Fund.exam 2

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?

"Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population."

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices?

"How do you protect yourself when having sex?" An open-ended question is the best type to use to gather the most information. Asking how the client uses protection during sex will obtain information about safer sex practices.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions." The nurse identifies nursing diagnoses to serve as a framework for planning care for a client. Nursing diagnoses guide the nurse toward appropriate interventions

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?

"Our 16-year-old just seems to butt heads with us at every turn." The statement about the daughter butting heads with the parents may suggest a conflict among family members and thus a risk factor for altered health Being assertive (not aggressive), being able to problem-solve, and having open communication about sexually transmitted infections promote family health.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

A nurse is working with a single-parent family. When planning the care for this family, which need should the nurse anticipate as being a priority concern?

Financial concerns Single parents have concerns and needs, such as meeting basic financial needs that a two-parent family may not have.

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?

Palpation

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client?

"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?" Adults learn best when the information given to them will be used immediately, is presented as important to the client, and when the client's autonomy is preserved

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?

"We need to validate the information obtained in this assessment." The assessment of a toddler should involve the parents, as they are the primary caretakers and most knowledgeable about their toddler's normal behavior and development, as well as the history of any presenting symptoms. The nurse will validate assessment data to verify information and clarify cues and inferences to determine if they are accurate and free of bias.

A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate?

"What do you know about support groups?" By asking the client an open-ended question the nurse can find out what the client knows about support groups. With the client's permission, the nurse can further educate on this topic. The nurse should acknowledge the client's ability to accept or reject the material to empower the client and lead to more healthy decision-making. The nurse cannot make the decision for the client by signing the client up for a support group. Although frustrating, the choice to follow suggestions in the end is the client's and the nurse must respect it as such

The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse?

"You have made an amazing recovery." Reinforcement of learning shows that the nurse supports and wants to encourage the client. Giving credit where it is due communicates these values.

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply.

38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg) Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person being assessed. Age, vital signs, height, and weight are objective data.

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?

A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment

The nurse receives a client assignment. Which client should the nurse see first?

A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90% According to Maslow's hierarchy of needs, first-level physiological client needs are most important. These needs are those that are necessary to sustain life, such as breathing and eating. Using Maslow's hierarchy, along with airway, breathing, and circulation (ABCs), assists the nurse to prioritize care when given a client assignment. The client who is experiencing acute respiratory issues with pneumonia who is restless, diaphoretic, and exhibiting an oxygen saturation level of 90% requires priority assessment and intervention.

The nurse is reviewing the health care records of several families from the health care clinic. Which families should the nurse identify as being at risk for factors affecting their health? Select all that apply.

A family that is vegan A family that uses herbal medicine A family that fasts for religious purposes A family that receives public assistance A family that is headed by a single mother A vegan diet affects health because it is low in protein, which is a dietary necessity. Use of herbal medicine and fasting for religious purposes can pose health risk factors, so the nurse should further assess the impact of these factors on the family members' overall health. A family on public assistance is in a lower socioeconomic status. A family headed by a single parent may have financial concerns and role shifts (i.e., having the roles of both parents). A family that has had their children vaccinated has no risk factors that would affect their health.

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis The client is seeking information related to healthy practices. Health promotion nursing diagnoses are formulated to assist the client to meet that need. The client has no health problem, risk of a health problem, or possible problem, so a problem-focused, risk, or possible nursing diagnosis would be inappropriate.

What are examples of meeting physiologic needs according to Maslow's hierarchy of needs? (Select all that apply.)

A nurse administers pain medication to a postoperative client. A home care practitioner requests quiet so that a client can sleep. Physiological needs—for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. The nurse counseling an overweight teenager would be Level 4, self-esteem.

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?

Address the disease but also incorporate the mind, body, and spirit. A holistic plan of care seeks to balance and integrate the use of crisis medicine, advanced technology, and the mind, body, and spirit, which are incorporated though the use of the nursing process.

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?

