Fundamentals Week 2 Test 1 Material

A 44-year-old client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which values? A. Urine output of 1500 mL in 24 hours B. An elevated hematocrit level C. An elevated urine specific gravity D. Oral intake of 1500 mL in 24 hours

A

A client from a minority culture has been hospitalized for 6 days for postoperative infection. The client's weight is decreasing each day, and the nutritional intake is declining. Which nutritional assessment question is most appropriate? A. "What type of food do you eat at home?" B. "Why aren't you eating your food?" C. "Are you aware that you are losing weight?" D. "Don't you like what is on your food tray?"

A

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? A. trochanter rolls B. foot splints C. roller sheets D. foot boards

A

A family recently immigrated to a new country. The parent reports that the teenager is showing signs of fear, has vague reports of stomach pain, and feels humiliated by peers because of their culture. What is the priority assessment for the nurse? A. Culture shock B. Cultural blindness C. Cultural assimilation D. Cultural imposition

A

A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices? A. A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest. B. A Native American/First Nations man stares at the floor while talking with the nurse. Assumption: The client is embarrassed by the conversation. C. A Black man rolls his eyes when asked how he copes with stress in the workplace. Assumption: He may feel he has already answered this question and has become impatient. D. A Hasidic Jewish man listens intently to a male physician, making direct eye contact with him, but refuses to make eye contact with a female nursing student. Assumption: Jewish men consider women inferior to men.

A

A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change? A. The client states, "I feel like I abandoned my religion." B. The client states, "I am glad that nurse told me what to do." C. The client states, "Why isn't blood administration forced on all who need that treatment?" D. The client states, "I can't get over my feelings of legalism as a Jehovah's Witness."

A

A nurse is assessing a family and identifying where the family is in the family life cycle. During this assessment, the nurse applies Duvall's theory. Which theory forms the basis for Duvall's theory? A. Erikson's theory of psychosocial development B. Piaget's theory of cognitive development C. Kohlberg's theory of moral development D. Freud's psychoanalytic theory

A

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? A. Obtain a three-prong grounded plug adapter. B.Use an extension cord to provide freedom of movement. C. Run the electrical cord of the pump under the carpet. D. Tape the electrical cord of the pump to the floor.

A

A nurse is working in a clinic that serves a community with a high population of immigrants. Which nursing assessment is the priority? A. Language assessment B. Blood sugar assessment C. Blood pressure assessment D. Spiritual assessment

A

A nurse overhears another nurse make a statement that indicates racism. The nurse makes this determination based on which characteristic indicative of social value? A. Skin color B. Language C. Size D. Dress

A

During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs? A. Physiologic B. Safety and security C. Love and belonging D. Self-esteem

A

In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which principle? A. The client may have a very different understanding of health promotion. B. The nurse should avoid performing health promotion education if this is not a priority in the client's culture. C. A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development. D. Health promotion is a concept that is largely exclusive to Western cultures.

A

It is time for a nurse to renew licensure. The nurse says, "I need some really easy and quick continuing education hours. I don't understand why we have to do these every year." What is the nurse's coworker's best response? A. "Life-long learning is part of the code for nurses." B. "It is hard to get enough hours since we work full time and have families." C. "There is lots of free continuing education online." D. "See if any of the classes we have to take at the hospital each year will count."

A

The nurse is assessing an older adult who immigrated at the age of 3 years. The client speaks the dominant language and lives in a neighborhood with many households from the country of origin. Which action by the nurse is most appropriate? A. Ask the client about special cultural beliefs or practices. B. Contact the client's oldest son to assist with healthcare decision making. C. Avoid direct eye contact with the client when speaking. D. Contact a shaman as part of culturally competent care of the client.

A

The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse? A. "We can wait until your spiritual healer arrives and work together to answer these questions." B. "I will leave the questionnaire here. Please fill it out when your spiritual healer arrives." C. "These questions need to be answered so we can provide you with the best care." D. "I can wait until your spiritual healer arrives, but you are the only one who can answer these questions."

A

The parents of a blended family have a baby boy age six months who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which type of factor is the primary influence on this aspect of the family's health? A. Community health care structure B. Lifestyle influences C. Economic factors D. Family risk factors

A

The use of one's culture as a cultural standard is known as: A. ethnocentrism. B. culture. C. cultural relativity. D. ritualism.

