Exam 3 foundations study
Which of the following groups of patients have are more to be concerned about body image? 1. infants 2. children 3. adolescents 4. geriatric
3. adolescents adolescents are more likely than children and adults to be concerned about body image
A nurse identifies that the client's blood pressure is elevated. Which of the following actions should the nurse take? A Ask the client about a family history of high blood pressure. B Identify if the client has risk factors for heart disease. C Recommend the client take an over-the-counter supplement to promote heart health. D Discuss a heart-healthy lifestyle with the client. E Refer the client for a follow-up with their primary care provider. F Provide the client with information about hig
A Ask the client about a family history of high blood pressure . B Identify if the client has risk factors for heart disease. D Discuss a heart-healthy lifestyle with the client. E Refer the client for a follow-up with their primary care provider. F Provide the client with information about high blood pressure.
During a Nursing Assessment Which of the following questions should a nurse ask when there is a Body image stressors? Select 4 that apply A. Which aspects of your body or physical appearance do you dislike or wish you could change? B How would you describe your physical appearance? C. How comfortable are you expressing your opinions and ideas? D What kind of support do you have to fulfill your various roles? E Which aspects of your body or physical appearance do you like and appreciate? F How i
A Which aspects of your body or physical appearance do you dislike or wish you could change? B How would you describe your physical appearance? E Which aspects of your body or physical appearance do you like and appreciate? F How important is it to always look your best?
A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired, is an important part of your treatment." B. "It's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." C. "It is normal to be tired when you're feeling depressed. The others in group therapy feel the same way.
A. "Attending group therapy, even if you're tired, is an important part of your treatment." Correct Answer: A. "Attending group therapy, even if you're tired, is an important part of your treatment." The nurse provides a therapeutic response by giving the client information to make an informed decision. Group therapy is beneficial to the client who has depression by promoting peer support and reducing social isolation. Incorrect Answers: B. A lack of energy is expected for a client who has depression. There is no indication that the client will have more energy for group therapy in the future. The nurse should also respect the client's autonomy and avoid giving a directive about required participation. C. The nurse should avoid minimizing the client's feelings by making a generalization in relation to others. D. The nurse should avoid giving approval to the client's decision and should encourage participation in group therapy to promote the improvement of depression.
A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."
A. "Call me when you are ready, and I will return with the medication."
A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now,
A. "Call me when you are ready, and I will return with the medication." The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration Incorrect Answers: B. At home, the client is responsible and accountable for actions regarding self-administration of medications. In an inpatient setting, the nurse is responsible for administering medication to the client. C. If the nurse returns to the client's room in 30 minutes, the nurse will not be able to verify that the client took the medication since the client could have hidden or discarded the medication. D. The nurse is responsible for administering the medication at the scheduled time. Although the policy about time may vary by facility, a medication generally may be given within 1 hour of the prescribed time (i.e. ≤30 minutes prior to or ≤30 minutes after the prescribed time of administration).
Which of the following patient statements would indicate an Identity stressor? A. "I just divorced my husband of 15 years, I really don't know how to feel." B. "Just woke up with many pimples and I don't want to go to school tomorrow, I don't want people to see me this way" C. "I just feel like I have so many tasks, I don't know how I'll be able to finish in time to get off of work at 5 pm" D.. "Since I lost my job last Monday I feel like I am failing at life ."
A. "I just divorced my husband of 15 years, I really don't know how to feel."
A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Scree
A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." Genetic screening has multiple legal and ethical considerations that must be addressed prior to testing. The client will need to sign an informed consent form prior to the screening. Incorrect Answers: B. Providing information for an abortion clinic without the client's request can be interpreted as coercion, which violates the client's legal rights and does not take into consideration the client's personal values or beliefs. C. Genetic screening is elective rather than a part of routine care. The client should be educated about genetic screening so that she can make an informed decision about whether she wants to complete the testing. D. Providing information for sterilization without the client's request can be interpreted as coercion, which violates the client's legal rights and does not take into consideration the client's personal values or beliefs. Peer Compar
Which of the following patient statements would indicate a body image stressor? select all that apply A. "My husband says I am beautiful but I don't believe him." B. "I am considering getting Botox because these wrinkles are becoming defined." C. "Sometimes it's hard to manage work and take care of my sick mother" D.. " I am not sure how to care for my elderly father since I am not familiar with his medical issues."
A. "My husband says I am beautiful but I don't believe him." B. "I am considering getting Botox because these wrinkles are becoming defined."
