Funds Exam 4 Practice Questions

A nurse is caring fro a client who has a new prescription for dialysis three times a week. The client avoids eye contact while taking to the nurse and explains that they work two jobs to support their partner and two children. The client also states " I don't know how I am going to have time for dialysis." Which of the following factors are influencing the clients communication? Select all that apply 1. Psychosocial factors 2. Cognitive factors 3. Situational factors 4. Environmental factors 5. Physiological factors

1 and 3

The nurse who uses appropriate therapeutic listening skills will display which behaviors? Select all that apply 1. observe both the content and the feeling the client is conveying 2. Presume an understanding of the client needs 3. Adopt an open professional posture 4. React quickly to the message 5. Reassure the client that everything will be fine.

1 and 3

A charge nurse is reviewing factors that can affect a clients perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? Select all that apply 1. Stress 2. Dietary practices 3. Culture 4. Social support 5. Disease severity

1, 3, 4,5

A client needs to learn to self-administer insulin injections. Which statements reflect possible low literacy skills? Select all that apply 1. " I will read the information later- Im too tired right now" 2. "Ive watched my brother give his own shots. I know how to do it" 3."Do you have a video showing how I should give myself the shot?" 4." I don't understand this one section in the handout"

1,2,3,4

A nurse Is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? select all that apply 1. Grimacing 2. Restlessness 3. Elevated temperature 4. Increased diaphoresis 5. Bradycardia

1,2,4

A nurse is planning to teach new assistive Personnel (AP) how to use a bedside glucose monitor to check a clients blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? Select all that apply 1. Verbal 2. Written 3. Electronic 4. nonverbal 5. Assertive

1,2,4

A nurse is discussing end of life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of-life pain management? Select all that apply 1. Fear of addiction 2. Belief that pain is an expected part of their illness 3. Inability to sleep 4. Lack of support 5. Inadequate pain assessment

1,2,5

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? Select all that apply 1. Face 2. Legs 3. Alert 4. Circulation 5. Consolability

1,2,5

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients pain control? Select all that apply 1. Consider each clients cultural preferences 2. Determine the effectiveness of non pharmacological strategies 3. Record the clients subjective reports rather than the nurses objective observations 4. Recognize that older adult clients over-report their pain level 5. Use a pain scale specific to each clients cognitive abilities.

1,2,5

A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? Select all that apply 1. Move the client to a quiet area or private room 2. Speak at a slower pace 3. Delay the assessment until the clients family member brings the hearing aid 4. Have a sign language interpreter translate the communication with the client 5. Stand next to the client when taking 6. Avoid using medical terminology

1,2,6

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? Select all that apply 1. Muscular pain 2. Active bleeding 3. Backache 4. Menstrual discomfort 5. Swollen extremity

1,3,4

During admission to a hospital unit, the client tells the nurse that her sleep tends to be very light and that it is difficult for her to sleep if she's awakened at night. Which intervention should the nurse implement? Select all that apply 1. Remain colleagues to keep their conversation to a minimum at night 2. Encourage the clients family members ti bring in a radio to play soft music at night 3. Deliver necessary medications and procedures at 1.5-3 hour intervals between 11 PM and 6 AM 4. Encourage the client to ask family members to bring in a fan to provide white noise 5. Increase the temperature in the room

1,3,4

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? Select all that apply 1. Transcutaneous electric stimulating unit (TENS unit) 2. Distraction techniques 3. Massage 4. Acupuncture 5. Cold therapy

1,3,4,5

A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurses assessment? Select all that apply 1. About of sleep he usually obtains during the week and on weekends 2. How much alcohol he usually consumes 3. Onset and duration of symptoms 4. Whether or not his classes are boring 5. What medications, including herbal remedies, he is taking

1,3,5

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? Select all that apply 1. " A clients religious beliefs might affect the way they respond to pain" 2. " Herbal therapies are not permitted for a client receiving prescription pain medication" 3." The clients past pain experiences are not related to their current pain and pain management" 4."If a client can rate their pain using a numerical pain scale, there is no need to note nonverbal findings" 5." Pain control might be harder to achieve if the nurse and client speaks different primary languages"

1,3,5

A nurse is discussing transcutaneous electronically nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? Select all that apply 1."You can be taught how to use TENS therapy at home" 2." We will insert very small sterile needles into your skin to block your pain" 3." This therapy may result in you having some temporary bruising at the side of application" 4." The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas" 5." We will adjust the intensity, pulse rate, and duration of the electrical pulse during your therapy"

1,4,5

A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing? 1. " You said that you're sad. What is making you feel sad?" 2. " If you want to lose weight, why do you keep eating fast food? 3." Have you always struggled with depression?" 4." Do you have any health problems?"

