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Which information does not apply to preconventional reasoning?

"The client sees moral reasoning based on his or her personal internalization of societal and others' expectations."

The nurse would expect a client in the precontemplation stage of wellness behavior change to exhibit which characteristics?

1) No intention of making any changes in the next 6 months 2) Does not show interest in information related to health behavior changes 3) Becomes defensive when confronted with information regarding current health behavior

Which similarity exists between Havighurst's stage-crisis theory and Erikson's psychosocial development theory?

Based on developmental tasks

While providing postoperative care for a client, who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery?

Expectoration of blood

Which record would the nurse use to record client data from admission through discharge?

Source record

Which risk(s) would the nurse state can be associated with adults who work on or around automobiles?

Asbestosis Dermatitis

Which disease process places a client at increased risk for infection? Select all that apply. One, some, or all responses may be correct.

Leukemia Lymphoma Emphysema Rationale Disease processes that increase the client's risk for infection include leukemia, lymphoma, and emphysema, which lead to a diminished immune system.

Which communication technique is a part of therapeutic communication?

Providing relevant information to the client

Which standard is important for the nurse to use in critical thinking?

Specific Relevant Rationale The standards important for critical thinking are specific and relevant knowledge about a task. Fairness, confidence, and independence are the attitudes required for critical thinking.

Magnet health care org

The nurse in Magnet health care organization must collect data on specific nursing-sensitive quality indicatory or outcomes. These data must be compared with the national, state, or regional database to demonstrate quality care. The nurse must always follow evidence-based practice while providing client care. Best practice may not always be beneficial for the client. The nurse must use a problem-solving approach and combine research-based practice with client preferences and values. Nurses in Magnet health care organizations are encouraged to practice with a sense of empowerment and autonomy to deliver quality care.

When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize?

Using medical terminology

Hand-off reports

reports that get transferred from one health care provider to another. The purpose of hand-off reports is to provide better continuity and individualized care for clients.

Acuity records

used to determine the hours of care and staff required for a given group of clients

Which steps would the nurse take when caring for a client to prevent nursing malpractice?

1) Be alert about common sources of client injuries. 2) Gain knowledge regarding current nursing practices. 3) Communicate with the client regarding tests and treatment plans.

Which scenario mentioned by the nurse is an example of continuing care?

Caring for a client with Parkinson disease who requires day care service

Which measure would the nurse take during the working phase of a helping relationship?

Use appropriate self-disclosure and confrontation Rationale During the working phase of a helping relationship, the nurse uses appropriate self-disclosure and confrontation. Evaluation of goal achievements with the client is performed during the termination phase. The nurse anticipates health concerns or issues that may arise during the preinteraction phase. The nurse prioritizes the client's problems and identifies his or her goals during the orientation.

Which categories are the four core roles for the advanced practice registered nurse (RN)?

Clinical nurse specialist Clinical nurse-midwife Certified RN anesthetist Certified nurse practitioner

Which question is open-ended?

"How are you feeling?" Rationale Asking the client how he or she is feeling now is an open-ended question. Open-ended questions prompt clients to describe a situation in more than one or two words.

A recent immigrant from China is critically ill and dying. To meet this client's emotional needs, which question would the nurse ask when collecting information?

"Which family member do you prefer to receive information?"

Which question would the nurse ask the client when obtaining their health history?

1) "Tell me about your food habits." 2) "Do you use alcohol or tobacco?" 3) "Have you ever experienced any allergic reactions?"

A client weighed 210 pounds on admission to the hospital. After two days of diuretic therapy, the client weighs 205.5 pounds. How many liters of fluid has the client excreted? Record the answer using a whole number. Record your answer using a whole number. __________ liters

2 L Rationale One liter of fluid weighs approximately 2.2 pounds (1 kg); therefore a 4.5-pound (2 kg) weight loss equals approximately 2 liters.

Which activity is the duty of the nurse when providing care for a client?

Determine the clients care preferences.

Which phase of helping relationships does the nurse exercise when collecting a client's medication information by interviewing the family and caregivers of the client?

Preinteraction phase

Which nursing intervention is an example of the nurse as a caregiver?

1) Encouraging the client to exercise daily 2) Setting goals for the client to reduce weight 3) Arranging for the client to meet a spiritual advisor

When the defining characteristics of a client's assessment data apply to more than one diagnosis, which action would the nurse take?