A nurse in an emergency department is caring for 4 clients. Which of the following findings requires the nurse to act as a mandatory reporter? A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg B. A client who was admitted for pneumonia and reports having no heat or running water at home C. A client who has depression and a self-inflicted wrist laceration D. A public official who is admitted with alcohol withdrawal and delirium tremens
A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg This child exhibits findings of neglect and endangerment. The nurse is a mandatory reporter for any client situation in which children or older adult clients are being abused or neglected. Incorrect Answers: B. This client would benefit from a referral to social services for assistance with living conditions. Mandatory reporting of this situation to legal authorities is not indicated. C. None of the information given indicates that this client is a danger to others. This client will likely be placed on suicide precautions, but disclosure to a legal authority is not indicated. D. Sharing this information outside the care team for this client is a violation of HIPAA regulations. Disclosure to a legal authority is not indicated.
During a Nursing Assessment Which of the following questions should a nurse ask when there is a Role performance stressor? Select the 4 that apply A. Describe two or three of your primary roles. How successful do you feel in fulfilling these roles? B How do the opinions of others impact how you see yourself? C. If your roles conflict, how do you cope or adapt to fulfill them? D. How much do you worry about what others think of you? E What kind of support do you have to fulfill your various rol
A. Describe two or three of your primary roles. How successful do you feel in fulfilling these roles? C. If your roles conflict, how do you cope or adapt to fulfill them? E What kind of support do you have to fulfill your various roles? F. Which feelings do you experience when thinking about some of your primary roles?
During a Nursing Assessment Which of the following questions should a nurse ask when there is a identity stressor? Select 4 that apply A. How is your identity influenced by others or by society? B How would you describe your physical appearance? C. What words might others use to describe you? D. How do the opinions of others impact how you see yourself? E .How would you describe yourself? F. How do you respond when you experience failure?
A. How is your identity influenced by others or by society? C. What words might others use to describe you? D. How do the opinions of others impact how you see yourself? E. How would you describe yourself?
A nurse is assessing a client who is experiencing changes in vision. She states, "When driving I use landmarks because I can't read the street signs but when reading a book I can see fine." This manifestation is consistent with which of the following eye disorders? A. Myopia B. Hyperopia C. Astigmatism D. Presbyopia
A. Myopia This is considered nearsightedness
Which of the following is the definition of Role conflict? A. Occurs when individuals are faced with two or more role expectations and find themselves unable to meet these expectations at the same time. B. Refers to the lack of clarity in understanding the actions that need to be taken to achieve proposed goals C. Occurs when the roles and responsibilities placed upon an individual are greater than their ability to effectively manage them or when they find themselves pressured to respond to t
A. Occurs when individuals are faced with two or more role expectations and find themselves unable to meet these expectations at the same time.
A nurse is Discussing the prevention of sexually transmitted infections with a community group, which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
A. Primary
A nurse is Teaching bicycle safety to school-age children, which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
A. Primary
A nurse scheduling a client for a screening for prostate cancer. Which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
A. Primary
A nursing is Distributing brochures about heart health at a center for older adults. Which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
A. Primary
A nurse is assessing a client who is experiencing changes in the blood vessels of the retina that can lead to blindness. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration
A. Retinopathy A. Manifestations of retinopathy include changes in the blood vessels of the retina that can lead to blindness.
A nurse is caring for a client who requests help to get out of bed and ambulate to the bathroom. Before assisting the client to get out of bed, the nurse makes sure that the client has on nonskid footwear and that the room is free from clutter that the client could trip over. Which of the following ethical principles is the nurse practicing when taking these actions? A Autonomy B Beneficence C Veracity D Justice E Fidelity F. Non-Maleficence
B Beneficence Beneficence - Minimizing harm and practicing in a way that benefits the client.
During a Nursing Assessment Which of the following questions should a nurse ask when there is a Self-esteem stressor? Select the 4 that apply A. Which aspects of your body or physical appearance do you like and appreciate? B How do you respond when you experience failure? C Describe two or three of your primary roles. How successful do you feel in fulfilling these roles? D. What are some of your accomplishments or qualities that make you feel good about yourself? E How comfortable are you expr
B How do you respond when you experience failure? D. What are some of your accomplishments or qualities that make you feel good about yourself? E How comfortable are you expressing your opinions and ideas? F.How much do you worry about what others think of you?
A nurse checks all clients for depression at well-client checkups. Which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
B Secondary
Which of the following patient statements would indicate a body image stressor? A. "I just divorced my husband of 15 years, I really don't know how to feel." B. "Just woke up with many pimples and I don't want to go to school tomorrow, I don't want people to see me this way" C. "I just feel like I have so many tasks, I don't know how I'll be able to finish in time to get off of work at 5 pm" D.. "Since I lost my job last Monday I feel like I am failing at life ."