1. " You said that you're sad. What is making you feel sad?"

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take? 1. Administer 1 mg IM 2. Request a prescription to give the medication IV instead 3. Request a prescription for a different medication 4. Administer 2 mg IM

1. Administer 1 mg IM

How can the nurse best assist a client style of learning? 1. Ask the client how he or she learns best 2. Use a variety of teaching strategies 3. Observe the clients interactions with others 4. Ask family members

1. Ask the client how he or she learns best

A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the clients request? 1. Cultural factor 2. Developmental factor 3. Environmental factors 4. Physiological factors

1. Cultural factor

A client recovering from abdominal surgery refuses analgesia saying that he is "fine, as long as he doesn't move." Which nursing diagnosis should be priority? 1. Deficient knowledge ( pain control measures) 2. Ineffective Health maintenance 3. Risk for ineffective airway clearance 4. Impaired physical mobility

1. Deficient knowledge ( pain control measures)

The nursing student reviews the pathophysiology of myocardial infraction in preparation for the next days clinical experience. This activity is an example of which type of knowledge development? 1. Empirical knowing 2. Aesthetic knowing 3. Personal knowing 4. Ethical knowing

1. Empirical knowing

The nurse teaches a client with diabetes how to make decisions about insulin management after discharge. This teaching most clearly affects which caring activity? 1. Empowering the client 2. Compassion 3. Knowing the client 4. Nursing presence

1. Empowering the client

During a well-child visit, a mother tells the nurse that her 4 year old daughter typically goes to bed at 10:30pm and awakens each morning at 7am. She does not take a nap in the afternoon. Which is the best response by the nurse? 1. Encourage the mother to consider putting her daughter to bed between 8 and 9 pm 2. Reassure the mother that it is normal for 4-year olds to resist napping, but encourage her to insist that she rest quietly each afternoon 3. Recommend that her daughter be allowed to sleep later in the morning 4. Reassure her that her daughters sleep patter in normal and that she has outgrown her need for an afternoon nap

1. Encourage the mother to consider putting her daughter to bed between 8 and 9 pm

A nurse is planning a presentation about skin care for a group of older adults at a senior center. Which of the following actions should the nurse take to enhance client learning? 1. Ensure the room is well lit 2. Have soft music playing in the background 3. Hand out samples of products during the teaching 4. Speak quickly during the teaching

1. Ensure the room is well lit

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PAC pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression? 1. Naloxone 2. Lidocaine 3.Prednisone 4.Amitriptyline

1. Naloxone

The nurse sits with the client and holds the client's hand as his pain decreases. This situation is an example of which caring practice? 1. Nursing presence 2. Assessment 3. Knowing the client 4. Empowering

1. Nursing presence

The nurse asks the client," What do you fear most about your surgery tomorrow?" This is an excuse of which communication technique?" 1. Providing general leads 2. Seeking clarification 3. Presenting reality 4. Summarizing

1. Providing general leads

A nurse tells a client who is struggling with cancer pains, " it is normal to feel frustrated about the discomfort." Which is most representative of the skills associated with the working phase of the helping relationship? 1. Respect 2. Genuineness 3. Concreteness 4. Confrontation

1. Respect

Leininger's theory, culture care diversity and universality , would provide the best framework for assessing which nursing situation? 1. The Indonesian parents of an infant prefer to use hot/cold therapies to prevent seizures so they withhold the prescribed seizure medication (phenobarbital) 2. Staff nurses on a hospital unit discuss how to reorganize client care to provide more continuity of staff with clients. 3. Nurses in a community agency search for learning resources about intravenous therapy in the home setting. 4. The nurse manager explores ways to assist new nursing graduates to develop clinical skills on the hospital unit.

