Exam 3
When educating a client, which are important factors to consider regarding the client's ability to learn and retain information? Select all that apply. 1. clients literacy level of client 2. desire and motivation 3. barriers to communication 4. development and physical limitations 5. culture and religious practices 6. family dynamics
1, 2, 3, 4, 5 family dynamics are important in education, but they
Healthy People 2020 include which of the following? Select all that apply. 1. Eliminate health disparities among various groups. 2. Decrease the cost of healthcare related to tobacco use. 3. Increase the quality and years of healthy life. 4. Decrease the number of inpatient days annually. 5. Promote hospice care to the elderly
1, 3 Eliminating health disparities and improving health of all groups is a Healthy People 2020 goal. Increasing the quality and years of healthy life is a goal of Health People 2020.
The nurse is admitting an elderly resident to an assisted living facility. In order to determine the resident's level of physical fitness upon admission, which of the following components should be included in the assessment? 1. Cardiorespiratory fitness 2. Hardiness 3. Muscular fitness 4. Flexibility 5. Nutritional status
1, 3, 4 Cardiorespiratory fitness is included in a physical fitness assessment. Muscular fitness is a part of a physical fitness assessment. Muscle strength and endurance are measured during this part of the assessment. Flexibility is included in a physical fitness assessment. Although flexibility measures the ability to move a joint through its range of motion, the most common part of this assessment is to evaluate low back and hip (trunk) flexion.
Which food item provides the body with no usable glucose? 1.Wheat germ 2.Potatoes 3.Honey 4.Brown rice
1. Wheat germ Dietary fiber, such as wheat germ, contains no usable glucose. Humans do not have the enzymes to digest fiber; thus, it provides no usable glucose.
A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? 1."Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." 2."You really need to continue breastfeeding your baby." 3."Give your baby formula until he is 6 months old; then you can introduce whole milk." 4."Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day."
1."Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." The nurse should emphasize the importance of giving the baby iron-fortified formula because fetal iron stores become depleted by age 4 to 6 months. The mother can give it to supplement any stored breast milk she might have in supply.
Which portion of a nutritional assessment must the registered nurse complete? 1.Analyzing the data 2.Obtaining intake and output 3.Weighing the patient 4.Taking the nutritional history
1.Analyzing the data The registered nurse should review and interpret (analyze) the data collected as part of a nutritional assessment.
A patient who was prescribed furosemide is deficient in potassium. Which nutritional goal is appropriate for this patient? The patient will increase consumption of: 1.Avocados, peaches, molasses, and potatoes 2.Eggs, celery, baking soda, and baking powder 3.Wheat bran, chocolate, eggs, and sardines 4.Egg yolks, nuts, broccoli, and sardines
1.Avocados, peaches, molasses, and potatoes Foods rich in potassium include peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes.
The nurse admitting a new patient to the medical-surgical unit is conducting a dietary history. What information should the nurse include? Select all that apply. 1.Basic eating habits 2.Food preferences 3.Attitude toward food 4.Body mass index (BMI) 5.Cultural dietary restrictions
1.Basic eating habits 2.Food preferences 3.Attitude toward food 5.Cultural dietary restrictions
For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Select all that apply. 1.Check inside the mouth for pocketing of food after eating. 2.Provide a full liquid diet that is easy to swallow. 3.Remind the patient to raise the chin slightly to prepare for swallowing. 4.Keep the head of the bed elevated for 30 to 45 minutes after feeding. 5.Encourage the use of straws to drink fluids easily.
1.Check inside the mouth for pocketing of food after eating. 4.Keep the head of the bed elevated for 30 to 45 minutes after feeding.
The nurse completes the nutrition assessment for a 14-year-old female with a body mass index (BMI) of 15. Which physical assessment finding would cause the nurse to suspect an eating disorder? 1.Cold intolerance 2.Hypertension 3.Excessively thick hair 4.Early development of sexual maturation
1.Cold intolerance Cold intolerance is a physical sign of an eating disorder.
Which instructions should the nurse give to the older adult patient experiencing constipation? Select all that apply. 1.Drink at least eight glasses of water or fluid per day. 2.Obtain a minimum of four servings of meat per day. 3.Consume whole grains and fresh greens. 4.Exercise vigorously at least 60 minutes per day. 5.Include both soluble and insoluble fibers in the diet.
1.Drink at least eight glasses of water or fluid per day. 3.Consume whole grains and fresh greens. 5.Include both soluble and insoluble fibers in the diet. To prevent constipation, the nurse should instruct the patient to drink at least eight glasses of water or fluid per day. Whole grains and fresh greens provide the needed fiber for constipation. Soluble fiber allows more water to remain in the stool, which makes it softer and easier to pass. Insoluble fiber adds bulk to the stool for easier defecation.
The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? 1.Folic acid 2.Calcium 3.Protein 4.Vitamin D
1.Folic acid The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing
A 52-year-old man has a body mass index of 28.9, and his weight exceeds the ideal body weight for height by 23%. Which nursing diagnosis should the nurse identify for this patient? 1.Imbalanced Nutrition: More Than Body Requirements 2.Risk for Imbalanced Nutrition: More Than Body Requirements 3.Imbalanced Nutrition: Less Than Body Requirements 4.Readiness for Enhanced Nutrition
1.Imbalanced Nutrition: More Than Body Requirements This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: body mass index is in the overweight category and weight is 20% over ideal for height and frame.
The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which nutrient? 1.Iron 2.Vitamin A 3.Protein 4.Vitamin C
1.Iron Patients with iron deficiency may have spoon-shaped, brittle nails.
To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply. 1.Whole grain rice 2.Legumes 3.Poultry 4.Eggs 5.Milk
1.Whole grain rice 2.Legumes Whole grain rice is an incomplete protein. Incomplete proteins are supplied by plant sources (e.g., grains, nuts, legumes, seeds, vegetables). They can be combined to make complete proteins Legumes are examples of incomplete protein. Grains, nuts, legumes, seeds, and vegetables are examples of incomplete proteins. They can be combined to make complete proteins.
The nurse is caring for a patient with a significant history of hypertension and cardiovascular disease. The nurse would be most interested in the findings of which laboratory results? 1.Lipoproteins, such as low-density and high-density lipoproteins (LDLs and HDLs) 2.Fatty acids, such as alpha-linolenic acid (omega-3) 3.B-complex vitamins 4.Vitamin K
1.Lipoproteins, such as low-density and high-density lipoproteins (LDLs and HDLs) LDLs transport cholesterol to body cells. Diets high in saturated fats increase LDL circulation in the bloodstream and may result in fatty deposits on vessel walls, causing cardiovascular disease. As a result, LDL is often known as the "bad cholesterol." HDLs remove cholesterol from the bloodstream, returning it to the liver, where it is used to produce bile; thus, a high HDL is considered protective against cardiovascular disease and is often known as the "good cholesterol."
The nurse assigned to an oncology unit reports that three of the patients with cancer do not have an appetite and have eaten little during the shift. What strategies can the nurse on the next shift use to increase these patients' appetites? Select all that apply. 1.Offer frequent, smaller meals. 2.Keep the patients' rooms neat and clean. 3.Provide or assist with frequent oral hygiene. 4.Increase liquid intake before meals. 5.Avoid high-protein supplements.
1.Offer frequent, smaller meals. 2.Keep the patients' rooms neat and clean. 3.Provide or assist with frequent oral hygiene.
The nurse is teaching a male patient about the importance of reducing saturated fats in the diet. The nurse will recognize that learning has occurred if, upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fats? Select all that apply: 1.Palm oil 2.Coconut oil 3.Canola oil 4.Peanut oil 5.Safflower oil
1.Palm oil 2.Coconut oil Palm oil is a source of saturated fat that are contained in many processed foods. The patient should be encouraged to read product labels to eliminate them from the diet. Many processed foods contain coconut oils, which are sources of saturated fat. The patient should be encouraged to read product labels to eliminate them from the diet.
The patient is irritable, temperature is elevated, and mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral? 1.Sodium 2.Potassium 3.Phosphorus 4.Magnesium
1.Sodium Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky tongue and mucous membranes, restlessness, irritability, and seizures.
The nurse is checking the aspirate for the patient receiving gastric tube feedings. The nurse notes the 200 mL of pale yellow and cloudy fluid with a pH of 7.3. Which action should the nurse take? 1.Stop the feeding immediately; then notify the prescribing provider. 2.Hold the tube feeding for 2 hours; continue if residual is less than 200 mL. 3.Flush tube with 30 mL of sterile water; resume tube feeding at prescribed rate. 4.Administer a promotility agent as prescribed; resume feeding in 1 hour.