B. "Just woke up with many pimples and I don't want to go to school tomorrow, I don't want people to see me this way"
A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is scheduled to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? A. Beneficence B. Autonomy C. Paternalism D. Justice
B. Autonomy Informed consent is based on the ethical principle of autonomy, which is the right to self-determination, independence, and freedom of choice. Incorrect Answers: A. Beneficence is based on the principle that actions should be taken with the intent to do good. It is associated with nonmaleficence, which is the requirement that health care providers do no harm to their clients. Although this is an important ethical principle in nursing, it is not the basis for informed consent. C. Paternalism is based on the assumption that one person can assume responsibility for making the decisions of another person. This principle limits freedom of choice. D. Justice is based on the principle that everyone should be treated similarly and fairly. This is an important ethical principle but is not the basis for informed consent.
An industrial health nurse is caring for a client who states, "I have been under a lot of stress lately." When the nurse suggests stress-management techniques, the client calmly states that he has a pistol in his car and intends to take his life in the parking lot after work that day. Which of the following actions should the nurse take? A. Have the industrial facility's security officers search the client's car and remove the pistol B. Call emergency medical services to transport the clie
B. Call emergency medical services to transport the client to a proper treatment facility Client safety is the nurse's primary concern. This client must be transported to a treatment facility as soon as possible. In addition, the nurse should not leave the client alone until he is safely evaluated by or admitted to a proper care facility. Incorrect Answers: A. There may be privacy and legal issues associated with having a facility employee enter a client's private vehicle. C. Privacy issues and HIPAA regulations restrict the nurse from contacting the client's family without his permission. In addition, once the client has revealed his suicidal intent to the nurse, it is the nurse's responsibility to make certain that he receives proper mental health care as soon as possible. D. The tertiary intervention phase will involve exploration of the client's feelings about suicide.
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice
B. Fidelity Correct Answer: B. Fidelity The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made. Incorrect Answers: A. The ethical principle of autonomy involves ensuring the client has the right to make personal decisions. C. The ethical principle of nonmaleficence involves doing no harm. D. The ethical principle of justice involves treating everyone fairly.
A nurse is assessing a client who is experiencing an increase in the opacity of the lens, blocking rays of light from entering the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration
B. Glaucoma Correct Answer: B. Glaucoma The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye.
A nurse is assessing a client who is experiencing changes in vision. He states, "I have to use a magnifying glass to read the newspaper. but when driving i can see the signs fine" This manifestation is consistent with which of the following eye disorders? A. Myopia B. Hyperopia C. Astigmatism D. Presbyopia
B. Hyperopia This is considered farsightedness
Which of the following is the definition of Role ambiguity? A. Occurs when individuals are faced with two or more role expectations and find themselves unable to meet these expectations at the same time. B. Refers to the lack of clarity in understanding the actions that need to be taken to achieve proposed goals C. Occurs when the roles and responsibilities placed upon an individual are greater than their ability to effectively manage them or when they find themselves pressured to respond to
B. Refers to the lack of clarity in understanding the actions that need to be taken to achieve proposed goals
A nurse in a provider's office observes a newly licensed nurse taking a client's health history while in the waiting area. Which of the following actions should the nurse take? A. Continue to observe the nurse B. Speak to the nurse immediately in private C. Consider using the same practice to make efficient use of time and office space D. Report the nurse's actions to the provider
B. Speak to the nurse immediately in private The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. Personal health information could be overheard by others in the waiting room. The nurse must immediately stop this behavior and speak to the newly licensed nurse in private to protect the privacy and confidentiality of the client. Incorrect Answers: A. Further observation is not necessary. The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. C. Even though nurses should use time efficiently and make the best use of office space, they also need to respect a client's right to privacy and confidentiality of personal health information. D. This action is not necessary. The nurse should stop this practice to protect the client's right to privacy and confidentiality.
A nurse is preparing to give a presentation to a group of clients in the community about Healthy People. The nurse knows that which of the following options should be included? A Health data from the last 50 years B Financial recommendations C Goals and objectives for healthy habits D Personal information about local people Submit
C Goals and objectives for healthy habits
A nurse is Implementing bladder retraining with a client who has a spinal cord injury. Which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
C Tertiary
A nurse is providing nutritional counseling for a client who has diabetes mellitus Which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
C Tertiary
A nursing is leading a support group for clients who have post-traumatic stress disorder. Which of the following levels of prevention does this fall under? A. Primary B Secondary C Tertiary D. Quaternary
C Tertiary
A nurse is caring for a client who asks if the client in the next room is in pain because she cries out frequently. Which of the following statements should the nurse make? A. "That client has cancer and is quite uncomfortable." B. "We are doing our best to keep that client as comfortable as possible." C. "Does the crying out bother you?" D. "Why don't you ask that client's family when they visit?"