1. The Indonesian parents of an infant prefer to use hot/cold therapies to prevent seizures so they withhold the prescribed seizure medication (phenobarbital)

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain? 1. The client is diaphoretic 2. The client is experiencing stabbing pain 3. The client is nauseated 4. The client states feeling dizzy

1. The client is diaphoretic

A new nursing graduates first job required 12-hour night shifts. Which strategy will make it easier for the graduate to sleep during the day and remain awake at night? 1. Wear dark wrap-around sunglasses when driving home in the morning and keep in a darkened bedroom 2. Exercise on the way home to avoid having to stand around waiting for equipment at the gym 3. Drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift 4. Try to stay in a brightly lit area when working at night.

1. Wear dark wrap-around sunglasses when driving home in the morning and keep in a darkened bedroom

a nurse in a providers office is caring for a client who has hypotension during a follow-up appointment and is forcing on the clients ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations? 1." Im glad you decided to continue your fitness routine" 2." You could achieve better results if you applied yourself more" 3." You are adjusting very well for your age" 4." Reducing your caffeine intake is good, but you really need to stop completely"

1." Im glad you decided to continue your fitness routine"

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include? 1." You should write down the pain interventions you use and your pain rate before and after" 2." You should understand that it is impossible to fix everyones pain" 3." Your provider is best at determining whether your pain treatments are effective" 4." Your care partner should manage your pain control because you are unable"

1." You should write down the pain interventions you use and your pain rate before and after"

A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic, Which of the following observations indicated the nurse should monitor the client closely? 1. Drowsy: drifts off to sleep before completing a sentence 2. Respirations = 18/min 3. Drowsy; easily aroused 4. Pain rating 1-2/10

1.Drowsy: drifts off to sleep before completing a sentence

A client is admitted for a sleep disorder. The nurse knows that the reticular activating system (RAS) is involved in the sleep/wake cycle. In the accompanying illustration, which letter indicated the location of the RAS?

2

After being admitted for emergency surgery, an 80-year-old client has just returned to the room from the PAR room, which nursing interventions are most likely to facilitate effective communication with this client? Select all that apply 1. Ask the client," Do you know where you are?" 2. Ask the client or support person about visual or learning problems. 3. Inform the client and support person(s) about events likely to occur during the next 2 hours 4. Provide the client with instructions about discharge 5. Tell the client, " You will feel better soon".

2 and 3

A client is scheduled to have a diagnostic procedure. Which questions by the nurse will most likely produce a "teachable moment" ?select all that apply 1. " Have you ever had this procedure done?" 2."What are your concerns about this procedure?" 3." What would you like to know about this procedure?" 4."Are you prepared for this procedure?" 5."What have you hear or read about this procedure?"

2,3,5

A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC pain scale to determine their pain level. 1. A 12-year-old client who has had an appendectomy 2. A 3-year-old toddler who has a fractured femur 3. A 6-day-old infant who had a surgical repair of a heart defect 4. A 14-year-old client who has severe cognitive and developmental delays 5. A 5-year-old preschooler who is experiencing pain during a sickle cell crisis.

2,4,5

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? Select all that apply 1. "interrupt the client occasionally during the conversation" 2. " Respect the client during the conversation" 3." Use complex terms when explaining with the client" 4." Allow time for reflection during the conversation with the client" 5. "Show empathy during the conversation with the client"

2,4,5

Which interventions, when implemented by the nurse, would apply the gate control theory of pain? Select all that apply 1. Oral analgesic around the clock 2. Massage 3. Patient-controlled analgesia 4. Heat or cold application 5. Acupressure

2,4,5

A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make? 1. " The nurse manager will need to email the discharge instructions to you" 2. " I am unable to send your discharge instructions via email due to the HIPPA privacy act" 3." You will need to ask your provider to email the discharge instructions to you" 4." Sending the discharge instructions to you via email would be a violation of the Affordable Care Act"

2. " I am unable to send your discharge instructions via email due to the HIPPA privacy act"

