HESI Questions Missed
A nurse is recalling Piaget's theory of cognitive development. Which statement is a characteristic of the concrete operations stage?
"A child is able describe a process without actually doing it."
A registered nurse is teaching a nursing student about Erikson's theory of psychosocial development. To which age group does Industry versus Inferiority apply?
6 to 11 years
Which of the following statements about a case manager is correct?
A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families. A change agent helps identify and implement new and more effective approaches to problems. A counselor helps clients identify and clarify health problems and choose appropriate courses of action. A caregiver applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families.
While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation?
A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.
What is a living will?
A living will is a written document that directs treatment on the basis of the client's wishes if he/she has a terminal illness or condition. A license allows registered nurses to offer the special skills to the public. A 'do not resuscitate' (DNR) order prevents primary healthcare providers from reviving clients or performing cardiopulmonary resuscitation (CPR). A durable power of attorney is a legal document that designates a person or persons chosen by a client to healthcare decisions on his/her behalf when the client is unable to do so.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?
A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.
What is the role of a nurse administrator in a healthcare setting?
A nurse administrator's function is to prepare the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development. A certified registered nurse anesthetist provides surgical anesthesia under the guidance and supervision of an anesthesiologist. The nurse practitioner provides comprehensive care and directly manages the medical care of clients who are healthy or have chronic conditions. Nurse educators provide knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings.
A nurse is teaching a parent about the different temperaments that a child may display. What characteristics does a slow-to-warm up child display? Select all that apply.
A slow-to-warm up child adapts slowly with frequent communication and reacts to novelty with mild but passive resistance. A slow-to-warm up child also reacts negatively and with mild intensity to new stimuli. An easy child is regular and predictable in his or her habits. A difficult child is highly active, irritable, and irregular in his or her habits.
What is a stressor?
A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.
A registered nurse is teaching a nursing student about the concepts that make up a theory. Which point noted by the nursing student needs correction?
A theory consists of interrelated concepts. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences.
A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain?
A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon. The domain is the perspective of a profession. A paradigm is a pattern of thought that is useful in describing the domain of a discipline. Environment or situation includes all possible conditions affecting clients and the settings in which their health care needs occur.
Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order. Incorrect 1. The set point of the hypothalamus is raised Incorrect 2. Immune system response is triggered Correct 3. Body temperature is increased Incorrect 4. Heat loss responses are initiated Incorrect 5. Pyrogens are destroyed
A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.
Which theorist suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptations to their environments?
According to King's theory, the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. According to Peplau's theory, the goal of nursing is to develop an interaction between nurse and client. According to Nightingale's theory, the goal of nursing is to facilitate the reparative processes of the body by manipulating a client's environment. According to Benner and Wrubel, the goal of nursing is to focus on a client's need for caring as a means of coping with stressors of illness.
nursing student is examining the health services pyramid. Keeping in mind that care services begin at the bottom of this pyramid, in which order should care services be arranged?
According to the health services pyramid, population-based health care services come first. Clinical preventive services form the next level of the pyramid. A nurse should then address the primary health care needs of clients; these needs include prenatal and baby care and nutrition counseling. The next level of health care is secondary health care services, which include emergency care and acute medical-surgical care. Tertiary health care forms the highest level of health care; these needs include intensive care and subacute care.
A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage?
According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.
A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage? Incorrect1 The nurse is learning about the profession through a specific set of rules and procedures. Correct2 The nurse is able to identify the basic principles of nursing care through careful observation. 3 The nurse is able to understand the organization and specific care required by certain clients. 4 The nurse is able to assess the entire situation and transfer knowledge gained from multiple previous experience
According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.
Arrange in order the items of personal protection equipment (PPE) removed after performing a surgical procedure
After performing a surgical procedure, the nurse should remove his or her gloves first to avoid the gloves coming into contact with other equipment. Next, the nurse removes the face shield, followed by the gown and mask. After removing all personal protection equipment (PPE), the nurse should wash his or her hands.
hich is used for determining the hours of care and staff required for a group of clients?
An acuity record is used to determine the hours of care and staff required for a given group of clients. A client's acuity level is based on the type and number of nursing interventions. Accurate acuity ratings justify overtime and the number and qualifications of staff needed to safely care for clients. A flow sheet helps to assess data about a client; this data includes vital signs and routine repetitive care. Standardized care plans based on an institution's standards of nursing practice are preprinted and established guidelines used to care for clients who have similar health problems. Discharge documentation includes medications, diet, community resources, follow-up care, and medical contact information in case of an emergency or query.
. Which professional standard does the nurse feel is most important for critical thinking?
An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.
Which of these cultural groups adopts a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness?