A

When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response? A. Ask the client about personal space preferences. B. Back away from the client. C. Ask the client why he or she is backing away. D. Move closer to the client.

A

Which nursing action displays linguistic competence? A. Learning pertinent words and phrases in the client's language B. Asking a family member to interpret for a client who does not speak the dominant language C. Speaking loudly to a client who does not speak the dominant language D. Repeating English statements to a client who speaks Spanish

A

A nurse is caring for a 79-year-old client who is new to a long-term care facility. Previously, the client lived in a rural community in a household consisting of the client and an adult child. The child is no longer able to care for the client. The client appears disoriented and reports being bothered by the "bright lights and constant activity." The nurse appropriately documents what condition in the chart? A. Culture shock B. Culture blindness C. Culture assimilation D. Culture disorientation

A ?

What factors must the nurse consider when creating a holistic plan of care? (Select all that apply.) A. The client's developmental life stage B. The client's emotional context C. The client's conceptual integration of life D. The client's physiologic health condition E. The client's physical environment

A, B, D

Which behaviors demonstrated by the client would the nurse consider reflections of the client's pride in ethnicity? Select all that apply. A. Asking to wear unique clothing B. Requesting assistance when transferring from bed to chair C.Requesting native cuisine D. Crying when given a diagnosis of cancer E. Listening to folk music and dance

A, C, E

The nurse is providing discharge information to the mother of a 4-year-old who was just diagnosed with influenza A. Which comments, made by the mother, indicate a potential problem in this child's future care? Select all that apply A. "How much does this antibiotic cost?" B. "I guess we will have to miss going to the movies this week." C. "She had her flu shot one week ago." D. "I have already missed two day's work because I was sick." E. "You will get to stay at grandma's house while I am at work."

A, D

Which factors contribute to the concept of a culture? Select all that apply. A. Beliefs about health practices B. Styles used for communication C. Items and clothing worn D.Type of disease contracted E. Language F. Art and music

All except D

A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision? A. Confidentiality B. Autonomy C. Beneficence D. Justice

B

A client is seeking care at the local clinic. The nurse is completing a cultural assessment. Which scenario would demonstrate cultural assimilation?A. The client and child cook traditional foods for the family. B. The client's child learned the dominant lanuguage as a second language. C. The client enjoys watching television programs from the home country. D. The client does not speak the dominant language and requires an interpretor.

B

A home health nurse is visiting a family after the recent death of their matriarch. The nurse observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function? A physical function B. affective and coping functions C. socialization function D. economical function

B

A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of the head, and multiple 1-cm round scabs and blisters on the upper back. The parents state that their child sustained the injuries by falling out of a high chair. What is the best action for the nurse to take? A. Document the suspected child abuse in the child's health care record. B. Report the suspected child abuse to Child Protective Services. C. Ask the physician to question the parents about the suspected child abuse. D. Refer the child and the family to social services for follow-up.

B

A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address? A. Self-actualization needs B. Self-esteem needs C. Safety and security needs D. Love and belonging needs

B

The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response? A. Explain to the client that the client is required to make all decisions related to the client's own health care. B. Document the client's request in the nursing care plan. C. Bring the client's spouse into the hallway to discuss surgical options for the client. D. Explain to the client that it is not a good idea to have the spouse in the room when discussing such a private matter.

B

The clinic nurse is obtaining demographic data from a client. The client states, "Why do you need to know what my ethnicity is?" How should the nurse respond? A. "Insurance companies requires us to ask all clients." B. "Collecting this information allows us to develop a personalized plan of care to meet your needs." C. "Understanding your background will prevent us from doing anything to offend you." D. "We require the information for identification purposes."

B

The nurse has just attended a seminar on concepts of cultural diversity. Which statement made by the nurse would require further education? A. "Culture helps to define identity within specific groups of people." B. "Culture cannot be influenced, and you are born with your culture." C. "Culture can be seen in attitudes and institutions of certain populations." D. "Language is the primary way that people share their culture."

B

The nurse is teaching a black client about common health conditions. Which statement by the client most directly addresses a health problem with an increased incidence in this population group? A. "I need to watch the amount of sugar that I eat." B. "It is important to monitor my blood pressure." C. "Increasing dairy will improve my bones." D. "Getting a mammogram in my thirties is important."

B

The nurse just attended a seminar on cultural diversity. Which statement by the nurse would require further education? A. "People of the same ethnicity share many of the same cultural and social beliefs." B. "Ethnicity and race are the same thing and are affected by cultural practice." C. "Ethnicity begins at birth or through adoption of characteristics." D. "Ethnicity can often determine dialect and political interests."