The nurse is communicating with a primary care providing about medical interventions prescribed for a client. Which statement is most representative of a collaborative relationship? 1. " That new medication you prescribed for Mr.Black is ineffective" 2. " I am worried about Mr.Blacks blood pressure. It is not decreasing even with the new antihypertensive medication ." 3. " Can we talk about Mr.Black?" 4. " Excuse me doctor. I think we need to talk about Mr. Blacks blood pressure"

2. " I am worried about Mr.Blacks blood pressure. It is not decreasing even with the new antihypertensive medication

Which statement best reflects the nurses assessment of the fifth vital sign? 1." Do you have any complaints?" 2. "Are you experiencing any discomfort right now?" 3." Is there anything I can do for you now?" 4." Do you have any complains of pain?"

2. "Are you experiencing any discomfort right now?"

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the clients knee for how long? 1. 60 min 2. 20 min 3. 30min 4. 45min

2. 20 min

A nurse is scheduling a teaching situation. Which client is most ready to learn? 1. A 45 year old man whose health care provider just informed him that he has cancer 2. A 3 year old child whose parents are reading a storybook about going to the hospital 3. A 60 year old female who received medication 5 minutes ago for relief of abdomen pain 4. A 70 year old man, recovering from a stroke who has returned from physical therapy

2. A 3 year old child whose parents are reading a storybook about going to the hospital

Which learning activity reflects Blooms affective domain? 1. Administering an injection 2. Accepting the loss of a limb 3. Inserting a catheter 4. learning how to read

2. Accepting the loss of a limb

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the clients pain and administer prescribed pain medication. Which of the following can the nurse be charged with? 1. Malpractice 2. Negligence 3. Nonmaleficence 4.Beneficence

2. Negligence

A nurse is obtaining a health history from a client who is newly admitted . The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication? 1. Auditory 2. Nonverbal 3. Emotional 4. Energetic

2. Nonverbal

Because if significant concerns about financial problems, a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? " By day 5, the client will: 1. Sleep 8 to 10 hours per day 2. Report falling asleep within 20 to 30 minutes 3. Have a plan to pay all the bills 4. Decrease worrying about financial problems and will keep busy until bedtime

2. Report falling asleep within 20 to 30 minutes

A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use? 1. Send an email to staff via the facility's email system 2. Schedule a face-to-face unit staff meeting 3. Place a copy of the policy on a bulletin board in the hallway 4. Leave a voicemail on each staff members phone

2. Schedule a face-to-face unit staff meeting

A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? 1. Receiver 2. Sender 3. Channel 4. Decoder

2. Sender

Which example best illustrates the principle of knowing the client? 1. The nurse provides a back rub to help the client relax, and the nurse makes the bed with clean linen 2. The nurse listens as the client describes how he has been caring for his diabetes at home 3. The nurse administers a piggyback antibiotic for a client with pneumonia 4. The nurse collects a urine specimen to send to the lab, and explains to the client the reason for the test.

2. The nurse listens as the client describes how he has been caring for his diabetes at home.

Which nursing theory is depicted by a model with spiritual ethical caring in the center, surrounded by technologic, physical, legal, political, economic, social-cultural, and educational systems? 1. Nursing as caring 2. Theory of bureaucratic caring 3. Caring, the human mode of being 4. Theory of human care

2. Theory of bureaucratic caring

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take? 1. Administer an antagonist to reverse the effects of the anesthesia 2. Use an alternative method for determining the clients pain level 3. Administer a pain medication as prescribed for several pains 4. Wait until the client is awake, alert, and able to vocalize their pain

2. Use an alternative method for determining the clients pain level

A client's learning outcome is "client will verbalize medication name, purpose, and appropriate precautions." which documented statement reflects evidence of learning? 1. Taught name, purpose, and precautions for the new cardiac medication; seemed to understand 2. Written information about the medication provided and reviewed; correct responses were given to follow up questions 3. Written information read to client; states he would read it when he got home 4. Asked questions about the new cardiac medication; satisfied with the information

2. Written information about the medication provided and reviewed; correct responses were given to follow up questions

A nurse is evaluating a clients pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter R? 1. " Can you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine?" 2." Can you point to where you are having pain?" 3." What does your pain feel like?" 4." What were you doing when your pain started?"

