Final Exam study NURS

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: -diagnosis. -intervention. -goal. -evaluation.

-intervention. -A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes

A nurse is reading an online journal article about different approaches to health. The nurse is reading about a practice approach that is supported by evidence-based practice and is particularly effective when aggressive treatment is needed in an emergency situation. The nurse is reading about which type of approach? -Traditional Chinese medicine -Ayurveda -Naturopathy -Allopathic

Allopathic -Allopathic medicine (or conventional medicine) is evidence-based practice that includes remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools. Allopathic medical care is particularly effective when aggressive treatment is needed in emergency or acute situations.

Which statement is most accurate in comparing nursing care provided in the acute care setting and that provided in the home care setting? -The acute care setting, unlike the home care setting, focuses on the client's needs. -Both care settings require the participation of the client's family. -Both settings focus on the holistic care of an individual. -The home care setting can only be initiated when the client returns to full function

Both settings focus on the holistic care of an individual. Although the setting for care and the type of intervention may change, the nursing focus is always the same: the holistic care of an individual. Wherever the nurse practices, the primary concern is to provide for health care that focuses not only on physiologic needs but also psychosocial and spiritual needs of the person in relation to the environment.

he nurse researcher is aware that the type of variable that can be manipulated in a study is which type of variable? Quantitative Dependent Independent Qualitative

Independent Explanation: The independent variable is presumed to have an effect on the dependent variable. It may be manipulated if the researcher is doing an experimental study; in a nonexperimental study, it is assumed to have occurred naturally before or during the study. The dependent variable may not be manipulated. Quantitative and qualitative are types of research, not types of variables.

A client refuses to allow any healthcare worker of Asian descent to provide care. This client is demonstrating what practice? Ethnic identification Ethnocentrism Racism Stereotyping

Racism

What is the purpose of establishing a nursing diagnosis? To meet accreditation criteria To describe a functional health problem To identify medical problems To collaborate with the physician

To describe a functional health problem Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? -"I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." -"I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." -"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." -"I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high."

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

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? "It was by chance that my sister, who is a nurse, was visiting me at the time." "I'm just glad that the paramedics came so quickly when I called 9-1-1." "I've been eating healthy and taking my medication. Otherwise, it could have been a lot worse." "Boy, I was really lucky that this was only a mild heart attack.

"I've been eating healthy and taking my medication. Otherwise, it could have been a lot worse." Explanation: A person with internal locus of control believes that personal behavior influences outcome and that he can achieve desired results. Therefore, the statement about eating healthy and taking medications indicates that the client believes that his actions influenced the outcome.

During an interview, a client states, "I want to be the CEO of a major company one day and earn the big bucks." Which response by the nurse is best? "Tell me about the plans you have to achieve that goal." "What makes you think you can achieve that goal?" "You will need a lot of support from your friends to make that happen." "How long do you think it will take you to achieve that goal?"

"Tell me about the plans you have to achieve that goal." Explanation: The nurse should use language that helps to explore the client's goals. Asking the client to describe the plan will help move the discussion forward and allow the client to express goals.

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: -"What did your health care provider tell you about your need to be admitted?" -"Can you tell me the medications you take on a daily basis?" -"Are you allergic to any medications?" -"Do you have an advanced directive or a living will?"

"What did your health care provider tell you about your need to be admitted?" When obtaining a nursing history, use the open-ended question technique to allow the client a wide range of possible responses. The greatest advantage of this technique is that it prevents the client from giving a simple "yes" or "no" answer, which limits the client's response. The questions related to medication use, allergies, and an advanced directive are examples of closed communication, in which only one or a few words are required for an answer.

The nurse is communicating with a client who has been newly diagnosed with cancer. Which statement(s) by the nurse is nontherapeutic? Select all that apply. -"Why did you not seek help when you first noticed a problem?" -"This is upsetting news for you. Let's talk about it." -"Keep your chin up. People survive this type of cancer all the time." -"What are your thoughts about what your health care provider has recommended?" -"You will be OK. Your health care provider is an excellent surgeon."

