EXAM 3: NURS 201 Prep U
Assess the factors that the client believes contribute to the problem.
Chapter 35: A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?
The client will likely not be able to sleep.
Chapter 35: A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?
Provide an opportunity for the client to talk about concerns
Chapter 35: A new client in the medical-surgical unit reports difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nurse identifies the nursing concern of altered sleep pattern with insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this this client's nursing concern?
"The CPAP assures you get enough oxygen throughout the night"
Chapter 35: A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?
They may be disoriented on awakening
Chapter 35: A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:
Hypothalamus
Chapter 35: A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?
The pulse is slow
Chapter 35: In Stage 4 sleep, the:
Keep the client safe by monitoring ambulation on the unit
Chapter 35: The nurse is caring for a client on the acute care unit who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?
Find a phone app that plays the sounds of the city
Chapter 35: The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?
Newborns sleep 16 to 17 hours per day
Chapter 35: The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?
Altered sleep pattern related to acute pain
Chapter 35: The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects which primary nursing concern?
14 to 18 hours
Chapter 35: The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours in a 24 hour period?
Use caution when driving an automobile
Chapter 35: The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:
Assess the client's vital signs and pulse oximetry
Chapter 35: The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take?
The child should limit fluids after supper
Chapter 35: The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep?
Rapid eye movement (REM)
Chapter 35: When a nurse notes that the client appears to be sleeping, is demonstrating irregular respirations, and is showing eye movement, the nurse identifies the stage of sleep the client is experiencing as
Low-flow oxygen
Chapter 35: When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the health care provider for which intervention?
Do you usually go to bed and wake up about the same time each day?
Chapter 35: Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern?
Cheese and crackers
Chapter 35:The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?
Assist the client in exploring thoughts and feelings related to body image changes
Chapter 42: A client had a traumatic amputation of the arm in a motor vehicle accident. Which intervention will the nurse use to assist a client in managing body image disturbance?
Personal identify
Chapter 42: The nurse is assessing for information about a client's self-concept. The information needed first is about which of the following?
Toddler
Chapter 42: Which developmental stage does Erikson term autonomy vs. shame?
Self-evaluation
Chapter 42: A 24-year-old man is suffering from depression. He has come to the clinic today for a follow-up visit with his provider and the nurse has been asked to provide some client education on the antidepressants he has been prescribed. When the nurse asks him how he is feeling today, he responds that he is feeling down because he feels as if he is a failure. This scenario best describes which dimension of self-perception?
Altered personal identity related to the unresolved crisis of their spouse's death
Chapter 42: A 73-year-old client has been the primary caregiver for their spouse, who had multiple sclerosis (MS). After 30 years with the disease, the spouse has died and the client has become increasingly withdrawn and refuses to leave the house. Which nursing concern is most appropriate for the nurse to identify for care planning?
"I want my crutches close to my bed"
Chapter 42: A client had an above-the-knee amputation due to necrotizing fasciitis. Which statement by the client indicates an adaptive response?
Altered personal identity related to the new environment and separation from family
Chapter 42: A client has recently immigrated without their family. The client reports that they cannot find a job and has no friends in the country. The client reports that without their family they do n0t know who they really are and everything around then is different. Which nursing concern is most appropriate?
Role strain
Chapter 42: A client started a nursing program and is trying to balance going to school full-time, a part-time job, and spending time with family. The client states, "I am trying to do everything and doing nothing well." Which role problem is this client experiencing from this role transition?
Explain that his life experience will help to develop a plan of care.
Chapter 42: A nurse is developing a plan of care for an older adult to promote self-esteem. What intervention would be most appropriate to include?
The client will be able to stop smoking
Chapter 42: A nurse is educating a client about smoking cessation. The nurse determines that the client has high self-efficacy. Which outcome would the nurse expect to occur?