1.Stop the feeding immediately; then notify the prescribing provider. Normal gastric fluid should be greenish brown or white, and acidic (pH 1 to 5.5). If the gastric aspirate has a pH of 7.3 (alkaline), the nurse must stop the tube feeding immediately and notify the prescriber of the feedings. This finding might indicate the feeding tube has migrated to the lungs, which could lead to aspiration pneumonia and become a medical emergency.
What should the nurse include in a plan for teaching adults about dietary trans-fatty acids? Select all that apply. 1.Trans fat increases the shelf-life of foods. 2.Trans fat decreases blood cholesterol levels and low-density lipoprotein (LDL) levels. 3.The Food and Drug Administration (FDA) mandates that trans fat content be listed on all food labels. 4.Check for hydrogenated vegetable oils on food labels. 5.Vegetable oil sprays used for cooking are high in trans fats.
1.Trans fat increases the shelf-life of foods. 3.The Food and Drug Administration (FDA) mandates that trans fat content be listed on all food labels. 4.Check for hydrogenated vegetable oils on food labels. Trans-fatty acids are saturated fats created when food manufacturers add hydrogen to polyunsaturated plant oils, such as corn oil. This process solidifies the fat, improves texture and flavor, and extends the shelf-life of the food. The FDA mandates that trans fat content be listed on all food labels. Intake of saturated and trans fat should be limited. Trans fats are found in many margarines and other processed foods containing hydrogenated vegetable oils.
The registered nurse (RN) on a medical-surgical unit is making assignments. Which tasks would the RN delegate to the licensed practical nurse (LPN)? Select all that apply. 1.Tube feeding 2.Fingerstick blood glucose 3.Nutritional history 4.Laboratory findings interpretations 5.Lipid administration
1.Tube feeding 2.Fingerstick blood glucose 3.Nutritional history
The pediatric nurse is preparing a teaching plan about vitamins for parents of school-age children. What vital information will the nurse include in the plan? Select all that apply. 1.Water-soluble vitamins are needed for cellular metabolism. 2.Vitamins are necessary for preventing particular deficiency diseases. 3.Because the body does not make vitamins, they must be supplied by the foods we eat. 4.The most important vitamin for children is vitamin C. 5.Vitamin E is needed to prevent night blindness.
1.Water-soluble vitamins are needed for cellular metabolism. 2.Vitamins are necessary for preventing particular deficiency diseases. 3.Because the body does not make vitamins, they must be supplied by the foods we eat.
A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, "If glucose is so important, then I think as long as my blood sugar is high I must be doing well." What is the most appropriate response by the nurse? 1."It depends on what you mean by high blood sugar. You will need to obtain more information from your provider as diabetes is a very complicated disease process." 2."I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells can't use the excess glucose." 3."I will be able to explain this to you a little better when we talk about diabetes. For now, I have to finish my assessment, and then we can get back to your question." 4."When I finish your assessment, I will teach you how to perform glucose testing. As long as your blood sugar remains somewhere in the 120-to-140 range, you will be doing well."
2."I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells can't use the excess glucose." Diabetes, an endocrine problem, may develop as a result of either insufficient insulin production or resistance to the existing supply of insulin. A high blood glucose level does not mean that there is more fuel available for cellular energy. A characteristic of diabetes is that although there is more than enough glucose in the blood, it cannot enter and be used by the cells.
The nurse is caring for a patient who states, "I have been smoking two packs of cigarettes a day for 20 years, and now my nurse practitioner wants me to take vitamins. Do you think I need to take vitamins?" What is the most appropriate response by the nurse? 1."Smoking is bad for your health. I believe if you stop smoking, you would certainly be better off and not have to take vitamins." 2."Smokers use vitamin C faster than do nonsmokers, and this is linked to iron deficiency. You can either eat more foods containing vitamin C and iron or take dietary supplements." 3."It is probably a good idea. With your history of tobacco use, I'm sure you are lacking in vitamins and nutrients." 4."I really cannot answer this question. You will need to speak with a nutritionist to find out more about this."
2."Smokers use vitamin C faster than do nonsmokers, and this is linked to iron deficiency. You can either eat more foods containing vitamin C and iron or take dietary supplements." Because vitamin C is an antioxidant, smokers metabolize vitamin C faster than do nonsmokers. The more a person uses tobacco, the more vitamin C is lost, yet, the body needs more vitamin C to counteract the damage smoking causes to cells. Additionally, because vitamin C aids in absorption of iron, a low level of vitamin C is also linked to iron deficiency. If a person cannot quit smoking, vitamin C and iron supplementation may help compensate.
A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. Which nutrient level will most likely be the lowest? 1.Iron 2.B vitamins 3.Calcium 4.Phosphorus
2.B vitamins Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid.
Which class of nutrients is the body's primary source of energy? 1.Proteins 2.Carbohydrates 3.Lipids 4.Vitamins
2.Carbohydrates Carbohydrates are the primary energy source for the body. Carbohydrates perform several functions. They supply energy for muscle and organ function, spare protein, and enhance insulin secretion.
A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? 1.Dehydration 2.Constipation 3.Hyperglycemia 4.Diarrhea
2.Constipation Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation.
Where in the body is glucose stored? Select all that apply. 1.Brain 2.Liver 3.Skeletal muscles 4.Smooth muscles 5.Bone marrow
2.Liver 3.Skeletal muscles
Which laboratory test result most accurately reflects a patient's nutritional status? 1.Albumin 2.Prealbumin 3.Creatinine 4.Hemoglobin
2.Prealbumin Prealbumin levels fluctuate daily, and is considered a better marker of acute change than albumin.
A group of pediatric nurses accepts an international assignment in an underdeveloped country. The nurses are informed that they will be caring for many children with kwashiorkor. The nurses will create a care plan focusing on which primary nutrient for these children? 1.Calories 2.Protein 3.Niacin 4.Vitamin C
2.Protein Kwashiorkor is a severe deficiency of dietary protein.
Which nutrient deficiency increases the risk for tissue breakdown? 1.Potassium 2.Protein 3.Fluoride 4.Vitamin D
2.Protein Protein is necessary for growth and maintenance of body tissues. Protein deficiency places the patient at risk for skin breakdown.
For an elderly client who is experiencing chronic nausea and weight loss, which laboratory result would the nurse recognize as being most consistent with a diagnosis of Imbalanced Nutrition: Less Than Body Requirements? 1.Serum glucose of 78 mg/dL 2.Serum albumin of 3.2 g/dL 3.Creatinine of 1.0 mg/dL 4.Hemoglobin of 12.8 g/dL
2.Serum albumin of 3.2 g/dL Serum albumin is a blood protein and marker for nutritional status. The value should be between 3.4 and 4.8 g/dL. This situation is consistent with undernutrition due to low nutritional intake.
After inserting a nasogastric feeding tube, what would be the nurse's priority action prior to starting the first tube feeding? 1.Auscultate bowel sounds over the abdomen. 2.Aspirate gastric contents and obtain a pH reading. 3.Obtain radiographic verification (x-ray). 4.Mix the feeding with water for the first feeding only.
3.Obtain radiographic verification (x-ray). Radiographic (x-ray) verification is the only reliable method for confirming tube placement; it must be performed before the first feeding is administered.
Which statement made by a client whose body mass index (BMI) is 34 and is attempting to lose weight would indicate the need for further teaching? 1."I should limit the number of fruit juices that I drink every day." 2."I need to tell my family and friends about my commitment to losing weight." 3."An online food diary is unlikely to help me to improve my food intake." 4."The amount of time that I spend in front of my computer and TV should be limited."
3."An online food diary is unlikely to help me to improve my food intake." Keeping a food diary (either traditional or online), reviewing nutritional intake (both food selections and serving size), and patterns of consumption have all been shown to assist clients in decreasing dietary intake.
While the nurse is performing a nutritional assessment, the patient states, "I am on a vegan diet. I have been a vegan for 10 years." What is the best response by the nurse? 1."Is this a religious or cultural requirement for you?" 2."It is fine; however, you may not be getting all the nutrients you need." 3."Can you tell me about the foods you eat along with any other supplements you take?" 4."I think it is your right to be on whatever diet you would like to be on."