"You will be OK. Your health care provider is an excellent surgeon." "Keep your chin up. People survive this type of cancer all the time." "Why did you not seek help when you first noticed a problem?"

The nurse cares for a successful chemical engineer, age 29 years, who is admitted with a respiratory infection. The client reports feeling more stress than ever since a job promotion 6 months ago and asks, -"Why would something so positive and wonderful cause so much stress for me?" Which is an appropriate response by the nurse? Select all that apply. -"People vary greatly in their perception of what constitutes a crisis or stressor." -"Even positive life events can affect us in negative ways." -"All major life events can cause stress for us." -"Positive life events do not cause stress or illness." -"Your job promotion probably has nothing to do with the stress you feel."

-"All major life events can cause stress for us." -"People vary greatly in their perception of what constitutes a crisis or stressor." -"Even positive life events can affect us in negative ways." People vary greatly in their perception of what constitutes a crisis or stressor, as well as the degree to which such experiences might disrupt or diminish self-concept. Major stressors place anyone at relative risk for maladaptive responses such as withdrawal, isolation, depression, extreme anxiety, substance use, or exacerbation of physical illness. It is true that even positive events, such as marriage, a new baby, or a job promotion can place clients at risk for great stress and all that goes with it. The client's promotion probably has a great deal to do with the stress level.

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation? -A 4% increase in the number of baccalaureate-prepared nurses employed in the facility -A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery -A rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission -Bed occupancy rates of 97% in the critical care areas and 92% in the non-critical care areas

-A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery

A nurse practices the ethical principle of autonomy when providing nursing care for clients. Which nursing actions best describe the use of this value? Select all that apply. A nurse stays past shift end to continue caring for a client in critical condition. A nurse reads The Patient Care Partnership to a visually impaired client. A nurse researches a new procedure that would benefit a client. A nurse keeps a promise to call a client's healthcare provider regarding pain relief. A nurse asks the surgeon to further explain details of a surgery to a client before obtaining informed consent. A novice nurse seeks the help of a more experienced nurse to insert a catheter in a client.

-A nurse reads The Patient Care Partnership to a visually impaired client. -A nurse asks the surgeon to further explain details of a surgery to a client before obtaining informed consent. Explanation: The professional value of autonomy is the right to self-determination.

The nurse is preparing to assess a client newly admitted to the behavioral health unit. The client has been diagnosed with anorexia. On which component of the assessment will the nurse focus during the assessment? Body image Signs of infection History of hypertension Level of pain

-Body Image The nurse assessing self-concept will focus on the client's personal identity, body image, self-esteem, and role performance. Anorexia is known to be brought about due to issues with body image.

A nurse has identified a nursing diagnosis of "Imbalanced nutrition: less than body requirements related to continued weight loss despite adequate intake." During the implementation phase of the nursing process, which activities would be appropriate for the nurse to perform in care of this client? Select all that apply. Contact a dietician to perform a calorie count. Ask the family to bring in a home-cooked meal. Change the outcome to denote an increase in body weight. Administer 100 mL of nutritional supplement as ordered at bedtime. Gather subjective and objective data.

-Contact a dietician to perform a calorie count. -Ask the family to bring in a home-cooked meal. -Administer 100 mL of nutritional supplement as ordered at bedtime During implementation, the nurse would institute actions to address the nursing diagnosis. These actions would include contacting the dietician to perform a calorie count, asking the family to bring in a home-cooked meal, and administering the nutritional supplement. Comparing weights and changing the outcome would occur during the evaluation phase. Gathering subjective and objective data is part of the assessment process.

A nurse is caring for an infant who requires a treatment procedure. What would be most important for the nurse to do to help support the infant's spiritual needs? -Provide the infant with soft toys or a feeding bottle. -Encourage parents to be present during the treatment. -Ask a child specialist to be present during the treatment. -Tell the infant that it will be over within a minute.