Adjustment to retirement Developmental tasks for families with adolescents and young adults include balancing teenagers' freedom with responsibility, maintaining supportive home base, and strengthening marital relationships. Adjusting to retirement is a developmental task for families with older adults.

Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?

Allow ample time for psychomotor skills. Older adults need more time to learn psychomotor skills. Sessions of 2 to 3 hours are too long; short-term rather than long-term memory loss affects older adults; and information can be structured or nonstructured, depending on the content.

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety Anxiety is an accurate diagnostic label, the name of the nursing diagnosis as listed in the taxonomy. It is also the only option related to the client's experience to the new experience of being hospitalized.

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea

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?

Increased financial concerns Single parents often have special problems and needs, including financial concerns and role shifts (i.e., having the roles of both parents).

A physical examination on a client should always include which components? Select all that apply.

Appraisal of health status Identification of health problems Establishment of a database for interventions When conducting a physical examination, the nurse should include appraisal of health status, identification of health problems, and establishment of a database for interventions. The nurse should collect information regarding the client's religious preference and socioeconomic status, which is used in developing the plan of care, during the client's interview, not during the physical examination.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure.

When providing care to a client, the nurse prioritizes the client's needs. Which intervention would the nurse employ to meet the client's physiologic needs? Select all that apply.

Assessing the client's skin color Weighing the client Promoting a high-fiber diet Physiologic needs—for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. These needs are the most basic in the hierarchy of needs and the most essential to life, and therefore have the highest priority. Assessing skin color, weighing the client, and promoting elimination via a high-fiber diet are interventions focused on meeting the client's physiologic needs. Teaching the client about a procedure helps meet the client's emotional safety and security needs. Including the client's spouse in the plan of care addresses the client's love and belonging needs.

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Auscultate the chest for breath sounds. The "assessment" phase of the nursing process includes gathering data by interviewing, observing, and performing a basic physical examination of people with common health problems with predictable outcomes. In this case, the nurse will gather data from the respiratory assessment by auscultating the lung sounds and observing the client's work of breathing.

A nursing student's parents are both physicians. The nursing instructor may feel the student has

Been socialized in healthcare Socialization happens by the process of living and experiencing in family and society. If the student comes from a family of healthcare professionals, this too is part of the socialization process.

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client?

Begin the session with a reference to the client's actual experience. Beginning the session with a reference to the client's actual experience will help provide a link to which the new learning can connect. The nurse should first engage with the client to find out the client's experience and specific issues.

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection Not all data need to be validated, but the nurse may validate data during the collection or at the end of the data-gathering process. When it is clear that the data are correct, the nurse may analyze the data and formulate nursing diagnoses.

What is an example of a community risk factor?

Children are kept inside on a sunny day due to a lack of recreational opportunities.

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?

Cognitive Learning in the cognitive domain involves processing information by listening to or reading facts and descriptions. Learning in the affective domain involves appealing to a person's feelings, beliefs, or values. Learning in the psychomotor domain involves learning by doing. Interpersonal is not a domain of learning but a type of communication in which ideas are exchanged between two or more people.

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?

Cognitive learning theory Cognitive learning theory is the result of people wanting to make sense of the world around them by assimilating and processing information to gain new understandings and insights. Developmental learning theory focuses on considering the patient's physical maturation and abilities, psychosocial development, and cognitive capacity when providing education. Behavioral learning theory focuses on how one learns and unlearns behaviors. Adaptive learning theory explains how learning is optimized when teaching is adapted to the particular learning style of the learner.

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem If a problem requires both physician- and nurse-prescribed actions to address, it is by definition a collaborative health problem.

The nursing diagnosis taxonomy provides nursing with

Common language A taxonomy, or classification system, provides nurses with a common language with which categorize client problems. Taxonomy applies primarily to nursing diagnoses and thus the diagnosing phase of the nursing process

A client says, "I live in a small community on the northwest side of the city." Why does the nurse consider it significant that the client reports living in a community rather than a neighborhood?