3."Can you tell me about the foods you eat along with any other supplements you take?" The most appropriate response by the nurse is to first assess what the patient is eating and what supplements the patient uses. This will assist the nurse in identifying the patient's knowledge level of the diet and in identifying proper supplements.
A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1.Vanilla shake 2.Orange juice 3.Grape juice 4.Skim milk
3.Grape juice
A patient's parenteral nutrition (PN) container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? 1.Sepsis 2.Aspiration 3.Hypoglycemia 4.Diarrhea
3.Hypoglycemia Because of the high glucose content of parenteral nutrition, any interruption in therapy places the patient at risk for hypoglycemia. PN should not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar (rebound hypoglycemia).
During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate? 1.Increases the rate by 7% 2.Decreases the rate by 14% 3.Increases the rate by 35% 4.Decreases the rate by 28%
3.Increases the rate by 35% Basal metabolic rate increases by 7% for each degree Fahrenheit (0.56°C); therefore, this patient's temperature rise is an increase of 35%: 102 - 97 = 5 ´ 7 = 35.
Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1.Limit intake of protein 2.Avoid foods containing gluten 3.Restrict use of sodium 4.Reduce intake of potassium-rich foods
3.Restrict use of sodium Patients with hypertension should limit their intake of sodium.
While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. The nurse emphasizes that doing so greatly reduces the risk of which complication? 1.Kidney failure 2.Asthma 3.Stroke 4.Lung cancer
3.Stroke Dietary fat should mainly be polyunsaturated and unsaturated to reduce the risk of heart disease and stroke.
After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates correct understanding of the topic? 1."I usually use dessert only as a reward for eating other foods." 2."I will make sure my child gets at least 2,000 kcal/day." 3."I do not give my child snacks; they simply spoil the appetite for meals." 4."I know that lifelong food habits are developed during this stage of life."
4. "I know that lifelong food habits are developed during this stage of life." Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to the child.
An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and has become weak. Her appetite and activity level are reduced, and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be? 1.Need for teaching about nutrition 2.Anxiety 3.Distaste for the food served 4.Frail elderly syndrome
4.Frail elderly syndrome With advancing age, older adults face many losses. As a result, depression and social isolation are common. Both negatively affect appetite. Frail elderly syndrome is a complex disorder characterized by weight loss, lessened activity and interaction, and increasing frailty.
Which intervention would help to prevent or relieve persistent nausea? 1.Assess for signs of dehydration. 2.Provide dietary supplements. 3.Place the patient in a supine position for 30 minutes after eating. 4.Immediately remove any food that the patient cannot eat.
4.Immediately remove any food that the patient cannot eat. Odors (even pleasant ones) and even the sight and smell of hot food can cause nausea, so any uneaten food should be removed immediately from the room.
What is the best explanation of teaching? 1. an interactive process involving planning and implementing instructional activities that meet intended outcomes as well as activities that allow the learner to learn 2. a change in behavior, knowledge, skills, or attitudes to reach common goals 3. a result of motivation to learn that involves planned or spontaneously occurring situations, events, or exposures 4. using techniques, counseling, and behavioral modification together to achieve effective client learning
1 effective teaching involves interaction between teacher and learner/student with information and activities included to reach a common goal
The student nurse is teaching a client with heart failure about healthy food options. When asked to choose between a hamburger and baked chicken, the client states that eating baked chicken is better than eating a hamburger. In this situation, which element represents the feedback? 1. The client stating that eating baked chicken is better than eating a hamburger 2. The student nurse listing the food options for the client 3. The client observing and listening to options 4. the student nurse asking the client to choose between options
1 feedback can be offered by the educator or by the learner and is often evidence that learning has taken place
A client has just been shown when and how to self-administer epinephrine (EpiPen). How can the nurse ensure the client fully understands and can self-inject it when needed? 1. the client can verbally explain why it is important as well as demonstrate the proper use of EpiPen 2. the client verbally explains how to administer epinephrine by pointing to areas of the body that are injections sites 3. the client demonstrates the movements of self-injection 4. the client repeats the importance of why epinephrine is to be used in an allergic reaction
1 when a client can both verbalize and demonstrate use, there has been a change in behavior
The nurse is aware a family assessment includes which areas? Select all that apply. 1. Coping patterns 2. Health beliefs 3. Medical history 4. Physical examination 5. Medication information
1, 2 Conducting a family assessment includes identifying family stressors and coping patterns. Conducting a family assessment includes identifying health beliefs.
Why is the role of teaching clients and families and ensuring their proper education important in health care? Select all that apply. 1. Empowers autonomy 2. allows client/family to perform self-care 3. allows for informed decisions regarding health care 4. empowers family to make decisions for clients
1, 2, 3
The nurse is aware the study of genomics and the use of a genogram are playing a larger role in personalizing a patient's plan of care. In which manner are genomics and the use of a genogram helpful to the nurse in personalizing a patient plan of care? Select all that apply. 1. Assists in development of better preventive care by identifying at-risk individuals 2. Helps to more accurately detect illness, even before symptoms appear 3. Provides insight to how people respond differently to specific drugs and treatments 4. Increases the trust a patient and family have in the healthcare professionals 5. Prevents a disease-related crisis from developing for patients and families
1, 2, 3 Genomics can be used to personalize a patient's plan of care by identifying at-risk individuals for certain conditions so more effective preventive care can be provided. Genomics allows for more accurate detection of illness, even before symptoms appear, and promotes tailoring healthcare to the individual while reducing a trial-and-error approach. The use of genomics assists in evaluating a person's response to care, and helping to understand how people respond differently to particular drugs and medical treatments.
The nurse working in an ambulatory care program asks questions about the client's locus of control as a part of his assessment because of which of the following? Select all that apply. 1. People who feel in charge of their own health are the easiest to motivate toward change. 2. People who feel powerless about preventing illness are least likely to engage in health promotion activities. 3. People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider. 4. People who feel in charge of their own health are less motivated by health promotion activities. 5. People who are not in control of their health decisions will be more motivated by positive change
1, 2, 3 Identifying a person's locus of control helps the nurse determine how to approach a client about health promotion. Clients who feel in charge of their own health are the easiest to motivate toward positive change. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider.
The nurse is conducting a risk appraisal related to the patient's lifestyle choices. What questions would be appropriate for the nurse to ask? Select all that apply. 1. "What is your job?" 2. "What is your marital status?" 3. "What are your hobbies?" 4. "Are you sexually active?" 5. "Have you moved recently?"
1, 2, 3, 4 A person's occupation is a significant component of his lifestyle, so this would be an important question to ask. Marital status plays an important role in lifestyle, so this is an appropriate question to ask. Hobbies should be assessed to determine specific lifestyle risks for this patient. Even married people should be asked about sexual activity because sexual activity can have a significant impact on health and risk for health problems.
The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Select all that apply. 1. Creating a weekly discussion group focused on contemporary news 2. Facilitating a relationship between local pastors and residents of subsidized housing 3. Coordinating a senior tutorial program for local children at the housing center 4. Establishing an on-site healthcare clinic operating 1 day per week 5. Providing free housing for seniors
1, 2, 3, 4 The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. A tutorial program offered by seniors to local children will facilitate occupational health. An on-site healthcare clinic addresses physical health.
The nurse is aware that homelessness is a growing problem in the United States. The nurse is aware of which primary causes of homelessness? Select all that apply. 1. Lack of job skills 2. Lack of social skills 3. Underlying mental illness 4. Substance abuse 5. Loss of a job
1, 2, 3, 4, 5 A cause of homelessness is directly impacted by a lack of job skills, a situation that causes a person to be unemployable. Lacking social skills is a key factor in being able to obtain a job. Persons who cannot interact appropriately with other are likely to be unemployable. Many homeless persons are affected by underlying mental illness, which makes the person difficult to place in programs aimed at resolving the homeless situation. Because persons who engage in substance abuse use whatever money they obtain for drugs, they are often homeless due to financial distress. Persons who are employed but lose their jobs are often times at high risk for becoming homeless. This is most frequent among persons with low job skills and menial pay scales.
