300 speciality exam review
the nurse is discussing discharge plans with a client. the client states, "i'm worried about going home". the nurse response "tell me more about this". which interviewing technique did the nurse use? exploring reflecting refocusing acknowledging
exploring rationale: exploring is a technique used to obtain more information to better understand the nature of the client's statement. reflecting is a technique used to either reiterate the content or the feeling message. in content reflection, aka paraphrasing, the nurse repeats basically the same statement; in feeling reflection the nurse verbalizes what seems to be implied about feelings in the comment. refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion
which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? analysis inference explanation interpretation
explanation rationale: explanation requires knowledge and experience for choosing strategies for care for clients. analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. the skill of inference is associated with noticing relationships in the findings. interpretation is associated with ordered data collection
which characteristic would the nurse associate with collaborative problems experienced by a client? they are the identification of a disease condition they include problems treated primarily by nurses they are identified by the primary health provider they are identified by the nurse during the nursing diagnosis stage
they are identified by the nurse during the nursing diagnosis stage rationale: the nurse assesses the client to gather information for reaching diagnostic conclusions. collaborative problems are identified by the nurse during this process. if the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem. a medical diagnosis is the identification of a disease condition. problems that require treatment by the nurse are referred to as nursing diagnoses. a medical diagnosis is identified by the primary health care provider based on the results of diagnostic tests
which action is appropriate for the registered nurse regarding assisted suicide? -nurses may have an open attitude toward the client's end of life -nurses participation in assisted suicide violates the code of ethics -nurses may listen to the client's expressions of fear and attempt to control the patient's pain -nurses can participate in assisted suicide only if the individual could make an oral and written request
nurses participation in assisted suicide violates the code of ethics rationale: according to the american nurses association ANA , the nurses participation in assisted suicide would violate the their code of ethics. according to the american association of colleges of nursing AACN and the international council of nurses, the nurse may have an open attitude toward the client's end of life. according to the AACN and the international council of nurses, nurses may listen to the client's expressions of fear and and attempt to control the client's pain. according to the oregon death with dignity act (1994) the primary health care provider in the state of Oregon can participate in assisted suicide only if an individual with terminal disease makes an oral and written request to end life in a humane and dignified manner
which statement correctly describes middle-range theories? select all that apply, one, some, or all responses may be correct 1. these theories are systematic and broad in scope and complexity 2. middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response 3. these theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching 4. middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty 5. these theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations
2. 4. 5. rationale: middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. mishel's theory of uncertainty in illness is an example of middle-range theory; it focuses on a client's experiences with cancer while living with continual uncertainty. middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontientce, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. middle-range theories are more limited in scope and less abstract than grand theories. middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching
the nurse notes that a client has mild hypothermia based on which body temperature? 29 C (82.4 F) 30 C (86 F) 33 C (91.4 F) 35 C (95 F)
35 C (95 F) rationale: hypothermia occurs when the body temperature falls below 36.2 C. based on the severity, it is classified as mild, moderate, and severe. mild hypothermia refers to a body temperature of 34-36 C (93.2-96.8). in this case, the client's body temperature is 35 C which indicates mild hypothermia. moderate hypothermia refers to a body temperature of 30-34 C (86-93 F) and severe hypothermia refers to a body temperature below 30 C (86 F). the client does not have severe hypothermia; therefore, the client does not have a body temperature of 29 C. the client does not have moderate hypothermia; therefore, the client does not have a body temperature of 30C or 33C
which definition does the World Health Organization (WHO) use to define 'health'? -a condition when people are free of disease -a condition of life rather than pathological state an actualization of inherent and acquired human potential -a state of complete physical, mental, and social well being
a state of complete physical, mental, and social well being rationale: the WHO defines health as a "state of complete physical, mental, and social well being, not merely the absence of disease or infirmity." pender murdaugh and parsons explains that for many people, health is a condition of life rather than pathological state. life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident; it is pender, murdaugh, and parsons who define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, satisfying relationships with others
which therapeutic communication is used when the nurse and a client have a conversation to self? focusing clarifying paraphrasing summarizing