C. "Does the crying out bother you?" This therapeutic response focuses on the client's feelings rather than on confidential information concerning the client in the next room. It summarizes the client's question and poses an open-ended, relevant query for the client to expand on if desired. Incorrect Answers: A. Revealing another client's diagnosis is an invasion of privacy and a violation of the Health Insurance Portability and Accountability Act (HIPAA) regulations. B. This nontherapeutic statement by the nurse uses a defensive response. It ignores the client's concerns because the nurse is focusing on defending the health care team. D. This nontherapeutic response by the nurse changes the subject and does not address the client's concerns. It also ignores the right to privacy for the other client.
Which of the following patient statements would indicate a Role performance stressor? A. "I just divorced my husband of 15 years, I really don't know how to feel." B. "Just woke up with many pimples and I don't want to go to school tomorrow, I don't want people to see me this way" C. "I just feel like I have so many tasks, I don't know how I'll be able to finish in time to get off of work at 5 pm" D.. "Since I lost my job last Monday I feel like I am failing at life ."
C. "I just feel like I have so many tasks, I don't know how I'll be able to finish in time to get off of work at 5 pm"
A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse provide? A. "That is your decision alone." B. "I would if I were you." C. "It sounds like you are unsure what to say to your partner." D. "Your provider is required by law to notify your partner."
C. "It sounds like you are unsure what to say to your partner." This response uses the therapeutic communication tools of clarification and restatement. It identifies that the client is unsure whether or how to approach the issue of being HIV positive with his partner, a common concern of clients due to fear of rejection. This response shows that the nurse is open to further communication with the client and encourages his expression of feelings Incorrect Answers: A. This is a nontherapeutic response that blocks conversation with a closed-ended response to the client. B. This is a nontherapeutic response that blocks conversation by offering personal advice to the client. D. This response is nontherapeutic because it does not address the client's feelings. It is also false; it would be a violation of HIPAA regulations to share the client's personal health information with another individual without consent.
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before
C. "Let's set up a meeting time with the doctor to discuss your options for home care." Correct Answer: C. "Let's set up a meeting time with the doctor to discuss your options for home care." In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment. Incorrect Answers: A. In family-centered care, the family and client are the focus; therefore, the family members must decide, with the input of the health care team, which community resources to contact. The nurse should still make suggestions and offer support. B. In family-centered care, the family and client are the focus. The nurse should provide suggestions and offer support but should not make the final decision about changes to the care plan. D. In family-centered care, the fami
Which of the following patient statements would indicate a role performance stressor? A. "My husband says I am beautiful but I don't believe him." B. "I am considering getting Botox because these wrinkles are becoming defined." C. "Sometimes its hard to manage work and take care of my sick mother" D.. " I am not sure how to care for my elderly father since I am not familiar with his medical issues."
C. "Sometimes its hard to manage work and take care of my sick mother" D.. " I am not sure how to care for my elderly father since I am not familiar with his medical issues."
A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A. "Wake up every 2 hr to urinate during the night." B. "Drink citrus juices throughout the day." C. "Try to block the urge to urinate until the next scheduled time." D. "Limit fluids to no more than 1 L (34 oz) during waking hours."
C. "Try to block the urge to urinate until the next scheduled time." When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, she should try slow, deep breathing to help reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises.
A nurse is assessing a client who is experiencing changes in their vision. She states, "I do not like to drive at night because the lights look like lines and look blurry." This manifestation is consistent with which of the following eye disorders? A. Myopia B. Hyperopia C. Astigmatism D. Presbyopia
C. Astigmatism Per Victors Sensory Alterations pp Astigmatism: a refractive error whereby the eye cannot focus evenly on the retina, causing blurred vision or distortion
A nurse is assessing a client who is experiencing an increase in the opacity of the lens, blocking rays of light from entering the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration
C. Cataracts Manifestations of cataracts include an increase in the opacity of the lens, blocking rays of light from entering the eye.