Evaluate his or her own self-concept
Chapter 42: A nurse is nervous about interacting with a new client due to the memories of a similar past situation the nurse has experienced. Which action should this nurse prioritize when caring for this client?
Makes decisions related to his care, uses available resources
Chapter 42: A rehabilitation nurse is caring for Steve Branson, a 23-year-old man, who has suffered a spinal cord injury and has tetraplegia. One of the rehabilitative goals for Steve is to attain adaptive patterns of behavior related to his injury. Which of the following would indicate that he is achieving this goal? Choose all that apply.
Limit visitation of friends
Chapter 42: A student nurse is preparing a care plan for a hospitalized school-age client focusing on ways to promote self-concept. Which intervention would not be appropriate?
Inadequate coping
Chapter 42: The emergency department nurse is triaging a 15-year-old adolescent who is brought in by a family member after finding the client with a bottle filled with a variety of pills. The family member shares that the client's parents recently divorced and the client's mother moved out-of-state, leaving the client and two younger siblings with the father. The father travels frequently for work, leaving the client alone to take care of the younger siblings. Which factor should the nurse prioritize?
I've been eating healthy and taking my medication. Otherwise, it could have been a lot worse."
Chapter 42: The nurse is providing care to a client who is recovering from mild myocardial infarction. The nurse determines that the client has an internal locus of control based on which client statement?
Intactness and mutilation
Chapter 42: The pediatric nurse is caring for a boy 5 years of age, who is being seen in the clinic today. He is very worried that the doctor may harm his body. His mother asks the nurse if this is normal for this age. The nurse shares with the mother that the very young child worries about which of the following related to his body?
The man's increasing level of dependence on his children
Chapter 42: Which of the following factors is most likely to present a challenge to the self-concept of a man 79 years of age?
Resistance
Chapter 43: A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in?
Mother's increased cortisol levels lead to increased anxiety and decreased attachment, Excessive noise and lights can increase cortisol levels in the neonate, The inability to hold and touch can lead to delay in bonding between mother and infant.
Chapter 43: A 2-day-old, 28-week gestation preterm infant is being cared for in the neonatal intensive care unit. The mother is recovering from a cesarean section and comes in to visit for the first time today. Determining that stress can affect infant development., what situation does the nurse identify can develop? Select all that apply.
Alcohol use
Chapter 43: A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client?
Joining the local garden club
Chapter 43: A 65-year-old client has experienced the death of a parent and a family pet in the span of 1 month. Which action is a coping mechanism that demonstrates adaptation?
Stressors
Chapter 43: A middle-age woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are:
"I don't know why he is acting like this. He hasn't had anyone to play with but his little brother all summer."
Chapter 43: A mother tells the school nurse that her 5-year-old is refusing to go to school and won't accept a "school night" bedtime. The school nurse knows the mother will need more instruction when the mother makes which statement?
Attempt to calm the client and administer oxygen
Chapter 43: A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs?
Seek assistance from family and friends
Chapter 43: A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention?
Provide care transition at discharge for speech therapy
Chapter 43: A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?
This behavior is known as regression
Chapter 43: A toilet trained toddler was admitted to the hospital for dehydration. Upon returning home, the toddler becomes incontinent of urine and stool. The parent is concerned regarding this return to previous behavior and calls the pediatric clinic. What is the nurse's best response to the parent?
Maladaptive
Chapter 43: An adolescent describes a dysfunctional home life to the nurse and reports smoking marijuana to help cope with the situation. How will the nurse identify this form of coping?
Burnout
Chapter 43: An intensive care unit (ICU) nurse with 11 years of experience has been frequently absent or late for shifts, has been verbally abusive with coworkers she feels are unskilled at the technological tasks of the job, and cursed under her breath at a distraught family member today. The nurse manager is threatening to suspend her if it happens again. The ICU nurse may be experiencing:
Repression
Chapter 43: During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement?