-Encourage parents to be present during the treatment. Explanation: Hospitalization and illness potentially disrupt an infant's basic trust in parents. As parents play an instrumental role in the lives of infants and newborns, attention given to recognizing the needs of parents can in turn assist in meeting infant needs.

A group of nurses is participating in a community health fair and is engaged in primary prevention activities. Which activities would these nurses be leading? Select all that apply. -Family planning services -Rehabilitation for relief of low back pain -Skin cancer screening -Accident prevention education -Heart-healthy nutrition services

-Family planning services -Accident prevention education -Heart-healthy nutrition services Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury.

Which is the primary goal of home health care? -Functioning within limitations -Treatment of illness -Prevention of disease -Provision of palliative care

-Functioning within limitations The primary goal of home health care is to help the client function within limitations. Home health care allows people to regain or maintain optimal health and to remain in the home environment.

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? -Stress tolerance -Low self-esteem -Inadequate coping -Lack of confidence

-Inadequate coping Stressful events can lead to inadequate coping

What are chief tasks of the home health care nurse? Select all that apply. -Providing client education and counseling -Providing continuity of care -Developing a nursing care plan -Administering medications -providing dignified death at home -collective payment for nursing care

-Providing client education and counseling -Providing continuity of care -Developing a nursing care plan -Administering medications

Which nursing action(s) best demonstrate the ethical principle of autonomy? Select all that apply. The nurse completes yearly continuing education requirements. -The nurse reviews best practice standards for procedures commonly performed on the unit. -The nurse checks to ensure an informed consent document is signed prior to transferring the client for a surgical procedure. -The nurse documents that a client refused a new medication. -The nurse calls the prescriber when a medication dosage seems too high for the intended client.

-The nurse checks to ensure an informed consent document is signed prior to transferring the client for a surgical procedure. -The nurse documents that a client refused a new medication. Explanation: Autonomy is respect for the client's right to make health care decisions. Informed consent and right to refuse medications are a part of autonomy. Reviewing standards of practice and checking a medication dosage are related to nonmaleficence. Yearly continuing education is related to keeping the promise to remain competent (fidelity).

Which nursing actions should the nurse document as objective data? observing the client's skin color -documenting whether or not the client has fatigue -recording whether or not the client has vomited -evaluating the client's level of pain -measuring the client's blood pressure

-measuring the client's blood pressure -recording whether or not the client has vomited -observing the client's skin color Objective data is observable and measurable, such as measuring blood pressure values, recording episodes or the absence of vomiting, and observing the client's skin color. Subjective data consists of information that the client can describe or experience, such as pain and fatigue.

The nurse is caring for a client who suffers from myasthenia gravis. The client has periods of great weakness and is unable to do the things for the family that the client would like to. The client tells the nurse about not being worth much these days. Which statement by the nurse is most helpful? "What are some of the things you do well?" "Does your family pitch in and help you with your care?" "Some days are like that with this condition." "I am sure that things will be better soon."

."What are some of the things you do well?" Explanation: Many clients focus on their deficiencies, so asking pointed questions about personal strengths can help a client identify positive factors.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested.

A client comes to the acute care facility for diagnostic testing and elective surgery. Which type of assessment would the nurse most likely complete? Focus assessment Admission assessment Time-lapse reassessment Emergency assessment

Admission assessment An admission assessment, also referred to as an initial assessment, is performed when the client enters a health care facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic.

The nurse admits a client to the critical care unit to rule out a myocardial infarction. The client has several family members in the waiting room. Which nursing action is most appropriate? -Allow all the visitors into the room. -Insist that only one family member can be in the room at a time. -Assess the client's beliefs about family support during hospitalization. -Explain to the family that too many visitors will tire the client.

Assess the client's beliefs about family support during hospitalization.

