Fundamentals of Nursing II - Exam 1

A hospital is implementing a computerized charting system, and all nursing staff is required to be oriented to the system by a specific deadline. Which type of change is occurring with the staff? 1. Overt change 2. Covert change 3. Unplanned change 4. Drift

Correct Answer: 1 Rationale 1: An overt change is one that is planned, and that people are aware of. Implementing a new computer system is certainly a planned, purposeful event. Rationale 2: Covert change is hidden or occurs without the individual's awareness it may be gradual, subtle, and unplanned. Rationale 3: An unplanned change is an alteration imposed by external events or persons and occurs when unexpected events force a reaction. Rationale 4: Drift is a type of unplanned change in which change occurs without effort on anyone's part.

A client with degenerative joint disease comes to the clinic and states that he has been reading a lot about essential oils that are helpful for stomach problems. The nurse should offer the client information about the use of which oil? 1. Chamomile 2. Eucalyptus 3. Lavender 4. Tea tree

Correct Answer: 1 Rationale 1: Chamomile oil soothes muscle aches, sprains, and swollen joints and is helpful as a GI antispasmodic. Rationale 2: Eucalyptus feels cool to the skin and warm to muscles; decreases fever; relieves pain; and acts as an anti-inflammatory, antiseptic, antiviral, and expectorant to the respiratory system in a steam inhalation. It can also boost the immune system. Rationale 3: Lavender oil is calming and is used as a sedative for insomnia. It may be massaged around the temples for headache, inhaled to speed recovery from colds or flu, and massaged into the chest to decrease congestion. It can also be used to heal burns. Rationale 4: Tea tree oil is good for athletes' foot as an antifungal. It can be used to soothe insect bites, stings, cuts, and wounds. It can be bathed in for yeast infection and drops on a handkerchief can be used for coughs or congestion.

A client reports feelings of spiritual anguish and depression as a result of experiencing numerous somatic complaints that make the client feel like everything is out of order. Which nursing diagnosis should the nurse identify for this client? 1. Energy-field disturbance 2. Powerlessness 3. Hopelessness 4. Anxiety

Correct Answer: 1 Rationale 1: Energy-field disturbance is defined as a state in which a disruption of the flow of energy surrounding a person's being results in a disharmony of the body, mind, or spirit. Rationale 2: Powerlessness is defined as a perception that one's own actions will not significantly affect an outcome. Rationale 3: Hopelessness is a subjective state in which an individual sees no alternatives or personal choices available and is unable to mobilize energy on his or her own behalf. Rationale 4: Anxiety is defined as a vague, uneasy feeling, the source of which is often nonspecific or unknown to the individual.

During a clinic appointment, a client prescribed medication for glaucoma reports vision problems. When taking a medication history, which herbal preparation should the nurse identify as being problematic for this client? 1. Ginseng 2. Echinacea 3. Valerian 4. St. Johns wort

Correct Answer: 1 Rationale 1: Ginseng may interact with caffeine and cause irritability and may also decrease the effectiveness of glaucoma medication. Rationale 2: Echinacea may reduce the effectiveness of immunosuppressants but does not appear to affect glaucoma medication. Rationale 3: Valerian may increase the sedative effects of antianxiety medication but does not appear to affect glaucoma medication. Rationale 4: St. Johns wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems.

A client has been diagnosed with post-traumatic stress syndrome and has difficulty sleeping because of recurrent nightmares. In working with this client to overcome the problem, what should the nurse implement as part of therapy? 1. Guided imagery 2. Hypnotherapy 3. Yoga 4. Meditation

Correct Answer: 1 Rationale 1: Guided imagery is a state of focused attention that encourages changes in attitudes, behavior, and physiologic reactions. Guided imagery can help people learn how to stop troublesome thoughts and focus on images that promote relaxation and decrease the negative impact of stressors. Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 3: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. Rationale 4: Meditation is a general term for a wide range of practices that relax the body and help ease the mind.

A client undergoing chemotherapy becomes very anxious and stressed just before the treatments. Which would be an appropriate therapy for this person to learn? 1. Meditation 2. Aromatherapy 3. Homeopathy 4. Yoga

Correct Answer: 1 Rationale 1: Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind. Meditation is a process that individuals can use to calm themselves, cope with stress, and, for those with spiritual inclinations, feel as one with God or the universe. Rationale 2: Aromatherapy is the use of essential oils that, when absorbed into the body, produce physiologic or psychologic benefit. Rationale 3: Homeopathy is a self-healing system in which doses of natural compounds stimulate a person's self-healing capacity. Rationale 4: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment.

A client visits a clinic that integrates Western medicine with complementary therapies. Which therapies might the client utilize and believe to keep the flow of qi at a therapeutic level? 1. Acupressure and reflexology 2. Therapeutic touch and Reiki 3. Aromatherapy and naturopathic remedies 4. Chiropractic and massage therapy

Correct Answer: 1 Rationale 1: Reflexology and acupressure are treatments rooted in the traditional Eastern philosophy that qi, or life energy, flows through the body along pathways known as meridians. When the flow of energy becomes blocked or congested, people experience discomfort or pain on a physical level. They may feel frustrated or irritable on an emotional level and may experience a sense of vulnerability or lack of purpose in life on a spiritual level. Rationale 2: Therapeutic touch and Reiki use the hands to alter the biofield or energy field. Rationale 3: Aromatherapy and naturopathic remedies utilize essential oils and plants for health benefits. Rationale 4: Chiropractic and massage therapy are examples of manual healing methods.

A client was in a motor vehicle crash where he sustained injury to his spinal cord that has resulted in difficulty with balance and holding his posture. Which should the nurse suggest the client consider? 1. Animal assisted therapy 2. Hypnotherapy 3. Chelation therapy 4. Detoxification

Correct Answer: 1 Rationale 1: Therapeutic horseback riding, a type of animal assisted therapy, is the use of the rhythmic movement of the horse to increase sensory processing and improve posture, balance, and mobility in people with movement dysfunctions. Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 3: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body. Rationale 4: Detoxification is based on the belief that physical impurities and toxins must be cleared from the body to achieve better health.

During an interview assessment, the client states a belief in nutritional lifestyle counseling and that the body's vital energy circulates through the body, which can be manipulated through specific anatomical points. Which type of healing practice should the nurse identify that this patient is following? 1. Traditional Chinese medicine 2. Native American healing 3. Ayurveda 4. Curanderismo

Correct Answer: 1 Rationale 1: Traditional Chinese medicine (TCM) is based on the premise that the body's vital energy or qi circulates through pathways and meridians and can be accessed and manipulated through specific anatomical points along the surface of the body. Practitioners use a variety of ancient methods, including acupuncture, acupressure, herbal medicine, massage, heat therapy, qigong, tai chi, and nutritional counseling. Rationale 2: Native American healing is very connected to spirituality, and health is viewed as a balance or harmony of body and mind. Rationale 3: Ayurveda emphasizes the interdependence of the health of the individual and the quality of societal life. Rationale 4: Curanderismo is a cultural healing tradition found in Latin American cultures and utilizes Western biomedical beliefs, treatment, and practices.

The nurse practices responsibility when functioning in the role of manager of a care area. What will the nurse manager demonstrate as evidence of responsibility? Standard Text: Select all that apply. 1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives 4. Problem solving 5. Managing the work team

Correct Answer: 1, 2, 3 Rationale 1: Managers are responsible for effective utilization of resources. Rationale 2: Managers are responsible for communication to subordinates. Rationale 3: Managers are responsible for the implementation of organizational goals and objectives. Rationale 4: Problem solving is a skill associated with critical thinking. Rationale 5: Managing the work team is a skill associated with building and managing teams.

The nurse has been promoted to a position that includes the supervision of first-level management and responsibility for activities in a specific department. This nurse will most likely have which title? Standard Text: Select all that apply. 1. Supervisor 2. Nurse manager 3. Head nurse 4. Primary care nurse 5. Vice president

Correct Answer: 1, 2, 3 Rationale 1: Middle-level managers may be called supervisors. Rationale 2: Middle-level managers may be called nurse managers. Rationale 3: Middle-level managers may be called head nurses. Rationale 4: First-level managers may be called primary care nurses. Rationale 5: Upper-level managers may be called vice presidents.

A staff nurse has been identified by others as being an effective leader. With this designation, the nurse implements which principles? Standard Text: Select all that apply. 1. Vision 2. Influence 3. Serve as a role model 4. Planning 5. Organizing

Correct Answer: 1, 2, 3 Rationale 1: Principles of effective leadership include vision, which is a mental image of a possible and desirable future state. Rationale 2: Principles of effective leadership include influence, which is an informal strategy used to gain the cooperation of others without exercising formal authority. Rationale 3: Principles of effective leadership include role modeling, an example of which is demonstrating caring toward coworkers and clients. Rationale 4: Planning is a function of management. Rationale 5: Organizing is a function of management.

The nurse is reviewing feedback from other staff members on leadership behaviors. Which characteristics are consistent with being an effective leader? Standard Text: Select all that apply. 1. Energetic 2. Creative 3. Optimistic 4. Open 5. Risk taking

Correct Answer: 1, 2, 3, 4 Rationale 1: Being energetic is a characteristic of an effective leader. Rationale 2: Creativity is a characteristic of an effective leader. Rationale 3: Optimism is a characteristic of an effective leader. Rationale 4: Being open is a characteristic of an effective leader. Rationale 5: Risk taking is a characteristic of a transformational leader.

A nurse is identified as being an effective leader. With this designation, the nurse will most likely demonstrate which characteristics? Standard Text: Select all that apply. 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others 5. Focus on systems

Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse as leader is self-aware. Rationale 2: The nurse as leader is focused on people. Rationale 3: The nurse as leader is an excellent communicator. Rationale 4: The nurse as leader mentors' others. Rationale 5: The nurse as manager is focused on systems.

The nurse has been promoted to the role of manager for a client care area. What responsibilities of the nurse will this new role include? Standard Text: Select all that apply. 1. Accomplish the goals of the organization. 2. Use the organizations resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards. 5. Manage relationships.

Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse manager is responsible for efficiently accomplishing the goals of the organization. Rationale 2: The nurse manager is responsible for efficiently using the organizations resources. Rationale 3: The nurse manager is responsible for ensuring effective client care. Rationale 4: The nurse manager is responsible for ensuring compliance with regulatory standards. Rationale 5: The nurse leader manages relationships.

The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination? Standard Text: Select all that apply. 1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication. 5. Determine whether there is enough time.

Correct Answer: 1, 2, 3, 4 Rationale 1: The right task is one of the five rights of delegation. Rationale 2: The right circumstance is one of the five rights of delegation. Rationale 3: The right person is one of the five rights of delegation. Rationale 4: The right communication is one of the five rights of delegation. Rationale 5: Enough time is not one of the five rights of delegation.

The manager identifies a staff nurse to serve as a change agent for the implementation of a computerized documentation system. What attributes did the manager observe to designate the staff nurse to have this role? Standard Text: Select all that apply. 1. Self-confident 2. Skilled in teaching 3. Hesitant with decision making 4. Excellent communication skills 5. Effective utilization of resources

Correct Answer: 1, 2, 4, 5 Rationale 1: Change agents are self-confident and are able to take risks and inspire trust in themselves and others. Rationale 2: Change agents are skilled in teaching. Rationale 3: Change agents are able to make decisions. Hesitancy is not a characteristic of a change agent. Rationale 4: Change agents have excellent communication skills with all levels and types of individuals. Rationale 5: Change agents have knowledge of available resources and know how to use them wisely.

Prior to delegating a task, the nurse reviews the rights of delegation; these include which rights? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task

Correct Answer: 1, 2, 5 Rationale 1: According to the National Council of State Boards of Nursing (NCSBN), right supervision is one of the rights of delegation. Rationale 2: According to the National Council of State Boards of Nursing (NCSBN), right evaluation is one of the rights of delegation. Rationale 3: The right client is not one of the rights of delegation. Rationale 4: The right time is not one of the rights of delegation. Rationale 5: According to the National Council of State Boards of Nursing (NCSBN), right task is one of the rights of delegation.