A young wife asking everyone repeatedly if they know where her husband is
Chapter 43: Many families are sheltering in the local middle school gymnasium during a severe tornado outbreak. Many homes have been destroyed and lives lost. The community health nurse expects to see negative stress reactions to the crisis, such as:
Anticipatory guidance
Chapter 43: Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique?
"They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight"
Chapter 43: The emergency department nurse suspects that an older adult client who fell and broke her hip is using a defense mechanism when the client states:
Compensation
Chapter 43: The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario?
Refer the client to a support group
Chapter 43: The nurse is caring for a 65-year-old widower whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with him about his spouse. Which is the nurse's priority intervention for this client?
A panic attack
Chapter 43: Upon arrival to the emergency room, the mother of a client involved in a motor vehicle accident becomes upset when she learns her son is unconscious and unstable. The mother begins to yell at the emergency room staff in unintelligible words, and she is trembling. She becomes short of breath and yells she can't breathe. What is the mother likely experiencing?
Homeostasis
Chapter 43: A client's body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as:
Have you received a human papillomavirus (HPV) vaccination?
Chapter 46: A 13-year-old female client comes in for a sports physical for school. During the exam, the client mentions she has a great boyfriend. Which question should the nurse prioritize with this client?
Intrauterine device (IUD) placement within past 3 months
Chapter 46: A client presents to the client reporting vaginal bleeding, feeling sad, headaches, increased acne, and recent weight changes. What information is important for the nurse to obtain during the assessment of this client?
"Gonads are the reproductive organs of the male and are responsible for the production of testosterone and spermatozoa."
Chapter 46: A client presents to the office with concerns of low testosterone and feels it is due to a pituitary gland disorder. Which teaching would the nurse provide to educate this client on how testosterone is produced?
"Malnutrition may cause impotence"
Chapter 46: A gerontology nurse is discussing sexual dysfunction with an older adult male client. The nurse determines that the education has been effective when the client states:
"I have noticed I have less lubrication with sexual intercourse."
Chapter 46: A nurse is collecting a sexual health history from an older adult woman who is postmenopausal. Which client statement requires further education by the nurse?
"Gender role behavior is the behavior a person conveys about being male or female."
Chapter 46: A nurse practitioner is teaching the student about sexual health and is evaluating the student's knowledge of sexual identity. The practitioner knows that the student understands when the student says which of the following?
STIs are most prevalent among adolescents and young adults.
Chapter 46: A school nurse is providing a class on sexually transmitted infections (STIs). Which statement is correct regarding STIs?
Acknowledge that masturbation is normal
Chapter 46: During a well-check visit of a toddler, the parent mentions that the child is exhibiting sexual behaviors. Which information on growth and development of a toddler will the nurse discuss with the parent?
"A normal sexual response for women may include multiple plateaus without an orgasm as a result."
Chapter 46: How would the nurse respond to a female client who says, "I do not think I have ever experienced an orgasm. Is that normal?
Cervical cap
Chapter 46: The nurse recommends a barrier method of contraception for a client who is concerned about the side effects of hormonal contraception. Which method might the nurse suggest?
Menarche
Chapter 46: The school nurse is educating a group of 5th and 6th grade girls on menstruation. One girl asks if there is a name for having her first menstrual period. The nurse replies with which of the following terms?
Feelings of relaxation and fulfillment
Chapter 46: What is associated with the resolution phase of the male sexual response cycle?
"How do you feel about yourself as a woman?"
Chapter 46: Which assessment question is most likely to yield data about a female client's sexual identity?
"Tell me more about what you know of masturbation."
Chapter 46: Which response will the nurse provide to a 13-year-old female client who says to the nurse, "My parents said masturbation is wrong. Is that true?"
Question the client concerning spiritual concern
Chapter 47: A client in a long-term care facility has recently begun to refuse to cooperate with the staff, is having difficulty agreeing with the treatment goals suggested by the nurse, and is showing more stress when the family goes home. What is the best response from the nurse?