2." Can you point to where you are having pain?"

A nurse is teaching stuff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make? 1." Justice allows the client the freedom of choice" 2." Justice allows the client the opportunity to be treated fairly " 3." Justice is causing no harm to the client" 4." Justice is doing good for the client"

2." Justice allows the client the opportunity to be treated fairly "

When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? 1. Pain tolerance 2. Pain intensity 3. Location of pain 4. Pain history

2.Pain intensity

A depressed client who has not bathes or dressed in clean clothes today is reading the lunch menu but is unable to make a decision. Which would be the most appropriate nursing diagnosis for this client.? 1. Anxiety 2. Powerlessness 3. Chronic Low-self esteem 4. Social isolation

2.Powerlessness

When planning care of pain control of older clients, which principles should the nurse apply? Select all that apply 1. Pain is a natural outcome of the aging process 2. Pain perception increases with age 3. The client may deny pain 4. The nurse should avoid use of opioids 5. The client may describe pain as an "ache" or "Discomfort"

3 and 5

Place the following descriptions of the helping relationship phases in the correct sequence. 1. After introductions, the nurse asks, " What plans do you have for the upcoming holiday weekend?" 2. The nurse states ," It sounds like you are concerned about the possible complications of having diabetes. What would be the most helpful for you at this time?" 3. The nurse reads in the medical history that the client was diagnosed with diabetes 1 week ago. 4. The nurse states," When we met, you knew very little about diabetes and now you are able to use your new information and apply it to your own personal situation.

3, 1, 2, 4,

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-inducted ventilatory impairment (OIVI)? Select all that apply 1. Bowel sounds 2. Deep tendon reflexes 3. Respiratory rate 4. Capnography 5. Oxygen saturation

3,4,5

The nurse is communicating with a well-oriented older adult client in a long-term care setting. Which statement best reflects respectful and caring communication? 1. "Are we ready for our shower?" 2. "Its time to go to the dinning room, honey" 3. " Are you comfortable, Mrs.Smith?" 4. " You would rather wear the slacks, wouldn't you?"

3. " Are you comfortable, Mrs.Smith?"

the nurse is answering questions after a presentation on sleep at a local senior citizen center. A women in her late 70s asks for an opinion about the advisability of allowing her husband to nap for 15 to 20 minutes each afternoon, Which is the nurses best response? 1. "Taking an afternoon nap will interfere with his being able to sleep at night. IF he is tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake" 2. " He shouldn't need to take an afternoon nap if he's getting enough sleep at night" 3. " Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine" 4. " Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon"

3. " Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine"

A client has a learning outcome of select foods that are low in fat content. Which of the following statements reflects that the client has met this learning outcome? 1. "I understand the importance of maintaining a low-fat diet." 2. "I feel better about myself now." 3. "See how I revised my favorite recipe to be lower in fat." 4. "Since changing my diet, my husband is also losing weight."

3. "See how I revised my favorite recipe to be lower in fat."

A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain? 1. A client who has osteoarthritis and reports difficulty ambulating for the past 6 months 2. A client who had surgery to repair a fractured tibia and reports incisional pain 3. A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury 4. A hospice client who has prostate cancer and reports pelvic pain

3. A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury

A primary care provider admitted a client experiencing hypertensive crisis because of the failure to take his prescribed medications. To determine learning needs, which client assessment by the nurse would have highest priority? 1.Age 2. Perception of the effects of hypertension 3. Ability to purchase needed medications 4. Support system

3. Ability to purchase needed medications

Which is the best method of helping a client newly diagnosed with diabetes to learn the dietary requirements associated with the disease? 1. Provide a videotape that addresses the dietary requirements associated with the disease 2. Ask a nutritionist to visit the client to present information and handouts about the diabetic diet 3. Ask the client to make a list of her favorite foods and how to work them into her diet 4. Have the client attend a group meeting for clients with diabetes to discuss their adaptation to this chronic health condition