A client comes to the clinic with a chief complaint of feeling dirty inside and asks the nurse how colonics would work to improve the client's overall well-being. What should the nurse respond to this client? 1. Colonics is a dangerous and not useful technique that no one should try. 2. There is much controversy about colonics. What do you know about it? 3. This is a good way to get rid of toxins in your system. 4. You'd better ask your doctor about this.

Correct Answer: 2 Rationale 1: Although colon cleansing is a controversial method of detoxification, and there tends to be no middle group in the beliefs about the usefulness of colonics, that option does not appropriately address the clients concerns. Rationale 2: Although colon cleansing is a controversial method of detoxification, establishing a baseline regarding the client's knowledge regarding the process is most appropriate. Rationale 3: Colonics is the procedure for washing the inner wall of the colon by filling it with water or herbal solutions and then draining it. Colon cleansing is a controversial method of detoxification and the issue requires further discussion. Rationale 4: This option defers the clients concerns to the doctor, which is inappropriate because the nurse should be prepared to discuss the issue with the client.

A nurse working on an Alzheimer's unit notes that just before the supper hour, many of the residents become more anxious and confused exhibiting typical sundowner's syndrome making the evening meal an unpleasant ordeal. As a method to try to decrease their turmoil during this time, which therapy should the nurse introduce into the daily routine? 1. Biofeedback 2. Music therapy 3. Pilates 4. Spiritual therapy

Correct Answer: 2 Rationale 1: Biofeedback is a relaxation technique that uses electronic equipment to amplify the electrochemical energy produced by body responses. Rationale 2: Quiet, soothing music without words is often used to induce relaxation. Music therapy can be used in a variety of settings, without much added cost and with little extra work on the part of staff. In this particular setting, the music may help to soothe the residents and promote a sense of balance or harmony on the unit. Rationale 3: Pilates is a method of physical movement and exercises designed to stretch, strengthen, and balance the body. Rationale 4: Spiritual therapy includes prayer and faith practices to promote healing.

A client living in a long-term care center has been withdrawn and subdued and does not eat in the dining room because of embarrassment about her physical decline. What might the nurse suggest that provides opportunities for unconditional love, achievement of trust, responsibility, and empathy toward others? 1. Chelation therapy 2. Animal-assisted therapy 3. Meditation 4. Pilates

Correct Answer: 2 Rationale 1: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body. Rationale 2: Animal-assisted therapy is defined as the use of specifically selected animals as a treatment modality in health and human service settings. The contributions include opportunities for affection, achievement of trust, responsibility, and empathy toward others. Pets in long-term care facilities become so perceptive that they actually gravitate to the rooms of people who are most isolated or depressed. Rationale 3: Meditation is a wide range of practices that relax the body and heal the mind. Rationale 4: Pilates is a method of physical movement and exercise designed to stretch, strengthen, and balance the body.

The nurse is working with a client who, during her interview, expresses feelings of groundedness. The nurse interprets this to mean that the client 1. is full of energy. 2. feels connected to her reality. 3. is focused on her center of energy. 4. feels down in the dumps.

Correct Answer: 2 Rationale 1: Energy is viewed as the force that integrates the body, mind, and spirit and doesn't relate to groundedness. Rationale 2: Grounding relates to one's connection with reality. Being grounded suggests stability, security, independence, having a solid foundation, and living in the present. Rationale 3: Centering refers to the process of bringing oneself to the center or middle and doesn't relate to groundedness. Rationale 4: This relates more closely with sadness or depression than groundedness.

The nursing staff is informed that the current system of record keeping is going to be changed to make it more efficient. In which stage of change is the nursing staff? 1. Refreezing 2. Unfreezing 3. Moving 4. Drift

Correct Answer: 2 Rationale 1: Refreezing is when the change is integrated and stabilized. Rationale 2: During the unfreezing stage, the need for change is recognized, driving and restraining forces are identified, alternative solutions are generated, and participants are motivated to change. Rationale 3: During the second stage, moving, participants agree that the status quo is undesirable, and the actual change is planned in detail and implemented. Rationale 4: Drift is a type of unplanned change in which change occurs without effort on anyone's part.

A nurse is helping a hospice client who has had difficulty with making end-of-life decisions. The nurse has encouraged the client to focus on her self-worth, her accomplishments, and having positive self-esteem in order to process through some of these decisions. The nurse is helping the client to achieve balance in which component? 1. Environmental 2. Physical 3. Mental 4. Spiritual

Correct Answer: 3 Rationale 1: Environmental aspects include physical, biologic, economic, social, and political conditions. Rationale 2: Physical aspects include optimal functioning of all body systems. Rationale 3: Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. In terms of optimal wellness, balance consists of mental, physical, emotional, spiritual, and environmental components. Each component needs to be balanced, and a sense of equality among the components is needed. Rationale 4: Spiritual aspects involve moral values, a meaningful purpose in life, and a feeling of connectedness to others and a divine source.

A nurse who works in a busy neonatal intensive care unit has been having difficulty with concentration after a long day's work. Which therapy should the nurse consider doing to help with this problem? 1. Guided imagery 2. Hypnotherapy 3. Qigong 4. Aromatherapy

Correct Answer: 3 Rationale 1: Guided imagery is a state of focused attention that encourages changes in attitudes, behavior, and physiologic reactions. Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 3: Qigong is a Chinese discipline consisting of breathing and mental exercises combined with body movements. The softness of movements develops energy without nervousness. The slowness of movements quiets the mind and develops one's powers of awareness and concentration. Rationale 4: Aromatherapy is the use of essential oils that, when absorbed into the body, produce physiologic or psychologic well-being.

A client who resides in a long-term care facility has no family or visitors. Her only social contacts are with the staff. The client is confined to bed and is not able to communicate verbally. As part of the clients care plan, the nurses provide massage therapy three times a week. What is the main benefit of this intervention for this client? 1. Stretch and loosen the muscles 2. Speed the removal of metabolic waste products 3. Help satisfy the need for caring and nurturing touch 4. Relieve pain

Correct Answer: 3 Rationale 1: Massage would be an appropriate intervention to address this option, but it is not the main benefit the client will experience. Rationale 2: Massage would be an appropriate intervention to address this option, but it is not the main benefit the client will experience. Rationale 3: Because she has no family, no visitors, and her only contacts are with the staff, this client will benefit at the emotional level, as massage satisfies the need for caring and nurturing touch. It also increases feelings of well-being, decreases mild depression, enhances self-image, reduces levels of anxiety, and increases awareness of mind-body connection. Rationale 4: Massage would be an appropriate intervention to address this option, but it is not the main benefit the client will experience.

The client asks whether herbal medicines are a good idea. What should the nurse respond? 1. Things found in nature are always healthy. 2. If your doctor didn't prescribe it, don't take it. 3. Are there specific ones you're wondering about? 4. Everything is good in moderation.

Correct Answer: 3 Rationale 1: Not all plant life is beneficial. Rationale 2: There are cautions and contraindications with some herbal preparations and over-the-counter (OTC) as well as prescription drugs. The use of such treatments may be helpful but should be discussed with a health care provider in order to minimize the risk of interactions. Rationale 3: Not all plant life is beneficial. Nurses must be open to exploring and discussing their clients uses of and questions regarding herbal medicine. There are cautions and contraindications with some herbal preparations and over-the-counter (OTC) as well as prescription drugs. The most important role the nurse plays in regard to herbal medicine is to find out what the client is taking and at what dosage and have a full list of the client's prescription medications as well as anything taken that is OTC. Rationale 4: Not all plant life is beneficial. This option is not a sufficient answer to the client's question.

The nurse is preparing to assess a group of assigned clients with chronic illnesses who use essential oils. For which health problem should the nurse particularly assess the clients? 1. Hypertension 2. Cardiac problems 3. Asthma 4. Cancer

Correct Answer: 3 Rationale 1: This type of alternative therapy does not appear to affect blood pressure. Rationale 2: This type of alternative therapy does not appear to affect the cardiac system. Rationale 3: Some oils can trigger bronchial spasms, so persons with asthma should consult their primary health care provider before using oils. Rationale 4: This type of alternative therapy does not appear to affect cancer.

A client has been undergoing therapy as a victim of severe emotional abuse. The goal of the client's therapy is to gain self-control of the situation, improve self-esteem, and become self-sufficient. Which application should the nurse suggest becoming a part of the client's therapy session? 1. Yoga 2. Meditation 3. Hypnotherapy 4. Guided imagery

Correct Answer: 3 Rationale 1: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. Rationale 2: Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind. Rationale 3: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous. Rationale 4: Guided imagery is a state of focused attention, much like hypnosis, that encourages changes in attitudes, behavior, and physiologic reactions.

A client asks the nurse about chiropractic medicine. What should the nurse explain as being among the goals of this type of health intervention? Standard Text: Select all that apply. 1. Improvement of blood and lymph flow through the body 2. Stimulation of specific points to help with pain relief, cures certain illnesses, and promote wellness 3. Reduce or eliminate pain 4. Correct spinal dysfunction 5. Preventive maintenance

Correct Answer: 3, 4, 5 Rationale 1: Massage therapy improves blood flow and lymph fluid through the body. Rationale 2: Acupressure and acupuncture are techniques of applying pressure or stimulation to specific points on the body in order to relieve pain, cure certain illnesses, and promote wellness. Rationale 3: The first clinical goal of chiropractic care is to reduce or eliminate pain. Rationale 4: By correcting spinal dysfunction, biomechanical balance is restored to the body to reestablish shock absorption, leverage, and range of motion. Muscles and ligaments are strengthened by spinal rehabilitative exercises to increase resistance to further injury. Rationale 5: Preventive maintenance of chiropractic medicine ensures that the problem does not recur.

The manager determines that a new graduate nurse needs additional training on the principles of delegation. What delegation to unlicensed assistive personnel did the manager observe to make this decision? Standard Text: Select all that apply. 1. Bathing a patient recovering from surgery 2. Weighing a patient who is prescribed diuretics 3. Discharge instruction teaching 4. Transferring and ambulating a client after hip replacement surgery 5. The care of an intravenous access device

Correct Answer: 3, 5 Rationale 1: Bathing can safely be delegated to unlicensed assistive personnel. Rationale 2: Weights can safely be delegated to unlicensed assistive personnel. Rationale 3: Client education may not be delegated to unlicensed assistive personnel. Rationale 4: Transferring and ambulation can be safely delegated to unlicensed assistive personnel. Rationale 5: The care of invasive lines may not be delegated to unlicensed assistive personnel.

A nursing student would like to do an observation on one of the inpatient units at a hospital. In assisting the student to meet this desire, the educator would look for which type of nurse? 1. Mentor 2. Manager 3. Team leader 4. Preceptor

Correct Answer: 4 Rationale 1: A mentor acts in a more nurturing role, perhaps for a longer period of time, and provides support, guidance, assistance, advice, and inspiration to a younger nurse. Rationale 2: A manager is a different type of management role. Rationale 3: A team leader is a different type of management role. Rationale 4: The preceptor is a person of experience who assists a new nurse in improving clinical skills and nursing judgment.

After having a difficult time saying no when asked to work yet another overtime shift, the nurse begins to feel overwhelmed and irritable. As a method to most effectively promote self-healing, what should this nurse do? 1. Clarify values and beliefs. 2. Set realistic goals. 3. Learn to manage stress. 4. Challenge the belief that others always come first.

Correct Answer: 4 Rationale 1: Identification of things that are important, meaningful, and valuable is part of clarifying values and beliefs and may help, but there is a more specific option available. Rationale 2: Identifying and setting goals may help, but there is a more specific option available. Rationale 3: Stress management may help, but there is a more specific option available. Rationale 4: Overwork and overinvolvement leave little time for fulfillment of personal needs. Nurses need to learn to ask for what they need and avoid feelings of selfishness when not responding to someone else's needs.