Separation from spiritual ties
Chapter 47: Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation?
Engage the client in a discussion about past and present religious practices.
Chapter 47: The nurse is caring for a 55-year-old client admitted to the hospital for liver failure. The client states being an active member of The Church of Jesus Christ of Latter-day Saints. The client tells the nurse about strictly adhering to the religious practices that are condoned by the Church. However, the nurse overhears two health care providers discussing that the client's liver failure is likely due to chronic alcohol use. The nurse suspects that the health care providers are incorrect. Which nursing nursing action is appropriate?
Ask the client how he or she expresses spirituality.
Chapter 47: When reviewing the history of a client admitted to the health care facility, the nurse notes that the client reported being an atheist. Which action will the nurse take to meet spiritual needs when planning nursing care for the client?
Islam
Chapter 47: While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?
Ask the client what diet is followed at home.
Chapter 47: A client self identifies as a member of the Jewish faith. When discussing diet and food preferences with the client, which assessment would be useful?
The client uses a type of spiritual experience that provides comfort
Chapter 47: A new nurse observes a priest visiting the clients every Saturday afternoon and praying with them. This activity supports which of the nursing outcomes?
Provide support that builds on the client's faith.
Chapter 47: A nurse is caring for a client with terminal illness who believes that death and reincarnation are the ultimate gifts from a higher power. What would be most appropriate to integrate into this client's plan of care when providing spiritual support?
Ideas related to after death, An identity as a group, Ethical code for right and wrong, Involvement of a sacred word or scripture
Chapter 47: A nurse is preparing a presentation for a group of staff nurses about spirituality and the importance of meeting clients' spiritual needs. As part the presentation, the nurse plans to address the major religious groups. Which characteristic would the nurse identify as being common to the major religions? Select all that apply.
Faith
Chapter 47: A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating?
Use silence and allow the husband to express his emotions.
Chapter 47: After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply?
Read a printed interfaith prayer to the client.
Chapter 47: An older adult client is spiritual and has a deep faith. The client asks the nurse to say a prayer for the client. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse?
Take the lead from the client by asking, "How would you like us to pray?"
Chapter 47: An older adult client who is very sick but very spiritual and has a deep faith asks the nurse to say a prayer for her. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse?
Faith
Chapter 47: The client states "I have lifted my cancer to God and am accepting of God's plan for me." This is an example of an adaptive expression of spiritual needs labeled:
"Do you have a preference as to which spiritual leader you would like to visit?"
Chapter 47: The nurse is assessing a 27-year-old Navajo male who is being admitted for surgery. The client requests a visit from the spiritual healer. Which is the best response from the nurse?
A pork chop
Chapter 47: The nurse is caring for a client that practices Islam in the hospital. When dietary brings the client a food tray for supper, which food on the tray should the nurse remove that is against the dietary laws for a practicing Muslim?
"What provides you with strength to deal with this health situation?"
Chapter 47: The nurse overhears a client, who is scheduled to begin chemotherapy, tell a family member that everything will eventually be okay and the cancer will be in remission. Which question will the nurse ask to begin a conversation about hope with the client?
Take measures to ensure privacy during the counselor's visit.
Chapter 47: When preparing for a spiritual counselor to visit a hospitalized client, the nurse should:
Explain the purpose and need for assistance during ambulation
Chapter 5: A nurse is caring for a postoperative client after knee arthroplasty. The nurse plans to help the client ambulate but is aware that the client may feel threatened by physical closeness because the client is from a culture that tends to prefer more personal space when interacting with others. Using the principles of culturally competent care, what would be the most appropriate nursing action?
"It is important to monitor my blood pressure."
Chapter 5: The nurse is teaching a Black client about common health conditions. Which statement by the client most directly addresses a health problem with an increased incidence in this population group?
Witchcraft
Chapter 5: The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study?
Ethnicity
Chapter 5: When reviewing the chart of an older adult client, the nurse notes that the client identifies as Japanese. The nurse realizes the client is referring to which ancestral and cultural factor?