focusing rationale: focusing is a therapeutic communication technieque that is useful when clients begin to repeat conversations to themselves. clarification helps check whether the client's understanding is accurate by restating an unclear or ambigous message. paraphrasing involves restating a message more briefly using one's own words. summarizing is a concise review of key aspects of an interaction
which skill in critical thinking requires the nurse to be orderly in data collection? analysis inference evaluation interpretation
interpretation rationale: interpretation is involved in the orderly collection of data. when information about a client is collected with an open mind, then the skill called analysis is being used. when the data collected about the client helps in solving an existing problem, then the skill called inference is being used. evaluation is used when the results of nursing actions are determined
what function is the role of the nurse administrator in a health care setting? -providing surgical anesthesia under the guidance and supervision of an anesthesiologist -preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development -providing comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions -educating staff about current nursing practices, trends, theories, and necessary skills in laboratories in clinical settings
preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development rationale: the nurse administratiors function is to prepare the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development. a certififed registered nurse anesthetist provides surgical anesthesia under the guidance and supervision of an anesthesiologist. the nurse practitioner provides comprehensive care and directly manages the medical care of clients who are healthy or have chronic conditions. nurse educators provide knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings
the nurse is caring for a child who has an external fixation device on the leg. which is the nurse's priority goal when providing pin care? easing pain minimizing scarring preventing infection avoiding skin breakdown
preventing infection rationale: pin sites provide a direct avenue for organisms into the bone. pin site care is priority over easing pain. some scarring will occur at the pin insertion site regardless of pin site care. skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented
which term would the nurse use to document a client with drooping of the eyelid over the pupil? ptosis ectropion entropion nystagmus
ptosis rationale: drooping of the eyelids over the pupil is called ptosis, which is how the nurse would document the finding. ectropion is when the eyelid margins turn out. entropion is similar, but is when the eyelid margins turn in and sometimes cause irritation of the conjunctiva and cornea. nystagmus is a involuntary oscillation of the eyes, and usually occurs after an eye injury
which nursing practice is associated with self-regulation skill? reflecting on one's experience contemplating one's own behavior supporting one's findings and conclusions clarifying any data that one is uncertain about
reflecting on one's experience rationale: self regulation involves reflecting on the nurse's experience. evaluation involves contemplating the nurse's own behavior. explanation involves supporting findings and conclusions. interpretation involves clarifying any data about which the nurse is uncertain
the nurse finds the client's fever spikes and falls without a return to a normal level. which fever is this a characteristic? relapsing sustained remittent intermittent
remittent rationale: in remittent pattern, fever spikes and falls without returning to normal temperature levels. periods of febrile episodes coupled with periods of acceptle temperature values are called relapsing pattern. a constant body temperature continuously above 100.4 (38) with little fluctuation refers to a sustained pattern. in an intermittent pattern, fever spikes are interspersed with normal temperature levels
upon assessing a client who is receiving chemotherapy, the nurse notes the client is using a scarf to cover her head. the nurse asks the client about coping with her altered body image. which functional pattern would the assessment include? value-belief pattern role-relationship pattern cognitive-perceptual pattern self-perception-self-tolerance pattern
self-perception-self-tolerance pattern rationale: the nurse is applying gordon's self0perception-self-tolerance pattern to assess the client. this functional pattern describes the client's self-worth, emotional patterns, and body image. the value-belief pattern describes patterns of values, beliefs, and spiritual practices, and goals that guide the client's choices or decisions. the role-relationship pattern describes patterns of role engagements and relationships. the cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability
when developing a nursing diagnosis for a client after surgery, the nurse documents the 'related to' factor as first-time surgery. which assessment activity enabled the nurse to draw this conclusion? the nurse notes nonverbal signs of discomfort the nurse observes the client's position in bed the nurse asks the client to explain the surgery the nurse asks the client to rate the severity of pain
the nurse asks the client to explain the surgery rationale: the nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. the nurse observes the client's positioning in bed to determine any abonormal signs such as discomfort or pain. the nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound
upon assessing a client who underwent abdominal surgery 10 days ago, the client reports abdominal pain. which type of pain would the client experience visceral pain somatic pain referred pain intractable pain
visceral pain rationale: visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. somatic pain arisiess from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. intractable pain is a neuropathic pain that is severe, constant pain that is not curable