A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow's human needs theory, at which level should the nurse recognize that the client is struggling? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem

Correct Answer: 4 Rationale 1: Physiological needs include air, food, water, rest, and sleep. Rationale 2: Safety and security needs are those things, both psychological and physiological, that help the person feel safe. Rationale 3: Love and belonging needs include giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging. Rationale 4: Self-esteem and esteem from others includes feelings of independence, competence, self-respect, recognition, respect, and appreciation. Self-hatred and disgust is opposite of what one would expect in the self-esteem level of Maslow's model.

A home health nurse is working with a client who has had to quit his job after a serious injury and whose future employability is uncertain. The client states that his life has no meaning or purpose anymore and that he feels lonely and abandoned. What is an appropriate nursing diagnosis for this client? 1. Body Image Disturbance 2. Health-Seeking Behavior 3. Altered Family Processes 4. Spiritual Distress

Correct Answer: 4 Rationale 1: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades ones biological and psychosocial nature. The feelings the client expresses have little to do with his body image. Rationale 2: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades ones biological and psychosocial nature. The client is not expressing the desire to increase his level of well-being. Rationale 3: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades ones biological and psychosocial nature. The feelings the client expresses have little to do with family processes. Rationale 4: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades ones biological and psychosocial nature. The feelings the client expresses have little to do with his body image or family processes, and he is not expressing the desire to increase his level of well-being.

A client who has a long-standing history of depression has been on a prescribed antidepressant for several months and states that he has also been trying St. Johns wort. Which vital sign should the nurse assess for possible adverse effects? 1. Temperature 2. Respiratory rate 3. Oxygen saturation 4. Pulse rate

Correct Answer: 4 Rationale 1: St. Johns wort would not affect the hypothalamus. Rationale 2: St. Johns wort would not affect the respiratory system. Rationale 3: St. Johns wort would not affect the respiratory system. Rationale 4: St. Johns wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems.

A client diagnosed with hypertension has had well-controlled follow-up of her blood pressure for the past 6 months. At today's clinic appointment, the clients blood pressure is 98/58. The client insists she has been taking her prescribed antihypertensive medication as prescribed, but also added an herbal tablet because she heard it was supposed to be good for her. Which is most likely interfering with the clients antihypertensive? 1. Valerian 2. Milk thistle 3. Ginseng 4. Garlic

Correct Answer: 4 Rationale 1: Valerian may increase the sedative effects of antianxiety medication but does not appear to affect antihypertensive medication. Rationale 2: Milk thistle reduces the effectiveness of oral contraceptives but does not appear to affect antihypertensive medication. Rationale 3: Ginseng may decrease the effectiveness of glaucoma medications but does not appear to affect antihypertensive medication. Rationale 4: Garlic reduces high blood pressure.

A client comes to the family planning clinic for follow-up and is currently taking an oral contraceptive. During the interview assessment, the client states she has been using some natural medicines. Which herbal preparation should alert the nurse to a possible interaction with oral contraceptives? 1. Valerian 2. Echinacea 3. Garlic 4. Milk thistle

Correct Answer: 4 Rationale 1: Valerian may increase the sedative effects of antianxiety medication. Rationale 2: Echinacea may reduce the effectiveness of immunosuppressants. Rationale 3: Garlic may cause a need for an increased dose of antihypertensives. Rationale 4: Milk thistle reduces the effectiveness of oral contraceptives.

Before helping a client with smoking cessation, the nurse reviews the steps of the change process. In which order should the nurse expect the client to progress through the stages of health change behavior? Arrange the following stages in the correct order: Choice 1. Preparation stage Choice 2. Contemplation stage Choice 3. Maintenance stage Choice 4. Precontemplation stage Choice 5. Termination stage Choice 6. Action Stage

Correct Answer: 4, 2, 1, 6, 3, 5 Rationale 1: This is the third stage, where the client intends to take action in the immediate future (e.g., within the next month). Some people in this stage may have already started making small behavioral changes, such as buying a self-help book. At this stage, the person makes the final specific plans to accomplish the change. Rationale 2: This is the second stage, where the client acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future (e.g., next 6 months). Rationale 3: This is the fifth stage, where the client strives to prevent relapse by integrating newly adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences temptation to return to previous unhealthy behaviors. It is estimated that maintenance lasts from 6 months to 5 years. Rationale 4: This is the first stage, where the client is not contemplating change for at least 6 months. Rationale 5: This is the sixth and last stage (the ultimate goal), where the individual has complete confidence that the problem is no longer a temptation or threat. It is as if the individual never acquired the habit in the first place or the new behavior has become automatic. Rationale 6: This is the fourth stage, where the client actively implements behavioral and cognitive strategies of the action plan to interrupt previous health risk behaviors and adopt new ones. This stage requires the greatest commitment of time and energy.

An unlicensed assistive person (UAP) is working on a rehabilitation unit. Which task would be appropriate for this person to delegate? 1. Taking and recording vital signs 2. Assisting with bathing 3. Making a bed 4. An unlicensed assistive person may not delegate tasks.

Correct Answer: 4 Rationale 1: Taking and recording vital signs is an appropriate task for the registered nurse to delegate to the UAP. Rationale 2: Assisting with bathing is an appropriate task for the registered nurse to delegate to the UAP. Rationale 3: Making a bed is an appropriate task for the registered nurse to delegate to the UAP. Rationale 4: The unlicensed person may not delegate tasks to another person. Delegation is part of the registered nurse's role.

An RN delegates the task of taking a newly admitted clients vital signs to a nurse's aide. The clients blood pressure was 182/98 but did not get reported to the physician for several hours. Who is responsible for the lapse in time between discovery and action? 1. Nurse manager 2. Aide 3. Client 4. RN

Correct Answer: 4 Rationale 1: The nurse manager did not delegate the task of vital signs and therefore is not responsible for the time lapse between discovery and action. Rationale 2: The aide did not delegate the task of vital signs and therefore is not responsible for the time lapse between discovery and action. Rationale 3: The client did not delegate the task of vital signs and therefore is not responsible for the time lapse between discovery and action. Rationale 4: The RN is ultimately responsible for the action, for reporting it, and for following through on any action. Part of delegation is supervision and evaluation ultimate responsibilities that belong to the RN.

A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change? 1. Termination stage 2. Maintenance stage 3. Contemplation stage 4. Action stage

Correct Answer: 4 Rationale 1: The termination stage occurs when the individual has complete confidence that the problem is no longer a temptation or a threat. Rationale 2: The maintenance stage is where the person integrates adopted behavior patterns into his or her lifestyle. This stage lasts until the person no longer has temptation to return to previous unhealthy behaviors. Rationale 3: In the contemplation stage, the person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones. This stage requires the greatest commitment of time and energy and is where the person is actually doing something to change the behavior.

The nurse is planning to explain the importance of culturally appropriate care to a new nursing assistant. What should the nurse include when explaining the term culture to this staff person? Standard Text: Select all that apply. 1. Culture involves groups who share biological markers. 2. Cultures seldom have diversity within them. 3. Male nurses are an example of a culture. 4. A culture is primarily exhibited through shared thoughts, actions, and beliefs. 5. A culture shapes its members view of the world.

Correct Answer: 4, 5 Rationale 1: Race has been a term used to refer to groupings of people according to common origin or background and associated with perceived biological markers. Rationale 2: Diversity occurs not only between cultural groups but also within cultural groups. Rationale 3: A subculture is usually composed of people who have a distinct identity and yet are related to a larger cultural group. Rationale 4: Culture is the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Rationale 5: Macro- and micro-cultures combine to shape the individual's worldview and influence interaction with the others.

Type: MCSA A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program? 1. Situational influences 2. Perceived benefits of action 3. Perceived barriers to action 4. Interpersonal influences

Correct Answer: 4 Rationale 1: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. Rationale 2: Perceived benefits of action affect the persons plan to participate in health-promoting behaviors and may facilitate continued practice. Rationale 3: Perceived barriers to action may be real or imagined and may affect health-promoting behaviors by decreasing the individual's commitment to a plan of action. Rationale 4: Interpersonal influences are a person's perceptions concerning the behaviors, beliefs, or attitudes of others. Family, peers, and health professionals are sources of interpersonal influences that can affect a person's health-promoting behaviors. Because this particular client does not have a close support system, the nurse will look to other possibilities (i.e., the other health professionals involved in the clients care such as other nurses, therapists, and physicians).

A nurse educator is explaining the concept of health and parallels this with interruption of body systems and symptoms of disease or injury. This educator is interpreting health according to which model? 1. Health illness continua 2. Eudemonistic 3. Adaptive 4. Clinical

Correct Answer: 4 Rationale 1: The health illness continua is often used to measure a person perceived level of wellness in which health and illness are at opposite ends of a health continuum. Rationale 2: The eudemonistic model incorporates a comprehensive view of health, where health is seen as a condition of actualization or realization of a person's potential. Rationale 3: In the adaptive model, health is seen as a creative process and disease is seen as a failure in adaptation or maladaptation. Rationale 4: The narrowest interpretation of health occurs in the clinical model, where people are viewed as physiologic systems with related functions and health is defined by the absence of signs and symptoms of disease or injury.

The nurse case manager is concerned about a particular client being discharged from the hospital. Which factors should alert the nurse to possible problems with this client's adherence to treatment? 1. The prescribed therapy is costly and of unknown duration. 2. The therapy will require no lifestyle changes of the client. 3. The client has not had difficulty understanding the regimen. 4. The client's culture is supportive of Western medicine.

Correct Answer: 1 Rationale 1: Adherence to a particular therapy can be compromised if the therapy is expensive or if the duration of the proposed therapy is long. Rationale 2: Adherence is the extent to which an individual's behavior coincides with medical or health advice. If no lifestyle changes are expected, then adherence should not be an issue. Rationale 3: Adherence is the extent to which an individual's behavior coincides with medical or health advice. If the client understands the regimen, adherence is not an issue. Rationale 4: Adherence is the extent to which an individual's behavior coincides with medical or health advice. Following Western medicine is not an adherence issue.

The nurse needs to determine the apical pulse of a client from a different culture. In order to show appropriate sensitivity to the client, the nurse should take which action? 1. Explain the procedure, then wait for permission to continue. 2. Explain to the client what will occur during the assessment. 3. Ask the client to stay quiet because the nurse will be listening to the heart. 4. Take the baseline vital signs, then determine if cardiac auscultation is necessary.

Correct Answer: 1 Rationale 1: Cardiac assessment requires that the nurse move into the client's intimate space. Before beginning this, the nurse should explain the procedure and then await permission to continue. Rationale 2: Explaining the assessment only while performing the procedure and not before is likely to cause the client anxiety and thus negatively affect the assessment values. Rationale 3: This option is not addressing the sensitivity issues appropriate for this scenario. Rationale 4: This option is not addressing the sensitivity issues appropriate for this scenario.

The nurse is planning to conduct a physical assessment with a client from a different culture. What is the best way for the nurse to show cultural sensitivity when addressing the personal questions required of the nursing history? 1. Break the assessment into shorter intervals and discuss general topics first. 2. Thoroughly explain the reason for asking many questions before beginning the assessment. 3. Pick a time when the family is present and can help with the admission assessment questions. 4. Wait until the nurse client relationship has been established.

Correct Answer: 1 Rationale 1: Clients may be offended when the nurse immediately asks personal questions. In some cultures, courtesies should be established before business or personal topics are discussed. Discussing general topics can convey that the nurse is interested and has time for the client. This enables the nurse to develop a rapport with the client before progressing to discussion that is more personal. Rationale 2: Even if the explanation is given, clients from some cultures may still find questions of a personal nature offensive so early in the nurse client association. Rationale 3: The sensitive issue is not necessarily one of language or communication barriers. Rationale 4: Waiting to complete the assessment is not a good idea as there is certain, initial information that needs to be collected from the client.

