Fundamentals finals 2

The nurse has entered a client's room to find the client diaphoretic and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?

Measure the client's oral temperature.

What statement most accurately describes Florence Nightingale's influence on nursing knowledge?

Nightingale differentiated between health nursing and illness nursing.

A home care nurse visits a client who is confined to bed and is cared for by a chemically dependence adult child. The home is cluttered and unclean and the nurse notes that the client is wet with urine, has dried feces on the buttocks, and signs of dehydration are present. After caring for the client, the nurse contacts the health care provider and reports the incident to Adult Protective Services. What ethical framework does the nurse determine is occurring?

Nonmaleficence

An unmarried couple in a committed relationship live together with their adopted twin boys. The adult male travels for his job and away from the home for several days at a time each week. Which of the following best describes this type of family?

Nuclear family

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the collaborative discharge planning team, of the client's discharge needs. This interaction is an example of which professional nursing relationship?

Nurse-health care team

A nurse has been working with a woman who wants to stop smoking. Which outcome decision would the nurse document if the woman has not smoked for 7 months?

Outcome met

The nursing student is assessing a community in regard to safety and security. Which of the following would be inappropriate for the nursing student to include under this basic need category?

Parks and swimming pools

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?

Physiologic

culture

A belief system held to varying degrees as absolute truth

stereotype

A preconceived and untested belief about people

an example of a community factor that may affect health?

Air and water quality

The nurse is assessing an aging couple newly admitted to the service. The nurse identifies that the clients are beginning to experience stage-specific risk factors for a family with older adults. What actions would the nurse take? Select all that apply.

Assess the clients' mobility and exercise potential. Assess the home for water and adequate heat in the winter. Screen both clients for chronic illnesses. Review medications, prescription and over-the-counter.

A couple recently married. Both the husband and the wife have previously been married and had two children. What name is given to this type of family?

Blended family

The nurse takes a patient's vital signs and finds the pulse rate to be 120 beats/min. What would the nurse do next to interpret and analyze this pulse rate?

Compare the patient's pulse rate to the standard range.

A nurse has developed a plan of care for a client that recently had a spouse die. A nursing diagnosis of: Risk for Loneliness was assigned. When evaluating the plan, the client tells the nurse new information about an active social life and there is satisfaction with social activities. What would the nurse do next?

Delete the nursing diagnosis.

During the course of assessing the family structure and behaviors of a pediatric patient's family, the nurse has identified a number of highly significant risk factors. Which of the following actions should the nurse prioritize when addressing these risk factors?

Engage in appropriate health promotion activities.

Who was the first nurse to develop a nursing theory?

Florence Nightingale

The nursing student asks the nurse about the difference between family-centered nursing and client-centered nursing. Which of the following would be inappropriate for the nurse to include when responding to the student?

Illness of one family member infrequently occurs in other members.

The client is being seen for chest congestion, coughing thick secretions, and shortness of breath for several days and is diagnosed with pneumonia. The client has a 2 pack per day smoking habit When developing the plan of care, what would be a priority nursing diagnosis for this client?

Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions

A nurse researcher is studying perceptions of vocational rehabilitation for clients after a spinal cord injury. What type of research method will be used to study the perceptions of this group of individuals?

Qualitative research

Which accreditation is a legal requirement for a school of nursing to exist?

State Board of Nursing accreditation

The nurse is providing primary prevention education to a group of clients. What actions by the nurse would indicate primary prevention activities? Select all that apply.

Teaching clients about a healthy nutritional plan Counseling a client about smoking cessation and making a plan .

Nurses evaluate many aspects of the health care delivery system. What is always the primary concern when performing the evaluating step of the nursing process?

The client

A nurse refers a client to group counseling for alcohol cessation. What is Rosenstock's health belief model based on?

The client's perceptions of susceptibility and seriousness of a disease and benefits of action

What statements explain reasons that models of health promotion and illness prevention are useful when planning health care? Select all that apply.

The models help overcome barriers related to increased number of people without health care. The models assist health care providers to understand health-related behaviors. The models overcome barriers to care for low-income and rural populations. The models are useful for adapting care to people from diverse backgrounds.

A nurse in a large metropolitan city enjoys working in a health clinic that primarily serves Russian clients. What does this statement imply about the nurse?

The nurse respects and values providing culturally competent care.

What is the best example of community-based nursing?

The nurse visits a mother and her newborn baby to ensure satisfactory bonding

A nurse is creating a care plan for a client that had surgery, which includes collaborative problems associated with this surgery. What is the focus of the diagnostic statement for a collaborative problem?

The potential complication

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of a moderately obese client. How should the nurse proceed after writing this diagnosis?

Validate the nursing diagnosis.

Ethnocentrism

Viewing one's own culture as the only correct standard

Philosophical knowledge

a type of general knowledge.

Justice

act fairly

A nurse is caring for a client who is a practicing Jehovah's Witness. The physician orders two units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the client's beliefs even though his blood counts are very low. What is the best description of the nurse's intentions?

acting in the client's best interest

nonmaleficence

avoid causing harm

Beneficence

benefit the patient

What phrase best describes the science of nursing?

body of nursing knowledge

What is the term that describes the inability of a person to recognize his own values, beliefs, and practices as well as those of others, because of strong ethnocentric tendencies?

cultural blindness

Fidelity

means to keep promises.

A nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. What is this principle known as?

nonmaleficence

autonomy

promote self-determination

After reviewing several research articles, the clinical nurse specialist on a medical surgical unit rewrites the procedure on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation?

scientific knowledge

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will:

terminate the plan of care.

The nurse is determining what interventions would best meet the needs of a client. What should the nurse base the decisions regarding provided interventions on for the plan of care?

the client's response to health and illness.

A nurse is concerned about the practice of routinely ordering an extensive series of laboratory tests for clients who are admitted to the hospital from a long-term care facility. An appropriate source in handling this ethical dilemma would be:

the institutional ethics committee.

There are four concepts common in all nursing theories. Which one of the four concepts is the focus of nursing?

the person (client)

The focal point of nursing is the nurse-client interaction. What must nurses consider when conducting the necessary assessment of their clients and significant others?

their own cultural orientation

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

to be sure interventions are individualized

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?

to identify etiologies of health problems