Asian Indians rely on a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness. East Asians use yin treatment (which uses needles to restore balance and flow of qi) and yang treatment (which uses moxibustion or heat with acupuncture to restore the yin/yang balance). Hispanics use a combination of prayers, herbs, and other rituals to treat traditional illnesses. Native Americans rely on a combination of prayers, chanting, and herbs to treat illnesses caused by supernatural, psychologic, and physical factors.
Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history?
Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.
What purpose does block and parish nursing serve in preventive and primary care services?
Block and parish nursing provides services to older clients or those who are unable to leave their homes. Community health centers provide primary care to a specific client population living in a specific community. Nurse-managed clinics provide nursing services with a focus on health promotion and education as well as on chronic disease. Occupational health services provide services that aim to increase worker productivity, decrease absenteeism, and reduce the use of expensive medical care.
Which factor can elevate the oxygen saturation during an assessment
Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.
A nurse changing the dressing on the client's perineum would fall into which zone?
Changing a client's dressing on the perineum falls under the intimate zone. For this action, the appropriate interpersonal distance between the nurse and the client should be between 0 and 18 inches. A nurse lecturing a class of students or speaking at a community forum lies within a public zone. A personal zone refers to a nurse sitting on the client's bedside, taking a client's history, or teaching a client individually. The vulnerable zone is where special care is needed.
What is the definition of descriptive research?
Descriptive research is defined as a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. Evaluation research tests how well a program, practice, or policy is working. Historical research is designed to establish facts and relationships concerning past events. Correlational research explores the interrelationships among variables without any active intervention by the researcher.
A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction?
Descriptive theories do not direct specific nursing activities. Instead, they help to explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.
Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation?
Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.
Which domain of the nursing intervention phase includes electrolyte and acid-base management?
Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiologic complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.
A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes?
During the process of negotiating outcomes, the nurse is required to provide a personal point of view. Negotiations may take place informally at the client's bedside or in a formal setting. After gathering relevant information regarding an ethical dilemma, the nurse is required to examine his or her own values and formulate an opinion regarding the matter. When verbalizing the problem, the group agrees to a statement of the problem to begin discussions. This step is performed before negotiating outcomes. Negotiations take place after determining all possible courses of action.
What are the elements of discovery of a lawsuit? Select all that apply.
Experts, medical records, and the depositions of witnesses are elements of discovery of a lawsuit. Proof of negligence is a part of a trial. Petition and elements of the claim are a part of the pleadings phase.
A registered nurse is teaching a nursing student about systems theories with a specific reference to Neuman's systems theory. Which statements made by the nursing student post teaching are accurate? Select all that apply.
Factors that change the environment also affect an open system. The components are interrelated and share a common purpose to form a whole. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. A system is composed of separate components, and there are two types of system, open or closed. Neuman's systems theory defines a total-person model of holism and an open-systems approach.
Which developmental changes should be evaluated in girls around 12 years of age?
Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.
Which psychophysiologic factors can influence communication between a nurse and a client?
Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.
Which system is used by a health care facility to determine certain aspects of client satisfaction?
HCAHPS is a standardized survey developed to measure client perceptions of their hospital experience. The survey asks 27 questions about the client's hospital experience. The survey is taken by clients who were discharged from the hospital between 48 hours and six weeks ago. Six Sigma is a data-driven approach to process improvement that reduces variation in the process. Value Stream Analysis focuses on the improvement of processes. It studies each step of a process to determine if that step adds value to that process. It also determines if the process reduces the organization's time, cost, and resources. The National Committee for Quality Assurance (NCQA) created HEDIS to collect various data to measure the quality of care and services provided by different health plans. It is the database of choice for the Centers for Medicare and Medicaid Services.
While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take?
Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event, along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.
The Magnet Recognition Program for health care organizations is based on fourteen forces of magnetism related to five magnet model components. Which force of magnetism is assessed to review the structural empowerment of the organization?
Health care organizations that apply for Magnet status must demonstrate innovations in professional practice. One of the forces of magnetism that impacts the structural empowerment of the organization is its personnel policies and programs. Personnel policies of an organization should provide an innovative environment in which the staff are developed and empowered. Empirical quality outcomes are reviewed by assessing the quality of care. New knowledge, innovations, and improvements are reviewed by assessing the quality improvement of the health care organization. Interdisciplinary relationships are assessed to review exemplary professional practice.
What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare?
Healthcare proxies enable another person or persons to make healthcare decisions on the client's behalf when the client is no longer able to make decisions on his or her own. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. This act is not related to healthcare proxies. The ethical doctrine of autonomy ensures the client's right to refuse medical treatment. A living will is a written document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition.