A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior? 1. Competing preferences 2. Competing demands 3. Situational influences 4. Interpersonal influences

Correct Answer: 1 Rationale 1: Competing preferences are behaviors over which an individual has a high level of control and depend on the individual's ability to be self-regulating. In this case, the individual must make a choice to use his peak flow meter every day. It's really his choice either he uses it, or he doesn't. Rationale 2: Competing demands are behaviors over which an individual has a low level of control; something unexpected competes with a planned activity. Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. Rationale 4: Interpersonal influences are a person's perceptions concerning the behaviors, beliefs, or attitudes of others.

A new graduate nurse is working in a busy emergency department of a hospital, situated in a culturally diverse area of the city. In striving to be culturally sensitive, what should the nurse do? 1. Try to learn about the attitudes toward health care and traditions of the different cultures in that area. 2. Understand and attend to the total context of the client's situation, using knowledge, attitudes, and skills. 3. Possess the underlying background knowledge that will provide these clients with the best possible health care. 4. Continuously strive to be culturally competent.

Correct Answer: 1 Rationale 1: Cultural sensitivity implies that nurses possess some basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in the setting in which they are practicing. Rationale 2: To understand and attend to the total context of the client's situation, using knowledge, attitudes, and skills, is a general nursing expectation and does not address cultural sensitivity directly. Rationale 3: To possess the underlying background knowledge that will provide these clients with the best possible health care is a general nursing expectation and does not address cultural sensitivity directly. Rationale 4: Becoming culturally competent is an ongoing process in which an individual develops along a continuum until diversity is accepted as a norm and the nurse has acquired greater understanding and capacity in a diverse environment.

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The clients record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened, and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake.

Correct Answer: 1 Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The clients clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Coded diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses. Rationale 2: This would not necessarily result in the problem related to reimbursement because it is a reasonable diagnostic test to perform in this situation. Rationale 3: This would not necessarily result in the problem related to reimbursement. Rationale 4: This would not necessarily result in the problem related to reimbursement.

A community health nurse works with a variety of cultures providing health care services that include preventive care, acute treatment, and education. Of the following clients, which is most likely to use folk medicine? 1. The client who speaks little English and does not have a job 2. A family who has numerous relatives in a Spanish-American sector of the city 3. A female client whose culture is one of male dominance 4. A Chinese client who has a small, family run business in the area

Correct Answer: 1 Rationale 1: Folk medicine is defined as beliefs and practices that relate illness prevention and healing to cultural traditions rather than modern medicines scientific base. People who have limited access to scientific health care may turn to folk medicine or folk healing. Because folk healing is more culturally based, it may be more comfortable and less frightening for the client who is not fluent in the English language and has limited access to scientific health care. Rationale 2: There is no evidence to suggest that this family would prefer to use folk medicine. Rationale 3: There is no evidence to suggest that this client would prefer to use folk medicine. Rationale 4: There is no evidence to suggest that this client would prefer to use folk medicine.

The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM

Correct Answer: 1 Rationale 1: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in laypersons terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid.

A client who is from a different culture than the nurse has not been able to achieve this goal: Client will select low-fat foods from a list by the end of the month. What should the nurse do? 1. Consider whether the clients belief system has been an influencing factor. 2. Extend the time frame and give the client a longer period to achieve the goal. 3. Make sure that the client understands the importance of the goal. 4. Select a different goal.

Correct Answer: 1 Rationale 1: If the outcomes are not achieved for a client from a different culture, the nurse should be especially careful to consider whether the clients belief system has been adequately included as an influencing factor. Rationale 2: Extending the time frame may not be as helpful as looking at the cultural practices including dietary ones of the client. Rationale 3: Checking how the client understands the importance of the goal may not be as helpful as looking at the cultural practices including dietary ones of the client. Rationale 4: Selecting a different goal may not be as helpful as looking at the cultural practices including dietary ones of the client.

The school nurse is conducting head lice screenings. Before checking the head of an Asian child, the nurse should first take which action? 1. Ask permission. 2. Make sure the child understands the reason for the contact. 3. Put gloves on. 4. Ask the child to wait until last, to avoid embarrassing the child.

Correct Answer: 1 Rationale 1: In some Asian cultures, only certain elders are permitted to touch the head of others, and children are never patted on the head. Nurses should, therefore, touch a client's head only with permission. Rationale 2: The nurse should explain the reason for the touching to all children. Rationale 3: Nurses should always wear gloves for this type of screening process. Rationale 4: Asking the child to wait until last to avoid embarrassment is not appropriate and does not address the cultural issue.

A client makes the following statement: I must be paying for all the wrongs I did in my life, to have such a diagnosis as this. The nurse suspects that this client views health from which type of belief? 1. Magico-religious belief 2. Holistic health belief 3. Biomedical health belief 4. Folk medicine

Correct Answer: 1 Rationale 1: In the magico-religious health belief view, health and illness are controlled by supernatural forces. The client may believe that illness is the result of being bad or opposing Gods will. Rationale 2: The holistic health belief holds that the forces of nature must be maintained in balance or harmony. Human life is one aspect of nature that must be in harmony with the rest of nature. Rationale 3: Biomedical health belief, also termed scientific belief, is based on the belief that life and life processes are controlled by physical and biochemical processes that can be manipulated by humans. Rationale 4: Folk medicine is defined as those beliefs and practices related to illness prevention and healing that derive from cultural traditions rather than from modern medicines scientific base.

A community health nurse is testing the theory of locus of control (LOC). Which client demonstrates the internal control concept of this theory? 1. A client who takes an active role in all health decisions 2. A client who allows the primary care provider to make all the decisions 3. A client who does not make any decisions without his or her spouses' input 4. A client who relies on information from the local hospital for his or her health needs

Correct Answer: 1 Rationale 1: Locus of control (LOC) is a concept from social learning theory. People who exercise internal control are more likely than others to take the initiative on their own health care and to be more knowledgeable about their health. They are also more likely to adhere to prescribed health care regimens such as taking medication, making and keeping appointments with physicians, maintaining diets, and giving up smoking. Rationale 2: People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. Rationale 3: People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. Rationale 4: People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals.

An occupational health nurse is surveying employees. Which employee should the nurse identify as being predisposed to an illness? 1. An employee who is in a middle-management position and takes stress from administration as well as the employees 2. An employee who works in the janitorial department 3. An employee who works 12-hour days, 3 days a week 4. An employee who works 4 days on and 3 days off

Correct Answer: 1 Rationale 1: People who hold management positions are in stressful occupational roles that predispose them to stress-related diseases. Rationale 2: Working as a custodian would not pose the same type of stress as the management position. Rationale 3: Working longer shifts would not pose the same type of stress as the management position. Rationale 4: Working longer shifts would not pose the same type of stress as the management position.

The nurse is using Kalishs adaptation of Maslow's hierarchy of needs when planning client care. Which client should the nurse identify as exhibiting a level of Kalishs adaptation? 1. Has a homosexual encounter for the first time 2. Has a need to participate in school sports and be on the team 3. Strives to become the CEO of a company 4. Is sleep deprived because of musculoskeletal discomfort

Correct Answer: 1 Rationale 1: Richard Kalish added a sixth level to Maslow's five levels and referred to it as stimulation needs. This level includes sexual activity, exploration, manipulation, and novelty. Rationale 2: A client who wants to be on the team is exhibiting characteristics of love and belonging needs; mentioned in Maslow's original five-level hierarchy. Rationale 3: Striving to be in charge of a company is part of self-actualization, mentioned in Maslow's original five-level hierarchy. Rationale 4: Sleep is one of the basic physiological needs mentioned in Maslow's original five-level hierarchy.

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex

Correct Answer: 1 Rationale 1: Standardized care plans were developed to save documentation time. These plans may be based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each client's specific needs. Rationale 2: Traditional care plans are written for each client, are specific, and are individualized for that client. Rationale 3: Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care. Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible for all health professionals.

The client states: I really don't want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning

Correct Answer: 1 Rationale 1: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the clients words; otherwise, they are summarized. Rationale 2: Objective data consist of information that is measured or observed. Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described. Rationale 4: Planning is the care designed to resolve the problem.

A client has received a high score on the Life-Change Index. For which part of the client's assessment should the nurse use this information? 1. Life stress review 2. Social support systems review 3. Lifestyle assessment 4. Health beliefs review

Correct Answer: 1 Rationale 1: The Life-Change Index is a tool that assigns numerical values to life events and is a way to identify clients in stress. Studies have shown that high levels of stress are associated with an increased possibility of illness in an individual. Rationale 2: A social support systems review takes into account the social context in which a person lives and works. Rationale 3: A lifestyle assessment focuses on the personal lifestyle habits of the client as they affect health. Rationale 4: A health beliefs review provides information about how much clients believe they can influence or control health through personal behaviors.

A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex

Correct Answer: 1 Rationale 1: The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a client's admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. Rationale 2: Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. Rationale 3: CBE stands for charting by exception and is not the form of documentation used for this type of assessment. Rationale 4: Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area.

The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making? 1. Considering how the loss of a client's job will affect the regulation of the client's diabetes 2. Making sure to do complete teaching regarding pharmacological interventions 3. Following physician treatments on schedule 4. Prioritizing the needs of the client assigned according to Maslow's hierarchy

Correct Answer: 1 Rationale 1: The concept of holism emphasizes that nurses must keep the whole person in mind and strives to understand how one area of concern relates to the whole person. In this situation, the stress from a job loss will affect the persons chronic condition. The nurse must also consider the relationship of the individual to the external environment and to others. Rationale 2: This option is only focused on the physiology of the persons condition. Rationale 3: This option is only focused on the physiology of the persons condition. Rationale 4: This option is only focused on the physiology of the persons condition.

When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the client's chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting

Correct Answer: 1 Rationale 1: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart. Rationale 2: In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information. Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called critical pathways. Rationale 4: Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format.

A nurse educator uses Madeleine Leininger's model and describes a formal area of study and practice focused on comparative human-care differences and similarities of the beliefs, values, and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people. What type of nursing is the educator practicing? 1. Transcultural nursing 2. Cultural competence 3. Cultural knowledge 4. Competent nursing

Correct Answer: 1 Rationale 1: Transcultural nursing focuses on providing care within the differences and similarities of the beliefs, values, and patterns of cultures. Rationale 2: Cultural competence is a life-long process in which the nurse continuously strives to achieve the ability and availability to effectively work within the cultural context of a client (individual, family, community). Rationale 3: Cultural knowledge reflects the presences of a sound educational foundation concerning the various worldviews of different cultures. Rationale 4: Transcultural nursing is a component of competent nursing.

During a home visit with a new community member, the nurse suspects that a client has a chronic illness. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Experienced symptoms for 8 months 2. Has periods where the symptoms disappear 3. Altered activities of daily living because of the illness 4. Problem disappeared with over-the-counter medication 5. Symptoms appeared abruptly and disappeared after treatment

Correct Answer: 1, 2, 3 Rationale 1: A chronic illness is one that lasts for an extended period, usually 6 months or longer, and often for the person's life. Rationale 2: Chronic illnesses usually have a slow onset and often have periods of remission, when the symptoms disappear. Rationale 3: With chronic illnesses clients often need to modify activities of daily living. Rationale 4: An acute illness may subside with the help of over-the-counter medication. Rationale 5: Symptoms of an acute illness appear abruptly and subside quickly after intervention.

The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client. Which characteristics should the nurse keep in mind during this assessment? Standard Text: Select all that apply. 1. They are self-regulating. 2. They are compensatory. 3. They are regulated by negative feedback systems. 4. They can require several feedback mechanisms to correct only one physiologic imbalance. 5. They are related to a closed system.