A client recovering from a traumatic brain injury (TBI) with short-term posttraumatic amnesia and impaired mobility is preparing for discharge. Considering the nature of this client's injury, how should the nurse proceed with discharge education on using a walker and signs of disorientation, confusion, chronic pain, and ataxia? Select all that apply. 1. Provide teaching in brief, frequent learning sessions. 2. Present information slowly. 3. Use repetition. 4. Omit certain components that may be extraneous. 5. be satisfied with slower progress
1, 2, 3, 5
According to Pender's Health Promotion Model, which variables must be considered when planning a health promotion program for a client? Select all that apply. 1. Individual characteristics and experiences 2. Levels of prevention 3. Behavioral outcomes 4. Behavior-specific cognition and affect 5. Health is compared to the spokes of a wheel
1, 3, 4 Individual characteristics and experiences are considered when applying Pender's health promotion model (HPM). Behavioral outcomes are considered when applying Pender's HPM. Behavior-specific cognition and affect are considered when applying Pender's HPM.
A young adult couple with two children tell the nurse in the pediatric department they have been struggling with raising them. They state, "We just don't know what we are doing sometimes and feel we are not always making good decisions for our children. It is time we sit down and figure this out." The nurse arrives at a nursing diagnosis of Family Processes: Readiness for Enhanced Parenting. Which nursing interventions are most appropriate for this family? Select all that apply. 1. Collaborate with the couple in problem solving and decision making. 2. Assign specific roles to each member of the couple's extended family. 3. Encourage the couple to verbalize concerns, fears, and perceptions. 4. Obtain a comprehensive family health assessment from each parent. 5. Promote adaptability, ability to deal with stress, and an openness to change.
1, 3, 5 The most appropriate interventions for this family are to collaborate with them in problem solving and decision making. Because communication is vital to a health family, the nurse encourages each member to verbalize concerns, fears, and perceptions. Honesty and freedom of expression include different opinions or viewpoints. The nurse will promote adaptability, ability to deal with stress, and an openness to change, which are characteristics of a healthy family.
The nurse, working in a substance abuse rehabilitation facility, is talking with a resident who says, "I'm just here to avoid going to jail. I'm not addicted to alcohol. I just enjoy it, but I'm going to quit to avoid getting arrested again." Which of Pender's Health Promotion Model assumptions is this resident demonstrating? Select all that apply. 1. Health professionals are part of the person's interpersonal environment. 2. The capacity for self-awareness includes assessing one's own competencies. 3. The person values positive growth and attempts to balance change and stability. 4. The person seeks to actively regulate his own behavior. 5. The person relies on family members to reconfigure person environment interactive patterns.
1, 3. 4 The resident is aware of the nurse as someone in the environment, so this assumption is demonstrated. The resident evidently values growth because he has agreed to enter a treatment facility to improve his addiction issue. The resident is trying to regulate his behavior while in the treatment facility.
Which family functions are outlined in the structural-functional family theory? Select all that apply. 1. Meeting the emotional needs of family members 2. Reinforcing ethical and moral values 3. Promoting joint decision making among parents and children 4. Being productive members of society 5. [Possessing certain features common to small groups
1, 4, 5 Family functions outlined in the structural-functional family theory include meeting physical and emotional needs of family members. This model is more focused on the outcomes of family function than the process by which action occurs. Family functions outlined in the structural-functional family theory include being productive members of society. According to the structural-functional theories, a family is a small group possessing certain features common to small groups.
The nurse is developing a teaching plan about coping strategies for an extended family of a severely disabled 11-year-old child. Which step does the nurse take first in developing this plan? 1. Assess the current coping patterns. 2. Establish each member's role. 3. Assign specific tasks and deadlines for each member. 4. Identify the family member with the most ineffective coping patterns.
1. Assessing family coping is the first step to helping the family develop more effective coping patterns.
According to Maslow's Hierarchy of Needs, which is the nurse's primary focus in caring for a homeless family? 1. Food and shelter 2. Access to healthcare 3. Strengthening family relationships 4. Decreasing social isolation
1. Homelessness is a growing problem in many U.S. cities, not only for individuals but also for families. The primary focus is on meeting basic needs of food and shelter, which, according to Maslow, must be met before the family can grow and address other areas.
The nurse is planning a health promotion class for adolescents. The presentation is too long. Which topic would be least important and therefore appropriate for the nurse to delete? 1. Stranger danger 2. Motor vehicle safety 3. Firearm safety 4. Alcohol and drug use
1. Stranger danger is more appropriate for school-age children, so this topic could be safely eliminated.
An older adult patient is admitted to the hospital with heart failure. The patient's best friend is present during admission. The couple has shared a home since each were widowed 3 years ago. Both have grown children who live out of state. Which family nursing approach does the nurse use? 1. Involve the friend and patient's children in the care, discharge planning, and home care. 2. Encourage the friend to wait until discharge to provide care for the patient at home. 3. Explain to the friend an inability to be involved in patient care for confidentiality reasons. 4. Encourage liberal visiting hours by the friend and the patient's children.
1. The nurse can best intervene by involving the friend and the patient's children in the patient's care, discharge planning, and home care.
The nurse on a medical-surgical unit is providing care for a patient with diabetes mellitus. During a teaching session with the patient and the family, the nurse asks questions regarding care at home, ability to perform blood glucose testing, and administering insulin. Which perspective of family nursing is the nurse providing? 1. Family as context for care 2. Family as unit of care 3. Family as a system 4. A blend of all of the above
1. The nurse is using family as the context for care. In this approach, the focus is on the ill individual, and family is viewed as either a resource or stressor to the patient.
Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? 1. Explain that when left untreated, hypertension may lead to stroke. 2. Ask the patient to let the nurse know when ready to learn. 3. Encourage the patient to learn about various treatment options. 4. Reassure the patient that adhering to the treatment produces a good outcome.
1. Explain that when left untreated, hypertension may lead to stroke. A patient newly diagnosed with hypertension may not be motivated to learn because he or she most likely has not experienced physical symptoms or other outward complications. Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of life if the blood pressure control is not achieved.
Which nursing intervention would be effective when dealing with the family members of a critically ill client? 1. Involve the family members in care conferences about the client's care. 2. Complete all of the client's care so the family is not inconvenienced. 3. Select the eldest child to make decisions and be involved in care conferences. 4. Invite the family member with better coping skills to the care conference.
1. Involve the family members in care conferences about the client's care. Allowing the family to participate in client care activities can often alleviate their sense of helplessness and powerlessness.
The nurse is assessing a client's learning needs regarding changing an ostomy bag. Which parameters would the nurse assess? Select all that apply. 1.Client's learning needs for changing the bag 2.Client's beliefs about an ostomy 3.Client's emotional readiness 4.Client's ability to move arms and hands 5.Client's relationship with parents
1.Client's learning needs for changing the bag 2.Client's beliefs about an ostomy 3.Client's emotional readiness 4.Client's ability to move arms and hands 1: The nurse would assess learning needs for changing the bag. 2: The nurse must assess the client's beliefs about an ostomy. 3: Assessing the client's emotional readiness to learn about an ostomy is essential. 4: The nurse must assess the manual dexterity of the client since will be manipulating and changing the ostomy bag.
Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar reading before taking insulin. Which action will best help the patient remember proper technique? 1.Encouraging the patient to check the blood sugar each time the nurse gives insulin 2.Providing feedback after the patient takes the blood sugar reading for the first time 3.Verbally instructing the patient about how to obtain a finger-stick blood sugar reading 4.Offering a brochure that describes the technique for checking a blood sugar reading
1.Encouraging the patient to check the blood sugar each time the nurse gives insulin Having the patient perform a finger stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge. Repetition increases the likelihood that the patient will retain information and incorporate it into the daily management of diabetes care.
A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child's anxiety before surgery? 1.Give the child a coloring book about the surgery 2.Offer the child a detailed rationale for the surgery. 3.Allow the child to use online sources of information to learn about the surgery. 4.Provide one-to-one instruction about the care the child will need after surgery.
1.Give the child a coloring book about the surgery To reduce anxiety in a preschool-age child requiring surgery, give the child a coloring book about what surgery might be like to take home.
The client with iron deficiency anemia does not know it is caused by low levels of iron in the body that can be improved by a diet high in iron. Based on this information, which nursing diagnosis is best? 1.Imbalanced nutrition: Less Than Body Requirements for iron r/t Deficient Knowledge of foods high in iron 2.Deficient Recall r/t Imbalanced Nutrition due to less than body requirements of iron 3.Imbalanced Nutrition: Less Than Body Requirements r/t Inability to Access Information 4.Inability to Access Information r/t Deficient Knowledge about dietary needs for iron
1.Imbalanced nutrition: Less Than Body Requirements for iron r/t Deficient Knowledge of foods high in iron The best use of the diagnosis Deficient Knowledge is as an etiology related to the primary diagnosis. Here, the primary nursing diagnosis is Imbalanced Nutrition: Less Than Body Requirements of iron (supported by presence of iron-deficiency anemia) r/t Deficient Knowledge of foods high in iron
A patient with diabetes is admitted to the hospital for possible amputation from an infected foot wound. Which nursing diagnosis would be appropriate for this patient? 1.Impaired Ability to Learn r/t fear and anxiety 2.Deficient Knowledge r/t foot care 3.Inability to Learn r/t learning disability 4.Lack of Knowledge r/t inability to learn
1.Impaired Ability to Learn r/t fear and anxiety Since the patient is admitted for possible amputation, fear and anxiety would be appropriate for this patient.
