Fundamentals Skills Adapative Quizzing
Which standards would the nurse explain are important for critical thinking? Multiple selection question Specific Fairness Relevant Confidence Independence
Specific Relevant The standards important for critical thinking are specific and relevant knowledge about a task. Fairness, confidence, and independence are the attitudes required for critical thinking.
A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? Multiple choice question Plasma Interstitial Dense tissue Body secretions
Interstitial Interstitial fluid constitutes about 16% of body weight, which is 10 to 12 L in an adult male of 68 kg (150 lb). Plasma is 4% of body weight. Dense tissue is part of the intracellular component. Body secretions are derived from extracellular fluid and are calculated as part of the 20% of the total body weight.
The nurse is assessing a Latino-Caribbean patient who was brought to the hospital by family members. The family reports the patient started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? Multiple choice question Bulimia nervosa Anorexia nervosa Shenjing shuairuo Ataque de nervios
Ataque de nervios Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.
A nurse developed and implemented a discharge teaching plan based on the specific needs of a hospitalized client. Which element of decision-making does the primary nurse exhibit in this situation? Multiple choice question Authority Autonomy Responsibility Accountability
Autonomy Autonomy refers to the freedom of making choices and the responsibility for making those choices. A professional nurse can make independent decisions and plan nursing care for a client within the scope of the nursing practice. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to duties and activities an individual is employed to perform. Accountability refers to individuals being answerable for their actions.
According to Swanson's caring process, the nurse must know the client. Which factors enable the nurse to know the client better? Multiple selection question Economic constraints Continuity of care by the nursing staff Fewer nurses in the healthcare facility Collection of data about the client's clinical condition Engagement in a caring relationship without assumptions
Continuity of care by the nursing staff Collection of data about the client's clinical condition Engagement in a caring relationship without assumptions The nurse gets to know the client over time with continuity in care. The nurse enters into a caring process by collecting data about the client's clinical condition. The data enables the nurse to use critical thinking and clinical judgments during client care. The nurse should engage in a caring relationship with the client without any assumptions and use knowledge and experience to detect changes in the client's health condition. Economic constraints may lead to the client spending less time in the healthcare facility. This acts as a barrier in providing client-centered care. Changes in the organizational structure may result in fewer nurses caring for more clients. This results in fewer interactions with the client.
Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? Multiple choice question Evaluation Explanation Interpretation Self-regulation
Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.
The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking? Multiple choice question "The pain is usually present in my fingers and knees." "I observed swelling and redness near the pain area." "I feel the pain in each and every joint of my hands and legs." "I run for 30 minutes every day; this exercise increases my pain."
"I run for 30 minutes every day; this exercise increases my pain." A precipitating factor is an activity or factor that worsens the symptoms. If running for 30 minutes each day increases the client's pain, this action is a precipitating factor. By saying, "The pain is usually present in my fingers and knees," the client is providing information about the location. Swelling and redness are concomitant symptoms of pain. The quality factor indicates the description of the symptom; this is exemplified by the statement, "I feel the pain in each and every joint of my hands and legs."
The registered nurse is teaching a nursing student about how to educate a client who is having trouble adapting to his or her illness. Which statement made by the nursing student indicates the need for further education? Multiple choice question "I should motivate the client's interest in learning." "I should assume that the family is involved." "I should identify the client's willingness to learn." "I should give information about how to perform skills within the home."
"I should assume that the family is involved." The nurse should not assume that the family is involved. The family should be involved in the teaching and the nurse should also provide education to family caregivers. If a client is passive and uninterested in learning, the nurse should motivate the client. The nurse should identify the client's willingness to learn before the session. The nurse should also include information about how to perform skills within the home.
An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is always angry at me." What is the nurse's best initial response? Multiple choice question "Your parent is frightened by impending death." "Your parent is working through acceptance of the situation." "Your parent is attempting to reduce your need for dependency." "Your parent is hurt that you will not provide physical care at home."