Correct Answer: 1, 2, 3, 4 Rationale 1: Homeostatic mechanisms are self-regulating. Rationale 2: Homeostatic mechanisms are compensatory. Rationale 3: Homeostatic mechanisms are regulated by negative feedback systems. Rationale 4: Homeostatic mechanisms can require several feedback mechanisms to correct a physiologic imbalance. Rationale 5: Homeostatic mechanisms are not related to a closed system.

The nurse determines that an older client is in the medical care contact stage of an illness. What did the client demonstrate to cause the nurse to make this decision? Standard Text: Select all that apply. 1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion. 5. The client stated that treatment is accepted and will be completed as identified.

Correct Answer: 1, 2, 3, 4 Rationale 1: In the medical care contact stage the client seeks reassurance that the illness can be treated, and the outcome predicted. Rationale 2: In the medical care contact stage the client wants validation of a real illness. Rationale 3: In the medical care contact stage the client wants the symptoms explained in understandable terms. Rationale 4: In the medical care contact stage the client may deny the diagnosis and seek the other of other health care professionals. Rationale 5: In the dependent client role the client becomes dependent on the professional for help.

The nurse educator is reviewing internal variables that affect people's health status. On which variables is this nurse focusing? Standard Text: Select all that apply. 1. Genetic makeup 2. Age 3. Developmental level 4. Environment 5. Spiritual and religious beliefs

Correct Answer: 1, 2, 3, 5 Rationale 1: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include genetic makeup. Rationale 2: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include age. Rationale 3: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Biologic dimensions include developmental level. Rationale 4: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Environment is an example of an external variable that affects a person's health. Rationale 5: Internal variables that affect people's health include biologic, psychologic, and cognitive dimensions. Cognitive dimensions include spiritual and religious beliefs.

A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor? Standard Text: Select all that apply. 1. Time management 2. Healthy eating habits 3. Exercise after stroke 4. Bicycle safety for children 5. Performing self-examination of the breasts

Correct Answer: 1, 2, 4 Rationale 1: Health promotion activities include those items that increase well-being and overall health. Rationale 2: Health promotion activities include those items that increase well-being and overall health. Rationale 3: Teaching about exercise following a stroke focuses on rehabilitation, not health promotion. Rationale 4: Health promotion activities include those items that increase well-being and overall health. Rationale 5: Performing self-examination of the breasts is a health protection activity.

The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism? Standard Text: Select all that apply. 1. The clients heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. 3. A child's bone growth occurs in spurts. 4. Decreased secretion of insulin occurs when food is not ingested. 5. Lactation occurs in a pregnant woman.

Correct Answer: 1, 2, 4 Rationale 1: Homeostatic mechanisms have characteristics that include self-regulation, such as automatically increased respiratory rates. Rationale 2: Homeostatic mechanisms have characteristics that include compensatory actions, such as shivering to create body heat. Rationale 3: This is not an example of a homeostatic mechanism; they are self-regulation, compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological imbalance. Rationale 4: Homeostatic mechanisms have characteristics that include regulation by negative feedback systems. Rationale 5: This is not an example of a homeostatic mechanism; they are self-regulation, compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological imbalance.

According to the National Council of State Boards of Nursing (NCSBN), which rights of delegation should the nurse follow? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task

Correct Answer: 1, 2, 5 Rationale 1: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Rationale 2: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Rationale 3: The right client is a part of the rights of medication administration. Rationale 4: The right time is a part of the rights of medication administration. Rationale 5: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation.

A community health nurse is learning about the REACH initiative and has decided to implement community education on this approach. What topics should the nurse include in this education? Standard Text: Select all that apply. 1. Child and adult immunizations 2. Cardiovascular disease 3. Chronic lower respiratory disease 4. Stroke 5. Infant mortality

Correct Answer: 1, 2, 5 Rationale 1: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Topics within the REACH initiative include child and adult immunizations. Rationale 2: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Topics within the REACH initiative include cardiovascular diseases. Rationale 3: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Chronic lower respiratory disease is not a topic within the REACH initiative. Rationale 4: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Stroke is not a topic within the REACH initiative. Rationale 5: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Topics within the REACH initiative include infant mortality.

The community health nurse is using the Heritage Assessment Interview tool with a group of community members. Which data indicate heritage consistent? Standard Text: Select all that apply. 1. A client frequently visits the old country neighborhood he grew up in. 2. A client is raised by a single parent. 3. The clients education occurred at a religious school. 4. The client participates in religious festivals and cultural events. 5. The client has been the first of his family to earn a college degree.

Correct Answer: 1, 3, 4 Rationale 1: The tool is designed to enhance the process of determining whether clients are identifying with their traditional cultural heritage (heritage consistent), such as by visiting an ethic neighborhood. Rationale 2: The tool is not designed to assess such nonculturally oriented events. Rationale 3: The tool is designed to enhance the process of determining whether clients are identifying with their traditional cultural heritage (heritage consistent), such as by attending a religiously affiliated school. Rationale 4: The tool is designed to enhance the process of determining whether clients are identifying with their traditional cultural heritage (heritage consistent), such as by attending and participating in religious and cultural events. Rationale 5: The tool is not designed to assess such nonculturally oriented events.

The nurse is planning to provide culturally responsive care to a minority client and family. What actions should the nurse perform when providing this care? Standard Text: Select all that apply. 1. Personally reflecting on feelings related to the client's nationality 2. Making an effort to direct all assessment questions initially to the client 3. Involving the family with the client's permission 4. Assessing the client's interest in alternative healing methods 5. Educating the client and family when appropriate

Correct Answer: 1, 3, 4, 5 Rationale 1: Culturally responsive care that involves family appropriately includes self-reflection to identify your personal assumptions, biases, attitudes, prejudices, and stereotypes. Rationale 2: Determine the cultural expectations related to the hierarchy of the family. Rationale 3: Culturally responsive care that involves family appropriately includes explaining in detail the client's condition and the treatment plan with the family if the client is willing for the nurse to do so. Rationale 4: Culturally responsive care that involves family appropriately includes asking about the clients use of cultural or alternative approaches to healing. Rationale 5: Culturally responsive care that involves family appropriately includes explaining in detail the client's condition and treatment plan with the family if the client is willing for the nurse to do so.

The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurse's advocacy? Standard Text: Select all that apply. 1. Participating in a community-focused 5-mile run. 2. Attending the local high schools football games. 3. Providing an educational program to senior citizens on blood pressure control strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques.

Correct Answer: 1, 3, 4, 5 Rationale 1: The nurse's role in health promotion includes modeling healthy lifestyle behaviors and attitudes. Rationale 2: This is not an example of active role modeling. Rationale 3: The nurse's role in health promotion includes assisting clients, families, and communities to develop and choose health-promoting options. Rationale 4: The nurse's role in health promotion includes advocating in the community for changes that promote a healthy environment. Rationale 5: The nurse's role in health promotion includes teaching client's self-care strategies to enhance fitness, improve nutrition, manage stress, and enhance relationships.

A female client is being discharged after a lengthy hospitalization. The family is from a male-dominated culture. Before discharge instructions are given, which action should the nurse take? 1. Make sure instructions are understood by the client. 2. Arrange for teaching when the spouse is available. 3. Make sure that the physician gives the instructions. 4. Ask the client when the best time for teaching would be.

Correct Answer: 2 Rationale 1: Regardless of cultural considerations, it's always necessary to make sure that the instructions are understood. Rationale 2: The nurse needs to identify who has the authority to make decisions in a client's family. If the decision maker is someone other than the client, as in this situation, the nurse needs to include that person in health care discussions. In this situation, we do not know if the nurse is male or female, so the best answer given with the information that is known is to arrange for teaching when the spouse is available. Rationale 3: This will not address the cultural issue of male dominance. Rationale 4: This will not address the issue of male dominance.

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? 1. A firewall to protect the server from unauthorized access 2. One-unit password to protect the unit's information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets

Correct Answer: 1, 3, 5 Rationale 1: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include the installation of a firewall to protect from unauthorized access. Rationale 2: Guidelines for confidentiality and security of computerized records include assignment of a personal password to enter and log off computer files. The password should not be shared with anyone, including other team members. Rationale 3: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. The nurse should learn to never leaving a monitor unattended after logging on. Rationale 4: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Turning the monitor away from view is not a sufficient safeguard. Rationale 5: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include shredding all confidential information.

A group of community health nurses work together in the same office. They are each responsible for their own caseloads and scheduling of appointments. Their major leadership directives come from the state health office, several hundred miles away. This group of nurses is functioning under what type of leadership. 1. Charismatic 2. Shared 3. Transformational 4. Transactional

Correct Answer: 2 Rationale 1: A charismatic leader is characterized by an emotional relationship between the leader and group members. Rationale 2: Shared leadership recognizes that a professional workforce is made up of many leaders. No one person is considered to have knowledge or ability beyond that of other members of the work group, as in this situation. Rationale 3: A transformational leader fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organizations vision. Rationale 4: A transactional leader has a relationship with followers based on an exchange for some resource valued by the followers.

A nurse is working with a home health client whose spouse was not born in the United States. During the home visit, the nurse realizes that the client has acquired the identity of her spouses' culture and has adopted some of the health practices of that culture. Which process should the nurse identify as occurring with the spouse? 1. Acculturation 2. Assimilation 3. Diversity 4. Heritage consistency

Correct Answer: 2 Rationale 1: Acculturation occurs when people adapt to or borrow traits from another culture. Acculturation can also be defined as the changes of one's cultural patterns to those of the host society. Rationale 2: Assimilation is the process by which an individual develops a new cultural identity. It encompasses various aspects such as behavior, marital roles, identification, and civic duties. The underlying assumption is that the person from a given cultural group loses his or her original cultural identity to acquire the new one. Rationale 3: Diversity is the fact or state of being different. Rationale 4: Heritage consistency relates to the observance of beliefs and practices of a person's traditional cultural system.

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation

Correct Answer: 2 Rationale 1: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an unattainable goal because a change in the clients care plan may result in success. Rationale 2: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations to what is planned in the critical pathway unexpected occurrences that affect the planned care or the client's response to care. Rationale 3: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an error in care planning because the success of a goal is dependent on specific interventions and individual client response. Rationale 4: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an error in implementation because the success of a goal is not solely dependent on the implementation of a single intervention.

A nurse manager has had to handle a particularly difficult physician who is demanding as well as demeaning. Through this situation, the nurse manager has learned that accuracy and honesty are attributes of which skill necessary for managers? 1. Critical thinking 2. Communication 3. Networking 4. Responsibility

Correct Answer: 2 Rationale 1: Critical thinking is a creative process that includes problem solving and decision making. Rationale 2: Good communication skills are essential to managers and include assertiveness, clear expression of ideas, accuracy, and honesty. Rationale 3: Networking is a process whereby professional links are established through which people can share ideas, knowledge, and information; offer support and direction to each other; and facilitate accomplishment of professional goals. Rationale 4: Responsibility is one of the principles of management, not a management skill.

A client has requested that she have a special item present in her room and explains that it gives her a feeling of comfort and a sense of organization. On which psychosocial component is this client focusing? 1. Culture 2. Religion 3. Ethnicity 4. Socialization

Correct Answer: 2 Rationale 1: Culture is a learned behavior and depends on underlying societal traits, including knowledge, beliefs, art, law, morals, and customs. Rationale 2: Religion may be defined by a system of beliefs, practices, and ethical values about divine or superhuman power and is closely related to ethnicity. Religion gives a person a frame of reference and a perspective with which to organize information. Rationale 3: Ethnicity describes the traits and common religious customs and language of a group within the social system. Rationale 4: Socialization is the process of being raised within a culture and acquiring the characteristics of that group.