Which outcome illustrates a common error nurses make when writing client outcomes? Client will demonstrate correct sequence of exercises by next office visit. Client will drink 100 mL of fluid every 2 hours from 0600 to 2100. On discharge, client will list five symptoms of infection to report. Client will be less anxious and fearful before and after surgery

Client will be less anxious and fearful before and after surgery. "Client will be less anxious and fearful before and after surgery" is vague and not a measurable outcome. Common errors when writing client outcomes include expressing the outcome as a nursing intervention, using verbs that are not observable and measurable, and writing vague outcomes.

What is the primary purpose of the client record? Advocacy Communication Research Education

Communication Patient records serve many purposes., but the ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities" (ANA, 2010, p. 5). Thus communication with the health care team is a more important purpose of documentation than advocacy, research, or education.

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. Which is the best action for the nurse to take? -Involve a friend who speaks both the dominant and the client's languages. -Allow the client's child to interpret. -Contact a professional interpreter. -Ask a fellow nurse who knows some words in the client's language to help.

Contact a professional interpreter.

It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests a minister to see him. Family is at the bedside. What action would the nurse take to address the client's spiritual distress on this day? -Contact the chaplain to request to see the client today. -Ask the client, "Can we pray together?" -Encourage the family to talk to the client. -Provide religious material for the client to read.

Contact the chaplain to request to see the client today. The client has asked for a minister to see him. To best address the client's need, the nurse would refer to the chaplain. Even on a holy day, there is usually a spiritual caregiver on call for the hospital. Encouraging the family to talk to the client ignores the client's request. The other options may bring some relief to the client, but they still ignore his request for a spiritual caregiver. Reference:

Which is a skill appropriate to use in therapeutic communication? -Use cliches to enhance a client's understanding of information. -Avoid the use of periods of silence. -Control the tone of the voice to avoid hidden messages. -Be precise and inflexible regarding the intent of the conversation.

Control the tone of the voice to avoid hidden messages. Conversation skills used in therapeutic communication include controlling the tone of one's voice so that exactly what is intended is conveyed and not any hidden message. Periods of silence have an important role in conversations because they allow for reflection. The nurse should avoid using cliches, and the conversation should be flexible.

A lawsuit has been brought against a nurse for malpractice. The client fell and suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation. Which element of liability does this description of the client's injuries represent in terms of proof of malpractice? Causation Breach of duty Damages Duty

Damages Explanation: Liability involves four elements: duty (an obligation to use care and follow standards), breach of duty (the failure to follow standards of care), causation (the failure to follow standards of care resulted in the injury), and damages (the actual harm or injury resulting to the client).

Which action is performed in the implementation step in the nursing process? Documenting the plan of care Selecting nursing interventions Documenting the nursing care and client responses Identifying measurable outcomes

Documenting the nursing care and client responses The implementation step in the nursing process involves documenting the nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? Evaluation Outcome identification Assessment Implementation

Evaluation Assessing the client's response to a diuretic medication is an example of evaluation.

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? Time-lapse Emergency Focused Head-to-toe

Focused In a focused assessment, the nurse gathers information about a specific problem that has already been identified.

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? Risk nursing diagnosis Actual nursing diagnosis Syndrome nursing diagnosis Health promotion nursing diagnosis

Health promotion nursing diagnosis Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? -Risk for Injury related to client's mismanagement of disease -Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen -Ineffective Health Maintenance related to client's denial of illness -Ineffective Coping related to client's inability to manage the diabetic regimen

Ineffective Health Maintenance related to client's denial of illness The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client denies that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.

The foundation for decisions about resource allocation throughout a society or group is based on the ethical principle of: confidentiality. justice. veracity. autonomy.

Justice Explanation: Justice is the foundation for decisions about ethical resource allocation throughout a society or group, because resources must be allocated fairly and equitably. The other ethical principles listed, veracity, autonomy, and confidentiality, have no direct application to resource allocation within society.