"Your parent is working through acceptance of the situation." Understanding the stages leading to the acceptance of death may help the family member understand the client's moods and anger. The parent may not be frightened unless stated by the client; some clients welcome death as a release from pain. It is unlikely that the parent is attempting to reduce the family member's need for dependency; anger is one of the stages of accepting death. It is an assumption by the nurse that the parent is hurt that the family member will not provide physical care at home unless stated by the client.
A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? Multiple choice question Instruct the client to call for help with elimination needs; answer the client's call light immediately to prevent incontinence. Place a waterproof pad under the client to prevent incontinence and soiling the linens. Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. Offer toileting to the client every 2 hours to prevent incontinence.
Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool. Placing a call bell within reach and instructing the client to call for help with elimination needs is not helpful, because the client is confused and unable to use the call bell. Placing a waterproof pad beneath the client helps to prevent soiling of the bed but does not keep feces away from the client's skin and therefore does not prevent skin breakdown. Toileting the client every 2 hours to prevent incontinence is not helpful, because the client is confused and unable to follow commands and has no control over elimination needs
While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? Multiple choice question Encircle the drainage on the dressing. Irrigate the suction tube with sterile saline. Clean the drainage port with an alcohol wipe. Compress the container before closing the port.
Compress the container before closing the port. A portable wound drainage system (e.g., Jackson-Pratt, Hemovac) is compressed before closing the port to reestablish the negative pressure necessary for suction. Encircling the drainage on the dressing is not necessary; a portable wound drainage system usually removes excess drainage before it leaks onto the dressing. Portable wound drainage systems are not irrigated, because this would increase the risk of instilling microorganisms into the wound. The nurse should avoid touching the port, because it is sterile.
Which condition in the client indicates need of nursing care that supports homeostatic regulation? . Multiple selection question Damaged tissue Obstructed airway Poor nutritional status Restricted body movement Altered patterns of urinary elimination
Damaged tissue Obstructed airway Damaged tissue and an obstructed airway indicate that the client needs nursing care that supports homeostatic regulation[1][2] Poor nutritional status, restricted body movement, and altered patterns of urinary elimination indicate that the client is in need of care that supports physical functioning.
While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe? Multiple choice question Dealing with retirement Taking on parental roles Adjusting to a reduction in family size Refocusing on midlife material and career issues
Dealing with retirement A family with members in the later life stage may involve the acceptance of the shifting of generational roles. Therefore, dealing with retirement would be an appropriate change for the family status that requires a developmental proceeding. The acceptance of new generations of members into the system would be associated with the stage of a family with young children; this stage involves taking on parental roles. An adjustment to a reduction in family size would be associated with the family life cycle stage of launching children and moving on. Midlife material and career issues are refocused during the family life cycle stage of adolescence.
A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine to be the cause of the edema? Multiple choice question Decrease in tissue hydrostatic pressure Increase in plasma hydrostatic pressure Increase in tissue colloid osmotic pressure Decrease in plasma colloid oncotic pressure
Decrease in plasma colloid oncotic pressure Because the plasma colloid oncotic pressure is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in colloid oncotic pressure caused by albuminuria results in edema. Hydrostatic tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.
According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? Multiple choice question Anger Denial Bargaining Depression
Denial Denial includes feelings that the healthcare provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.
Which intervention by the nurse helps the family feel in control when the client is to be discharged home? Multiple choice question Instruct the family to ensure the client's room is safe. Ask the family to ensure that the client has only low-fat meals. Ask the family to coordinate with the staff at the rehabilitation center. Ensure a family member is confident about changing dressings correctly.
Ensure a family member is confident about changing dressings correctly. The nurse should identify a family member who is capable and willing to learn how to change the client's dressings. The nurse should teach a family member and have that member demonstrate the process to ensure the procedure is executed correctly. This gives confidence to the client and family, who will feel in control when the client is discharged home. The nurse should not only instruct but also offer suggestions about rearranging the client's room to make it safe. The nurse should offer suggestions and ask the family for ideas on how to prepare low-fat meals that meet their ethnic considerations. The nurse should coordinate with the nursing staff at the rehabilitation center to ensure continuity of care.
A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? Multiple choice question "Inhale completely and exhale in short, rapid breaths." "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." "Exhale halfway, then inhale a rapid, small breath; repeat several times."
Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. When teaching clients, it is important to provide exact step-by-step instructions, thus not leaving out any critical points.
A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? Multiple choice question Assess the strength of the affected leg. Explain the transfer procedure step by step. Instruct the client to bear weight evenly on both legs. Encourage the client to keep the affected leg elevated.
Explain the transfer procedure step by step. The client should understand the steps in the transfer to assist appropriately and avoid injury. Assessing strength in the affected leg is not advisable because it may disrupt the repair of the affected hip; also, weight bearing initially is not permitted on the operative leg. Bearing weight on the affected leg is contraindicated initially. The client may touch the floor with the foot of the affected leg, but may not bear weight on the affected leg. Elevating the leg will cause hip flexion, which is contraindicated initially because it may precipitate hip dislocation.
A client is hospitalized for treatment of severe hypertension. Captopril and alprazolam are prescribed. Shortly after admission, the client says, "I don't think any of you know what you are doing. You are just guessing what I need." What does the nurse determine as the probable cause of this behavior? Multiple choice question Denial of illness Fear of the health problem Response to cerebral anoxia Reaction to the antihypertensive drug
Fear of the health problem Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear. There is no evidence that the client denies the existence of the health problem. Although disorders such as brain attacks and atherosclerosis, which are associated with hypertension, may lead to cerebral anoxia, there is insufficient evidence to support this conclusion. Captopril (an antihypertensive) is a renin-angiotensin antagonist that reduces blood pressure and does not cause behavioral changes; alprazolam is prescribed to reduce anxiety.
What principle must a nurse consider when caring for a client with a closed wound drainage system? Multiple choice question Gravity causes fluids to flow down a pressure gradient. Fluid flow rate is determined by the diameter of the lumen. Siphoning causes fluids to flow from one level to a lower level. Fluids flow from an area of higher pressure to one of lower pressure.
Fluids flow from an area of higher pressure to one of lower pressure A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Newton's law of gravity is not the physical principle underlying the functioning of a portable wound drainage system. Although fluid flow rate is determined by the diameter of the lumen and siphoning causes fluids to flow from one level to a lower level, they are not what cause the fluid to drain in a portable wound drainage system.
The nurse is communicating with an older adult who has a hearing disability. Which intervention by the nurse is beneficial to promote communication? Multiple selection question Giving the client a chance to speak Assuming the client is being uncooperative Chewing gum while talking to the client Making sure that the client knows you are speaking Keeping the communication concise
Giving the client a chance to speak Making sure that the client knows you are speaking Keeping the communication concise When communicating with an older adult who has hearing disability, the nurse should give the client a chance to speak, make sure that the client knows the nurse is talking, and keep the communication concise. The nurse should not assume that the client is uncooperative if he or she does not reply or gives a delayed response. The nurse should also not chew gum while talking because this action may garble the nurse's language.
The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what? Multiple choice question Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia
Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium, resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells, and extracellular fluid and does not result in hyperkalemia.
When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? Multiple choice question It reduces general anxiety. It is negatively affected by aging. It requires continued reinforcement. It necessitates readiness of the learner.
It requires continued reinforcement Neurologic aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.
A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? Multiple choice question Family in later life Family with adolescents Unattached young adult Launching children and moving on
Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.
A client with hyperthyroidism has been treated with radioactive iodine ( 131I) to destroy overactive thyroid gland cells. To reduce radiation exposure, the nurse's principles for providing care should be based on what? Multiple choice question Wearing a lead-shield apron at all times Limiting time with and increasing distance from the patient Wearing a radiation meter to measure exposure Remaining at least 6 feet (1.8 m) away from the client at all times
Limiting time with and increasing distance from the patient When caring for clients who are radioactive, the three most important concepts for reducing radiation exposure are to limit exposure time, increase distance, and use shielding. In this situation, time and distance provide the best reduction in radiation exposure. Wearing a lead-shield apron will help prevent radiation exposure, but time and distance are the first priorities. A radiation meter measures exposure, but does nothing to protect caretakers. Remaining at least 6 feet (1.8 m) away from the client at all times is not a practical approach.