The nurse is giving the oncoming nurse the shift report. The nurse states the client's diagnoses, treatments, and course of hospitalization. When describing the client, the nurse states, "Whenever I try to teach him something, he becomes difficult and argumentative." What client information about patient teaching should the oncoming nurse ask? Select all that apply. 1.Level of literacy 2.Primary language 3.Need for humor 4.Level of anxiety 5.Insurance status
1.Level of literacy 2.Primary language 4.Level of anxiety 1: If using print-based materials or providing verbal instructions for patient teaching, the nurse would need to know the client's literacy level and make sure information is presented at the appropriate level. 2: The nurse must be aware of the client's primary language to communicate effectively with the client. The nurse might plan to use various tools for translation, if language proficiency is a problem. 4: When the nurse starts teaching, the client shows anxiety about the health topic by the difficult and argumentative behavior. The level of client anxiety can be a barrier to learning, the nurse must assess anxiety and stress to make sure the teaching is done at a time of the lowest levels of anxiety and stress.
What is the benefit of having a client learn in the psychomotor learning domain? 1. Clients are able to analyze information to create ways to meet their own health-care needs. 2. Clients tend to value what they have learned and understand and implement skills and changes, thus experiencing both affective and cognitive learning. 3. Clients have a sense of a feeling of accomplishment, which builds autonomy. 4. Clients can remember more factual information.
2 Rationale: When clients value what they have learned, they are more apt to make behavioral changes to implement changes, which is psychomotor in nature.
Which description best explains learning? 1. An interactive process involving planning and implementing instructional activities that meet intended outcomes as well as activities that allow the learner to learn 2. A change in behavior, knowledge, skills, or attitudes to reach common goals 3. A result of motivation to learn that involves planned or spontaneously occurring situations, events, or exposures 4. Using teaching, counseling, and behavioral modification together to achieve effective client learning
2 Rationale: When there is a change in behavior as well as knowledge and attitude, learning has taken place, which is the result of teaching.
What teaching points will the nurse develop to address Healthy People 2020 goals? Select all that apply. 1. How to assess developmental milestones 2. How to file for Medicaid 3. How to maintaining a safe home and neighborhood 4. How to develop and maintain a healthy lifestyle 5. How to develop a low-fat, low-calorie diet
2, 3, 4 Improving access to healthcare is a goal of Healthy People 2020, so teaching patients how to file an application for Medicaid would be an appropriate teaching point. Maintaining a social and physical environment that promotes good health is a Healthy People 2020 goal, so teaching patients how to maintain a safe home environment would be an appropriate teaching point. Teaching patients to develop and maintain a healthy lifestyle would meet the Healthy People 2020 goal of promoting quality of life, healthy development, and healthy behaviors in all stages of the life span.
Identify interventions that would be effective when assisting a client in making behavior changes that would reduce his health risk factors. Select all that apply. 1. Ask the client to follow a plan you wrote for him. 2. Have the client identify two or three goals for change. 3. Help the client to understand the benefits of change. 4. Allow the client to identify available support and resources within the community. 5. Ask the family members to create a plan according to family values and rules.
2, 3, 4 The nurse will need to help clients to identify goals that are individualized. The client will need to understand the benefits of change. The client will need support and resources to create positive change.
The nurse is conducting a family assessment. Which assessment findings suggest a family health problem may exist? Select all that apply. 1. Family members respect each other's need for privacy. 2. Family members enact decisions made by the most powerful member. 3. Family members consider a conflict resolved when everyone agrees. 4. Family members set boundaries between family members. 5. Family members seem unaffected by an unkempt environment.
2, 3, 5 In healthy families, there is typically egalitarian distribution of power. When family members enact decisions made by the most powerful member, the nurse can suspect a family health problem. In healthy families, it is not always necessary for all members to agree; instead, they have the ability to compromise, and members feel free to disagree. If family members consider a conflict is resolved when everyone agrees, the behavior is likely indicative of a family health problem. In a healthy family, the environment is most likely to be well kept. If the family seems unconcerned about the orderliness of the surroundings, the nurse recognizes the probability of a family health problem.
A 3-year-old is going to have a myringotomy with tubes on the left ear. Which teaching strategy is most appropriate for this developmental stage? 1. Developing a teaching module in which the child can determine what will happen next 2. Using play and placing a bandage on a doll's ear 3. Encouraging the child to vocalize what he or she has learned 4. Discussing with the child what will happen and describing each step and who will be involved
2. using play to teach is the most appropriate method for teaching a child of this age
The nurse is teaching a class for diabetics and tells them, "Maintaining your blood glucose within normal limits helps reduce the risk for complications of diabetes." What type of activity does this class represent? 1. Health promotion 2. Health protection 3. Primary prevention 4. Tertiary prevention
2. Health protection is motivated by a desire to avoid illness.
A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1. Invincibility 2. Hardiness 3. Baseline strength 4. Vulnerability
2. One of the characteristics of a hardy person is the belief in the ability to control the experience.
The nurse teaches a class for the community discussing routine screening tests for different types of cancer. What level of health prevention would the nurse classify this activity? 1. Primary 2. Secondary 3. Tertiary 4. Maintenance
2. The nurse is providing secondary health prevention because the individuals are being taught to get screened for existing disease.
For which patient in the emergency room is it most important that the nurse conduct a thorough assessment for abuse and neglect? 1. A 6-year-old African American male with complaints of abdominal pain 2. A 2-year-old Caucasian male with injuries from a fall 3. A 7-year-old Caucasian female with a broken arm from a motor vehicle accident 4. A 4-year-old Hispanic female who complains of an earache
2. The younger the child, the more vulnerable he or she is to abuse owing to their dependency, small size, and inability to defend themselves. Statistics indicate that Caucasian children are at a high risk for abuse. The 2-year-old child is the youngest and of the high-risk race, and the injuries are from a fall. The nurse should assess all children and adults for signs of violence and neglect; however, the 2-year-old has priority.
The nurse is providing care for a seriously ill child on the pediatric unit. Many family members are present, including parents, aunts, and uncles. The nurse tells the nurse manager, "Every time I go into the room, everyone is shouting at each other, they shout at me, and they ask me the same questions over and over." Which is the most appropriate response by the nurse? 1. "This is unacceptable and disruptive behavior. Tell them if the behavior continues, we may need to call security." 2. "Families experience a range of emotions when caring for an ill member, and these can be normal reactions. Don't take it personally." 3. "There may be too many people in the room. You might consider limiting the number of visitors at a time." 4. "I know about this family's culture and expect this behavior. Don't worry about it; it is just the way they are."
2. When a family member is ill or hospitalized, the other family members experience a range of emotions—especially when the illness is severe or of sudden onset. Family members may display signs of stress in a variety of ways, for example, by arguing with each other or with healthcare providers, in insisting on immediate care for their loved one, by being critical of the care provided, or by frequently asking that information be repeated. These are normal reactions; do not take them personally.
The nurse is planning a health promotion class for young adult women. What topic would be most important for the nurse to include for this group? 1. Immunizations 2. Papanicolaou (Pap) test every 2 or 3 years 3. Annual mammograms 4. Screening colonoscopies
2. Women should begin having Pap tests by age 21 and have repeat tests every 2 to 3 years; therefore, this would be an appropriate topic to include in a health promotion class.
Which type of health promotion programs seeks to raise the level of knowledge and awareness of individuals and groups about health habits? 1. Environmental evaluation and protection 2. Information dissemination 3. Wellness assessment and appraising health risk 4. Lifestyle and behavior changes
2. Disseminating information at the individual, group, or community level will help a person recognize a problem and understand options for change. It increases knowledge of health habits for any level; therefore, these are examples of health promotion programs.