A young adult has been in a motor vehicle accident and sustained a laceration across the left side of the face, resulting in a large scar. Which emotional support will the nurse appropriately offer to this client? Reassuring the client that everything will be alright Providing the client with make-up tips to improve appearance Encouraging the client to forget the trauma and move on Listening and allowing the client to share feelings

Listening and allowing the client to share feelings -Body image is the subjective view a person has about one's own physical appearance. Disturbances in body image occur with any alteration in bodily appearance, structure, or function. The nurse should spend more time listening than speaking and allow the client to share feelings.

A nurse would like to study the effect that a new hand washing technique has on client infection rates. What is the independent variable? Client infection rates Wearing gloves New hand washing technique Nurse

New hand washing technique Explanation: The independent variable is the presumed cause or influence on the dependent variable. In this case, the independent variable is a new hand washing technique; the dependent variable is client infection rates. The nurse and wearing gloves are not variables in this study.

A nurse is using the nursing process to provide care to a client admitted to the facility. During the assessment phase, which activities would the nurse likely perform? Select all that apply. Check the results of the client's blood work. Administer prescribed medications. Obtain a baseline oxygen saturation level. Perform passive range of motion exercises. Obtain a weight

Obtain a baseline oxygen saturation level. Check the results of the client's blood work. Obtain a weight During the assessment phase, the nurse evaluates the client's health state, collecting subjective and objective data. Assessment occurs through observing, interviewing, and examining the client and interpreting laboratory data and diagnostic tests. Therefore, obtaining a baseline oxygen saturation level and checking the blood work results would be considered assessment. Administering prescribed medications and performing passive range of motion exercises would be interventions that are performed during implementation. Obtaining a weight is part of the objective assessment.

A client tells a nurse that he does not think he can have the recommended heart surgery because transfusions are against his religion. What is the best response of the nurse in this situation? -Obtain all the information needed for the client to make an informed decision. -Prepare the client for a visit from his spiritual advisor. -Have the client sign a form stating his refusal of the treatment. -Tell the client that the surgery is necessary to keep him alive and is the only choice.

Obtain all the information needed for the client to make an informed decision. The nurse's role is to assist the client in obtaining the information needed to make an informed decision and to support the client's decision making. Because what the nurse says, and the way it is said, may powerfully influence the client's decision, it is important to maintain objectivity. Conflicts that resist resolution may be referred to an ethics committee or consult team. Telling the client that the surgery is necessary to keep him alive and is the only choice is inappropriate.

Which is an example of nonmaleficence? Protecting clients from a chemically impaired practitioner Administering pain medications to a client in pain Performing dressing changes to promote wound healing Providing emotional support to clients who are anxious

Protecting clients from a chemically impaired practitioner Explanation: Protecting clients from a chemically impaired practitioner is an appropriate example of nonmaleficence. Nonmaleficence means to avoid doing harm, to remove from harm, and to prevent harm. Performing dressing changes to promote wound healing, providing emotional support to clients who are anxious, and administering pain medications to a client in pain are examples of beneficence, which means doing or promoting good.

The nurse researcher would like to gather data about the attitudes of young adults on spirituality and health care. What is the most effective form of research on this topic? Delphi study Qualitative research Methodologic survey Quantitative research

Qualitative research Attitudes on spirituality and health care require the nurse to interview clients or informants to obtain qualitative research.

In SBAR, what does R stand for? Response Recommendations Report Reinforcing data

Recommendations

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? PIE charting narrative charting FOCUS charting SOAP charting

SOAP charting

A series of classes on the dangers of smoking are being prepared for children between ages 8 and 10. Which professional would be the one to most likely develop the classes? -Pediatric nurse -School nurse -Teacher -Outside consultant

School nurse School nurses provide many different services, including maintaining immunization records, providing emergency care, administering prescribed medications, conducting routine screenings, conducting health assessments, and teaching for health promotion (e.g., the dangers of smoking).