A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief but the client is still reporting pain. Which actions of the nurse would help the client to get relief? . Multiple selection question Learning more about the client Looking for different distraction techniques Using known scientific and practice-based criteria Involving the client's family in creating a new plan for pain relief Bringing co-workers together to find a solution
Looking for different distraction techniques Involving the client's family in creating a new plan for pain relief Looking for a different distraction technique can help the client in pain relief. The nurse should also involve the client's family in adapting new approaches to pain relief. Learning more about the client will not help the nurse provide effective pain relief to the client. Scientific and practice-based criteria are used to perform assessments and evaluations. When some facts about the client are missing, then the nurse brings all the co-workers together to find the solution of the problem.
he nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? Multiple choice question Primary Secondary Superinfection Nosocomial
Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.
What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Multiple selection question Refrain from smoking around the infant. Refrain from co-sleeping or bed-sharing. Position the infant on the side while sleeping. Use soft pillows to support the infant while sleeping. Refrain from placing stuffed toys on the infant's bed.
Refrain from smoking around the infant. Refrain from co-sleeping or bed-sharing. Refrain from placing stuffed toys on the infant's bed. The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS
The nurse is assisting a client in labor. Which intervention should the nurse perform as soon as the newborn is delivered? Multiple choice question Remove nasopharyngeal secretions Cover the newborn in a warm blanket Determine the newborn's Apgar score Place the newborn directly on the mother's abdomen
Remove nasopharyngeal secretions The most important intervention immediately after the newborn is delivered is to maintain an open airway. The nurse must first remove the nasopharyngeal and oropharyngeal secretions with a suction or a bulb syringe to ensure airway patency. Newborns are easily susceptible to heat loss and cold stress. Therefore, the nurse should wrap the newborn in a warm blanket. An Apgar assessment is generally conducted between one and five minutes after birth. A healthy newborn may be placed directly on the mother's abdomen and covered in warm blankets after a patent airway is maintained. These three interventions should be performed after the newborn's airways are cleared.
A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? Multiple choice question Social Physical Materialistic Environmental
Social Without some form of communication, there can be no socialization. People interact with other social beings, not with inanimate objects. Physical, materialistic, and environmental surroundings are all inanimate and cannot interact.
A patient reports that the patient's family members are pressuring the patient to attend physical therapy sessions. What does the nurse infer from this report? Multiple choice question The patient is not motivated. The patient is intrinsically motivated. The patient is extrinsically motivated with self-determination. The patient is extrinsically motivated without self-determination.
The patient is extrinsically motivated without self-determination. If the patient participates in an activity as a result of family pressure and does not understand the importance of the activity, the patient is said to be extrinsically motivated without self-determination. If the patient is not motivated, she would likely not participate in the activity regardless of family pressure. If the patient is intrinsically motivated, she would participate in the activity irrespective of external pressure. If the patient is extrinsically motivated with self-determination, she would likely interpret her family's advice as encouragement and actively participate in the therapy sessions.
A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? Multiple choice question Tubing injection port Distal end of the tubing Urinary drainage bag Catheter insertion site
Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.
To prevent septic shock in the hospitalized client, what should the nurse do? Multiple choice question Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.
Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.
What type of functional health pattern would the nurse explain describes values and goals? Multiple choice question Value-belief pattern Role-relationship pattern Self-perception-self-concept pattern Health perception-health management pattern
Value-belief pattern Value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client for making choices or decisions. The role-relationship pattern includes the description of the client's patterns in role engagements and relationships. In the self-perception-self-concept pattern, the nurse may describe the client's self-concept pattern and perceptions of self. It involves self-concept/worth, emotional patterns, and body image. Health perception-health management pattern is associated with the description of the client's self report of health and well-being.
What is the most important nursing action involved in caring for a client using medications to manage disease? Multiple choice question Administering the medications Teaching about the medications Ensuring adherence to the medication regimen Evaluating the client's ability to self-administer medications
Administering the medications The most important part of the nursing practice regarding medication is administering the medications. Administering medications safely requires an understanding of the legal aspects of healthcare, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, ensuring adherence to the medications, and evaluating the client's ability to self-administer medications are responsibilities of the nurse performed before or after the administration of medicines.