Which statement about Henderson's theory of nursing care is correct?
Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental.
Which statement is true about the nursing model "team nursing"?
Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.
Which type of breathing pattern alteration is manifested with hypercarbia?
Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul's respirations.
Which definition is involved in the caring process called knowing according to Swanson's theory of caring?
In Swanson's theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.
A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion?
In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.
Which skill in critical thinking requires to be orderly in data collection?
Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.
Which statement best describes a diagnostic label?
It is identified from the client's assessment data and associated with the diagnosis. A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.
A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?
Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.
Which term refers to the exaggeration of the posterior curvature of the thoracic spine?
Kyphosis is an excessive outward curvature of the spine that causes hunching of the back. Lordosis is the excessive inward curvature of the lumbar part of the spine. Scoliosis is the abnormal lateral curvature of the spine. Osteoporosis is characterized by a loss of bone mass and a deterioration of bone tissues.
A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall?
Labeling
Which positioning should be avoided while assessing a client with a history of asthma?
Lateral recumbent The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.
A nursing student notes the characteristics of middle-range theories. Which points noted by the nursing student are accurate? Select all that apply. 1 Middle-range theories are systematic and broad in scope and complexity. Correct2 Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. 3 Middle-range theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching. Correct4 Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Correct5 Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations.
Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Mishel's theory of uncertainty in illness is an example of a middle-range theory; it focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories are more limited in scope and less abstract than grand theories. Middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching.
Which type of theory is the Neuman systems model?
Neuman systems model is an example of a grand theory that provides a comprehensive foundation for scientific nursing practice, education, and research. Theories related to growth and development are descriptive theories. Prescriptive theories address nursing interventions for a phenomenon, describe the condition under which the prescription occurs, and predict the consequences. Mishel's theory of uncertainty is a prescriptive theory. Middle-range theories tend to focus on a specific field of nursing. Mishel's theory of uncertainty in illness is a middle-range theory.
What services do nurse-managed clinics provide in preventive and primary care services? Select all that apply.
Nurse-managed clinics provide wellness counseling, health risk appraisal, and employment readiness. Crisis intervention services are provided by school health centers. Communicable disease control services are provided by occupational health centers.
Which nursing theory focuses on the client's self-care needs?
Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.
Which statement about Orem's theory needs to be corrected?
Orem's theory explains the factors within a client's living situation. These factors may support or interfere with the client's self-care abilities, but they do not refer to the family's health. This theory interprets data that determine a client's self-care needs, self-care deficits, and self-care abilities. Orem's theory explains, predicts, or describes nursing care that will help the client in bettering his or her health. The theory also aids in the design of nursing interventions for the promotion of self-care by the client during times of illness, such as asthma, diabetes mellitus, or arthritis.
What is the inflammation of the skin at the base of the nail called?
Paronychia is the inflammation of skin at the base of nail. Concavely curved nails are called koilonychias. Transverse depressions in nails indicating a temporary disturbance of nail growth are called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis and are called splinter hemorrhages.
Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family?
Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.
While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate?
Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent.
Which theory details nursing interventions for a specific phenomenon and the expected outcome of care?
Prescriptive theories detail nursing interventions for a specific phenomenon and the expected outcome of the care. Grand theories provide the structural framework for broad, abstract ideas about nursing. Predictive theories identify conditions or factors that predict a phenomenon. Descriptive theories help to explain client assessments.
What is the primary focus of the nurse when providing evidence-based care to the client?
Problem-solving approach
What does a nurse understand by the term regulatory law as applied to nursing practice?
Regulatory law reflects the decisions made by administrative bodies such as the State Boards of Nursing.
Which statement made by a nursing student about Swanson's theory of caring needs correction?
Swanson's theory of caring provides a basis for identifying and testing nurse caring behaviors to determine if caring will improve client health outcomes. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.
A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do?
The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.
What do the Nurse Practice Acts do?
The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.
Which statement regarding Roy's theory of nursing needs correction?
The Roy adaptation model views the client as an adaptive system. The need for nursing care occurs when a client cannot adapt to internal and external environmental demands. Roy's model believes the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.
A nursing student is listing the points that need to be remembered regarding the United Network for Organ Sharing (UNOS) program. Which point listed by the nursing student is accurate?
The United Network for Organ Sharing (UNOS) has a contract with the federal government. The National Organ Transplant Act of 1984 protects the donor's estate from liability for injury or damage. The United Network for Organ Sharing gives priority to clients in their geographical area who need organs on an urgent basis. The National Organ Transplant Act of 1984 provides civil and criminal immunity to the hospital and the healthcare provider.