A group of nursing students have been discussing the benefits of forming a study group. They realize that reviewing disease processes and treatments together may be more helpful in retaining new information and applying it to the clinical setting than if they continued to study individually. According to Prochaska and DiClemente's Transtheoretical Model of Change, which stage of behavior change are they exemplifying? 1. Precontemplation 2. Contemplation 3. Preparation 4. Action Stage
2. During the contemplative stage, the individual acknowledges the problem, considers changing a specific behavior, actively gathers information and verbalizes plans to change. Discussing benefits of a study group would fall into this stage.
A nurse is providing care for a patient newly diagnosed with type 1 diabetes mellitus. The patient's spouse states, "We are a family of diabetics." The nurse advises attendance to the free nutrition, cooking, and exercise classes at the health center near their neighborhood. The nurse also provides the name of the public health nurse for their area. Which perspective of family nursing is the nurse practicing? 1. Family as a unit of care 2. Family as a system 3. Family as the context of care 4. Family as a resource and stressor
2. The nurse is viewing the family as a system because the nurse is providing information based on the spouse's response that will benefit the entire family. A system approach looks beyond the immediate family and views the community and its resources as a part of the suprasystem.
The nurse is providing care for a patient diagnosed with lung cancer. The patient and the spouse are 2 years from retirement. The nurse is aware that a variety of developmental stages among families can exist due to delayed childbearing. However, which typical stage of family development is this couple likely experiencing? 1. Family launching young adults 2. Postparental family 3. Family with frail elderly 4. Family with teenagers and young adults
2. This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust to their children moving into phases of adulthood.
The patient newly diagnosed with type 2 diabetes mellitus needs to make lifestyle changes. In relationship to the Trans-theoretical Model of Change, which nursing action would best support the patient during the "contemplation" stage? 1. Showing the patient how to use the fingerstick blood glucose monitor 2. Providing information about various types of exercise to facilitate weight loss. 3. Teaching the patient about the purpose for having his HbA1C tested monthly. 4. Telling the patient that if he does not change his lifestyle, he will die.
2. Providing information about various types of exercise to facilitate weight loss. Providing information about exercise would help the patient to decide what changes would best fit his personal goals. The contemplation stage involves the decision-making process.
According to Leavell and Clark's work, blood pressure screening is an example of which type of healthcare? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention
2. Secondary prevention Secondary prevention involves screening activities and education for detecting illnesses in the early stages.
The client needs to be taught how to find and check his own radial pulse. The nurse will complete this teaching. 1. Only if the client asks her to do so, to avoid causing stress 2. When the client recognizes the need to learn the skill 3. Before pain medication is administered when the client is alert 4. Right before the client is discharged so he can remember the skill
2. When the client recognizes the need to learn the skill The client will be most motivated to learn when he recognizes why this skill is important to the success of his overall treatment plan (e.g., medication effectiveness).
A nurse has demonstrated the proper cleaning and dressing change techniques for a client's postoperative wound. The nurse has the client then demonstrate the proper technique and repeat the instructions on when to change the dressing and why. By allowing the client to demonstrate learning, which type of educational learning has been practiced? 1. cognitive 2. psychomotor 3. affective 4. practical
2. psychomotor psychomotor learning involves performing skills that require both mental and physical activity, ensuring both cognition and affective results; repeating the technique is an example of psychomotor learning
Which statement by the patient demonstrates health literacy? 1."I speak and understand little English but will do what I am told." 2."I will take my medications after I ask the nurse a few questions." 3."I have not taken my prescribed antibiotics because I can't read the labels." 4."I stopped my medications when I started feeling better."
2."I will take my medications after I ask the nurse a few questions." Taking medication as prescribed after asking the nurse questions to clarify information demonstrates health literacy. Health literacy is the ability to understand basic health information and services needed to make appropriate healthcare decisions.
The nurse explains to a patient that dressing changes will improve healing and decrease infection and then demonstrates the correct aseptic technique to the patient. The patient is asked to return a demonstration of this dressing change and to describe the reasons for it to the nurse. This example includes which type of learning and which learning domains? Select all that apply. 1.Affective 2.Active 3.Cognitive 4.Psychomotor 5.Passive
2.Active 3.Cognitive 4.Psychomotor 2: Active learning involves the learner's participation. A return demonstration is a classic example of active learning in which the participant experiences the content. 3: The item shows cognitive learning; from the nurse's description of the task, the patient learns why to do the dressing change. 4: Psychomotor learning occurs as the patient returns the demonstration of the dressing change. With the patient describing the task and demonstrating it, the nurse can evaluate the patient's level of understanding and skill as well.
A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching sessions? 1.Within 10 minutes after the next dose of oral pain medication 2.After the patient wakes up from a restful nap 3.Right before the surgeon debrides the wound 4.Before the patient undergoes flow studies of the affected leg
2.After the patient wakes up from a restful nap For learning to be most effective, teaching must occur when the patient is most receptive. Therefore, the best time to teach this patient is when he or she is rested, such as after a restful nap.
Which patient is most likely experiencing positive nitrogen balance? A patient admitted: 1.With third-degree burns of the legs 2.In the sixth month of a healthy pregnancy 3.From a nursing home who has been refusing to eat 4.For acute pancreatitis
2.In the sixth month of a healthy pregnancy A positive nitrogen balance typically exists during pregnancy when new tissues are being formed and nitrogen intake exceeds output.
Which teaching strategy is typically most effective for presenting information to large groups about health promotion? 1.Distributing printed materials 2.Lecturing using audiovisual format 3.Using online sources of information 4.Role modeling
2.Lecturing using audiovisual format Lecturing using audiovisual materials appeals to learners who best process information by hearing and seeing. From a practical point of view, a lecture format (traditional classroom or webinar) is efficient and effective with large groups.
How can the nurse best provide teaching for a patient whose primary spoken language is not the same as the nurse's? 1.Offer written materials in the patient's primary language. 2.Make arrangements to teach using an interpreter. 3.Provide a demonstration and request a return demonstration. 4.Use visual teaching aids to convey information.
2.Make arrangements to teach using an interpreter If the patient is not fluent in the prevalent language, the nurse may need to use an interpreter or use a translator application.
For which patient is the nursing diagnosis Knowledge Deficit most appropriate? 1.Adolescent with Down syndrome with a long history of cardiac problem 2.Young adult admitted with acute renal failure who requires hemodialysis immediately 3.Middle-aged woman with breast cancer receiving the last round of chemotherapy 4.Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer
2.Young adult admitted with acute renal failure who requires hemodialysis immediately The young adult patient admitted with acute renal failure who needs hemodialysis will probably have Knowledge Deficient related to the treatment regimen of hemodialysis.
The nurse is caring for a patient with a nursing diagnosis of Activity Intolerance secondary to cardiac disease that causes the patient to produce less energy than is expended with activity. Which theory of health and wellness would support this nursing diagnosis? 1. World Health Organization (WHO) 2. Jean Watson 3. Betty Neuman 4. Myers, Sweeney, and Witmer
3. Betty Neuman's theory defines health as more energy generated than expended, and illness, possibly even death, as more energy expended than generated. This theory describes health as an expression of living energy displayed as a continuum, with high energy being wellness at one end and low energy (illness) at the other end.
The school nurse at a local elementary school is performing physical fitness assessments on the third grade children. When assessing students' cardiorespiratory fitness, the most appropriate test is to have the students: 1. Step up and down on a 12-inch bench 2. Perform the sit-and-reach test 3. Run a mile without stopping, if they can 4. Perform range-of-motion exercises
3. Field tests are good for children and can be used when assessing cardiorespiratory fitness.
A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has "learned what to do." He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? 1. "By now, you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own." 2. "Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success." 3. "You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle." 4. "You have entered the 'determination stage' and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time."
3. If a participant exits a program before the end of the maintenance stage, relapse is likely to occur as the individual resumes his previous lifestyle.
Which would be an appropriate topic for the elementary school nurse to include in health promotion activities for students? 1. Housing conditions 2. Poor sanitation 3. Stranger danger 4. Preventing sexually transmitted infections (STIs)
3. Stranger danger is a risk for harm for elementary school students, so this would be an appropriate topic for discussion to promote health.
A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Health promotion
3. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing.
The Americans with Disabilities Act (ADA) defines a disability as a physical or mental impairment that substantially interferes with a person's ability to engage in major life activities. Among the various disabilities in the United States, which is the most prevalent? 1. Vision 2. Hearing 3. Ambulation 4. Learning
3. The ADA defines one component of disability as a physical or mental impairment that substantially interferes with a person's ability to engage in major life activities. Among the various types of disabilities, 10.2 million are people with ambulatory disabilities.