B

The staff nurse overhears the charge nurse, who is of Italian heritage, talking to the unlicensed assistive personnel. Which statement made by the charge nurse is an example of ethnocentrism? A. "People who are Irish are usually alcoholics." B. "Italians are best at everything." C. "Hispanics are usually lazy." D. "Asian people are bad drivers."

B

What is the priority assessment for the nurse when developing a plan of care for a client living in poverty? A. Access to affordable housing B. Access to care C. Access to health insurance D. Access to financial assistance

B

Which scenario is an example of cultural competence in nursing? A. Assessing the rate at which an illness causes death in a culture B. Attending a conference for cultural diversity C. Assuming the provider and the client share beliefs and values D.Attending one's own church

B

Which actions by the nurse demonstrate the ethical principle of fidelity? Select all that apply. A. Taking scheduled breaks on time B. Maintaining current nursing registration and meeting continuing education requirements C. Performing an intervention for a client at the time that was promised D. Calling in sick due to a lack of sleep E. Taking an extra client assignment so that the client will be cared for

B, C, E

A nurse gives the 400 IU of a vitamin supplement that was in the client's medications instead of the 200 IU that was prescribed. The dosage was given when the unit was busy admitting three clients and another client was in crisis. Which action(s) by the nurse demonstrate the professional value of integrity? Select all that apply. A. The nurse says, "This is not fair, we are so busy." B. The nurse documents the dose given. C. The nurse blames the pharmacy for the error on the prescription. D. The nurse dismisses the dose difference, because it is not critical. E. The nurse completes a variance or incident report.

B, E

Assessing the rate at which an illness causes death in a culture Attending a conference for cultural diversity Assuming the provider and the client share beliefs and values Attending one's own church A. Ask the client's adolescent child to answer questions. B. Request assistance from a certified interpreter. C. Have a bilingual nurse assist with the health history. D. Speak in detailed sentences using exact medical terminology. E. Use the facility telephonic interpreting system.

B,C,E

A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the: A. genetics. B. past history. C. media. D. nursing personality.

C

A family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which aspect of the family's structure and function would be considered a psychosocial risk factor? A. The mother has a history of heavy alcohol use. B. The family lives in a small apartment in a poor neighborhood with high crime rates. C. The parents have a tumultuous relationship, with frequent separations in the past. D. The family's electricity has been cut off at various times due to nonpayment

C

A nurse is providing care to a client who is from a different culture. Which aspect about culture would be most important for the nurse to integrate into the client's care? A. Individuals learn culture in a purposeful manner. B. Culture is relatively static and unchanging. C. Not all members of the same culture act and think alike. D. Individuals can easily describe their culture.

C

A nurse is providing care to a client with end-stage cancer. After weighing the alternatives, the client decides not to participate in a clinical trial offered and is requesting no further treatment. The nurse advocates for the client's decision based on the understanding that the client has the right to self-determination, interpreting the client's decision as reflecting which ethical principle? A. Fidelity B. Beneficence C. Autonomy D. Justice

C

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating? A. Autonomy B. Altruism C.Integrity D. Social justice

C

A staff nurse meets with the charge nurse and is reporting that all the new nurses are leaving messes on the unit. The staff nurse states, "These youngsters think they can waltz in here and get our jobs." What is this nurse demonstrating? A. Cultural diversity B. Cultural assimilation C. Cultural conflict D. Cultural blindness

C

The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take? A. Reorient the client to person, place, and time. B. Notify the physician. C. Position the client in a side-lying position. D. Document the type of seizure in the client's health record

C

The nurse is caring for a client who perceives time differently. What action should the nurse take for this client? A. Have the client set all times for the interventions. B. Perform interventions at random times during shift. C. Maintain flexibility when the client requests interventions at specific times. D. Set all interventions to be done at specific times.

C

The nurse is preparing to administer prescribed medication to a client who is Native American/First Nations. The nurse enters the room and observes a shaman performing a healing ritual for the client. What action would be the most appropriate by the nurse? A. Ask the shaman to leave the room. B. Administer the medication while the shaman continues the ritual. C. Leave the room and return when the shaman is finished. D. Wait in the room until the shaman is done.