A nurse is planning to participate in a research project and is looking for information about what is already known about the topic. The nurse is involved in which step of the research process? Scientific literature review Problem statement formulation Identification of theoretical framework Problem area identification

Scientific literature review Explanation: the nurse is engaged in a review of the scientific literature to find out what is already known about the subject and to prevent duplication of effort if the subject is already well studied. Identifying the problem area is completed first. This then guides the literature review. From there the nurse identifies the theoretical framework as a guide to identify and study systematically the logical relationships between variables. The problem statement identifies the direction the project will take.

The labor and delivery nurse is getting report from the previous shift regarding a client with Asian heritage. The departing nurse states that the client did not ask for pain medication because "Asian people can handle pain." The nurse receiving report understands that this an example of what? Ageism Stereotyping Culture shock Ethnocentrism

Stereotyping

A nurse is developing a plan of care to meet a client's spiritual needs. When identifying appropriate interventions, which concept would the nurse need to integrate as the foundation for all the interventions? Supportive presence Prayer Strength Religion

Supportive presence A nurse's supportive presence must underlie all other types of intervention to meet the client's spiritual needs. The aim of this intervention is to create a hospitable and sacred space ("holy ground") in which clients can share their vulnerabilities without fear. Supportive presence communicates value and respect. Prayer, strength and religion are not foundational to spiritual interventions.

A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care? Primary Tertiary Chronic Secondary

Tertiary Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate clients to a maximum level of functioning.

The nurse formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made? -The nurse expressed the client outcomes as a nursing intervention. -The nurse used verbs that are not observable and measurable. -The nurse included more than one client behavior in the outcome. -The nurse wrote vague outcomes that will confuse other nurses.

The nurse included more than one client's behavior in the outcome. Two client behaviors have been included in the outcome statement: drawing up insulin and identifying four signs and symptoms. Both behaviors are observable and measurable outcomes, not vague, and not interventions.

An adolescent rapidly develops secondary sex characteristics and body changes. What should the nurse assess to determine how these changes might affect the adolescent's self-concept? Meaningful use of time Developmental environment Expectations of the parents Understanding of changes

Understanding of changes Explanation: The nurse should assess the adolescent's knowledge of, and understanding of, body changes.

Which is an example of a psychomotor outcome? Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. The client's skin will remain smooth, moist, and without breakdown or ulceration. The client will verbalize understanding of the need to continue to take medications as prescribed.

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. Psychomotor outcomes describe the client's achievement of new physical skills, such as changing an abdominal dressing

A construction worker age 33 years experienced a fall on a job site that resulted in a spinal cord injury. In recent days, the client has alluded to the fact that he feels "useless" because he now sees himself as "a burden instead of a provider." The nurse would be justified in choosing interventions to: -address the client's negative self-concept. -help the client develop a positive body image. -enhance the client's mobility. -temporarily perform all of the client's activities of daily living.

address the client's negative self-concept. The client's statements reveal a strongly negative self-concept, a fact that the care team should address in an appropriate way. The client's statements relate more to his role and ability than his body image. Enhancing his mobility may be beneficial, but this will not necessarily change the fundamental way in which the client sees himself. Performing his ADLs may exacerbate, rather than alleviate, his negative self-concept.

The charge nurse overhears two new graduate nurses talking in the break-room. One graduate nurse states, "I hate getting reports from the older nurses; they are just too slow." The charge nurse understands that the nurse is demonstrating what? stereotyping cultural shock ageism ethnocentrism

ageism

A nurse is attempting to provide education to a newly diagnosed diabetic. The client states, "It doesn't matter what I eat, my future health is up to God." The nurse understands that this client has: -self-concept deficit -external locus of control. -internal locus of control. -self-esteem deficit

external locus of control. A person with external locus of control perceives that outcomes happen because of luck, chance, or the influence of powerful others. A person with internal locus of control believes that personal behavior influences outcome, and that he can achieve desired results.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: important information. factual statement. interpretation of data. relevant data.

interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.