To prevent a reduction in herd immunity, which information does the nurse teach in a class of pregnant women? 1. "You should increase your intake of milk to meet your growing calcium needs." 2. "It is important to take prenatal vitamins daily to provide the essential vitamins and minerals your body needs." 3. "You should ensure your child gets immunizations at the recommended scheduled times." 4. "You should limit the time your child is in crowded environments for the first 6 months of life."
3. A reduction in herd immunity occurs when families do not follow the immunization schedule. Old diseases, once thought eradicated, begin to reappear and cause illness and even death in persons who are not adequately protected through immunizations. Such diseases include pertussis (whooping cough), measles, polio, mumps, and small pox.
The nurse is participating in a family conference regarding one of the patients on the geriatric unit. During the conference, each family member is asked about their role in the family, communication style, coping strategies, and relationship with other family members. This type of family conference best illustrates the use of which theory related to family care? 1. General systems theory 2. Structural-functional theory 3. Family interactional theory 4. Developmental theory
3. Family interactional theory views the family as a unit of interacting personalities. The major emphasis is on family roles. This approach to understanding families de-emphasizes the influence of the external world on what occurs within the family. The focus is on interaction, communication roles and power, family coping, and relationships.
The nurse working in an acute care setting provides what level of health prevention most often? 1. Primary 2. Secondary 3. Tertiary 4. Assessment
3. Patients who are admitted to the hospital are usually admitted for tertiary prevention, which focuses on stopping the disease from progressing and helping to return the individual to pre-illness health. This is the type of care most often provided.
The nurse meets with patients who have quit smoking or are planning to quit. Which statement made by a patient would lead the nurse to conclude that that patient is in the maintenance stage of change? 1. "I haven't smoked in 2 weeks, but I have to constantly resist the urge to light a cigarette." 2. "I don't even think about cigarettes anymore. I really don't miss smoking." 3. "Each day I don't smoke, I put money that I would have spent in a jar to pay for a vacation." 4. "I am chewing gum and eating carrot sticks to keep myself from lighting a cigarette."
3. Rewarding and reinforcing ongoing success by putting money in a jar to pay for vacation is demonstrating the maintenance stage.
The graduate nurse tells the preceptor that the newly admitted patient has a strange living arrangement. The patient lives in a household that consists of two aunts, a grandparent, a niece, a nephew, and her best friend. Which response by the preceptor is best? 1. "You are correct. That is a different type of household." 2. "That is an example of a family defined by a different culture." 3. "This is considered an extended family, which is not unusual." 4. "This type of blended family is statistically shown to be increasing."
3. The description fits the definition for an extended family, which can consist of various biological relatives and also nonrelatives who live together or in close proximity.
The nurse is aware of which situation best depicting a mid-life crisis? 1. A college graduate moves in with parents because of an inability to find employment. 2. Parents enroll their two toddlers in day care because two incomes are needed meet the household's financial demands. 3. After the couple's daughter leaves for college, the husband quits his job and decides to "see the world." 4. An older adult widower rejects the children's advice to move into an assisted living facility.
3. The middle-aged years occur after the demands of raising children are over. This can be a time of personal fulfillment, career success, and social expansion. It can also be a time of intense questioning about the meaning of life, longing for one's youth, and seeking direction in life (mid-life crisis). It is not uncommon for couples who have been married for many years to get a divorce or for one spouse to engage in atypical behaviors.
You are caring for a 22-year-old female client admitted with complaints of headache. She was accompanied by her roommate, her best friend since age 5, who confidentially confides that the client is a victim of dating violence. What is the nurse's initial best response? 1. "I can only take a history from the client." 2. "Thank you. I will pass the information to the provider." 3. "Tell me more and how this relates to her headaches." 4. "What is his name and how have you tried to help her get out of the relationship?"
3. "Tell me more and how this relates to her headaches." This open-ended question will provide more insight into the client's immediate problems. These two individuals have a 17-year friendship and can be seen as providing family-type support to each other. Any form of violence should be immediately addressed and the nurse should explore any relationship between the reported violence and the client complaints.
As the nurse, you are going to teach a patient about strategies to prevent hypertension. In order to provide effective care, you know that the action that you should implement first is 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension.
3. Assess what the patient already knows about hypertension. All of these steps will be used to provide safe and effective nursing care, but assessment is the first step of any teaching session. An effective assessment provides the basis for individualized patient teaching. Assessing what the adult patient currently knows improves the outcomes of patient education.
Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding in a culturally competent manner? 1. Obtain your radial pulse q a.m. before taking your digoxin dose. 2. Return to your healthcare provider for monthly laboratory studies of your digoxin levels. 3. Call your provider if you notice that objects look yellow or green. 4. Always take the same brand of medication because certain brands may not be interchangeable.
3. Call your provider if you notice that objects look yellow or green. The nurse should provide written instructions that contain short sentences and easy-to-read words. Calling the provider when objects look yellow or green is the clearest statement for patient teaching because the instruction is short, concrete, and written with easy-to-understand words.
Nurses must possess the knowledge and skills needed for patient teaching so that 1. they can complete the documentation forms related to client teaching accurately 2. The nurse must assess the manual dexterity of the client since will be manipulating and changing the ostomy bag 3. They can promote the health, safety, and rights of clients through education 4. . They can meet the patient rights delineated in the "Patient Care Partnership."
3. They can promote the health, safety, and rights of clients through education The A N A's Code of Ethics for Nurses With Interpretive Statements (2015) holds that nurses are responsible for promoting and protecting health, safety, and rights of patients. Patient teaching is essential in fulfilling that responsibility.
Which technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? A. Provide a manufacturer's pamphlet with detailed instruction 2. explain the best technique for performing glucose testing 3. demonstrate the procedure, then ask for a return demonstration 4. suggest that the assistant watch a DVD showing the procedure
3. demonstrate the procedure, then ask for a return demonstration The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration.
An older adult patient who underwent bowel resection is recovering from surgery without complication. During the healthcare team's morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient's most significant obstacle for learning? 1.The patient's baseline physical condition 2.A negative environmental influence 3.Anxiety associated with the new diagnosis 4.Reduced ability to understand the diagnosis
3.Anxiety associated with the new diagnosis Anxiety associated with the new diagnosis of cancer will most likely be a barrier to learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort with treatment options, fear of altered role in home or work life, and many other fears accompany the anxiety that patients often experience when potentially life-threatening diagnoses are communicated.
The nurse is preparing to teach a client about crutch walking. Which action would the nurse take first? 1.Mutually develop learning goals for crutch walking. 2.Demonstrate how to use the crutches. 3.Determine what the client already knows about crutches. 4.Create a teaching plan for crutch walking.
3.Determine what the client already knows about crutches. Assessing what the client already knows is the first action the nurse would take. Assessment must start the teaching process.
It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about the medications. How can the nurse most efficiently use the time and provide this education? 1.Write down instructions so the patient can read them at home. 2.Discuss the information while assisting the patient with the bath. 3.Educate the patient about the medications as each one is given. 4.Follow up with the patient after discharge with a phone call.
3.Educate the patient about the medications as each one is given. Teaching does not have to be performed in a formal session but is often most effective as a teachable moment when the information is perceived as most relevant, such as at the time the medication is given to the patient. Additionally, the information is more memorable when the patient can see the actual dose and identify it with the information presented.
Which substance is stored in the liver? 1.Insulin 2.Ketones 3.Glycogen 4.Vitamin C
3.Glycogen Humans store glucose in liver and skeletal muscle tissue as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis.
In a patient with type 1 diabetes mellitus admitted with hyperglycemia, fats are being broken down for energy. Which alternative fuel does the breakdown of fats produce? 1.Glycogen 2.Insulin 3.Ketones 4.Proteins
3.Ketones When fats are used for energy, they are converted directly into an alternative fuel called ketone.
The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions? 1.One hour before implementation 2.One day before implementation 3.One week before implementation 4.One month before implementation
3.One week before implementation People retain information better when they have the opportunity to use it soon after it is presented. Therefore, the nurse manager should schedule teaching sessions 1 week before implementation of the equipment.
The nurse preparing a teaching plan ensures that the information is tailored to the client's life experiences and learning level. These are examples of which "right" of teaching? 1.Right time 2.Right context 3.Right content 4.Right goal
3.Right content The right content needs to be aligned with the client's needs, learning level, and life experiences.