The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing? 1. Environmental control 2. Information dissemination 3. Health risk appraisal and wellness assessment 4. Lifestyle and behavior change

Correct Answer: 2 Rationale 1: Environmental control programs have been developed as a result of the continuing increase of contaminants of human origin that have been introduced into the environment. Rationale 2: Information dissemination is the most basic type of health promotion program. This method makes use of a variety of media to offer information to the public about the risk of a particular lifestyle choice and personal behavior as well as the benefits of changing that behavior. Rationale 3: Health risk appraisal and wellness assessment programs are used to describe risk factors to people and motivate them to reduce specific risks and develop positive health habits. Rationale 4: Lifestyle and behavior change programs require participation of the individual and are geared toward enhancing the quality of life and extending the life span.

A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This client is modeling which behavior? 1. Health promotion 2. Health protection 3. Tertiary prevention 4. Primary prevention

Correct Answer: 2 Rationale 1: Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential. Rationale 2: Health protection or illness prevention is behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness. Expressing a desire to quit smoking would be modeling this behavior. The information we are given does not tell us if the client has pathology or not, but the client certainly has been exposed to a health hazard. Rationale 3: Tertiary prevention focuses on restoration and rehabilitation it is not a behavior. Rationale 4: Primary prevention focuses on health promotion it is not a behavior.

A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions? 1. Interpersonal influences 2. Perceived benefits of action 3. Situational influences 4. Perceived self-efficacy

Correct Answer: 2 Rationale 1: Interpersonal influences are a person's perceptions concerning the behaviors, beliefs, or attitudes of others including family, peers, and health professionals who can influence their success. Rationale 2: Behavior-specific cognitions and affect are considered to be of major motivational significance for acquiring and maintaining health-promoting behaviors. Perceived benefits of action affect the persons plan to participate in health-promoting behaviors and may facilitate continued practice. If this client has prior positive experience with the behavior or observations of others engaged in the behavior, he or she may be motivated to success. Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of options, demand characteristics, and the aesthetic features of the environment. Rationale 4: Perceived self-efficacy refers to the conviction that a person can successfully carry out the behavior necessary to achieve a desired outcome.

A nurse manager is working on new job descriptions for all nursing units of the hospital. Which management function is this nurse conducting? 1. Planning 2. Organizing 3. Directing 4. Coordinating

Correct Answer: 2 Rationale 1: Planning involves assessing a situation, establishing goals and objectives that identify priorities, delineating who is responsible, determining deadlines, and describing how the intended outcome is to be achieved and evaluated. Rationale 2: Organizing is an ongoing process of management that involves determining responsibilities, communicating expectations (which job descriptions would fall under), and establishing the chain of command for authority and communication. Rationale 3: Directing is the process of getting the organizations work accomplished. Coordinating is the process of ensuring that plans are carried out and evaluating outcomes. Rationale 4: Coordinating is the process of ensuring that plans are carried out and evaluating outcomes.

The nurse educator provides developmental testing for kindergarten through third grade students. Which level of prevention is the nurse performing? 1. Primary 2. Secondary 3. Tertiary 4. Community

Correct Answer: 2 Rationale 1: Primary prevention is true health promotion and precedes disease or dysfunction. Rationale 2: Secondary prevention emphasizes early detection of disease and health maintenance for individuals experiencing health problems. This would include providing assessment of the growth and development of children. Rationale 3: Tertiary prevention begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Rationale 4: Community health is a broad category that includes many facets. It is not a level of prevention.

A client has had a severe brain injury and has been in a rehabilitation hospital for several months. Recently, the client developed pneumonia and is currently on intravenous antibiotic therapy. Which level of prevention should the nurse use to address the health problem of pneumonia? 1. Primary 2. Secondary 3. Tertiary 4. Acute

Correct Answer: 2 Rationale 1: Primary prevention is true health promotion and provides specific interventions against disease. Rationale 2: Secondary prevention emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Because the pneumonia is a current health problem, interventions focused on that would be considered secondary prevention. Rationale 3: All cares related to rehabilitation following the brain injury would be tertiary prevention. Tertiary prevention focuses on rehabilitating individuals to an optimum level of functioning. Rationale 4: Acute care is a part of health care, but not one of the levels of prevention.

The nurse is preparing a menu for a Jewish client who observes kosher customs. Which food items would be appropriate to serve this client, assuming all have been properly inspected and prepared? 1. Hamburger, fruit, and milk 2. Fish, vegetables, and hot tea 3. Ham, baked potato, and fresh fruit 4. Cream soup, sausage, and toast

Correct Answer: 2 Rationale 1: The eating of milk products and meat products at the same meal is prohibited. Rationale 2: This menu is in accordance with the kosher tradition because there is no pork being served and dairy and meat are not served together. Rationale 3: Orthodox Judaism and Islam prohibit the ingestion of pork or pork products (ham and sausage). Rationale 4: The eating of milk products and meat products at the same meal is prohibited.

A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration? 1. Rest and exercise 2. Adjusting to physiologic changes and limitations 3. High obesity percentages 4. Safety promotion and injury prevention

Correct Answer: 2 Rationale 1: Rest and exercise are life span considerations of children. Rationale 2: In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Rationale 3: In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Rest and exercise and high obesity percentages are life span considerations of children. Rationale 4: Safety promotion and injury prevention are life span considerations for adolescents.

A client is hospitalized with numerous acute health problems. According to Maslow's basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client? 1. Risk for Injury related to unsteady gait 2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients 3. Self-Care Deficit related to weakness and debilitation 4. Powerlessness related to chronic disease state

Correct Answer: 2 Rationale 1: Risk for Injury would be the lower priority need. Rationale 2: In needs theories, human needs are ranked on an ascending scale according to how essential the needs are for survival. Physiologic needs are those such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance, which are all crucial for survival. Nutritional deficits would fall into this level and take priority over the others listed. Rationale 3: Self-Care Deficit would fall in the fourth level self-esteem needs. Rationale 4: Powerlessness is part of the need to develop one's maximum potential. It falls into the fifth and highest level of self-actualization.

A newly immigrated client is constantly attended to by family members. This has presented a problem to the nursing staff and the delivery of nursing care. In order to address this issue in a culturally sensitive manner, the nurse should take which action? 1. Explain to the client that he has to limit visitors. 2. Evaluate the benefits of family participation in the client's care. 3. Question the family members as to how they see their interaction with the client. 4. Have the physician limit the number of visitors the client can have.

Correct Answer: 2 Rationale 1: Telling the client he has to limit visitors or having the physician do this may be in conflict with cultural values and is not helpful to the client. Rationale 2: Cultural family values may dictate the extent of the family's involvement in the hospitalized clients care. In some cultures, the entire community may want to visit and participate in the client's care. The nurse should evaluate the positive benefits of family participation in the clients care and modify visiting policies as appropriate. Rationale 3: It would be more appropriate to question the client, not the family members, about the positive benefits of the family interactions because the family members are obviously supportive of their presence. Rationale 4: This is a nursing issue and should be managed by the nurse.

A client has specific cultural needs that affect the plan of care. In which part of the client's problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

Correct Answer: 2 Rationale 1: The database includes information about the client when admitted to the facility. Rationale 2: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the clients physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs. Rationale 3: The plan of care is made with reference to the active problems. Rationale 4: Progress notes are chart entries made by all health professionals involved in a client's care.

During a particularly heated staff meeting regarding staff assignments, the nurse manager makes this comment: When you all can come to a decision, let me know and well move on from there. This leader is best identified as which of the following? 1. Democratic leader 2. Permissive leader 3. Bureaucratic leader 4. Situational leader

Correct Answer: 2 Rationale 1: The democratic leader encourages group discussion and decision making, provides constructive criticism, offers information, makes suggestions, and asks questions. Rationale 2: The permissive leader recognizes the groups need for autonomy and self-regulation by assuming a hands-off approach. Allowing the group to come to its own decision and then accepting that decision reflects the style of a permissive leader. Rationale 3: The bureaucratic leader relies on the organizations rules, policies, and procedures to direct the groups work efforts. Rationale 4: A situational leader is one who adapts his or her leadership style to the situation.

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as it's his record. How should the nurse respond to this client's request? 1. You'll have to ask your doctor for permission to do that. 2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records. 3. Well make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details. 4. There's a new law that protects your records, so you're not going to be able to have access to them.

Correct Answer: 2 Rationale 1: The doctor's permission is not a requirement for the release of a client's medical record. Rationale 2: Although the clients record is protected legally as private, access to the record is restricted to health professionals involved in the client's care. The institution or agency is the rightful owner of the client's record, but the client has the right to access all information contained within his own record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health information and maintain confidentiality of client records. Rationale 3: The client does have a legal right concerning his medical record, so this option doesn't adequately address the question. Rationale 4: This option is not correct; the client does have a legal right to access his medical records.

A non-English speaking client is needs to have an emergency surgical procedure. The hospital has an interpreter available. When the interpreter arrives to explain the procedure and help with the consent form, the nurse provides the best support when 1. asking the interpreter to use words the client is familiar with for the best understanding. 2. requesting that the interpreter translate, as closely as possible, the same words used by the professional staff. 3. suggesting that the questions be directed to the interpreter, so nothing is omitted. 4. addressing the questions to the client's family.

Correct Answer: 2 Rationale 1: The objective of the professional interpreter is for the complete transfer of the thought behind the utterance in one language into an utterance in a second language. Rationale 2: An interpreter is an individual who mediates spoken or signed communication between people using different languages without adding, omitting, or distorting meaning or editorializing. The objective of the professional interpreter is for the complete transfer of the thought behind the utterance in one language into an utterance in a second language. Rationale 3: The questions should be addressed to the client, not the interpreter. Rationale 4: The questions should be addressed to the client, not the family, unless the client is incapable of answering.

A client is attending classes on building positive relationships with significant others as well as learning skills to be open-minded and respectful to those whose opinions are different. The nurse realizes that this client is focusing on which component of wellness? 1. Physical 2. Social 3. Emotional 4. Environment

Correct Answer: 2 Rationale 1: The physical component of wellness is the ability to carry out daily tasks, achieve fitness of all body systems, and practice positive lifestyle habits. Rationale 2: The social component of wellness focuses on the ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs. Rationale 3: The emotional component deals with the ability to manage stress and express emotions appropriately. Rationale 4: The environmental component focuses on the health measures that improve the standard of living and quality of life in the community.

The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes

Correct Answer: 2 Rationale 1: The problem statement is labeled P and referred to by number. Rationale 2: The interventions employed to manage the problem are labeled I and numbered according to the problem. Rationale 3: The E is the evaluation of the effectiveness of the intervention and is labeled and numbered according to the problem. Rationale 4: Progress notes are not part of the identified labels of PIE charting.

A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the clients care plan includes working on coping with her current limitations since the injury. This nurse is working within which model of health? 1. Role performance 2. Adaptive 3. Eudemonistic 4. Clinical

Correct Answer: 2 Rationale 1: The role performance model defines health in terms of the individual's ability to fulfill societal roles or to perform work. According to this model, people who fulfill their roles are healthy, even though they may have an illness. Rationale 2: In the adaptive model, health is a creative process; disease is a failure in adaptation or maladaptation. The aim of treatment is to restore the ability of the person to adapt and cope, as in a rehabilitation setting. Rationale 3: The eudemonistic model incorporates a comprehensive view of health, which is seen as a condition of actualization or realization of a person's potential. Rationale 4: The clinical model is a narrow interpretation of health, which is defined by the absence of disease.

Type: MCSA The nurse is teaching a client from a culture that is present oriented about a dressing change that should be performed twice a day. How should the nurse address the cultural issue? 1. Allow the client to select the times the dressing will be changed. 2. Instruct the client to change the dressing after breakfast and before going to bed. 3. Explain that the client should complete the dressing change at 10 AM and 4 PM. 4. Suggest that the dressing change can be performed whenever the client chooses, as long as it gets done twice daily.