A nurse is caring for a client who is receiving treatment at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort? A. Administering an incorrect dose of benzodiazepine B. Informing the client's family member of the admission without the client's knowledge C. Informing the client that an injection will be administered if the client remains agitated D. Failing to recognize suicide risk, resulting in the clien
C. Informing the client that an injection will be administered if the client remains agitated This is an example of assault. Assault is an intentional tort that is characterized by a threat toward a client that makes the client fearful of harm or unwanted touching. Incorrect Answers: A. This action is an example of negligence, which is the failure to use expected care in any situation when there is a duty to do so. Negligence is an unintentional tort. B. This is an example of invasion of privacy, which is a quasi-intentional tort and a violation of the Health Information Portability and Accountability Act (HIPAA). Confidential information such as a client's admission should not be shared without the written consent of the client. D. This is an example of negligence. Even if negligence resulted in the client's death, this is still considered an unintentional tort. Peer Comparison A 10% B 23% C 59% D 8% Difficulty level: Hard
A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? A. Ask the client's neighbor to call a family member to interpret. B. Ask the client's neighbor to translate the information. C. Obtain the services of an interpreter. D. Document the inability to provide disc
C. Obtain the services of an interpreter. Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language. Incorrect Answers: A. Using a family member to interpret could breach the client's confidentiality. In addition, the family member might not be familiar enough with medical terminology to translate information accurately. B. Although the neighbor can speak both languages, this action could breach the client's confidentiality. In addition, the neighbor might not be familiar enough with medical terminology to translate information accurately. D. The nurse is responsible for providing discharge instructions that the client can understand.
Which of the following is the definition of Role overload? A. Occurs when individuals are faced with two or more role expectations and find themselves unable to meet these expectations at the same time. B. Refers to the lack of clarity in understanding the actions that need to be taken to achieve proposed goals C. Occurs when the roles and responsibilities placed upon an individual are greater than their ability to effectively manage them or when they find themselves pressured to respond to t
C. Occurs when the roles and responsibilities placed upon an individual are greater than their ability to effectively manage them or when they find themselves pressured to respond to the many roles they hold
A nurse is caring for a client who is a local public official. A newspaper reporter repeatedly phones the unit seeking information and states, "The public has a right to know the health status of elected officials." Which of the following actions should the nurse take? A. Acknowledge that the person is a client on the unit but give no specific details of the client's condition. B. Refer any calls directly to the client's room so that the client and her family can decide what to tell the
C. Refer all media inquiries to the nursing supervisor. The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent. The reporter should be told that, due to confidentiality issues, no information can be given about any client. The nurse should refer the reporter to the nursing supervisor. Incorrect Answers: A. The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent. B. The nurse should not forward the call to the client's room because this will disclose the hospitalization. D. Hanging up on callers from the news media is unprofessional. The nurse should refer calls to the nursing supervisor.
A charge nurse is observing a group of newly licensed nurses. Which of the following actions should the charge nurse report to the nurse manager as a violation of HIPAA? A. Assigning a client who requested a private room to a semi-private room due to unavailability B. Placing a client who is confused in restraints C. Talking about clients with other nurses in the cafeteria D. Wheeling a client who is wearing a sheet down the hall into the shower room
C. Talking about clients with other nurses in the cafeteria The nurse should not discuss information about clients—including their personal concerns, diagnoses, and treatments—with anyone who is not directly involved in the client's care. Doing so is a violation of HIPAA regulations. Nurses should take special care not to compromise this right by discussing client care in such places as elevators, restaurants, or other areas that are accessible to the public in which the discussion might be overheard. Incorrect Answers: A. While this is an unfortunate circumstance, it does not violate HIPAA regulations. If no private rooms are available, the nurse should assign the client to an available room and plan to move the client when a private room becomes available. B. Placing a client in restraints is not a violation of HIPAA regulations. However, this action could be considered false imprisonment if it is done without first taking other measures to ensure the client's safety. D. A
A charge nurse is conducting an in-service training session on ethics to a group of newly licensed nurses. Which of the following situations should the charge nurse include as an example of the ethical principle of veracity? A. A nurse truthfully answers the client's questions about upcoming chemotherapy. B. A nurse stops inserting an NG tube when the client refuses the procedure. C. A nurse provides the same amount of time to all clients regardless of condition. D. A nurse reports an as
Correct Answer: A. A nurse truthfully answers the client's questions about upcoming chemotherapy. A nurse who truthfully answers the client's questions about treatment, such as chemotherapy, is demonstrating the ethical principle of veracity. Veracity refers to telling the truth and being straightforward and clear with clients about the treatment being delivered. Incorrect Answers: B. A nurse who is inserting an NG tube but stops when the client refuses is demonstrating the ethical principle of autonomy. Autonomy is including the client in the decision-making process for all aspects of care, including treatment. C. A nurse who provides the same amount of time with all clients regardless of condition is demonstrating the ethical principle of justice, which involves fairness. D. A nurse who reports an assistive personnel who fails to follow the safety guidelines within the facility for transferring a client is demonstrating the ethical principle of responsibility
A nurse is participating in an ethics committee meeting about a client who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first? A. Collect information related to the issue. B. Consider the possible choices of action. C. Make a decision regarding transplant recommendation. D. Justify the recommendation for or against a transplant.
