a client
The nurse asks the client about his health goals
The postoperative patient's plan of care contains an intervention to ambulate twice a day 200 feet with assistance of one member of the healthcare team. The intervention was not completed one morning due to his pain. Which of the following would be the appropriate way to document the missed event? -The patient complained of too much pain to ambulate and was returned to bed -The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order. -The patient was assisted to standing but reported severe pain and begged to return to bed. Patient was assisted to bed. -The intervention was not completed due to the patients severe pain level -The patient was in too much pain to complete the morning ambulation
The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order.
Chronic illness may be characterized by periods of remission. Remission is best defined as:
The presence of a disease with the absence of symptoms.
A man with Alzheimer's disease in a nursing home will follow directions for dressing and feeding better with one nurse than with other staff members. This factor is related to
Therapeutic model of interaction
A researched nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers? -They tend to work in community health centers and long-term care units -They serve as liaisons between staff members and directors of nursing -They usually have a baccalaureate degree in nursing -They are responsible for the continued development and advancement of nursing
They are responsible for the continued development and advancement of nursing
The nurse working with an LPN understands which of the following about LPNs? -They must take a licensure exam -They have a higher degree than most RNs -They may work independently -The program is 4 years in length
They must take a licensure exam
What is the primary purpose of standards of nursing practice?
To ensure knowledgeable, safe, comprehensive nursing care
The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals?
To restore health
The nurse is addressing primary prevention with a group of college students. Which is an example of a primary prevention measure?
Use of condoms and safer sex practices
During the Reformation, what factor influenced the decline of nursing?
Women's subordination to men
The RN is working with hospital administration to transform care at their facility. Which of the following nursing competencies will be critical for the nurse to utilize? -Navigate the electronic medical records system -Do things the way they have always been done -Correctly utilize and troubleshoot high-tech equipment -Work effectively in interdisciplinary teams
Work effectively in interdisciplinary teams
The need for university-based nursing education programs was brought to light during which important historical time?
World War II
Which of the following is the best example of the nurse acting as an advocate? -Writing legislator for insurance coverage for screening colonoscopies -Communicating clients' test results to the physician -Leading implementation of electronic medical records on the unit -Testing which product is the best for healing diabetic foot ulcers
Writing legislator for insurance coverage for screening colonoscopies
Clients demonstrating apnea have what?
a temporary cessation of breathing
Shuba and Raul are a couple in their late seventies. According to Duvall, which developmental task is appropriate for this older adult family? Maintain a supportive home base Strengthen marital relationships Cope with loss of energy and privacy Adjust to retirement
adjust to retirement rationale: . The developmental tasks of the family with older adults are to adjust to retirement and possibly to adjust to the loss of a spouse and loss of independent living. Maintaining a supportive home base and strengthening marital relationships are tasks of the family with adolescents and young adults. Coping with loss of energy and privacy is a task of the family with children.
An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?
advanced age
The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?
apical
Stage 1: Adult is newly married, with no children The person assumes the spousal role Stage 2: First child is born Role of parent is added. Stage 3: Oldest child is between 2 and 6 Role of parent changes Stage 4: Oldest child is in school Parental role changes again Stage 5: Oldest is an adolescent Parental role changes again Stage 6: Oldest child leaves home Parental role involves helping child become independent Stage 7: All children have left home Sometimes called the post-parental stage Stage 8: One or both spouses have retired
duvall 8 stages
self-actualization
full potential acceptance of self and others as they are; focusing on problems outside the self strengths and abilities
what is an example of an attainable goal for a patient?
give a patient a few days to learn how to inject themselves with medication. something like that may not take a few hours to learn
An older adult client who has been hospitalized due to a stroke is about to be discharged from a rehabilitation center where the he had to relearn how to feed and dress himself. The client often voiced a desire to be as active as possible. The client now expresses a strong desire to go home. The nurse recognizes that these statements made by the client indicate that the client is:
giving up the dependent role.