C

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action? A. Apply extra gauze dressings to the wound to absorb the drainage. B. Use sterile gloves to change the abdominal dressing. C. Wash the nurse's hands before and after the dressing change. D. Change the abdominal dressing more frequently.

C

The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study? A. Food B. Cold air C. Witchcraft D. Impurities in water

C

When an American client states, "I only want an American doctor," the client is expressing: A. cultural relativity. B. racism. C. ethnocentrism. D. cultural pervasiveness.

C

Which nursing intervention reflects culturally appropriate care when addressing a client? A. "You can sit in this chair, Sally." B. "Thank you for coming to the clinic today." C. "Good morning, Mr. Smith. I am your nurse, John." D. "I see you are here because you have a sinus infection."

C

A client believes that the illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating? A. Stereotyping B. Cultural diversity C. Ethnocentrism D. Cultural blindness

D

A client is admitted with end-stage pancreatic cancer and is experiencing extreme pain. The client asks the nurse whether an acupuncturist can come to the hospital to help manage the pain. The nurse states, "You won't need acupuncture. We have pain medications." Which characteristic has the nurse displayed? A. Culture shock B.Stereotyping C. Cultural conflict D. Cultural imposition

D

A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with the client in a one-bedroom apartment. Which consideration is the priority nursing concern? A. The client receives government assistance. B. The client has no hope for the future. C. The client does not have air-conditioning. D. The client does not have running water.

D

A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family? A. "We've taught our kids to be assertive when appropriate." B. "We've encouraged our kids to talk to us about sex and sexually transmitted infections." C. "All of us have faced problems along the way but we've worked them out." D. "Our 16-year-old just seems to butt heads with us at every turn."

D

A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of: A. cultural competence. B. cultural stereotyping. C. ethnocentrism. D. cultural ritual.

D

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

D

The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs? A. Self-actualization B. Love and belonging C. Self-esteem D. Safety and security

D

The nurse just attended a seminar on cultural diversity. Which statement by the nurse would require further education? A. "People of the same ethnicity share many of the same cultural and social beliefs." B. "Ethnicity can often determine dialect and political interests." C. "Ethnicity begins at birth or through adoption of characteristics." D. "Ethnicity and race are the same thing and are affected by cultural practice."

D

Which scenario is an example of cultural competence in nursing? A. Assessing the rate at which an illness causes death in a culture B. Assuming the provider and the client share beliefs and values C. Attending one's own church D. Attending a conference for cultural diversity

D

When completing a transcultural assessment of communication, which assessment by the nurse is most appropriate? A. Assessment of religious beliefs and prayer schedules B. Assessment of income level to determine poverty status C. Assessment of racial identification and cultural affiliation D.Assessment of eye contact, personal space, and social taboos

D *communication is your "CLUE" word

A group of girls is camping in the woods with camp counselors. They should be instructed to: A. run on smooth surfaces. B. use the buddy system. C. eat nutritious foods. D. get adequate amounts of sleep.

B

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? A. The nurse details the client's response and the examination and treatment of the client after the incident. B. The nurse calls the primary health care provider to fill out and sign the safety event report. C. The nurse adds the information in the safety event report to the client health record. D. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident.

A

A nurse is providing care to a client who is feeling lonely and isolated. In an effort to develop a trusting nurse-client relationship, the nurse exhibits a caring attitude, ensures the client's privacy, and spends time with the client to promote therapeutic communication. The nurse is meeting which category of client needs? A. Love and belonging B. Self-esteem C. Physiologic D. Safety and security

A

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? A. Pull the fire alarm lever. B. Extinguish the fire. C. Evacuate the unit. D. Confine the fire.

A

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? A. "You have lost the padding in your joints and the friction causes pain." B. "If you recently fell, you might have a fractured hip." C."Because you lose muscle tone with age, it hurts to walk." D."Osteoarthritis is painful and very common as you age."

A

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table? A. The client is aware of spatial relationships to avoid the table. B. The cerebellum is responding to impulses from the inner ear. C. The client's muscles are being stretched to walk around the table. D. The brain is sending impulses to the muscles to avoid the table.

A

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? A. 19-year-old male college student majoring in physics B. 25-year-old female who just accepted her first job C. 40-year-old female who is working two jobs D. 34-year-old male who does not use a seat belt

A

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? A. move the client to edge of the bed opposite the side that client will be turning B. pull the client to the edge of the bed to which the patient will be turning C. push the client to the edge of the bed to which the client will be turning D. push the client to the opposite side of the bed

A

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: A. steps into the walker when walking. B. uses the sides of the walker to rise from a chair. C. places the walker far in front when walking. D. leans over the walker when walking.

