Fundamentals

Which documentation would the nurse utilize to report that a client's degree of edema has a depth of 8 mm?

4+

When conducting a client interview, which nurse's response is an example of back channeling? a. "All right, go on..." b. "What else is bothering you?" c. "Tell me what brought you here." d. "How would you rate your pain on a scale of 0-10?"

a. "All right, go on..." (back channeling involves the use of active listening prompts that encourage the client to complete the full story)

which statement is not true of concepts? a. concepts consist of interrelated theories b. concepts help describe or label phenomena c. concepts that affect the client system are physiological, psychological, sociocultural, developmental, or spiritual d. concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences

a. concepts consist of interrelated theories

which statement describes a client in the stage of contemplation in the stages of change? a. considers change w/in the next 6 months b. no intention of making changes w/in the next 6 months c. actively engages in strategies to change behavior; this lasts up to 6 months d. displays sustained change over time; begins 6 months after action has started and continues indefinitely

a. considers change w/in the next 6 months

which theory focuses on developing the interpersonal relationships b/n the nurse, client, and the client's family? a. Orem's theory b. Peplau's theory c. Leiniger's theory d. Henderson's theory

b. Peplau's theory

which variable is an internal variable? a. family practices b. emotional factors c. cultural background d. socioeconomic factors

b. emotional factors

Which client assessment finding would the nurse document as subjective data? a. BP 120/82 b. pain 5/10 c. K+ 4.0 mEq d. SpO2 96%

b. pain 5/10

which group benefits from Medicare? a. self-insured employers b. people who are 65 years or older c. members of low-income families d. children who are not poor enough for Medicaid

b. people who are 65 years or older

An adolescent client w/ sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a PCA pump. the current pain rating is 5/10 at right elbow. the nurse observes that the pump is "locked out" for another 10 min. which action would the nurse take? a. turning on tv for diversion b. placing the prescribed as-needed warm/wet compress on the elbow c. calling primary hcp for another analgesic prescription d. informing the client gently that they must wait until the pump reactivates to get more medication

b. placing the prescribed as-needed warm/wet compress on the elbow

which variable is an example of an external variable? a. spiritual factors b. developmental issues c. socioeconomic factors d. perception of functioning

c. socioeconomic factors

the nurse notes that a client has mild hypothermia based on which body temperature? a. 29 C (84.2 F) b. 30 C (86 F) c. 33 C (91.4 F) d. 35 C (95 F)

d. 35 C (95 F)

which potential health problem would the nurse include in the young adult's discharge teaching? a. kidney dysfunction b. cardiovascular diseases c. eye problems, such as glaucoma d. accidents, including their prevention

d. accidents, including their prevention

which skill in critical thinking requires the nurse to be orderly in data collection? a. analysis b. inference c. evaluation d. interpretation

d. interpretation

Which activity places a client at risk for hyperthermia? a. snowmobiling b. skiing in the winter c. hiking Alaskan mountains d. performing strenuous activity in high humidity

d. performing strenuous activity in high humidity

which characteristic would the nurse associate w/ collaborative problems experienced by a client? a. they are the identification of a disease condition b. they include problems treated primarily by nurses c. they are identified by the primary hcp d. they are identified by the nurse during the nursing d/o stage

d. they are identified by the nurse during the nursing d/o stage

in which sequence of techniques would the nurse assess a client's abdomen? 1. palpation 2. inspection 3. auscultation 4. percussion

inspection, auscultation, percussion, palpation

which is the role of a case manager in a health care organization? a. the delegate work on the unit suitably b. to follow up w/ the client after discharge c. to provide direct care for the client at the bedside d. to unite the strategic direction of the organization

b. to follow up w/ the client after discharge

which research design would the nurse researcher utilize when examining subjects' responses to chlorhexidine and povidone-iodine as antiseptics? a. evaluation research b. descriptive research c. correlational research d. experimental research

d. experimental research

which step in the nsg process would involve promoting a safe environment for the client? a. planning b. d/o c. assessment d. implementation

d. implementation

which statement correctly describes middle-range theories? (SATA) a. these theories are systematic and broad in scope and complexity b. middle-range theories provide a basis to help nurses understand how clients cope w/ uncertainty and the illness response c. these theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching d. middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences w/ cancer while living w/ continual uncertainty e. these theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations

BDE b. middle-range theories provide a basis to help nurses understand how clients cope w/ uncertainty and the illness response d. middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences w/ cancer while living w/ continual uncertainty e. these theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations

which term would the nurse use to document a client w/ drooping of the eyelid over the pupil? a. ptosis b. ectropion c. entropion d. nystagmus

a. ptosis

which principle refers to the professional obligation of the nurse to assume responsibility for actions? a. accountability b. individuality c. responsibility d. bioethics

a. accountability

while assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries? a. bruit b. ectropion c. entropion d. borborygmi

a. bruit

which purpose describes the Nurse Practice Acts? a. describe and define the legal boundaries of nursing practice within each state b. reflect the knowledge and skills possessed by nurses practicing in their profession c. provide requirements that describe the minimum acceptable nursing care d. protect individuals from losing their health insurance when changing jobs by providing portability

a. describe and define the legal boundaries of nursing practice within each state

which role is the nurse fulfilling when explaining the reason for IV infusion and kit to the client? a. educator b. manager c. advocate d. caregiver

a. educator

school health nursing programs have which goal? a. health promotion b. disease management c. chronic care management d. environmental surveillance

a. health promotion

a client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention for this situation? a. immediately involve pastoral services while caring for the client. b. involve the family member in the client's care instead of pastoral support. c. listen to the client's request for support then carry on with the clinical work. d. falsely promise that pastoral services has been contacted and plan to see the client.

a. immediately involve pastoral services while caring for the client.

Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? a. nurse b. pharmacist c. music therapist d. primary HCP

a. nurse

which nursing practice is associated w/ self-regulation skill? a. reflecting on one's experience b. contemplating one's own behavior c. supporting one's findings and conclusions d. clarifying any data that one is uncertain about

a. reflecting on one's experience

the nurse assessed a client's pulse rate and recorded the score as 3+. which descriptor reflects the strength of the pulse? a. strong b. bounding c. expected d. diminished

a. strong

which database would the nurse use to find studies r/t allied health services? a. EMBASE b. MEDLINE c. National Guidelines Clearinghouse d. Cochrane database of systematic reviews

b. MEDLINE

Which nursing process would the nurse undertake when collecting the medical hx of a client? a. dx b. eval c. assess d. implement

c. assessment

which cation regulates intracellular osmolarity? a. sodium b. potassium c. calcium d. calcitonin

b. potassium (*think intracellular; sodium is extracellular)

which function is the role of the nurse administrator in a health care setting? a. providing surgical anesthesia under the guidance and supervision of an anesthesiologist b. preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development c. providing comprehensive care by directly managing the medical care of client who are healthy or who have chronic conditions d. educating staff a/b current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings

b. preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development

while assessing a client after surgery, which finding would the nurse obtain from the primary source? a. x-ray reports b. severity of pain c. results of blood work d. family caregiver interview

b. severity of pain

while examining a client, the nurse finds a 0.6 cm circumscribed elevation of the skin filled with serous fluid on the cheek. which term would the nurse utilize for documentation? a. papule b. vesicle c. nodule d. pustule

b. vesicle

during a routine physical, a 50-yr-old client asks why a stool specimen for occult blood testing was prescribed. which response would the nurse utilize? a. "you will need to ask your hcp; this test is not part of the usual tests for people your age." b. "there must be concern of a family hx of colon cancer; that is a primary reason for an occult blood stool test." c. "starting at your age, this test is performed routinely as part of an assessment for colon cancer." d. "there must have been a positive finding after your hcp performed a digital rectal exam."

c. "starting at your age, this test is performed routinely as part of an assessment for colon cancer."

Planning to provide self-care health information for several clients, which client would the nurse anticipate will be most motivated to learn? a. A 55-year old client who had a mastectomy and is very anxious about her body image. b. An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking. c. A 56-year old client who had a heart attack last week and is requesting information about exercise. d. a 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain.

c. A 56-year old client who had a heart attack last week and is requesting information about exercise.

which point would the nurse not associate w/ grand theories of nursing? a. require further specification through research b. systematic and broad in scope and complex c. Mishel's theory of uncertainty in illness d. do not provide guidance for specific nursing interventions

c. Mishel's theory of uncertainty in illness (it's a middle-range theory)

the nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty? a. caring b. veracity c. advocacy d. confidentiality

c. advocacy

when informing the hcp of a client requesting pain meds after surgery, which role did the nurse play? a. educator b. manager c. advocate d. administrator

c. advocate

which statement is not true of descriptive theories? a. the first level of theory development is descriptive theory b. the role of a descriptive theory is to explain, relate, and in some situations predict nursing phenomena c. descriptive theories help direct specific nursing activities d. these theories describe phenomena, speculate on why they occur, and describe their consequences

c. descriptive theories help direct specific nursing activities

Which program is LEAST likely to focus on medication delivery process modification? a. evaluation research b. quality improvement c. experimental research d. performance improvement

c. experimental research

which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? a. analysis b. inference c. explanation d. interpretation

c. explanation

which assessing technique involves tapping a client's skin w/ the fingertips to cause vibrations in the underlying tissues? a. palpation b. inspection c. percussion d. auscultation

c. percussion

the nurse is caring for a child who has an external fixation device on the leg. which is the nurse's priority goal when providing pin care? a. easing pain b. minimizing scarring c. preventing infection d. avoiding skin breakdown

c. preventing infection

the nurse finds the client's fever spikes and falls w/out a return to normal level. which pattern of fever is this characteristic? a. relapsing b. sustained c. remittent d. intermittent

c. remittent

when developing a nsg d/o for a client after surgery, the nurse documents the "r/t" factor as first-time surgery. which assessment activity enabled the nurse to draw this conclusion? a. the nurse notes nonverbal signs of discomfort b. the nurse observes the client's position in bed c. the nurse asks the client to explain the surgery d. the nurse asks the client to rate the severity of pain

c. the nurse asks the client to explain the surgery

which definition does the WHO use to define "health?" a. a condition when people are free of disease b. a condition of life rather than pathological state c. an actualization of inherent and acquired human potential d. a state of complete physical, mental, and social well-being

d. a state of complete physical, mental, and social well-being

the nurse applies a cold pack to relieve MSK pain. which rationale explains the analgesic properties of cold therapy? a. promotes analgesia and circulation b. numbs the nerves and dilates the blood vessels c. promotes circulation and reduces muscle spasms d. causes local vasoconstriction, preventing edema and muscle spasms

d. causes local vasoconstriction, preventing edema and muscle spasms