1) Gather more information 2) Identify related factors 3) Review all defining characteristics

Which example might an individual experience in Erikson's initiative versus guilt stage?

1) Pretends and tries out new roles 2) May develop a superego or a conscience 3) Fantasizes and imagines discovering the environment

Which statement explains the similarity between grand theory and descriptive theory?

Both theories are nonspecific to a particular nursing intervention. Rationale Both grand theory and descriptive theory provide a wide range of ideas about nursing. Hence, they are not specific to a particular nursing intervention. Neuman's model is a grand theory, not a descriptive theory. Descriptive theory is considered the first level of theory development. An individual's maturation process at different ages is described under descriptive theory.

While preparing to teach a client about self-injection of insulin, which nurse's action would increase the effectiveness of the teaching session?

Assess the client's barriers to learning self-injection techniques.

Which professional responsibility does the nurse display when teaching deep breathing exercises to a client recovering from surgery?

Autonomy Rationale The nurse practices autonomy by initiating independent nursing interventions without medical orders. Autonomy is an essential element of professional responsibility. The nurse explains concepts and facts related to health but does not advise the client. As a caregiver, the nurse helps the client improve physical, emotional, spiritual, and social well-being.

Which is the most important skill of the nurse leader?

Clinical care coordination Rationale: The most important leadership skill for the nurse leader is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary component included in clinical care coordination.

Block nursing

The services of nurses living within a neighborhood. The nurse generally provides services for older clients or those who are unable to leave their home. Running errands is one of the services offered by the block nurse.

Which goal of nursing would the nurse relate to King's theory?

Using communication to help client reestablish positive adaptation to environment

A client tells the nurse, "I need help planning an exercise regimen to help manage my weight." Which stage of health behavior change does this reflect?

Preparation

Educatory

ex. the nurse demonstrates the procedure for administering insulin injection. The nurse also reinforces and evaluates learning

Which complication would the nurse monitor for in a client on strict bed rest for 3 days?

1) Atelectasis 2) Hypotension 3) Constipation 4) Pressure injuries 5) Urinary tract infection

Arrange the steps taken by a nurse while assessing the visual level of a client in sequential order.

1) Direct the client to stand or sit 60 cm away from eye level. 2) Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye. 3) Close the opposite eye to superimpose the field of vision 4) Move a finger equidistant between the nurse and the client outside the field of vision. 5) Ask the client to report when he or she is able to see the finger. Rationale: The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level. Next, the nurse should ask the client to gently close or cover one eye and look at the nurse's eye directly opposite. Then, the nurse should also close his or her right eye to superimpose the field of vision. After this, the nurse should move a finger equidistant between the nurse and the client outside the field of vision. Finally, the nurse should ask the client to report when he or she is able to see the finger.

According to Piaget's theory, what are the cognitive or moral developmental changes in children aged 6 to 12 years? Select all that apply.

1) The child develops logical thinking. 2) The child is in the concrete operations period. Rationale According the Piaget's theory, a child is in the concrete operations period between the ages of 6 and 12 years and develops logical thinking. According to Piaget's theory, a child from the age of 18 months is in the sensorimotor period. A child from the age of 18 months to 3 years is in the preoperational period. A child between 18 months and 3 years old progresses from reflex activity to simple repetitive actions.

In which sequential order would the nurse perform the assessment of a lesion?

1) collecting information about its color, size, shape, type, grouping, and distribution 2) observing for any exudate, odor, amount, and consistency 3) measuring the size of the lesion in centimeters by using a small, clear, flexible ruler 4) measuring each lesion for height, width, and depth

Arrange in order the items of personal protection equipment (PPE) removed after seeing a client in droplet precautions.

1) gloves 2) face shield 3) gown 4) mask

Which statement accurately describes primary prevention?

Applied to clients who are physically and emotionally healthy. Rationale Primary prevention is true prevention. This prevention is applied to clients who are considered to be physically and emotionally healthy. The tertiary level of prevention is directed at providing rehabilitative care to clients. Secondary prevention includes screening techniques and treatment of early stage of disease. Secondary prevention is focused on individuals who are ill and are at risk for further complications.

For the client with a closed chest tube drainage system connected to suction, which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water-seal chamber Rationale Constant bubbling in the water-seal chamber is indicative of an air leak.

According to Watson's theory, in which practice is the nurse least likely to engage?