A

The nurse is assessing a family parented by a 60-year-old grandmother and three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families? A. Increased financial concerns B. Lack of knowledge about child safety C. Child abuse and neglect D. Conflict between family members

A

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? A. supporting the client's back B. under the client's feet C. under the client's head D in front of the client's abdomen

A

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met? A. Grab bars are installed in a client bathroom to facilitate safe showering. B. A client enrolls in art class after recovering from major surgery. C. A nurse identifies strengths in a client who is scheduled for a mastectomy. D. A nurse arranges for a teenage client to have visits from school friends.

A

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? A. transfer belt B. mechanical lift C. roller sheet D. transfer boards

A

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? A. Sims' B. supine C. prone D. Fowler's

A

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select? A. risk for impaired skin integrity B. risk for disuse syndrome C. impaired transfer ability D. impaired physical mobility

A

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? A. shortness of breath after walking up five stairs B. walking with a slow and uncoordinated movement C. joint stiffness after sitting for an hour D. a change in pulse from 80 to 84 after walking up 20 stairs

A

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment? A.Encourage exercise that improves balance and muscle strength B.Suggest a high-fiber, low-fat diet C. Provide a pamphlet on maintaining healthy sleep habits D. Restrict consumption of liquids before bedtime

A

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse? AFirmly grasp the gait belt and gently lower the client into bed. B.Quickly pivot the client into the wheelchair to prevent client fall. C. Have the client stand without moving to see if the dizziness will pass. D.Apply oxygen 2L via nasal cannula to the client.

A

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? A. Supine B. Prone C. Sim's D. Lateral

A

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? A. Shift their weight back and forth, from back leg to front leg. B. Turn the client from side to side while pushing upward. C. Rock the client back and forth to raise the client up in bed. D. Shift their weight back and forth from the legs to the back muscles.

A

Which factor is related to the highest proportion of falls in long-term care settings? A. Toileting B. Agitation C. Polypharmacy D. Impaired sleep patterns

A

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? A. Social pressure B. Normal rebellion C. Poor judgment D. Past experience

A

Which statement should the nurse include in the teaching plan for a family learning about fire safety? A. "Most fires occur outside of the home when grilling out or camping." B. "Cigarette smoking is no longer a major cause of home fires because most people smoke outside." C."Electric heaters are safer and do not usually increase the risk of fire in the home." D. "Most people who die in home fires die from inhalation and not from burns."

A

A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply. A. Launder the stockings at least every three days. B. Measure each leg and take an average to determine size to order. C. Order at least two pairs of stockings. D. Remove the stockings and massage the legs once each day. E. Plan to put the stockings on the client right before bedtime.

A & C

A nurse is conducting a presentation for a local community group about families and current family structures. When describing a cohabiting family, which information would the nurse include? Select all that apply. A. Members may include unmarried retired individuals. B. The members live together for a variety of reasons. C. Blended families are considered a form of this type of family. D.Adults in this family structure are considered single-parent families. E. Members are usually younger in age.

A, B

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. A. Drowsiness B. Vomiting C. Headache D. Fever E. Increased thirst

A, B, C

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. A.Client-centered care B. Establishment of clinical career ladders C. Teamwork and collaboration D.Revamping the licensing requirements for foreign-educated nurses E. Quality improvement (QI)

A, C, & E

Which community characteristics affect the health of individuals? Select all that apply A. Recreation programs B. Communication facilities C. Genetic testing facilities D. Education programs E. Transportation services

A, D, E

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. A. removing clutter from the floor B. moving the bedroom to the ground floor C. installing hardwood floors D. placing nightlights in the bathroom and hallways

A,B,D

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group? A. Use protective sporting equipment. B. Use caution when descending stairs. C. Do not text while driving. D. Be cautious of electrical outlets.

A. Use protective sporting equipment

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? A. Activate the fire alarm on the unit. B. Rescue anyone who is in immediate danger. C. Attempt to extinguish the fire. D. Evacuate clients and staff.

B

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? A. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. B. The report provides a detailed and objective account of the circumstances before, during, and after the event. C.The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed. D. The report becomes a confidential part of the client's health record once it is reviewed by hospital administration.