Which risks would the nurse state may be associated with adults who work on or around automobiles? . Multiple selection question Infertility Asbestosis Dermatitis Skin cancer Nasopharyngeal cancer
Asbestosis Dermatitis Automobile workers are at greater risk of asbestosis (a lung disease resulting from the inhalation of asbestos particles) and dermatitis (skin becomes red, swollen, and sore, sometimes with small blisters). A worker exposed to anesthetics is at greater risk of reproductive effects, such as infertility. Agricultural workers are at risk of skin cancer. A carpenter may have a high risk of nasopharyngeal cancer.
A client requests information about the prescribed medication regimen. What is the best response by the nurse? Multiple choice question Give a computer printout about the medication to the client. Ask the client to state what is already known about the medication. Advise talking to the primary healthcare provider to seek information about the medication. Delegate the task of sharing information about the medication to the licensed practical nurse.
Ask the client to state what is already known about the medication. Assessing the client's knowledge to delineate baseline information should be done before planning appropriate health teaching. Providing written material without knowing the client's ability to read is inappropriate; also, it limits the nurse's personal involvement in the teaching process. Having the client talk with the healthcare provider avoids carrying out the nurse's responsibility to provide teaching about a prescribed medication regimen. Health teaching about medication is the responsibility of the registered professional nurse.
The nurse in the emergency department identifies that the admission consent form signed by a critically ill client is not legible. Which statement best reflects the status of this consent? Multiple choice question Consent is legal. Signature is illegal. Critically ill clients cannot sign a consent form. Family members should sign for clients whose signatures are illegible.
Consent is legal. If a competent adult gives informed consent and the signature is witnessed, it is a legal document even if the signature is illegible or the client is critically ill. The signature is legal even if it is illegible. The signature is legal even if the client is critically ill. A cosignature is not required as long as the client is competent and the signature is witnessed.
A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate? Multiple choice question Core rewarming with warm fluids Ambulation to increase metabolism Frequent oral temperature assessments Gastric tube feedings to increase fluid volume
Core rewarming with warm fluids Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.
A client complains to the nurse that a staff member did not respond to the client's call. The nurse politely reassures the client, and makes the client comfortable. The nurse speaks to the staff member about the incident and solves the problem. Which critical thinking attitude has the nurse demonstrated in this situation? Multiple choice question Fairness Discipline Confidence Responsibility
Fairness Listening to both sides of the story, in this situation, listening to the client and the staff member regarding the client's complaint indicates fairness. The nurse collects inputs from both parties involved before coming to a conclusion. Taking time to become thorough and managing time effectively reflects discipline in critical thinking. Encouraging the client to ask questions reflects confidence. Following the correct standard of practice in care reflects responsibility.
Which carative factor of Watson's transpersonal caring theory is reflected when the nurse practices loving kindness in practice? Multiple choice question Instilling faith-hope Forming a human-altruistic value system Cultivating sensitivity to one's self and others Promoting and expressing positive and negative feelings
Forming a human-altruistic value system A human-altruistic value system is formed in nursing practice by using loving kindness. The nurse should use self-disclosure appropriately to promote a therapeutic alliance with the client. The carative factor "instilling faith-hope" includes providing a connection with the client. It offers purpose and direction to the nurse-client relationship. While cultivating sensitivity to one's self and to others, the nurses should learn to accept him- or herself and others. For promoting and expressing positive and negative feelings, the nurse should accept and support the client's feelings.
A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? Multiple choice question Have the client void every 2 hours. Maintain the client in an isolation room. Spend time with the client to allow verbalization of feelings. Wear two pairs of gloves when touching the client during care.
Maintain the client in an isolation room. During radiation therapy with radium implants, the client is placed in isolation so that exposure to radiation by family and staff is decreased. Voiding every 2 hours is unnecessary; a full bladder will not disrupt the seeds. Excess exposure to radiation is hazardous to personnel. Gloves will not protect the nurse from radiation.