3. Ask the client to make a list of her favorite foods and how to work them into her diet

A 74 year old client who takes multiple medications tells the nurse ," I have no idea what that little yellow pill is for." What is the best nursing diagnosis for the client? 1. Deficient knowledge 2. Health-seeking behavior 3. Deficient knowledge (medication information) 4. Noncompliance

3. Deficient knowledge (medication information)

A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take? 1. Use medical terminology during teaching 2. Sit across from the client at a table in the cafeteria during teaching 3. Ensure the client is wearing their glasses during teaching 4. Use the communication technique of probing during teaching

3. Ensure the client is wearing their glasses during teaching

In a reflective journal, a nursing student writes this statement about a comatose client on the hospital unit:" the Do-not-resuscitate order was not on the chart, and none of the nurses knew what measures should be taken if the client stopped breathing". This statement most clearly reflects which of the four ways of knowing? 1. Empirical 2. Personal 3. Ethical 4. Aesthetic

3. Ethical

A nurse is caring for an older adult. client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take? 1. Use the Crying, Requires Oxygen, Increased Vital signs, Expression, Sleeplessness (CRIES) pain scale 2. Reassures family members that older adult clients have a decreased ability to sense pain 3. Evaluate the client for pain by observing their behavior 4. Assign a pain scale number based on the FACES pain scale

3. Evaluate the client for pain by observing their behavior

A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship? 1. Identification 2. Orientation 3. Exploration 4. Resolution

3. Exploration

A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, " Thank you. I never really knew what caused diabetes." using the Schramm model of communication, the nurse should recognize the clients statement as an example of which of following components of the model? 1. Sender 2. Channel 3. Feedback 4. Receiver

3. Feedback

A student nurse is caring for a 72 year old client with Alzheimers disease who is very confused. Which is the most appropriate communication strategy to be used by the student nurse? 1. Written directions for bathing 2. Speaking very loudly 3. Gentle touch while providing ADLs 4. Flat facial expression

3. Gentle touch while providing ADLs

During the transduction phase of nociception, which method of pain control is most effective? 1.Tricyclic antidepressants 2. Opiods 3. Ibuprofen 4. Distraction

3. Ibuprofen

Mayeroff described allowing the other to grow in his own way and time. This behavior most clearly reflects which major ingredient of caring? 1. Humility 2. Knowing 3. Patience 4. Courage

3. Patience

A nurse is providing end-of-life care for a client who is unresponsive and near death. The clients family asks the nurse about managing the clients pain. Which of the following statements should the nurse make to the clients family? 1. " Your family member will not require pain medication" 2. " Your family member can inform the provider about their decision for pain management" 3." Your family member has the right to receive effective pain management" 4." Your family member will not be able to tolerate the effects of pain medication"

3." Your family member has the right to receive effective pain management

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this clients pain? 1. Cancer pain 2. Acute pain 3.Chronic pain 4. Neuropathic pain

3.Chronic pain

A client who describes his pain as 7 on scale 0 to 10 is classified as having which of the following? 1. No pain 2. Mild pain 3. Moderate pain 4. Sever pain

3.Moderate pain

A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating? 1. Assertive 2. Aggressive 3.Passive-agressive 4.Passive

3.Passive-agressive

A 40-year-old client who comes to the clinic for a routine physical exam asks the nurse how much exercise is recommended for a healthy lifestyle. Which answer is most appropriate? 1. Moderate activity for 10. minutes daily 2. Moderate activity for 20 minutes two to three times a week 3.Vigorous activity for 25 minutes three times a week 4. Vigorous activity for 30 minutes daily

3.Vigorous activity for 25 minutes three times a week

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions? 1. "I can use the morphine as needed as long as I don't take it more than six times a day" 2. " I will used my household teaspoon to measure the correct amount of morphine" 3." I will monitor for high blood pressure while taking the morphine" 4. " I will keep the morphine bottle in a locked cabinet in my kitchen

4. " I will keep the morphine bottle in a locked cabinet in my kitchen

The client made the following statement to the nurse, " My doctor just told me that he cannot save my leg and that I need to have an above-the-knee amputation." Which response by the nurse is most appropriate? 1. " Dr. Jones is an excellent surgeon" 2. " Are you in pain" 3. " IF I were you, I'd get a second opinion" 4. " Tell me more..."