Correct Answer: A. Collect information related to the issue. According to evidence-based practice, the committee should take the first step in ethical decision-making by identifying the ethical issue and problem. This step includes asking questions to define the issue and the complexities of the situation. Incorrect Answers: B. The second step in ethical decision-making involves identifying and analyzing all of the available alternatives for action, even if the actions seem unlikely. C. The third step in ethical decision-making involves selecting one of the alternative actions to follow. The committee should apply ethical principles to make the best decision possible. D. This is the final step in ethical decision-making. The committee should specify reasons for the action selected and be able to present the ethical basis behind the decision made.
A nurse at a long-term care facility is providing teaching to a group of adolescents who are new volunteers. The nurse should explain that older adult clients are most likely to exhibit a decrease in which of the following? A. Short-term memory B. Creative ability C. Decision-making skills D. Cognitive capacity
Correct Answer: A. Short-term memory The ability to process short-term memories decreases as part of the aging process. As a result, older adult clients may require reminders regarding their medications, ADLs, or daily schedules. The nurse should tell the volunteers that residents might have difficulty remembering their names from day to day, ask the same question repeatedly, or need assistance remembering recent events. Incorrect Answers: B. Creative ability does not decrease in older adult clients. Most long-term care facilities provide recreational activities, including opportunities for creativity through artistic expression. Clients who have dementia and other neurological disorders may still be able to participate in creative activities. C. Decision-making skills do not decrease in older adult clients as a result of the aging process. Clients who have dementia and neurological disorders may still be able to participate in making decisions about themselves or their care. Unles
A nurse is speaking with a client whose partner was killed unexpectedly. The client states, "I just don't know what to do now." Which of the following actions should the nurse take? A. Talk to the client about available community resources B. Distract the client by discussing events not related to the crisis C. Reassure the client that he will feel better soon D. Give the client advice about what to do during the next few days
Correct Answer: A. Talk to the client about available community resources Initial steps should be taken to make a client who is experiencing a crisis feel safe and less anxious. The priority for the nurse is to ensure the client is safe, which includes assessing any thoughts of self-harm. After promoting client safety, the nurse should let the client know what personal and community resources are available. The nurse should determine the client's perception of the crisis, availability of support, and ability to cope with the crisis. Incorrect Answers: B. Changing the subject from the crisis invalidates the client's feelings and can make the client feel isolated. C. The nurse should avoid giving false reassurance, which belittles the client's feelings. D. Giving advice inhibits clients' ability to problem-solve. Clients have autonomy over their lives and should be allowed to make decisions about situations that affect them. The nurse can use therapeutic communication techniques
A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is scheduled to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? A. Beneficence B. Autonomy C. Paternalism D. Justice
Correct Answer: B. Autonomy Informed consent is based on the ethical principle of autonomy, which is the right to self-determination, independence, and freedom of choice. Incorrect Answers: A. Beneficence is based on the principle that actions should be taken with the intent to do good. It is associated with nonmaleficence, which is the requirement that health care providers do no harm to their clients. Although this is an important ethical principle in nursing, it is not the basis for informed consent. C. Paternalism is based on the assumption that one person can assume responsibility for making the decisions of another person. This principle limits freedom of choice. D. Justice is based on the principle that everyone should be treated similarly and fairly. This is an important ethical principle but is not the basis for informed consent.
A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt
Correct Answer: B. Industry vs. inferiority The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (ages 6 to 12 years). Incorrect Answers: A. Initiative vs. guilt is the developmental task of early childhood (ages 3 to 6 years). C. Identity vs. role confusion is the task of the adolescent (ages 13 to 19 years). D. Autonomy vs. shame and doubt is the developmental task of a toddler (ages 12 months to 3 years).