A mother tells the nurse she is worried that her 20-year-old daughter lacks the understanding regarding the need for follow-up care after her discharge. Which behaviors suggests that the patient needs further discharge teaching? Select all that apply. The patient: 1.States she will be on time for her scheduled appointment 2.Demonstrates correct care of the dressing 3.States she does not understand much English 4.Watches television while the nurse is speaking to her 5.Plans to get medications from the pharmacy on her way home
3.States she does not understand much English 4.Watches television while the nurse is speaking to her 3: This indicates the client needs further discharge teaching. Poor language fluency and comprehension interfere with learning. 4: This indicates the client needs further discharge teaching. The client watching television while the nurse is giving discharge instructions shows a lack of readiness for learning.
Which phrase would the nurse include in the plan of care as a teaching goal for a patient who had bowel resection with creation of a colostomy? The patient: 1.Empties the colostomy appliance when half filled 2.Performs skin care around the stoma site 3.Will perform ostomy self-care within 3 days after surgery 4.Applies a new ostomy appliance, making sure it adheres properly
3.Will perform ostomy self-care within 3 days after surgery Performing ostomy self-care is an appropriate teaching goal for a patient who needs to learn colostomy self-care after surgery. Teaching goals are broad in scope and set down what is expected as the final outcome of the teaching and learning process.
The nurse schedules a meeting with a family to assess and assist with improving the family's communication patterns. Which is of primary importance for the nurse to focus on during the assessment? 1. Identifying how family decisions are made 2. Documenting the number of family members attending the meeting 3. Assessing for the most frequently used means of communication among family members 4. Making careful observations of body language and nonverbal expressions during the meeting
4. Do not rely solely on the information provided by the family members during the interview process. Families usually want to "put on the best face" for healthcare providers, so they may be careful to give socially desirable responses. Carefully observe the words people use and other cues involved in communication, such as body language, direct eye contact, and other nonverbal expressions, particularly among family members.
The nurse conducts an assessment of a 38-year-old patient's fitness using the step test. At the end of the test, which heart rate would indicate the patient is in very poor physical condition? 1. 96 beats/min 2. 106 beats/min 3. 114 beats/min 4. 134 beats/min
4. A heart rate higher than 130 beats/min indicates the patient is in very poor physical condition.
The nurse is working with a client who is obese and reports having a sedentary lifestyle. What is the nurse's first action to promote this client's health? 1. Teach the client how to follow a low-calorie diet. 2. Assist the client in a plan to increase his activity level. 3. Explain the risks associated with the client's weight and lifestyle. 4. Help the client identify goals for promoting health.
4. Before instituting any interventions, such as diet teaching, creating a plan for increasing activity, or discussing risks associated with weight and lifestyle, the nurse must first help the patient identify goals. Most health promotion strategies must be implemented by clients, not by healthcare providers, so the client's goals are essential in planning actions that are likely to be successful. Recall that in the nursing process, interventions are developed on the basis of goals. If the nurse immediately starts teaching about diet and activity, it may be discovered that this patient may not be interested in exercising or increasing activity level.
The parents of three children, aged 3, 6, and 8 years, comment that although the children are close in age, they each seem to have different needs. The nurse teaches the parents what tasks the children should accomplish based on the different age groups and provide strategies to help meet the children's needs. Which theory best explains the nurse's teaching plan? 1. General systems theory 2. Family interactional theory 3. Family as a context theory 4. Developmental theory
4. Developmental theories focus on the stage of development of each family member, usually based on age or growth stage. These theories have developmental tasks that should be accomplished at each stage of development to successfully progress and master the next stage. These stages begin at birth and continue through old age. Thus, each child will have different developmental tasks based on his or her age and stage of development; because tasks are different, so are each child's needs.
A client informs the nurse that he has quit smoking because his father died of lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? 1. Healthy living 2. Health promotion 3. Wellness behaviors 4. Health protection
4. Health protection is motivated by the desire to avoid illness, which is the reason that the client stated in this scenario.
The grown child of an older adult patient tells the nurse, "I'm starting to worry about my father's eating habits. He lives alone and has been able to cook, but now he doesn't want to cook and says he is too tired to go to the store." Which is the most appropriate response by the nurse? 1. "We may need to contact the physician for a nutritional assessment." 2. "Your family members will need to get together and bring him meals." 3. "It may be time for you to think about nursing home placement." 4. "What are your feelings on using some community resources for meals?"
4. Maintaining good nutrition and hydration becomes more difficult as a person ages. Nutrition in older adults may be compromised for a multitude of reasons, such as forgetting to eat, inadequate transportation to shop, lack of money, loss of appetite, and physical changes. It is easy to understand how one of the above problems can affect another.
The new mother who just gave birth tells the nurse, "I don't know anything about babies, so I want you to teach me everything you can to help me be a good mother." What nursing diagnosis would be most appropriate for this patient? Readiness for Enhanced: 1. Breastfeeding 2. Communication 3. Family Coping 4. Parenting
4. Readiness for Enhanced Parenting is the best nursing diagnosis for this patient, who is seeking information to improve her ability to care for her child (i.e., to nurture growth and development of the child).
It is important for the nurse to understand the structure of the client's family so that he or she can 1. Address the various family members correctly. 2. Tailor visiting hours to the family's needs. 3. Avoid embarrassing moments during client interventions. 4. Develop a holistic plan that includes the whole family.
4. Develop a holistic plan that includes the whole family. The nurse must know how the client defines "family" and what persons the client considers part of his or her family in order to develop a plan of care that includes that family.
The client is given a pamphlet to read about how to manage his newly inserted central venous access device at home. It will be most important for the nurse to assess the client's 1. Health beliefs 2. literacy level 3. fine motor abilities 4. ability to see
4. ability to see If the client has vision problems, the nurse will have to find another strategy to convey the information.
When the nurse is about to give instructions for discharge, the nurse notices that the television is on and the patient is eating a meal. What is the best action for the nurse to take to ensure that the patient's discharge teaching is understood? 1.Review all important discharge teaching while in the room. 2.Ask whether the patient has any questions about the discharge. 3.Inform the patient that the instructions are on the discharge sheet. 4.Arrange another time with the patient to review the discharge teaching.
4.Arrange another time with the patient to review the discharge teaching. The nurse understands that multiple distractions in the patient's room, including having the television on and eating a meal, can be barriers to learning. The nurse must assess each situation to identify the best time to effectively teach the patient. Therefore, the nurse identifies that there are too many distractions at that time and speaks to the patient to determine a mutually agreeable time for the discharge teaching to be done
The nurse is preparing to teach an older adult about hypertension. Which action would the nurse take? 1.Avoid the use of sharing life experiences about high blood pressure. 2.Print information about hypertension in a blue font color. 3.Use long stories to emphasize high blood pressure problems. 4.Cover diet and exercise to help control hypertension in one teaching session.
4.Cover diet and exercise to help control hypertension in one teaching session. Diet and exercise are only two topics and are within the range of topics to introduce. Usually, tackling one to three new topics or skills is enough for older adults.
During advanced cardiac life support (ACLS) training, a nurse learns about defibrillation by using a mannequin. Which teaching tool is being employed? 1.Journaling 2.Computer-assisted instruction 3.Role modeling 4.Simulation model
4.Simulation model ACLS training uses simulation models by using resuscitation mannequins and teaching healthcare workers to respond appropriately to life-threatening cardiopulmonary events.
According to structural-functional theory, families function differently in the various stages of the family life cycle. A. True B. False
B. False Structural-functional theories present concepts related to family roles and interactions as they relate to family functioning.
The nurse is working with a spouse who is caring for a chronically ill patient who requires around-the-clock care. The nurse notices the spouse often speaks to the patient sharply. The bed linens are soiled with food and the patient has a strong body odor. Both the house and the spouse are unkempt. When encouraged to talk, the spouse says, "I just drag around. I can't make myself do anything. I'm so tired of it all." Which nursing diagnosis best fits these defining characteristics? 1. Dysfunctional Family Processes 2. Caregiver Role Strain 3. Defensive Coping 4. Impaired Verbal Communication
The defining characteristics best fit a nursing diagnosis of Caregiver Role Strain. The caregiver exhibits dysfunctional communication (speaking sharply), is not performing well in the caregiver role (soiled bed linens, patient's body odor), and is experiencing and expressing depressive symptoms.