Community indicates people who share similar characteristics. Communities are thought to contain persons who share similar characteristics, whether it be social interaction, cultural or ethnic ties, or geographic area Communities may be larger or smaller than a neighborhood and are not defined by geography. Communities exist because they meet basic human needs.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique. Documentation of teaching must include who was taught, the topic taught, and some indication of the success of the learning plan beyond a simple verbal statement by the client.

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?

Describe how the walker can improve the client's quality of life. Motivating the older adult client can be done by showing the client how the new knowledge will improve the client's quality of life, regardless of how long that may be. It will also demonstrate how the new knowledge could improve the client's level of independence

Which theorist supports the developmental framework of family assessment?

Duvall Duvall supports the developmental framework of family function.

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?

Emphasizing the client's strengths To help meet a client's self-actualization needs, the nurse focuses on the person's strengths and possibilities rather than on problems.

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?

Erikson's theory of psychosocial development Duvall's theory, based on Erikson's theory of psychosocial development, states that all families have certain basic tasks for survival and continuity, as well as specific tasks related to developmental stages throughout the life of the family.(unattached adult, newly married adults, childbearing adults, preschool-age children, school-age children, teenage years, launching center, middle-aged adults, and retired adults.)

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?

Family patterns of communication The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. When assessing the family of a depressed client for affect and coping function, it is helpful for the nurse to be aware of the family's communication style. This information can help identify family difficulties and teaching points that could benefit the client and the family.

A community health nurse is providing care to several farming families in a rural community. Which concept would be most important for the nurse to integrate into the plans of care for these families?

Family structures may change over time. Nurses must remember that there are no absolutes, such as "rights" or "wrongs," about what makes a family. The structure of an individual's family may change several times over a lifetime, and the nurse must learn to address clients' needs throughout these changes

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

Focused The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified An initial assessment involves the nurse collecting data concerning ALL aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.

Which piece of client information is subjective?

Generalized myalgia or muscle pain Symptoms such as muscle pain or myalgia are considered subjective cues in a client's health history, as only the client can determine its presence.

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?

Grab bars are installed in a client bathroom to facilitate safe showering. According to Maslow, safety and security needs follow basic physiologic needs; therefore, grab bars in a bathroom helps ensure safety in the client's shower.

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have the client rate pain level, and reschedule the teaching session. The client is not ready or able to learn and is reporting a need that first must be met. It is best to address the physical needs before attempting to educate the client.

The nurse records the name, age, and genetic background of the client. The data are components of which tool?

Health history Components of a health history tool include the client's profile, which consists of name, age, sex, genetic background, marital status, religion, occupation, and education. These are subjective data that are collected from the client.

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis. Two cues must be present for a valid health promotion nursing diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate.

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis

The epidemiology nurse finds a lower occurrence of influenza cases in a section of a large metropolitan city. Further research reveals higher influenza immunization rates in that section of the city. The nurse determines which probable cause for this occurrence?

Immunization has become a community norm The most probable cause for this occurrence is that immunization has become a community norm. People tend to do what others in their community do. Free or low-cost immunizations are given in many areas without increasing the immunization rate. Education has little to do with immunization or vaccination rates. Tobacco use may complicate course of illness for those who contract influenza but is not likely to positively impact immunization rates.

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a newborn.

Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease?

Intellectual development Piaget's theory of intellectual development is a major learning theory. By understanding how children and adolescents develop learning abilities, the nurse can use this knowledge when teaching clients. School-age children are capable of logical reasoning and should be included in the teaching-learning process whenever possible. Teaching strategies that include clear explanations and reasons for procedures, stated in a simple and logical manner, are most successful.

Which are examples of objective data? Select all that apply.

Laboratory test results Breath sounds on auscultation A client's temperature Objective data are those that the nurse can gathered from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory test results, reports from other health care team members), and physical assessment (e.g., breath sounds, strength of extremities, blood pressure, temperature). Subjective data are those that only the person experiencing them can perceive and report, such as pain and a feeling of being unable to breathe.

A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply.

Learning style preferences Literacy level Available resources Availability of resources, learning style preference, and literacy level affect the planning of effective teaching strategies.