A nurse is administering medications to a client who is recovering from a stroke and has right-sided paralysis. The nurse places the client's medications on the left side of the mouth and administers pills one at a time. Which of the following ethical principles is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice
Correct Answer: B. Nonmaleficence Nonmaleficence is the duty to do no harm and to protect clients from harm by eliminating threats. These actions taken by the nurse are important for the safety of the client by preventing aspiration. Incorrect Answers: A. Autonomy is the right to self-determination, independence, and freedom of choice. C. Fidelity is the obligation to be faithful to commitments made to self and others. D. Justice is the obligation to be fair and to treat people in an equal manner
A charge nurse is discussing ethics with a newly licensed nurse. Which of the following actions should the charge nurse include as an example of beneficence? A. Taking a continuing education course about recognizing risk factors of suicide B. Spending extra time reorienting a client who is experiencing command hallucinations C. Acknowledging and accepting a client's refusal of a psychotropic medication D. Describing the purpose, action, and side effects of a psychotropic medication
Correct Answer: B. Spending extra time reorienting a client who is experiencing command hallucinations The nurse should include this action as an example of beneficence, which is the duty to act to promote the good of others. Reorienting a client who is experiencing command hallucinations is in the best interest of the client and can protect the client from harm. Incorrect Answers: A. This action describes fidelity, C. This action describes autonomy, D. This action describes veracity,
A nurse is caring for a client with stage 4 ovarian cancer who has decided to stop treatment and enter hospice care. Which of the following ethical principles is the nurse displaying by supporting the client in her decision? A. Responsibility B. Accountability C. Advocacy D. Confidentiality
Correct Answer: C. Advocacy By following the ethical principle of advocacy, the nurse supports the client in the decisions she makes about her own health care. Incorrect Answers: A. By following the ethical principle of responsibility, the nurse upholds obligations. B. By following the ethical principle of accountability, the nurse answers for personal actions. D. By following the principle of confidentiality, the nurse protects the client's privacy and health care information.
A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001
Correct Answer: C. Hct 55% An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output. Incorrect Answers: A. This BUN falls within the expected reference range; therefore, it does not indicate hypovolemia. B. This capillary refill time is within the expected reference range. With dehydration, it tends to be longer. D. This low urine specific gravity indicates hypervolemia, not hypovolemia.
A nurse is caring for a client who is dying and unable to make decisions for himself. The client's adult children disagree about his code status. Which of the following sources should the nurse depend on for decisions regarding the client's end-of-life care? A. The client's oldest child B. The attending provider C. The client's health care proxy D. The facility's ethics committee
Correct Answer: C. The client's health care proxy If the client cannot speak for himself, the nurse should follow the directions of the client's health care proxy, as this is the person the client chose to make decisions under these circumstances. Incorrect Answers: A. If the client does not have advance directives or has not named a health care proxy, the family may be asked to make end-of-life decisions. B. The attending provider may offer suggestions on end-of-life care, but the client or the client's health care proxy directs treatment. D. In the absence of advance directives, the facility's ethics committee may be called upon to intervene if a conflict occurs regarding end-of-life decisions.
A charge nurse is reviewing the Code of Ethics for Nurses during a staff meeting. Which of the following statements should the charge nurse include in the teaching? A. "The Code of Ethics for Nurses is legally binding." B. "The Code of Ethics for Nurses is mandatory for the practice of nursing." C. "The Code of Ethics for Nurses is a description of licensure requirements." D. "The Code of Ethics for Nurses is a guide for professional actions."
Correct Answer: D. "The Code of Ethics for Nurses is a guide for professional actions." The American Nurses Association's Code of Ethics for Nurses is a guide for fulfilling nursing responsibilities in a way that reflects quality in nursing care and upholds the ethical obligations of the nursing profession. It provides a guide for professional actions. Incorrect Answers: A. The American Nurses Association's Code of Ethics is not a legally binding contract for nurses. B. The American Nurses Association's Code of Ethics for Nurses is not mandatory for the practice of nursing. C. The American Nurses Association's Code of Ethics for Nurses is not a description of requirements for nursing licensure.
A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse perform? A. Administer the medication by another route. B. Refer the client's refusal to the facility's ethics committee. C. Inform the client that, due to her involuntary admission, she cannot refuse a sedative. D. Document the client's refusal of the medication in the
Correct Answer: D. Document the client's refusal of the medication in the medical record. The nurse should respect the client's right to refuse medication, even if the client is receiving treatment due to an involuntary admission. The nurse should document this refusal in the medical record and assess the reasons for the client's refusal. Incorrect Answers: A. It is beyond the nurse's scope of practice to administer a medication by a route other than what was prescribed by the provider. B. The client's refusal of medication is a legal issue, not an ethical issue. The nurse should recognize the client's right to refuse medication and collaborate with the provider to meet the client's needs. C. The nurse should be aware of the client's rights regarding an involuntary admission. This is incorrect information to share with the client.
A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A. Allows minimal treatment B. Benefits the client's family C. Offers hope for a cure D. Supports self-determination
Correct Answer: D. Supports self-determination The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right. Incorrect Answers: A. The client has the right to refuse all treatment, and the nurse has a duty to honor that right. B. The nurse's priority is to provide care that benefits the client, not necessarily the family. C. Offering hope for a cure when lung cancer is advanced is a nontherapeutic response and provides false reassurance to the client.