1. Honeymoon, 2. disenchantment, 3. begging resolution, 4. effective function
Chapter 5: A 45-year-old client who is hospitalized for the first time in the client's life is experiencing culture shock, not understanding what is going on with the client's body or in the hospital. Place the stages of culture shock listed below in the order in which the client will most likely experience them. 1. honeymoon 2. effective function 3. disenchanment 4. begging resolution
The client states, "I feel like I abandoned my religion."
Chapter 5: A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change?
Cultural ritual
Chapter 5: A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of:
Require an individualized approach by the nurse
Chapter 5: A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms:
Client's height
Chapter 5: Nurses are responsible for delivering culturally competent care for all clients. Culturally competent care does not account for:
Healthcare culture
Chapter 5: Nurses are socialized into the:
Health disparities
Chapter 5: Persistent gaps between the health status of minorities and non-minorities are defined as:
Document the client's request in the nursing care plan.
Chapter 5: The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response?
Sterotyping
Chapter 5: The nurse caring for several clients on a surgical unit notes that one of the clients has a surname associated with Arabic ancestry. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action?
Determine in which language the client communicates effectively, Schedule a certified interpreter when collecting client health history, Review facility policy on communication with clients who do not speak the dominant language
Chapter 5: The nurse is caring for a client who does not speak the dominant language. In order to facilitate unencumbered communication with the client, the nurse will take which action(s)? Select all that apply.
Respond by saying, "Stereotypes keep us from accepting others as unique individuals."
Chapter 5: The nurse overhears a colleague state, "All people from that client's country are rude." What is the appropriate nursing response?
Allowing the client to keep a religious necklace on until going into the operating room, Asking the client questions regarding health care beliefs related to the client's culture, integrating the client's cultural practices when assisting with the creation of the plan of care
Chapter 5: The nurse works in an urban hospital and cares for a diverse population of clients. Which action(s) by the nurse demonstrates the delivery of culturally sensitive care to clients? Select all that apply.
"What type of food did your family prepare for you, and does it have special meaning?"
Chapter 5: The unlicensed assistive personnel reports to the nurse that the client is refusing to eat the food on the meal tray. The nurse observes the client eating the food brought in by family members. How should the nurse respond?
The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit.
Chapter 5: The younger nurses on a unit, who seem to adapt easily to the new technology presented, are perceived as threatening by two nurses who have worked on the unit for years. The older nurses begin to ridicule the younger nurses, saying, "You might be able to work a computer, but we know how to provide real care." How should the charge nurse respond?
Avoiding older adult clients because their care is time consuming
Chapter 5: Which behavior by the nurse is stereotyping?
Burdensome to family, Physically impaired, Uninterested in intimacy
Chapter 5: Which stereotypical ideas about older adult clients does the nurse associate with the concept of ageism? Select all that apply.
The working phase
Chapter 8: A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?
Aggressive
Chapter 8: A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:
Be silent and allow the client to continue speaking when ready
Chapter 8: A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?
A communication channel
Chapter 8: A nurse touches the client's hand while discussing the client's diagnosis. This action is:
"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"
Chapter 8: The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply
Orientation phase
Chapter 8: The nurse makes a contract with the client during which phase of the nurse-client relationship?
A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client.
Chapter 8: What nursing care behavior by the nurse engenders a client's trust in the nurse?
Empathy
Chapter 8: A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?
Orientation phase
Chapter 8: A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?
Ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel
Chapter 8: A nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the new nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to:
Sit at the bedside and allow the client to explain the statement
Chapter 8: A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:
"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."
Chapter 8: A nurse is calling a health care provider to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?
Pull the curtain dividing the two beds
Chapter 8: A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment?
"I understand you have four kids; how many times have you actually been pregnant?"
Chapter 8: A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?
"All of the people got themselves out of the car"
Chapter 8: Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?