What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? Multiple choice question Highly active Irritable and irregular in habits Negative reaction to new stimuli A positive mild-to-moderately intense mood
Negative reaction to new stimuli A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.
The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant? Multiple choice question Cognitive age Past coping styles Financial resources General physical health
Past coping styles Lifelong coping styles are most important in how a person will deal with stress. Age may influence defense mechanisms, but lifelong coping styles will most significantly affect a person's behavior. Financial resources are a factor to be considered, but past coping ability is the most significant factor to predict future coping. General physical health is a factor to be considered, but past coping ability is the most significant factor to predict future coping.
A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? Multiple choice question Suddenness of the change Obviousness of the change Extent of the change Perception of the change
Perception of the change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.
A client is undergoing radiation therapy. The nurse reassures the client and stays with the client throughout the therapy. Which caring behavior does this nursing action reflect? Multiple choice question Touch Spiritual caring Knowing the client Providing presence
Providing presence The nursing action of providing reassurance and being with the client reflects the caring behavior "providing presence." Providing presence conveys closeness and a sense of caring. Touch conveys concern and support to the client. Spiritual nursing care involves establishing the client's well-being through the individual's beliefs and expectations. Knowing the client involves understanding the client's needs and planning interventions accordingly.
The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? Multiple choice question Upright at 90 degrees Supine position Raised to 30 degrees Raised to 10 degrees
Raised to 30 degrees Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees, or at 10 degrees.
Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? Multiple choice question Listening Spiritual caring Providing presence Relieving pain and suffering
Relieving pain and suffering Relieving pain and suffering is not just about giving medications but providing comfort, dignity, respect, and peace to a client. Listening helps to obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps to convey closeness and a sense of caring.
The nurse listens to and validates the feelings expressed by a confused older adult. Which elements does the nurse convey in this situation? Multiple selection question Recalling Respecting Reassuring Reinforcing Understanding
Respecting Reassuring Understanding Validation therapy is an alternative approach to communication with a confused older adult. By listening with sensitivity to the client and validating what the client is expressing, the nurse conveys respect, reassurance, and understanding. Recalling is related to reminiscence. Reinforcing is not related to validation.
Which nursing actions may help in effective assessment of older clients? Multiple selection question The nurse makes eye contact with the client. The nurse leans backward during the interaction. The nurse smiles at the clients during the interaction. The nurse shrugs her shoulders in response to a client's question The nurse asks the clients to express details as quickly as possible.
The nurse makes eye contact with the client. The nurse smiles at the clients during the interaction The nurse should make eye contact while interacting with the client. It shows that the nurse is interested to hear client issues. The nurse shows positivity and of good humor with a smile during an interaction. The nurse should lean forward while interacting with the client; this shows attention and interest. The nurse should answer questions verbally, not simply with body language. Older adults may need time to think and answer; therefore, the nurse should allow pauses and time while asking client to explain anything.
Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? Multiple choice question Reminiscence Reality orientation Validation therapy Therapeutic communication
Validation therapy Validation therapy is the psychosocial concern involved in accepting the descriptive statements made by a confused older client. Reminiscence is recalling the past. Reality orientation involves helping a confused older client agree with the nurse's statements. Therapeutic communication enables the nurse to perceive and respect the older client's uniqueness and healthcare expectations.
Which feature is most likely related to entry-level nurse competencies? Multiple choice question Motivating others Setting the objectives and guiding the staff Using a participatory approach in decision-making Working as a team member and collaborating with other team members
Working as a team member and collaborating with other team members The entry level nurse competency involves the nurse working as a team member and collaborating with other team members. A nurse leader motivates others, set the objectives, guides the staff, and shows a participatory approach in the decision-making process.
A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what? Multiple choice question Serum sodium Urinary output Hematocrit level Serum potassium
Urinary output As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.
Which nursing intervention is performed for a middle-aged adult in restorative and continuing care? Multiple choice question Establishing independence Focusing on problems related to sense of identity Reorganizing intimate relationships and family structure Determining the coping mechanisms of the client and the family
Determining the coping mechanisms of the client and the family The nurse should determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.