To eliminate needlesticks as potential hazards to nurses, the nurse should:
immediately deposit uncapped needles into a puncture-proof plastic container.
what occurs when love and belonging needs are not met?
loneliness and isolation
Think back to Samuel Kaplan, the man caring for his wife with Alzheimer disease. The nurse could refer Mr. Kaplan to a support group for caregivers of patients with Alzheimer disease to help meet Mr. Kaplan's needs. this fits under what level of hierarchy...
love and belonging
What is level 3 of the Maslow Hierarchy?
love and belongings
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease
A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?
older adult
The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:
orthopnea
what is the most essential physiological need?
oxygen
Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?
palpation of the radial pulse on the thumb side of the inner aspect of the wrist.
what are 5 major family functions?
physical, economic, reproductive, affective and coping, and socialization
What is 1st level of Maslow Hierarchy?
physiological needs
Surgical technique (sterile technique)
practices used to render and keep objects and areas free of microorganisms
Which term indicates a potentially serious client condition?
pyrexia
The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?
remind the student that a fitted N95 respirator is required
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room
A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply.
respiratory rate 30/min headache red or flushed skin
what needs has both physical and emotional components?
safety and secuirty needs
The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse? Physiologic Safety and security Self-esteem Love and belonging
safety and security
What is level 2 of Maslow Hierarchy?
safety and security needs
holistic plan of care?
seeks to balance and integrate the use of crisis medicine, advanced technology along with the mind, body and spirit which are incorporated though the use of the nursing process
What is level 5 of the Maslow Hierarchy?
self - actualization needs
What is level 4 of the Maslow Hierarchy?
self - esteem needs
A client enjoys eating high-calorie carbohydrate meals, but understands her blood sugar can increase sharply, ultimately causing the feeling of butterflies in her stomach as her blood sugar decreases. This is considered:
self-concept. Explanation: A person's self-concept is influenced by having knowledge and the ability to care for oneself, recognizing one's strengths and limitations.
community?
social group, whose members may or may not share common geographic boundaries, yet who interact because of common interests or shared values to meet the needs within a larger society.
An adult pulse greater than 100 bpm is:
tachycardia
socialization?
teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving
what does a positive self esteem facilitate?
the person's confidence and independence
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
urinary catheter
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift
safety and security needs:
using proper hand hygiene using electrical equipment properly adminstering medications knowledgeably, moving and ambulating patients skillfully, trusting others and being free of fear and anxiety
Is oxygen the most essential of all human needs?
yes
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
"Help me understand your thoughts about vaccinations."
When taking the client's temperature, the student nurse will require further education when they state:
"The axillary route is the most accurate of all routes."
Lab data indicating infection are?
-Elevated WBC count: normal is 5000 to 10,000/mm3 -Increase in specific types of WBC -Elevated erythrocyte sedimentation rate (RBCs settle more rapidly to the bottom of a tube of whole blood when an inflammation is present) -Presence of pathogen in urine, blood, sputum, or draining cultures
5. A nurse works with families in crisis at a community mental health care facility. What is the best broad definition of a family? A father, a mother, and children A group whose members are biologically related A unit that includes aunts, uncles, and cousins A group of people who live together and depend on each other for support
A group of people who live together and depend on each other for support
Which patient need has the highest priority? A patient who needs to ambulate to prevent DVT A patient who is in isolation and feels lonely A patient who recently lost her husband An elderly patient who is at risk for falls
A patient who needs to ambulate to prevent DVT rationale: PHYSIOLOGIC NEED. at bottom of hierarchy meaning highest priority!
The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health. Which example describes one of these risk factors? The family does not have dental care insurance or resources to pay for it. Both parents work and leave a 12-year old child to care for his younger brother. Both parents and their children are considerably overweight. The youngest member of the family has cerebral palsy and needs assistance from community services.
Both parents work and leave a 12-year old child to care for his younger brother. rationale: Inadequate childcare resources is a psychosocial risk factor. Not having access to dental care and obese family members are lifestyle risk factors. Having a family member with birth defects is a biologic risk factor
The nurse caring for patients in a long-term care facility knows that the highest level on Maslow's hierarchy of needs is self-actualization needs. Which statements accurately describe the achievement of self-actualization? Select all that apply. Humans are born with a fully developed sense of self-actualization. Self-actualization needs are met by depending on others for help. The self-actualization process continues throughout life. Loneliness and isolation occur when self-actualization needs are unmet. A person achieves self-actualization by focusing on problems outside self. Self-actualization needs may be met by creatively solving problems.
The self-actualization process continues throughout life. A person achieves self-actualization by focusing on problems outside self. Self-actualization needs may be met by creatively solving problems. rationale: Self-actualization, or reaching one's full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a guideline for solving problems and pursuing interests. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs.
A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply. Who is the person you depend on for emotional support? Who is the breadwinner in your family? Do you plan on having any more children? Who keeps your family together in times of stress? What family traditions do you pass on to your children? Do you live in an environment that you consider safe?
Who is the person you depend on for emotional support? Who keeps your family together in times of stress? rationale: The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Asking who provides emotional support in times of stress assesses the affective and coping function. Assessing the breadwinner focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function.
A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
Write it down