Which of the following is the definition of Role strain? A. Occurs when individuals are faced with two or more role expectations and find themselves unable to meet these expectations at the same time. B. Refers to the lack of clarity in understanding the actions that need to be taken to achieve proposed goals C. Occurs when the roles and responsibilities placed upon an individual are greater than their ability to effectively manage them or when they find themselves pressured to respond to the
D, Occurs when an individual has difficulty meeting the responsibilities of a particular life role or when incompatible demands are placed upon an individual.
A nurse is teaching a group of newly licensed nurse managers about the principle of justice. Which of the following statements by a nurse manager indicates an understanding of this teaching? A. "I will refer an unhappy employee to the individual with whom a conflict arose." B. "I will allow staff members to schedule their birthday holidays on alternate days, as long as staffing levels are maintained." C. "I will encourage staff participation in choosing new telemetry monitors for the unit.
D. "I will compose staff schedules so that each person works two holidays a year." Correct Answer: D. "I will compose staff schedules so that each person works two holidays a year." Justice means treating everyone fairly. By scheduling each person to work two holidays per year, the nurse manager is requiring staff members to work an equal share of holidays. Incorrect Answers: A. This is an example of the appropriate use of conflict management. By referring unhappy staff members to the individuals with whom they have conflicts, the nurse manager is encouraging individual problem-solving behaviors. B. This demonstrates the principle of autonomy. By allowing staff members to participate in scheduling while maintaining appropriate levels of staffing, the nurse manager is encouraging independent, professional behavior. C. This is an example of change theory. By allowing staff members to participate in decision-making for the unit, the nurse manager is encouraging staff input in the
A nurse is working in the triage area of an emergency department. Which of the following activities is unlikely to be the nurse's responsibility in this setting? A. Fostering positive public relations for the facility B. Performing a comprehensive client assessment C. Preventing cross-contamination of infectious clients D. Educating a client and his family members
D. Educating a client and his family members In the triage setting, the nurse's priority is assessment and control of client flow. The triage nurse does not allocate time to provide education to clients or their families. Education is handled by the emergency department staff once the treatment of a client begins. Incorrect Answers: A. In most instances, the triage nurse is the first professional the client encounters when seeking emergency services. Professionalism and positive client relations are necessary behaviors for the triage nurse to implement in order to foster a positive perception of the facility. B. The triage nurse does perform comprehensive assessments to determine the urgency status of the clients' conditions. C. Preventing cross-contamination of infectious clients is a responsibility of the triage nurse. In this setting, the nurse must be able to separate clients to prevent cross infection from one client to another.
A nurse is assessing a client who is experiencing a decrease in the ability to focus up close or with small print. This manifestation is consistent with which of the following eye disorders? A. Myopia B. Hyperopia C. Astigmatism D. Presbyopia
D. Presbyopia Per Victors Sensory Alterations pp Presbyopia: decrease in the ability to focus up close or with small print
A nurse in the emergency department is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and discharges the client. Which of the following actions should the nurse take? A. Request a social services consultation B. Contact the child's guardian to discuss the suspicion C. Report the provider's actions to the state medical board D. Report the suspected abuse to law enforcement
D. Report the suspected abuse to law enforcement Nurses are legally mandated to report suspected child and vulnerable adult abuse. The nurse should report the suspected child abuse to the appropriate agency of the state in which she is practicing. Incorrect Answers: A. HIPAA regulations do not supersede the suspicion of abuse. B. C. The nurse should report the suspected abuse to the appropriate state agency.
A nurse is teaching a group of unit nurses about the Health Insurance Portability and Accountability Act (HIPAA). Which of the following pieces of information should the nurse include in the teaching? A. The Privacy Rule limits the client's rights to personal health information. B. The electronic transfer of information allows each provider to use his/her own electronic format for claim transactions. C. Standardized numbers can have a varied format for identifying health plans. D. The Se
D. The Security Rule provides a uniform level of security to protect client records. The security rule provides a uniform level of protection of clients' records, which includes maintaining the confidentiality, integrity, and availability of the client's records. Incorrect Answers: A. The privacy rule gives the client the right to access personal health information and medical records. B. Providers use a standardized transfer process when transferring electronic information among health care organizations. C. A standard format is used for standardized numbers, which identify the client's health plans, providers, and employers (e.g. an employer's tax identification number). Peer Comparison A 6% B 5% C 3% D 87% Difficulty level: Easy
Which of the following patient statements would indicate a Self-esteem stressor? A. "I just divorced my husband of 15 years, I really don't know how to feel." B. "Just woke up with many pimples and I don't want to go to school tomorrow, I don't want people to see me this way" C. "I just feel like I have so many tasks, I don't know how I'll be able to finish in time to get off of work at 5 pm" D.. "Since I lost my job last Monday I feel like I am failing at life ."
D.. "Since I lost my job last Monday I feel like I am failing at life ."