A nurse should employ which technique to maintain surgical asepsis? Multiple choice question Change the sterile field after sterile water is spilled on it. Put on sterile gloves and then open a container of sterile saline. Place a sterile dressing no more than half an inch from the edge of the sterile field. Clean the surgical area with a circular motion, moving from the outer edge toward the center.
Change the sterile field after sterile water is spilled on it. A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the field. The outsides of containers and packages are not considered sterile, and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.
The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? Multiple choice question Place the client in a semi-Fowler position. Stand behind the client during the transfer. Turn the chair so it faces away from the bed. Instruct the client to dangle the legs.
Instruct the client to dangle the legs The nurse should place the client in high-Fowler position, or 80 to 90 degrees, and then assist the client to the side of the bed. Next, the nurse helps the client sit on the edge of the bed and then instructs the client to dangle the legs. The nurse then faces the client and places the chair next to and facing the head of the bed. The semi-Fowler, or 30 to 45 degrees, position is not high enough to get the client in a sitting position.
A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? Multiple choice question Teaching how to make a room allergy-free Referring to a support group for individuals with asthma Arranging with the college to ensure a speedy return to classes Evaluating whether the necessary lifestyle changes are understood
Evaluating whether the necessary lifestyle changes are understood Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.
A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what? Multiple choice question Providing instructions about restraints used during the procedure Administering a Fleet enema 1 hour before the procedure Encouraging increased intake of clear fluids Administering morphine 30 minutes before the procedure
Administering a Fleet enema 1 hour before the procedure To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A Fleet or tap water enema should be used. Restraints are not typically used during the procedure. The client will be kept nothing by mouth (NPO) for at least 8 hours before the procedure. Morphine is not typically used as a preoperative medication before a sigmoidoscopy.
A nurse preparing to apply restraints to a client should understand which of the following principles? Multiple choice question The law prohibits restraining clients until a written prescription is obtained. A felony charge may be leveled against nurses who use restraints improperly. Nurses are not obligated to report institutions that use restraints unlawfully. Charges of assault and battery may be leveled against nurses who use restraints improperly.
Charges of assault and battery may be leveled against nurses who use restraints improperly. Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid primary healthcare provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint prescriptions may differ from state to state and in different settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to report institutional misuse of restraints, because this may constitute false imprisonment and abuse.
Which are extrinsic factors responsible for falls in older adults? Multiple selection question Impaired vision Cognitive impairment Environmental hazards Inappropriate footwear Improper use of assistive devices
Environmental hazards Inappropriate footwear Improper use of assistive devices Environmental hazards, inappropriate foot wear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.
Which concept refers to respecting the rights of others? Multiple choice question Maturity Systematicity Inquisitiveness Open-mindedness
Open-mindedness Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on one's own judgments and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.
Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Multiple selection question Prayer Hypnosis Medication Aromatherapy Guided imagery
Prayer Hypnosis Aromatherapy Guided imagery Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.
According to Kohlberg's development of moral reasoning, at which phase of life would a child develop premoral orientation? Multiple choice question Preschool Adolescence Middle childhood Early childhood/toddler
Preschool The preschool stage, from 3 years up to 5 years, is characterized by development of premoral orientation according to the Kohlberg's stages of moral development. The adolescence period, called the postconventional level, involves development of social contract orientation. The middle childhood period, from the age of 6 to 12 years, is called the conventional level, and involves development of good boy-nice girl orientation. Toddlers are considered to be in the preconventional level, characterized by development of punishment-obedience orientation.
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? Multiple choice question Right task Right person Right supervision Right communication
Right communication Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations while delegating a task. Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person is delegating a task to the correct person who has the ability to perform said task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? Multiple choice question Sodium Potassium Chloride Calcium
Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.
A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? Multiple choice question Blended family Extended family Alternative family Single-parent family
The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. A single-parent family is formed when one parent cares for the children following the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.
During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding? Multiple choice question The nurse restores the client's sense of reality. The nurse builds self-esteem by asking about a client's previous achievements. The nurse agrees to a confused client's incorrect statement. The nurse meets the expressed and unexpressed needs of the client.