B

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? A.Evaluation of all of his cranial nerves B. Assessment of vital signs and respiratory status C. C. Initiation of a peripheral intravenous (IV) line for fluid administration D. Assessment of head circumference

B

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? A. "To prevent foot drop." B. "To prevent the legs from rotating outward." C. "To avoid contractures." D. "To preserve the client's functional ability to grasp and pick up objects."

B

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family? A. Reproductive B. Socialization C. Physical D. Affective and coping

B

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? A. Environmental dimension B. Sociocultural dimension C. Physical dimension D. Emotional dimension

B

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? A. Physical dimension B. Sociocultural dimension C. Environmental dimension D. Emotional dimension

B

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize? A. Notify the organization's leader that a disaster has been called B. Establish the nurse's role during a disaster C. Identify the resources available for the nursing unit D. Provide simple explanations to maximize client safety

B

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include? A. Maintain open communication B. Adjustment to retirement C. Maintain a supportive home environment D. Strengthen the marital relationship

B

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? A. Extension B. Adduction C. Abduction D. Circumduction

B

Which nurse would be at the highest risk of causing a hazardous situation? A.A nurse who is administering medications to four clients B. A nurse who has worked 32 hours of overtime this week C. A nurse who has placed a client in the bed with three side rails up D. A nurse who is transferred to another unit to assist with care

B

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant? A. "We place our baby in a rear-facing car seat in the front of the car so that we can see him in case he chokes." B. "We place our baby in a rear-facing car seat in the back seat of the car." C. "We place our baby in a front-facing car seat in the front of the car so that he doesn't cry." D. "We place our baby in a front-facing car seat in the middle of the back seat of the car."

B

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. A. Twist or bend electric cords to make sure the cords are not dragging on the floor. B. Use three-pronged electric plugs whenever possible. C. Only operate equipment the nurse is familiar with. D. Clean all equipment with soap and water after use. E. Use equipment only for the use for which it was intended.

B & E

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A. Fires are responsible for most hospital incidents. B.A medication regimen that includes diuretics or analgesics places an individual at risk for falls. C. Between 15% and 25% of falls result in fractures or soft tissue injury. D. Some people are more at risk for accidents than others. E. A person with a history of falls is likely to fall again.

B,D, E

A nurse is assessing a family for possible risk factors that may be contributing to the family's altered health status. When assessing for environmental risk factors, which questions would the nurse ask? Select all that apply. A. "Does anyone in the home have a problem with alcohol?" B. "Is there anything going on at work that is causing you stress?" C. "How often does the family visit the dentist?" D. "Is the family eating a nutritious diet?" E. "Are you financially able to keep your home safe for your children?"

B,E

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? A. Monitor the activities of the toddler. B. Avoid unattended baths for the toddler. C. Instruct the toddler not to go near the pool. D. Allow the child to swim with friends.

B. Avoid unattended baths for the toddler.

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: A. decubitus ulcers. B. pooling of blood. C. blood pressure changes. D. foot drop.

D

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? A. Most home fires are caused by children playing with matches. B. Most people who die in house fires die of smoke inhalation rather than burns. C. About 10% of home fire deaths occur in a home without a smoke detector. D. Most fatal home fires occur while people are cooking.

B. Most people who die in house fires die of smoke inhalation rather than burns.

A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not: A. prevent constipation. B. improve sleep quality. C. decrease appetite. D. enhance mood.

C

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: A. complete an incident report to determine who was primarily responsible for the event. B. document strategies in the client's health record for preventing future incidents. C. fill out an incident report, with the goal of preventing a similar event in the future. D. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents.

C

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? A. Assure bed alarms are activated B. Request a sedative from health care provider C. Conceal IV tubing with gauze wrap D. Ask visiting family member to stay

C

A new graduate nurse asks a nurse manager working at the community health center, "I've heard people talk about community health nursing and community-based nursing. Is there a difference?" Which response by the nurse manager would be appropriate? A. "Community health nursing focuses primarily on providing care to people in their homes and living in a specific community." B. "There really isn't any difference between the two at all. Both terms are used to denote health care for all groups of people." C. "Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population." D. "Community health nursing emphasizes the need to address the cultural differences among the individuals and families in the community while community-based nursing does not."