4. " Tell me more..."

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is a greatest risk for respiratory depression ? 1. A client who has chronic pain and recently started taking paroxetine 2. A client who has cancer and has taken oxycodone PRN for several months 3. A client who has been accidentally taking twice the amount of prednisone as prescribed 4. A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN

4. A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following expamples should the nurse include as an example of autonomy? 1. A nurse allows a client to wait longer for their pain medication than other clients 2. A nurse does not properly clean a vial of pain medication prior to withdrawing medication from the vial, which results in the client contracting an infection 3. A nurse administers scheduled pain medication and provides therapeutic distraction technique for a client in pain 4. A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

4. A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? 1. Take the last pill on a Friday night so disrupt sleep can be compensated on the weekend 2. Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible. 3. Discontinue taking the pills 4. Continue taking the pills and discuss tapering the dose with the primary care provider

4. Continue taking the pills and discuss tapering the dose with the primary care provider

a client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? 1. Do you have a history of cardiac irregularities? 2. Do you have a history of any kind of nasal obstruction? 3. Have you had chest pain with or without activity? 4. Do you have difficulty with daytime sleepiness?

4. Do you have difficulty with daytime sleepiness?

The client has an order of morphine 2.5 to 5.0 mg intravenous (IV) every 4 hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0 to 10. He is now watching television and visiting with family members. When asked about his pain , he rates it as a 5. His vital signs are stable. What nursing intervention is the most appropriate? 1. Give morphine 3.4 mg IV and inform him to continue watching TV because it is a distraction from his pain 2. Give 2.5 mg of morphine IV to avoid the client becoming addicted 3. Give nothing at this time because he is not exhibiting any signs of pain 4. Give morphine 5.0 mg IV and reassess in 20 minutes

4. Give morphine 5.0 mg IV and reassess in 20 minutes

A nurse enters a clients room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take? 1. Leave the clients room to go check on other clients 2. Ask the client why they are ignoring the question 3. Repeat the question in a loud voice 4. Lower the volume on the television

4. Lower the volume on the television

A nurse, sitting quietly in a chair, breathing deeply, and focusing on the mental image of a crystal is using which mind-body therapy? 1. Storytelling 2. Yoga 3. Music therapy 4. Meditation

4. Meditation

During an admission nursing assessment, a client with diabetes describes his leg pain as a "dull, burning sensation." The nurse reorganizes the description to be characteristic of which type of pain? 1. Physiological 2. Somatic 3. Visceral 4. Neuropathic

4. Neuropathic

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse that their pain is still a 7 and has not changed. Which of the following actions should the nurse take? 1. Administer another 5-mg dose of the oral opioid now 2.Administer 10 mg of oxycodone every 2 hr 3. Inform the provider that the clients pain medication is not effective 4. Offer to assist the client with non pharmacological relief strategies.

4. Offer to assist the client with non pharmacological relief strategies.

During a yearly physical, a 52-year old man client mentions that his wife frequently complains about him snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to his client? 1. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife 2. Refer him to a dietitian for a weight loss program 3. Caution him not to drink or take sleeping pills since they may make the snoring worse 4. Refer him to a sleep disorder center for evaluation and treatment for his symptoms

4. Refer him to a sleep disorder center for evaluation and treatment for his symptoms

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which pf the following actions should the nurse take? 1. Ask a staff member who speaks the same language as the client to interpret 2. Ask a family member of the client to interpret the information 3. Search the internet for an electronic application to use for translating 4. Request assistance from the facility interpreter.

4. Request assistance from the facility interpreter.

A nurse is caring for a client who has refused to have a biopsy. The client states," I don't need the biopsy; I wouldn't do anything about it anyways if its cancer." The nurse replies ," You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using? 1. Affirmation 2. Open-ended question 3. Reflection 4. Restarting

4. Restarting

A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client? 1. Explain the daily schedule to the client in detail 2. Turn the overhead lights on in the clients room when speaking with them 3. Speak in a loud voice to the clients 4. Speak to the client clearly and at a slow pace

4. Speak to the client clearly and at a slow pace