hesi pt 2

Unintentional torts

Negligence Malpractice

Which points about nursing care and nursing practice have been accurately stated? Select all that apply.

Nursing theories help to describe, explain, predict, and/or prescribe nursing care measures. The scientific work used in developing theories expands the scientific knowledge of the profession. The expertise required to interpret clinical situations and make clinical judgments is the essence of nursing care and the basis for advancing nursing practice and nursing science.

The nurse provides crutch-walking instructions to a client who has a left-leg cast. Where would the nurse teach the client to place their weight?

On the hands Rationale Body weight should be placed on the hands and not under the arms of the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side or the side the client prefers.

Maslow's hierarchy of needs first level

Physiological needs: air, water, and food

Maslow's hierarchy of needs second level

Physiological security and safety needs

Upon entering an examination room for assessment of a confused client, which action would the nurse take?

Plan a focused physical assessment.

The nurse advises a client to refrain from adding salt to food as a way to prevent high blood pressure. Which health care service is this?

Primary care

In what position should a nurse place the head of the bed to obtain the most accurate reading of jugular vein distension?

Raised to 30 degrees

When assessing risk factors, which question would the nurse ask a client who had developed pneumonia?

"Are you diabetic?"

Which point represents a characteristic of nursing research?

1) "Research means to search again or to examine carefully." 2) "Nursing research is a way to identify new knowledge, improve professional education and practice, and use resources effectively." 3) "The knowledge generated provides a scientific basis for nursing practice and validates the effectiveness of nursing interventions."

Which action would the nurse take when a client is receiving total parenteral nutrition?

1) Monitor for hydration 2) Monitor weight daily 3) Monitor vital signs every 4 hours 4) Discard any solution after 24 hours 5) Check the expiration date of the solution before administration

Which information is appropriate for the nurse to include in the education for a group of nursing students regarding near-miss events?

1) No actual harm is caused to clients 2) They are caused by a variation in standard care. 3) The cause may be analyzed by a failure modes effects analysis (FMEA).

Which agencies have the power to implement Medicare and Medicaid reimbursement?

1) The Joint Commission (TJC) 2) National Committee for Quality Assurance (NCQA) 3) Community Health Accreditation Program (CHAP) 4) Accreditation Commission for Health Care (ACHC)

Which point represents an attribute of nursing theory?

A nursing theory helps identify the focus, means, and goals of practice. Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions.

What findings would necessitate holding feedings and medications and notifying the health care provider immediately?

Absence of bowel sounds, presence of abdominal distention, residual capacity exceeding 300 mL, positive guaiac test of abdominal contents, seepage of feeding around tracheostomy

Prescriptive theories

Address nursing interventions for a phenomenon, guide practice change, and predict the consequences

Which professional organizations work towards identifying nursing informatics competencies? Select all that apply.

American Medical Informatics Associations (AMIA) Health Information Management Systems Society (HIMSS) Technology and Informatics Guiding Education Reform (TIGER) initiative

A daughter of Chinese-speaking client approaches the nurse and asks multiple questions while maintaining direct eye contact. Which culturally related concept would the daughter's behavior reflect?

Assimilation

Maslow's hierarchy of needs fourth level

addresses the self-esteem and confidence of a client

which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised?

fidelity

A nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana? Select all that apply.

lung cancer emphysema heart disease

axillae

the underarm or armpit

Upon entering the exam room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse?

Find a way to interview the client in private.

Which level of Maslow's Hierarchy of needs would the nurse need to follow for a client brought to the emergency department with sever breathing difficulty?

First level

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway

While performing a physical assessment of a client, the nurse notices patchy areas with pigmentation loss on the skin, hands and arms, With which probable cause would the nurse associate this finding?

Autoimmune disease

Which entities are examples of high-reliability organizations?

Aviation Air traffic control Nuclear power plants

The nurse recognizes that the root cause analysis tool will be useful in which case?

Death due to nosocomial infection

A client has seeds containing radium implanted in the pharyngeal area. Which would the nurse include in the client's plan of care?

Maintain the client in an isolation room Rationale During radiation therapy with radium implants, the client is placed in isolation so that exposure to radiation by family and staff is decreased. Voiding every 2 hours is unnecessary; a full bladder will not disrupt the seeds. Excess exposure to radiation is hazardous to personnel. Gloves will not protect the nurse from radiation.

While assessing a client, the nurse identifies adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound is clearly heard while the client is coughing. Which condition would the nurse associate with these sounds?

Muscular spasms in the larger airways

Which action would the nurse take to provide patient-centered based on the five Institute of Medicine (IOM) competencies?

Share decision-making and management.

Preventive care

includes blood pressure and cancer screening, immunizations, mental health counseling and crisis prevention, and community legislation

Maslow's hierarchy of needs third level

social needs

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behaviors indicate the client is emotionally accepting the impending death?

Revising the client's will and planning a visit to a friend.

Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. One, some, or all responses may be correct.

1) Client with corneal arcus 2) Client with yellow lipid lesions on eyelids

The nursing student has enrolled in a Public Health Informatics (PHI) fellowship program. Which concept would the student expect to learn in this program?

1) Designing new tools for biosurveillance 2) Developing online analytic processing tools 3) Methodologies for determining outbreak response

A nurse is recollecting Sigmund Freud's psychoanalytical model of personality development. What are the characteristics of the phallic stage, as per this model? Select all that apply.

1) In this stage, a child may develop an oedipal complex. 2) In this stage, a girl may experience 'penis envy' feelings. 3) In this stage, the genital organs are the focus of pleasure.

Which factors may help in providing excellent health care services to the client? Select all that apply.

1. Cultural sensitivity 2. Competent health care 3. Interprofessional teamwork

Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds?

Turbulence due to muscular spasm and fluid or mucus in the larger airways

When assessing a client, the nurse notices that the action stage of health behavior change has been reached. Which client reaction would the nurse expect after providing suggestions for change?

Previous habits that may prevent taking action related to new behaviors Rationale In the action stage, the client's pre

Which represents a significant shift in U.S. health policy in recent years?

There is a focus on better managing clients with multiple chronic conditions.

which objective was the goal of executive order incentives for the use of health information technology and establishing the position of the national health information technology coordinator?

develop a nationwide health information technology system