C

A nurse is caring for a client diagnosed with pancreatitis. Which is a priority need for nursing management of this client? A. Lack of self-confidence B. Depression due to recurrent symptoms C. Acute pain in the abdomen D. Inability to take care of family

C

A nurse is planning education on self-administration of insulin to the client and the client's family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be? A."Family members are a point of contact and are able to check on your progress." B. "Family members are at risk of developing diabetes mellitus in the future." C. "Family members are equally involved in planning and implementation of care." D. "Family members can take you to the hospital if any emergency occurs."

C

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? A.near the client's hip, with legs together B.to the nondominant side of the client, with legs together and one foot near the head of the bed. C. near the client's hip, with legs shoulder width apart and one foot near the head of the bed D. to the dominant side of the client, with legs together and one foot near the head of the bed

C

The community environment affects the well-being of the individual and the family. Which is the health responsibility of the family? A. Provide recreational services B. Provide educational facilities C. Maintain a healthy lifestyle D. Facilitate health care services

C

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? A.increased metabolic rate B. increase in circulating fibrinolysin C. predisposition to renal calculi D. increase in the movement of secretions in the respiratory tract

C

The nurse is assessing the family structure of the client. The family household comprises two parents, three children, and one grandparent. The nurse recognizes that this is a(n): A. Traditional Family B. Blended Family C. Extended Family D. Nuclear Family

C

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? A. Place the bed in the highest position. B. Put the chair at the foot of the bed. C. Raise the head of the bed to a sitting position. D. Make sure the bed brakes are unlocked.

C

The nurse receives an 8-year-old client in the pediatric unit following a tonsillectomy. Which assessment finding requires immediate intervention by the nurse? A. The client tells the nurse that the client's throat hurts. B. The client is sleepy from the anesthesia, but arouses when addressed by name. C. The client makes a rattling noise when breathing through the mouth. D. The client cries to the nurse that the client wants to go home.

C

The nurse recognizes that the community affects the ability of individuals to meet basic human needs. Which example is not a characteristic of a healthy community? A. A new youth centre provides after school programs for teens. B. Volunteer opportunities for older adults increased the past two years. C. The number of assaults increased 2% over the last year. D. The quality of drinking water exceeds the state requirements.

C

Which are stressors that affect the health of the family? A. Many job opportunities with adequate income B. Family members who live in the same geographic location C.Inadequate childcare services D. Public transportation present throughout the community

C

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age? A. "Never smoke in the bed in the house when young children are present." B. "Store medications in a locked area to prevent children from getting into them." C. "Always provide close supervision for young children when they are in or around pools and bathtubs." D. "Never keep firearms in the home with young children."

C

A nurse is caring for a client newly diagnosed with diabetes mellitus and developing a holistic plan of care. For this plan of care to be successful, it must what? A. Take into account the cost of care. B. Connect families, friends, and the environment. C.Provide a connection between medicine and nursing. D. Address the disease but also incorporate the mind, body, and spirit.

D

The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action? A. Call the out-of-state family and ask if they can take turns watching the client. B. Apply the waist restraint over the gown and abdominal dressing. C. Notify the primary care provider and obtain an order for a client sitter. D. Apply bilateral wrist restraints and secure to the bed frame with a quick-release knot.

C. Notify the PCP & obtain an order for a client sitter.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? A. Logrolling will maintain straight alignment when the client is sitting in a chair. B. Logrolling can be performed by one experienced nurse. C. It is acceptable to twist the client's head, but not the hips, while logrolling. D. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

D

A community is defined as a social group that may or may not share common geographic boundaries yet interact because of: A. Similar school districts B. Political beliefs C.Economic interests D. Common interests

D

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? A. "We'll have the nursing assistant watch you while you walk around the unit the first time." B. "When your crutches fit right, most of your body weight will be supported by your armpits." C. "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." D. "Your elbows will be slightly bent when you are using your crutches."

D

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? A.CMS may choose to divert clients to other health care facilities in the future. B. The hospital will be fined by CMS because the client developed a pressure injury. C. CMS will bear the hospital's costs if the client chooses to sue the hospital. D. The hospital must bear any costs incurred for treating the client's injury.