Correct Answer: 2 Rationale 1: This option does not assure the dressing changes will occur as prescribed. Rationale 2: For clients who are present oriented, it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments, such as in the morning or after breakfast, and in the evening or before going to bed. This would fit better with the client who isn't focused on times of the day, such as 10 AM and 4 PM, but will provide for a dressing change twice daily. Rationale 3: This option is not likely to be followed by a client who is present oriented. Rationale 4: This option does not comply with the intended order for the dressing changes.

The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? Standard Text: Select all that apply. 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly.

Correct Answer: 2, 3, 5, 6 Rationale 1: This system is not inexpensive to maintain. Rationale 2: This is considered a positive aspect of this type of charting. Rationale 3: This is considered a positive aspect of this type of charting. Rationale 4: The effectiveness of this system to protect a client's privacy is dependent upon the personnel using it. Rationale 5: This is considered a positive aspect of this type of charting. Rationale 6: This is considered a positive aspect of this type of charting.

The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which role? 1. Facilitator 2. Advocate 3. Teacher 4. Coordinator of services

Correct Answer: 3 Rationale 1: A facilitator is involved in the assessment, implementation, and evaluation of health goals. Rationale 2: The advocate helps implement changes that promote a healthy environment. Rationale 3: The teaching role focuses on self-care strategies such as enhancing fitness, improving nutrition, managing stress, and enhancing relationships. Rationale 4: A coordinator helps to guide and reinforce the client's development in effective problem solving and decision making as well as reinforces personal and family health-promoting behaviors.

A client is the child of an African American father and Asian American mother. The client has been exposed to cultural foods, traditions, and customs from both parents throughout life. What term should the nurse use to describe this client's cultural development? 1. Diversity 2. Subculture 3. Multicultural 4. Cultural sensitivity

Correct Answer: 3 Rationale 1: Diversity refers to the fact or state of being different. Rationale 2: A subculture is usually composed of people who have a distinct identity yet are related to a larger cultural group. Rationale 3: Multicultural is used to describe a person who has multiple patterns of identification or crosses several cultures, lifestyles, and sets of values. Rationale 4: Nurses demonstrate cultural sensitivity when they possess some basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in a setting in which they are practicing.

The nurse is providing care within the total care context. What should the nurse consider when using this care approach? 1. The individualism of the client 2. Principles applicable to the client at this moment 3. Principles general to all clients of the same age and condition 4. The persons self-identity

Correct Answer: 3 Rationale 1: In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time. Rationale 2: In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time. Rationale 3: In the total care context, the nurse considers all the principles and areas that apply when taking care of any client of that age and condition. Rationale 4: The persons self-identity is part of the individual health dimension of any one client.

The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report.

Correct Answer: 3 Rationale 1: It is never a good idea to leave blanks in any charting area because it implies that the area was ignored. Rationale 2: It is never a good idea to leave blanks in any charting area. Adding the information in the progress notes is not an appropriate use of that section. Rationale 3: Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse. Rationale 4: Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation.

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed. 3. Recorder responded to clients call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

Correct Answer: 3 Rationale 1: It should never be assumed that the client fell out of bed. Rationale 2: It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else. Rationale 3: Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client. Rationale 4: It should never be assumed that the client became tangled in bedding, or anything else.

The nurse manager is concerned that a staff nurse provides client care with a cultural prejudice. Which situation did the manager observe to come to this conclusion? 1. Making an assumption that all members of each culture are alike 2. Believing that all culture members will have the same beliefs 3. Bringing previous negative information and experiences into this situation 4. Taking general knowledge from literature and applying it to the situation

Correct Answer: 3 Rationale 1: Making an assumption that all members of each culture are alike describes stereotypical behavior. Rationale 2: Believing that all culture members have the same beliefs describes stereotypical behavior. Rationale 3: Prejudice is a negative belief or preference that is generalized about a group, which leads to prejudgment. Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Rationale 4: Taking general knowledge from literature and applying it to the situation is a form of stereotyping.

Before a client goes to surgery, he requests to have his spiritual leader present and pray over him. According to the HEALTH traditions model, which traditional method is the client invoking? 1. Maintaining HEALTH 2. Protecting HEALTH 3. Restoring HEALTH 4. Changing HEALTH

Correct Answer: 3 Rationale 1: Methods of maintaining HEALTH include following a proper diet, wearing proper clothing, concentrating and using the mind, and practicing one's religion. Rationale 2: Traditional methods of protecting HEALTH include wearing protective objects such as amulets, avoiding people who may cause trouble, and placing religious objects in the home. Rationale 3: Traditional methods of restoring HEALTH physical, mental, and spiritual include the use of herbal remedies, exorcism, and health rituals. This situation describes a healing ritual. Rationale 4: Changing HEALTH is not one of the traditional methods in the HEALTH traditions model.

A nurse manager allows the staff members to make their own schedules and do their own client assignments on their shifts. However, during a code situation, the nurse manager will make decisions for the staff by instructing which nurse to assume which responsibility. This manager is exemplifying which style of leadership? 1. Permissive 2. Democratic 3. Situational 4. Bureaucratic

Correct Answer: 3 Rationale 1: Permissive leaders assume a hands-off approach. Rationale 2: The democratic leader encourages group discussion and decision making. Rationale 3: According to contingency theorists, effective leaders adapt their leadership style to the situation. Unlike the singular style of authoritarian, democratic, and permissive leaders, the situational leader adapts his or her leadership to the readiness and willingness of the group to perform the assigned task. Rationale 4: A bureaucratic leader relies on the organizations rules, policies, and procedures to direct the groups work efforts.

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided, assessment findings, and client problems during a 12hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care

Correct Answer: 3 Rationale 1: Problem-oriented recording is arranging the data according to the problem the client has. Rationale 2: Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. The plan of care is part of the problem-oriented medical record. Rationale 3: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. Rationale 4: The plan of care is part of the problem-oriented medical record.

The nurse is working in a clinic setting and is meeting a new client for the first time. In order to convey cultural sensitivity, how should the nurse introduce herself? 1. I'm Jane, and I'll be your nurse today. 2. I'm Dr. Smith's nurse, Jane. 3. I'm Jane Brown, and I'm a nurse here at the clinic. 4. I'm glad to meet you. You can call me Jane.

Correct Answer: 3 Rationale 1: The appropriate introduction should include introducing themselves by full name, then explaining their role. This helps establish a relationship and provides an opportunity for clients, others, and nurses to learn the pronunciation of one another's names and their roles. This option does not fulfill these requirements. Rationale 2: The appropriate introduction should include introducing themselves by full name, then explaining their role. This helps establish a relationship and provides an opportunity for clients, others, and nurses to learn the pronunciation of one another's names and their roles. This option does not fulfill these requirements. Rationale 3: Ways for nurses to be culturally sensitive and to convey sensitivity to clients include introducing themselves by full name, then explaining their role. This helps establish a relationship and provides an opportunity for clients, others, and nurses to learn the pronunciation of one another's names and their roles. Rationale 4: The appropriate introduction should include introducing themselves by full name, then explaining their role. This helps establish a relationship and provides an opportunity for clients, others, and nurses to learn the pronunciation of one another's names and their roles. This option does not fulfill these requirements.

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

Correct Answer: 3 Rationale 1: The database consists of all known information about the client upon admission. Rationale 2: The problem list includes all identified problems, listed in the order in which they are identified. Rationale 3: The initial list of orders or plan of care is made with reference to the client's active problems in this type of charting. Physicians write physician orders or the medical care plan. Rationale 4: Progress notes are chart entries made by all health professionals involved in the client's care.

The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which is the most appropriate diagnosis for this client? 1. Risk for Situational Low Self-Esteem 2. High Risk for Caregiver Role Strain 3. Readiness for Enhanced Coping 4. Readiness for Enhanced Nutrition

Correct Answer: 3 Rationale 1: The information given in the scenario does not indicate that the client is experiencing problems with low self-esteem. Rationale 2: The information given in the scenario does not indicate that the client is experiencing problems with caregiver role strain. Rationale 3: Wellness diagnoses describe the human responses to levels of wellness in an individual. In this situation, even though the client is young and single, she is making every effort to be well in her situation. Attending parenting classes, meeting with peers, and learning about nutrition all point to a person who has a positive outlook but requires teaching. Rationale 4: The client is doing much more than just learning about nutrition. She is learning how to cope and be well in her life and the life of her child.

The nurse is assisting a client and his family after the client had a stroke and is no longer able to return to his previous employment. The nurse has made a referral to vocational rehabilitation for assistance in retraining the client in a different occupation. With which component of wellness is the nurse assisting this client? 1. Intellectual 2. Environmental 3. Occupational 4. Emotional

Correct Answer: 3 Rationale 1: The intellectual component focuses on learning and using information effectively for personal, family, and career development. It also involves striving for continued growth and learning to deal with new challenges effectively. Rationale 2: Environmental components focus on standards of living and quality of life in the community and include basic human needs such as water, air, and food. Rationale 3: Occupational components deal with a balance between work and leisure time. A person's beliefs about education, employment, and home influence personal satisfaction and relationships with others. Assisting a client in retraining to find gainful employment and to attain satisfaction in his work is part of the occupational component of wellness. Because the client requires retraining, he must learn anew those aspects of a job that allow for growth, which would better fit under the occupational component of wellness. Rationale 4: Emotional components of wellness involve the ability to manage stress and express emotions appropriately.

A charge nurses responsibility include the day-to-day management and coordination of therapies for the clients, client assignments, and scheduling. Which type of management is the charge nurse performing? 1. Top level 2. Middle level 3. First level 4. Upper level

Correct Answer: 3 Rationale 1: Upper-level (same as top-level) managers are organizational executives who are primarily responsible for establishing goals and developing strategic plans. Rationale 2: Middle-level managers supervise a number of first-level managers and are responsible for the activities in the departments they supervise. Rationale 3: First-level managers are responsible for managing the work of nonmanagerial personnel and the day-to-day activities of a specific work group (rehabilitation unit in this case). Rationale 4: Upper-level (same as top-level) managers are organizational executives who are primarily responsible for establishing goals and developing strategic plans.

During the admission interview, the culturally diverse client averts her eyes and refrains from answering questions for long periods of time. The culturally sensitive nurse should take which action? 1. Come back at a different time, when the client is feeling more communicative. 2. Have another nurse finish the interview, as there is something uncomfortable the client senses. 3. Understand that this may be completely appropriate and take cues accordingly. 4. Leave the room and come back after having learned more about this particular culture.

Correct Answer: 3 Rationale 1: The nursing interview is the nurse's responsibility and should not be postponed for what the nurse perceives as the client's reluctance to communicate. Rationale 2: The nurse is responsible for the admission interview and it should not be avoided for reasons of discomfort. Rationale 3: Nonverbal communication includes silence, touch, eye movement, facial expressions, and body posture. Some cultures are quite comfortable with long periods of silence. Many people value silence and view it as essential to understanding a person's needs or use silence to preserve privacy. Before assigning meaning to nonverbal behavior, the nurse must consider the possibility that the behavior may have a different meaning for the client and family. Rationale 4: The admission history cannot be postponed in order for the nurse to improve his or her cultural awareness.

A nurse is conducting a community assessment to determine which diseases are prevalent and most likely to occur. The nurse is basing the assessment on which model of health? 1. Role performance 2. Eudemonistic 3. Ecological 4. Adaptive

Correct Answer: 3 Rationale 1: The role performance model defines health according to how individuals are able to fulfill their roles or perform their work. Rationale 2: The eudemonistic model incorporates a comprehensive view of health, which is seen as a condition of actualization or realization of a person's potential. Rationale 3: The ecological model also called the agent-host-environment model of health and illness is used primarily in predicting illness rather than promoting wellness. Identification of risk factors results from interactions between agent, host, and environment, and is helpful in promoting and maintaining health. Rationale 4: The adaptive model defines health as a creative process and disease as a maladaptation. The aim of treatment is restoration of the person's ability to cope.