The nurse builds self-esteem by asking about a client's previous achievements. Reminiscence theory involves helping the client to recall past experiences to help resolve current conflicts. A nurse who builds a client's self-esteem by asking about his or her previous achievements is using the theory. Reality orientation is associated with the restoration about the sense of reality. Validation therapy is associated with agreeing with a confused older client's incorrect statement. The nurse may use therapeutic communication to address the expressed and unexpressed needs of the client.
While interacting with an older adult, the nurse leans towards the client. What does this posture convey? Multiple choice question The nurse is relaxed and comfortable with the client. The nurse is involved and interested in the interaction. The nurse is there to listen and is interested in what the client is saying. The nurse is involved and has willingness to listen what the client is saying.
The nurse is involved and interested in the interaction. Leaning towards the client conveys that the nurse is involved and interested in the interaction. Sitting in a relaxed way conveys that the nurse is relaxed and comfortable with the client. If the nurse sits facing to the client, this posture conveys that the nurse is there to listen and is interested in what the client is saying. If the nurse maintains intermittent eye contact, this posture conveys the nurse's involvement in and willingness to listen to what the client is saying.
The nurse is caring for a client who got discharged from the hospital. The nurse finds that the client is having difficulty in determining which medications to take. What would be the best nursing intervention in this situation? Multiple choice question The nurse fills and labels the medication bottles. The nurse advises the caregiver to support the client in taking medication. The nurse recommends the client's pharmacy to re-label the medication in large letters. The nurse shows the client examples of pill organizers that will help the client to sort the medication.
The nurse recommends the client's pharmacy to re-label the medication in large letters. The nurse should recommend the client's pharmacist to re-label the medications in large letters so that the client can easily read the name of the medicine and can take the medications properly. The nurse should show the client examples of pill organizers that will help the client to sort the medications by the time of day for a period of seven days. The nurse does not need to fill the medication bottles or label because this action is already done by pharmacist when the client picks up the medicine from the pharmacy. Because the caregiver will not be with the client all day, the client should learn to take medication on his or her own.
The nurse is teaching the parent of an infant about inspecting the crib before putting an infant to sleep. Which statement made by the parent indicates a need for further education? Multiple choice question "I should remove mobiles from the infant." "I should attach crib toys with hanging strings." "I should check whether the crib's mattress fits snugly." "I should disassemble and throw away the unsafe cribs."
"I should attach crib toys with hanging strings." Parents should check whether the crib toys are attached firmly with no hanging strings. The mobile should be removed from the infant as soon as he or she is able to reach mobiles. Parents should check whether the crib's mattress fits snugly. Unsafe cribs should be disassembled and thrown away.
Which action demonstrates the "analyticity" concept of a critical thinker? Multiple selection question The nurse is organized and focused. The nurse trusts one's own reasoning process. The nurse accepts multiple solutions to a problem. The nurse uses evidence-based knowledge for clinical decision-making. The nurse anticipates possible results or consequences in a given situation.
The nurse uses evidence-based knowledge for clinical decision-making. The nurse anticipates possible results or consequences in a given situation. Analyticity is one of the concepts of a critical thinker and involves the use of evidence-based knowledge for clinical decision-making. This skill may also help in anticipating possible results or consequences of a procedure or a given situation. Being organized and focused reflects systematicity. Trusting one's own reasoning process reflects self-confidence. Accepting multiple solutions to a problem reflects maturity.
The nurse reviews the medical record of a patient who is eligible to receive end-of-life care. What are the criteria for a patient to receive this type of care? Multiple selection question When the patient is nearing death When the expected death of the patient is within 6 months When the patient seeks no aggressive disease management When a family member has signed an informed consent form When the patient has been issued a "do not resuscitate" order
When the expected death of the patient is within 6 months When the patient seeks no aggressive disease management When the patient has been issued a "do not resuscitate" order Patients who do not seek aggressive disease management and are expected to die in a span of 6 months are eligible for end-of-life care. The patient may require end-of-life care when he or she has signed a "do not resuscitate" order. A patient who is nearing death may not receive end-of-life care; instead, the patient receives comfort care. An informed consent form signed by a family member is not necessary for the patient to receive end-of-life care.