A nurse is working as part of a group to address factors within the community affecting the health of the families in that community. Which area would the nurse identify as playing a role in contributing to altered health status? Select all that apply.

Limited number of institutions providing health care Small number of recreational opportunities for adults and children Overlapping of industrial zones with residential zones

The community environment affects the well-being of the individual and the family. Which is the health responsibility of the family?

Maintain a healthy lifestyle Maintaining a healthy lifestyle is the health responsibility of the family. Providing educational, health care, and recreational services is the responsibility of the community.

The nurse assesses a client who is postoperative day 1 following a total abdominal hysterectomy. Assessment data includes blood pressure (BP) 150/88 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 22 breaths/min with a pain scale of 8 on a scale of 1 to 10. The abdominal dressing is clean, dry, and intact. The client's prescriptions indicate ambulation today. Which is the priority nursing action?

Medicate the client for pain as prescribed by the health care provider. The nurse is likely to use Maslow's hierarchy of needs as a tool for setting priorities for client care. Using this tool, the nurse considers the client's physical needs, such as managing pain, as a priority in this situation.

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client?

Motivational Motivational counseling involves discussing feelings and incentives with the client. Long-term counseling extends over a period of time. Developmental counseling occurs when a client is going through a developmental stage or passage. Situational counseling occurs when a client faces an event or situational crisis.

A family that consists of two homosexual parents and three children living in the same house is an example of which type of family?

Nuclear The nuclear family is also known as the traditional family and is composed of two parents and their children. The parents might be heterosexual or homosexual, are often married or in a committed relationship. A blended family is also a traditional family formed when parents bring unrelated children from previous relationships together to form a new family.

Which nursing skill uses all five senses?

Observation Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data.

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?

Observing a mother expressing the breast milk Observing is one of the levels of psychomotor skills, which involves watching an experienced person perform a physical skill Telling, showing, and advising are examples of addressing the cognitive domain, which helps the mothers process information by listening or reading facts.

The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action?

Obtain a medical interpreter. A medical interpreter should always be contacted to ensure accuracy in communication. The nurse can then be assured that client teaching has been appropriately communicated. It is not appropriate, or as reliable and accurate, to have family members translate, to request other health care providers to be present, or to use translation applications.

The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate?

Offer the client an extra blanket. Notifying the physician is not necessary because the temperature is within normal range. A normal or low temperature is not an indicator of dehydration, so increasing the intake of oral fluids is not necessary. A normal or low temperature is not an indication of respiratory distress, so an assessment of the client's respiratory rate is not necessary.

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?

Pain Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects the total being. Which would best be considered a holistic approach to health?

Physical, emotional, and spiritual well-being A holistic approach to health reconnects the mind and body, which are treated separately in traditional approaches. The connection of physical, emotional, and spiritual well-being must be understood and considered when providing health care.

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?

Physiologic Rest is a basic physiologic need, because it allows time for the body to rejuvenate and be free of stress. Love and belonging is related to acceptance in a group. Self-esteem is related to how one sees one's self.

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?

Position the client in a side-lying position. The need for oxygen is the most essential of all physiological needs. Aspiration is a risk for the client after a seizure because of lethargy and increased oral secretions. The client needs to be positioned on the side to allow the secretions to drain from the mouth

A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?

Preparation This client is in the preparation stage, as the client is actively making changes to lose weight. During the precontemplation stage, the client is not even thinking about or considering making a change. During the contemplation stage, the client is considering making a change. During the preparation stage, the client has decided to make a change and is preparing for it. During the maintenance stage, the client attempts to maintain the change in lifestyle begun in an earlier stage.

A nurse assisting a new mother in the act of breastfeeding represents which form of learning?

Psychomotor

Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session in a quiet environment.

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?

Report the suspected child abuse to Child Protective Services. All suspected cases of abuse must be reported to the appropriate agency or authority. Failure to report suspected child abuse is considered nursing negligence. Documenting "suspected abuse" in the client's record is inappropriate. Only the objective physical findings and observations should be documented. Asking the physician to question the parents about the suspected abuse can jeopardize the child's safety by alienating the parents and creating distrust between the parents and the healthcare providers.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for Community Contamination would address the broad concerns of the nurse

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?