A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In describing Healthy People 2010, which goal should the nurse emphasize for this group? 1. Eliminating health disparities 2. Believing that individual health is closely related to community health 3. Increasing quality and years of life 4. Developing partnerships between individual and community health

Correct Answer: 3 Rationale 1: The second goal of Healthy People 2010 is to eliminate health disparities, which reflects the diversity of the entire population, not just the elderly. Rationale 2: The foundation for this document is the belief that individual health is closely linked to community health, and the reverse, but this applies to the entire population, not just the elderly. Rationale 3: Healthy People 2010 has four main goals. The first is to increase quality and years of healthy life, which applies to the clients who will be the focus of this workshop. Rationale 4: The foundation for this document is the belief that individual health is closely linked to community health, and the reverse. In order to bring this about, partnerships are important to improve the health of individuals and communities, but this applies to the entire population, not just the elderly.

Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying? 1. Termination stage 2. Preparation stage 3. Contemplation stage 4. Action stage

Correct Answer: 3 Rationale 1: The termination stage is the ultimate goal, where the individual has complete confidence that the problem is no longer a temptation or threat. Rationale 2: The preparation stage occurs when the person undertakes cognitive and behavioral activities that prepare the person for change. Rationale 3: During the contemplation stage, the person acknowledges the problem, considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. Discussing benefits of a study group would fall into this stage. They haven't started a group, nor have they made any preparation toward it; they have merely been talking about it. Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones.

A nurse manager has the reputation of being an autocratic leader. Which of the following statements by this manager would support that reputation? 1. I'd like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit. 2. I'm putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit. 3. The new work schedule is posted for the next 6 weeks. 4. I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front.

Correct Answer: 3 Rationale 1: This option is more reflective of a democratic style leader. Rationale 2: This option is more reflective of a democratic style leader. Rationale 3: An autocratic leader makes decisions for the group. This style is likened to a dictator in that the autocratic leader gives orders and directions to the group, determines policies, and solves problems without input from the group. Rationale 4: This option is more reflective of a democratic style leader.

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. Confidentiality and privacy laws don't apply to students. 2. Most students review so many records and charts that they could not possibly remember details from any one of them. 3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence. 4. As long as the clinical instructor is in the area, accessing client records is part of the education process.

Correct Answer: 3 Rationale 1: This option is not correct; the laws do apply to students. Rationale 2: Although this may or may not be a true statement, it is not an appropriate response to the student's question. Rationale 3: For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the client's privacy by not using a name or any statements in the notations that would identify the client. Rationale 4: Although this is true, the nursing instructor should not imply that the laws of confidentiality don't apply to students.

A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to health care and live in poverty. According to Dunn's high-level wellness grid, the nurse will be working with clients in which quadrant? 1. Emergent high-level wellness in an unfavorable environment 2. Protected poor health in a favorable environment 3. Poor health in an unfavorable environment 4. Protected poor health in an unfavorable environment

Correct Answer: 3 Rationale 3: According to Dunn's grid, the health axis extends from peak wellness to death, and the environmental axis extends from very favorable to very unfavorable. A health mission to an environment such as rural Haiti would involve clients who are not being treated for problems because of poor access and who also live in poor environmental conditions such as poverty and below standard sanitation.

The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement risk management? Choice 1. Analyzing, classifying, and prioritizing risks Choice 2. Evaluating and modifying risk reduction programs Choice 3. Anticipating and seeking sources of risk Choice 4. Developing a plan to avoid and manage risk Choice 5. Gathering data that indicate success at avoiding or minimizing risk

Correct Answer: 3, 1, 4, 5, 2 Rationale 1: Analyzing, classifying, and prioritizing risks is the second step of the risk management process. Rationale 2: Evaluating and modifying risk reduction programs is the fifth step of the risk management process. Rationale 3: Anticipating and seeking sources of risk is the first step of the risk management process. Rationale 4: Developing a plan to avoid and manage risk is the third step in the risk management process. Rationale 5: Gathering data that indicate success at avoiding or minimizing risk is the fourth step of the risk management process.

A hospital was named in a lawsuit after a client had to undergo a second surgical procedure because an arthroscopy was performed on the wrong knee during surgery. The hospital settled out of court with the client for damages. This is an example of which principle of management? 1. Authority 2. Responsibility 3. Coordination 4. Accountability

Correct Answer: 4 Rationale 1: Authority is defined as the right to direct the work of others. Rationale 2: Responsibility is an obligation to perform a task. Rationale 3: Coordination is a function of management, not one of the principles. Rationale 4: Accountability is the ability and willingness to assume responsibility for one's actions and to accept the consequences of one's behavior. The hospital had a responsibility to the client for quality care and service. That was not provided; therefore, the hospital was willing to accept the consequences of the injury experienced by the client.

The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception

Correct Answer: 4 Rationale 1: Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Rationale 2: Focus charting is organized into data, action, and response sections, referred to as DAR. Rationale 3: SOAP charting is a way to organize data and information in the client's record: S = subjective data; O = objective data; A = assessment; P = plan. Rationale 4: Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE.

A nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet, and has supportive, sound relationships with her spouse and children. According to Dunn's high-level wellness grid, this client would exemplify which health characteristic? 1. Emergent high-level wellness in a favorable environment 2. Emergent high-level wellness in an unfavorable environment 3. Protected health in a favorable environment 4. High-level wellness in a favorable environment

Correct Answer: 4 Rationale 1: Dunn describes a health grid in which a health axis and an environmental axis intersect. The intersection of the two axes forms four quadrants of health and wellness. Emergent high-level wellness in a favorable environment is not part of Dunn's four quadrants of health and wellness. Rationale 2: Dunn describes a health grid in which a health axis and an environmental axis intersect. The intersection of the two axes forms four quadrants of health and wellness. Emergent high-level wellness in an unfavorable environment would be exemplified by a client who has the knowledge to implement healthy lifestyles, but does not implement them because of family responsibilities, job demands, or other factors. Rationale 3: Dunn describes a health grid in which a health axis and an environmental axis intersect. The intersection of the two axes forms four quadrants of health and wellness. Protected health in a favorable environment is not part of Dunn's four quadrants of health and wellness. Rationale 4: Dunn describes a health grid in which a health axis and an environmental axis intersect. The intersection of the two axes forms four quadrants of health and wellness. High-level wellness in a favorable environment involves biopsychosocial, spiritual, and economic resources that support healthy lifestyles.

After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart. 4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it.

Correct Answer: 4 Rationale 1: Erasure, blotting out, or correction fluid should not be used. Rationale 2: Erasure, blotting out, or correction fluid should not be used. Rationale 3: When a mistake is recorded, the correction applies to only the erroneous information, not the entire page. Rationale 4: When a mistake is recorded, a line should be drawn through it and the words mistaken entry written above or next to the original entry, then initial or signature whichever is agency policy. The original entry must remain visible.

A Chinese client is hospitalized with a fever of unknown origin and follows a very traditional, cultural view of illness. Which food should the nurse offer the client? 1. Hot tea 2. Warm soup 3. Spicy meat 4. Cold liquids

Correct Answer: 4 Rationale 1: In this case, the fever would be considered a hot illness and the client is not likely to select this treatment. Rationale 2: In this case, the fever would be considered a hot illness and the client is not likely to select this treatment. Rationale 3: In this case, the fever would be considered a hot illness and the client is not likely to select this treatment. Rationale 4: The concept of yin and yang in the Chinese culture is an example of a holistic health belief. A Chinese client who has a yang illness, or a hot illness, may prefer a yin or cold treatment. In this case, the fever would be considered a hot illness and the client may prefer the opposite or yin treatment.

A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which cultural groups? 1. Latino American 2. Asian American 3. Native American 4. African American

Correct Answer: 4 Rationale 1: Latino Americans view the family as being a major social support system. Rationale 2: Asian Americans view the family as being a major social support system. Rationale 3: Native American people live in social networks that foster mutual assistance and support. Rationale 4: In the African American community, the family and church have been major providers of social support.

The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the client's life. What action is the nurse assisting the client to complete? 1. Lifestyle assessment 2. Social support systems review 3. Health beliefs review 4. Spiritual health assessment

Correct Answer: 4 Rationale 1: Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Rationale 2: A social support systems review takes into account the social context in which a person lives and works and is important in health promotion. This includes individuals, groups, and interpersonal relationships that provide comfort, assistance, encouragement, and information. Rationale 3: A health beliefs review is a clarification of those beliefs that determine how a person maintains control of his or her own health status. Rationale 4: Spiritual health is the ability to develop one's spiritual nature to its fullest potential, including the discovery of how to experience love, joy, peace, and fulfillment. An assessment of spiritual well-being is a part of evaluating the persons overall health.

A new graduate nurse is moving from a small rural college town to a metropolitan area to begin work in a county hospital. The nurse has had limited prior experience with the various cultural groups that are served by the hospital. What might be this nurse greatest challenge? 1. Prejudice 2. Stereotyping 3. Discrimination 4. Assimilation

Correct Answer: 4 Rationale 1: Prejudice is a negative belief or preference that is generalized about a group and leads to prejudging. Rationale 2: Stereotyping is assuming that all members of a culture or ethnic group are alike. Rationale 3: Discrimination occurs when a person acts on prejudice and denies another person one or more of the fundamental rights. Rationale 4: Assimilation is the process by which an individual develops a new cultural identity. Assimilation means becoming like the members of the dominant culture. Because this is a conscious effort, it is not always possible, and the process may cause severe stress and anxiety.

Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis? 1. A child who is used to getting ready for school alone 2. A teenager whose circle of friends includes single parents of the same age 3. An elderly person who has just moved to a long-term care facility 4. A young adult who is in a long-term relationship

Correct Answer: 4 Rationale 1: Psychologic homeostasis is acquired or learned through the experience of living and interacting with others. Individuals can develop psychologic homeostasis if they are in a stable physical environment where they feel safe and secure. A child who is alone while getting ready for school may not feel safe and secure. Rationale 2: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. Having friends of the same age who are parents may eliminate healthy adult role models for the teenager. Rationale 3: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. Moving into a long-term care facility can be a huge adjustment for some people, which may affect feelings of safety and security. Rationale 4: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. A young adult who has a relationship that lasts is the one option that would fit most of these mechanisms.

A home health client participates in cultural health practices that the nurse feels may be detrimental to his health. In order to remain attentive to cultural sensitivity and provide appropriate cultural nursing care, the nurse should take which action? 1. Explain the right and wrong of the client's treatment and try to persuade him to follow the scientific perspective. 2. Have the clients physician explain the care to the client in a firm but gentle manner. 3. Validate the client's practices and understand that for this client, it may be beneficial to continue with his preferences. 4. Try to negotiate with the client by exploring his views and then provide relevant scientific information.

Correct Answer: 4 Rationale 1: Right and wrong terms should be avoided in culturally sensitive areas and where differing views are present. Rationale 2: The nurse, not the physician, is the caregiver in this situation, so it is the nurse's responsibility to teach and see that the plan of care is carried out. Rationale 3: If the clients views can lead to harmful behavior or outcomes, then an attempt is made to shift the client's perspectives to the scientific view. Rationale 4: Negotiation acknowledges that the nurse client relationship is reciprocal and that different views exist of health, illness, and treatment. During the negotiation process, the client's views are explored and acknowledged, then relevant scientific information is provided.

Before providing care, the nurse reviews the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The clients medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex

Correct Answer: 4 Rationale 1: The medical record contains this type of information, but the complete chart is lengthy and would take the student more time to review. Rationale 2: The MAR includes only those medications that are prescribed or scheduled to be administered during the clients stay. It would not include other information like diagnostic tests, daily care, and so on. Rationale 3: The written care plan may be utilized, but there is another more effective option available. Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system is on either an index-type file or a computer-generated form. Information is usually organized into sections: client history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic procedures, allergies, how the client's physical needs are met (type of diet, bathing needs, etc.), and a problem list with stated goals.