Curing the disease before engaging in care of the client.

Which condition(s) in the client indicate(s) need for nursing care that supports homeostatic regulation?

Damaged tissue Obstructed airway Rationale Damaged tissue and an obstructed airway indicate that the client needs nursing care that supports homeostatic regulation. Poor nutritional status, restricted body movement, and altered patterns of urinary elimination indicate that the client is in need of care that supports physical functioning.

A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client's anxiety. Which critical thinking attitude is involved in this situation?

Discipline Rationale The nurse shows discipline in collecting a thorough assessment to find the source of the client's anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.

Which action would the nurse take to comply with the ethic of nonmaleficence in the health care setting?

Focus on doing no harm.

Which objective would the nurse understand about the secondary level of prevention?

Focused on individuals who are in the early stage of their illnesses Rationale The secondary level of prevention is focused on individuals who are experiencing health problems or illnesses. Tertiary prevention is aimed at helping clients achieve the highest level of function possible. The tertiary level of prevention is focused on minimizing the effects of a long-term disease or disability. The primary level of prevention is aimed at attaining health promotion through wellness development activities.

Which record may the nurse use to document information specific to the client's health in a story-like format?

Narrative documentation

Which scenario mentioned by the RN is considered secondary acute care?

Prepares a client who has suffered from repeated cerebral attacks for a CT scan Rationale Secondary acute care includes emergency care, acute medical-surgical care, and radiological procedures for acute problems.

Which nursing action establishes the nurse as a caregiver for a client in spiritual distress?

Provides therapeutic treatment to the client Rationale The nurse serves as a caregiver by meeting all the health care requirements of the client by providing measures that restore a client's emotional, spiritual, and social well-being. In the given scenario, the nurse provides therapeutic treatment to the client as a caregiver. As an educator, the nurse teaches the client about the signs of spiritual distress. As a client's advocate, the nurse communicates the wishes of the client to family members. The nurse follows the principle of accountability by collaborating with the agency chaplain to pursue the best treatment plan.

In which way is public health nursing different from community health nursing?

Public health nursing focuses on a population. Rationale Public health nursing focuses on a population or a collection of individuals who have one or more personal or environmental characteristics in common, whereas community health nursing has a primary focus on the health care of individuals, families, and groups in a community. Both public health nursing and community health nursing focus on health promotion. Both types of nursing are part of a community-based health care delivery system and neither is part of primary health care. Both public health nursing and community health nursing require nurses to hold a graduate degree.

While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit?

Radial and apical pulse Rationale Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used to measure blood pressure. The temporal pulse is used to assess the pulse in children.

Which purpose would the nurse ascribe to evaluation research?

Test how well a program, practice, or policy is working Rationale The purpose of evaluation research is to establish how well a program, practice, or policy is working. Historical research is designed to establish facts and relationships concerning past events. Exploratory research is designed to develop or refine a hypothesis about the relationships among phenomena. Correlational research explores the interrelationships among variable of interest without any active intervention.

According to Freud's psychoanalytical model or personality development, which characteristic is part of the oral stage?

The child realizes that he or she is a separate individual. Rationale In the oral stage, the infant realizes they are separate individual. In the oedipal stage, the child fantasizes about the parent of the opposite sex as their first love interest. In the anal stage, the infant's focus of pleasure changes the anal zone. In the anal stage, the infant delays a gratification to meet parental and societal expectations.

A client who does not understand English requires an interpreter. Which action by the nurse may exacerbate health disparities?

The nurse talks only to the interpreter about the client.

Which point requires correction regarding the characteristics of an ethical issue?

The problem aims at the greatest good for the greatest number of people.

Which scenario is an example of restorative care? a. Performing radiological procedures on a client who has sustained a heart attack b. Monitoring the blood pressure of an older adult with insomnia and hypertension c. Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby d. Visiting a private residence to perform maggot-aided debridement therapy of a client's wound

d. Visiting a private residence to perform maggot-aided debridement therapy of a client's wound Rationale Visiting a client's residence to perform maggot-aided wound debridement is an example of restorative care. Performing radiological procedures on a client who has sustained a heart attack is an example of secondary acute care. Monitoring the blood pressure of an older adult with insomnia and hypertension is an example of preventive care. Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby is an example of primary care.

source records

separate section for each discipline such as an admission sheet, nursing records and medications. These are used for recording information from a client's admission until discharge.