Role-playing

The nurse is conducting a home assessment and suggests that the client's family remove scatter rugs from the home and increase the lighting. Which basic human need is being addressed by the nurse's suggestions?

Safety and security Making changes in the home environment, such as removing scatter rugs and increasing lighting, promotes the safety of the family members.

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?

Safety and security Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as moving and ambulating patients. Assisting the patient to ambulate ensures that the patient will not experience a fall

The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which is an individual need?

Safety is an individual need and a part of Maslow's hierarchy. Educational, socialization, and political needs are provided by the family.

A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?

Self-esteem needs The adolescent would have issues and concerns in the self-esteem stage. Self-esteem needs would include fear, sadness, loneliness, and accepting self; all would be appropriate with this client. Safety and security would focus on the environmental aspect and would include areas such as housing and community/ neighborhood to name a few. Self-actualization needs are in the intellectual and spiritual dimension and would include areas such as thinking, learning, decision making, values, beliefs, and helping others.

A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage?

Setting up parenting classes Setting up parenting classes is the only answer that addresses the stated developmental stage. . The community clinic would not focus on screening for congenital defects.

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?

Sociocultural dimension Communication is essential for interaction with others and is an example of the sociocultural dimension. The physical dimension incudes physiological health and nutrition. Housing and community are examples of the environmental dimension. The emotional dimension includes fear, sadness, loneliness, and acceptance of self.

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?

Tell me about what signs of infection you will report to the health care provider." Cognitive domain learning may be evaluated through oral questioning.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?

The client and the nurse are equal participants Effective learning occurs when clients and health care professionals are equal participants in the teaching-learning process, not when the nurse is viewed as the expert.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?

The client describes signs and symptoms of hypoglycemia.

Which assessment findings would support the nursing diagnosis of Acute Pain? Select all that apply.

The client had an abdominal hysterectomy 1 day ago. The client is crying in pain about 20 minutes before pain medicine is due. Pain that a client might be experiencing from past back surgery would be chronic and would not support the diagnosis of Acute Pain. Just because a client has a history of a painful condition, such as osteoarthritis, does not mean that the client is currently in acute pain.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher. The occupations of the parents provide financial support for the family and contribute to the socioeconomic status of the family.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client. By asking open-ended questions the nurse can gain more information as to why the client is crying

Which statement is true regarding Friedman's theory of family-centered nursing care?

The role of the family is essential in every level of nursing practice. Friedman and associates identified the importance of family-centered nursing care, based on four rationales. First, the family is composed of interdependent members who affect one another. If some form of illness occurs in one member, all other members become part of the illness. Second, a strong relationship exists between the family and the health status of its members; therefore, the role of the family is essential in every level of nursing care. The third rationale is that the level of health of the family and, in turn, each member can be significantly improved through health-promotion activities. Finally, illness of one family member may suggest the possibility of the same problem in other members

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

Time-lapsed assessment A nurse is comparing a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the care plan. This assessment can be comprehensive or focused.

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include?

Tracheobronchial suctioning Based on the assessment of the client, the nurse should identify specific cues, such as thick secretions, excessive sputum, and coughing, that indicate a problem with the client's ability to maintain a clear airway. Tracheobronchial suctioning would be the appropriate intervention to clear the client's airway. The nurse would increase fluids to thin secretions, not limit fluid intake for this client.

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician. The nurse should report any abnormal assessment findings or changes in the client's health status to the client's physician or the charge nurse immediately for prompt and appropriate treatment of the health alterations

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses. Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.

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?

affective and coping functions This family exhibits the function of affective and coping by observing the ritual of "Sitting Shiva." By observing this Jewish, seven-day period of mourning for first-degree relatives (husband, wife, parent, or child) the family provides emotional comfort to family members, helps to establish their identity, and maintains it in times of stress