Patiently await the client's responses after asking questions, Provide the client with a tablet or whiteboard to attempt communication, Have the client point to common phrases or spell with alphabet letters on a laminated form
Chapter 8: The nurse is caring for a client who had a stroke with residual affective aphasia. What is an effective method(s) for the nurse to communicate with the client? Select all that apply.
Contacting the interprofessional care team to discuss alternative treatment options
Chapter 8: The nurse is caring for a postoperative client who refuses a blood transfusion due to religious beliefs. The nurse is demonstrating trustworthiness when taking which action in response to the client's treatment wishes?
"Could you tell me more about how you are feeling right now?"
Chapter 8: The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?
Identify oneself by name and title with each entry into the client's room.
Chapter 8: The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication?
"Why did the health care provider prescribe this medication for you?"
Chapter 8: Which is an open-ended question?
A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment
Chapter 9: A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?
Have client rate pain level and reschedule the teaching session
Chapter 9: As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?
Lecture/discussion
Chapter 9: What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?
A client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself, A client who views disease as a serious threat, A client who believes there are actions that will reduce the probability of contracting the disease
Chapter 9: A nurse caring for clients in a skilled nursing facility assesses client motivation to participate in care. Based on the health belief model, which clients would be most motivated? Select all that apply
"How are you supposed to take your medication?"
Chapter 9: A nurse is assessing a client who has come to the clinic for a follow-up appointment. The client was diagnosed with asthma several months ago and has missed several appointments since that time. The client also has not been following the medication plan and has not kept the appointment for allergy testing. The nurse suspects that the client may be experiencing problems with health literacy. The nurse teaches the client about the condition and prescribed treatment. Which question from the nurse would help to assess the client's health literacy about the condition?
The client describes signs and symptoms of hypoglycemia.
Chapter 9: A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?
Available resources, Literacy level, Learning style preferences
Chapter 9: A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply.
The nurse ignores the restrictions of the client's environment, The nurse uses medical jargon frequently when discussing the teaching plan, The nurse fails to accept that clients have the right to change their minds.
Chapter 9: A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.
Personal perception of health and aging
Chapter 9: An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis?
Critical thinking
Chapter 9: An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:
"Tell me about what signs of infection you will report to the health care provider."
Chapter 9: The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?
"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."
Chapter 9: The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?
Cognitive
Chapter 9: When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?
Psychomotor
Chapter 9: When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?
The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.
Chapter 9: When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners?
Intellectual development
Chapter 9: Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease?
A 70-year-old female who is the client's spouse and is learning the care so the client can come home
Chapter 9: Which statement describes the person who is likely the most motivated to learn?
Condoms
Chapter 46: The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is:
Theism
Chapter 47: When the client tells the nurse that she believes God's reality is personal, and that God is the creator of all beings, the nurse determines the client is expressing:
His faith
Chapter 47: While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying:
The choice not to start a family
Chapter 46: The community health nurse is aware that many factors influence a client's decision for contraception. Which of the following is the most likely reason a client would select permanent contraception?
"What questions or concerns do you have about your sexual health?"
Chapter 46: The nurse assessing an adolescent's need for further information regarding sexual health should ask which question?
"Some oral contraceptives protect against STIs"
Chapter 46: The nurse has provided information to a client about oral contraceptives. Which statement by the client would indicate a need for further education?
Antihypertensive medication
Chapter 46: The nurse is justified in assessing for sexual dysfunction among male clients who are receiving which of the following?
"I can leave my diaphragm in for up to 48 hours."
Chapter 46: The nurse is providing education about barrier contraceptives. Which statement by the client indicates a need for further education?
Discuss the sleep pattern with the health care provider
Chapter 35: A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns?
Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."
Chapter 9: Which documentation example best reflects the complexity of client teaching by the nurse?
Preparation
Chapter 9: A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?
Positive feedback
Chapter 9: A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?