D

A community-based nurse acts as a case manager for a small town about 60 miles from a major healthcare center. What is the most important factor of community-based nursing for this nurse to be knowledgeable about? A. Possible charges for any services provided C. Transportation costs to the healthcare center B. Eligibility requirements for services D. Community resources available to clients

D

A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important? A. Addressing the client's problems B. Promoting socialization C. Reducing fear D. Emphasizing the client's strengths

D

An adolescent confides in the school nurse that the adolescent is arguing daily with her mother and often wonders whether her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health? A. A developmental risk factor B. A lifestyle risk factor C. A biologic risk factor D. A psychosocial risk factor

D

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms? A. Dorsiflexion B. Abduction C. Adduction D. Flexion

D

The nurse in the adolescent in-patient psychiatric unit is interviewing the family of a 16-year-old client admitted for depression and threatened suicide. What assessment information is most essential for the nurse in determining the affective and coping function of the family? A. Employment history of the parents B. Responsibilities of the adolescent C. Environmental hazards in the home D. Family patterns of communication

D

The nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care? A. "I am a Christian and believe in Jesus. What does your religion believe?" B. "Will your religion allow us to give you blood if you need it?" C. "Do you have any dietary restrictions that we should know about?" D. "What can we do to help you meet any religious needs you may have?"

D

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? A. "This is typical adolescent behavior. Ignore it and it will improve." B. "Let's admit your child to an acute care facility so that we can run more tests." C. "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." D. "These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

D

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? A. the 18-month-old child who is unable to stack blocks B. the 3-month-old child who is unable to raise the head when prone C. the 6-month-old child who is unable to roll over D. the 24-month-old child who is unable to walk unassisted

D

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family? A. The family celebrates Hanukkah and Passover with special meals. B. The family consults their rabbi and synagogue members during times of stress. C. The family members vacation together every year at a beach resort. D. The father is an engineer and the mother is an elementary school teacher.

D

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? A.Risk for Injury related to substance use B. Altered Sensory Perception related to decreased visual acuity C. Risk for Falls related to immobility D. Risk for Poisoning related to poor eyesight and the inability to read medication labels

D

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? A. Place all household cleaners out of reach. B. Buy protective sporting equipment. C. Supervise your child on the changing table. D. Peer pressure causes children of this age to take risks.

D

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care? A. pull sheets B. log rolling C. trochanter rolls D. trapeze bar

D

The nurse receives a client assignment. Which client should the nurse see first? A. A client admitted for chronic angina who is scheduled for an angiogram this afternoon B. A client with a history of stroke and right-sided weakness admitted for a new urinary tract infection C. A client with right-sided heart failure with crackles in the lower lung bases bilaterally and 1+ pitting edema to the lower extremities D. A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

D

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? A. "Induce vomiting and call 911 right away." B. "Did you leave the household chemical in reach of your child?" C."You should not have left your child alone while you showered." D. "Is your child breathing at this time?"

D

Using proper body mechanics, which motions would the nurse make to move an object? A. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. B. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. C. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. D. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

D

What is a benefit of regular exercise over time? A. increased risk for blood clots B. increased work of breathing C. decreased venous return D. decreased heart rate

D

What is an example of a community risk factor? A. A child is born with a severe intellectual disability. B. A client is genetically inclined to develop crippling arthritis. C. An 80-year-old client is at risk for falls at home due to clutter in the hallways and stairways. D. Children are kept inside on a sunny day due to a lack of recreational opportunities.

D

What is the primary role of the nurse in the care of clients who experience domestic violence? A. Identifying health education and counseling measures for the family B. Serving as a witness in court C. Calling the police D. Providing prompt recognition of the potential or actual threat to safety

D

Which item would alert the home care nurse to a safety hazard threatening a young child? A. A gated stairway B. Padded child safety seat C. Three blankets in a crib D. Dangling blind cords

D

Which statement is true regarding Friedman's theory of family-centered nursing care? A. The focus on health should be directed at improving the health of the sickest member of the family. B. Illness of one family member strengthens the roles of the sick member in the family structure. C. The family is composed of independent members who live and function individually. D. The role of the family is essential in every level of nursing practice.

D

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? A. The nurse should request permission from the client to photograph the bruises. B. The nurse should contact the facility's social services department. C. The nurse should notify the primary care physician about the bruises. D. The nurse should question the client about the source of the bruises.

D. The nurse should question the client about the source of the bruises.

Place the following nursing interventions in order of priority according to Maslow's hierarchy of basic needs: A. The nurse assists the client in making a phone call to call the clients mother. B. The nurse positions the bed of the muslim client who is breastfeeding toward Mecca. C. The nurse teaches the daughter how to administer the clients insulin. D. The nurse teaches the client about foods high in fiber.

In order: D C A B