A nursing student is listing the professional responsibilities and roles of the nurse. Who is the most independently functioning nurse?
The advanced practice registered nurse is the most independently functioning nurse. The nurse educator, nurse researcher, and nurse administrator all must be associated with an organization to pursue their professional prospects.
A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising five days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing?
The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to six months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins six months after the change has started and continues indefinitely.
What is the correct order of steps of the nursing diagnostic process?
The diagnostic reasoning process involves the use of assessment data for the client. The assessment data is obtained from the client, family, and health care resources. The nurse validates and ensures the data is accurate and uses critical thinking to interpret and analyze the data before it is classified and organized into data clusters. This organization helps the nurse identify the client's health needs. The nurse then formulates the nursing diagnoses using standard formal nursing diagnostic statements.
A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition?
The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions
Arrange these fine-motor skills in ascending order as the infant develops them
The infant begins to develop fine-motor skills within the first month of its birth. The reflexive grasp is seen in the first month. By the age of two to four months, the infant begins to look at his fingers and play with them. The infant is able to bring objects from the hand to the mouth. At four to six months, the infant begins to pull his or her feet to his or her mouth to explore. By the age of six to eight months, the infant is able to hold objects and bang them together. The infant begins to crawl by the age of eight to 10 months and use a pincer grasp to pick up small objects. At this age, the infant also shows a hand preference. The infant is able to pick up objects and place them in containers by the age of 10 to 12 months.
Arrange these fine-motor skills in ascending order as the infant develops them. Correct 1. Reflexive grasp Correct 2. Looks at and plays with fingers Incorrect 3. Uses pincer grasp Incorrect 4. Pulls feet to the mouth Incorrect 5. Bangs objects together
The infant begins to develop fine-motor skills within the first month of its birth. The reflexive grasp is seen in the first month. By the age of two to four months, the infant begins to look at his fingers and play with them. The infant is able to bring objects from the hand to the mouth. At four to six months, the infant begins to pull his or her feet to his or her mouth to explore. By the age of six to eight months, the infant is able to hold objects and bang them together. The infant begins to crawl by the age of eight to 10 months and use a pincer grasp to pick up small objects. At this age, the infant also shows a hand preference. The infant is able to pick up objects and place them in containers by the age of 10 to 12 months.
While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition?
The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.
Which theory is based on the model of primacy of caring?
The model of primacy of caring is the basis of Benner and Wrubel's Theory. This theory focuses on client's need for caring as a means of coping with stressors of illness. According to Roy's theory, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. This theory promotes health, restoring the client to health, and preventing illness. Neuman's theory is based on stress and the client's reaction to the stressor.
Which feature according to Benner is observed in a nurse at the "proficient" level?
The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills. The novice nurse learns by means of a set of rules, which are usually stepwise and linear. The advanced beginner has observational experience and is able to identify the principles of nursing care. The expert nurse is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse.
Which nursing actions reflect Leininger's caring theory in practice?
The nurse learns culturally specific behaviors to meet the client's needs.
The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?
The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.
A client is ambivalent about making a change in health behavior. Which stage of health behavior does the nurse suspect?
The nurse suspects that the client is in the stage of contemplation. This stage of health behavior is characterized by the client's attitude toward a change and the client is most likely to accept that change over the next 6 months. In the preparation stage, the client believes that a change in behavior will be advantageous. The client may need assistance to bring about the change in behavior. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to receive any information about changes in behavior and may become defensive and confrontational.
client is in a state of ambivalence. Which of these stages of health behavior will the nurse suspect?
The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude towards a change; the client is most likely to accept that change in the next six months. The stage of preparation is when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about the changes in the behavior.
The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?
The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client's health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client's response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client's care. The nurse selects interventions (nursing and collaborative) individualized to each of the client's nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client's response and whether the interventions were effective. The nursing process is dynamic and continuous.
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.
The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format?
The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions.
On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client?
The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.
How many levels of critical thinking exist for nursing judgment
There are three levels of critical thinking in nursing judgment. The first level is basic critical thinking, in which the nurse has faith that the expert has the right answer to each problem. The second level is complex critical thinking. The nurse examines and analyzes information provided by the expert. A nurse engaging in this critical thinking may discover that another option is available with which to solve an issue. The third level of critical thinking is commitment. A nurse at this level can make choices without help from others. The nurse at this level of critical thinking takes full responsibility for every action in which he or she engages.
How many levels of critical thinking exist for nursing judgment?
There are three levels of critical thinking in nursing judgment. The first level is basic critical thinking, in which the nurse has faith that the expert has the right answer to each problem. The second level is complex critical thinking. The nurse examines and analyzes information provided by the expert. A nurse engaging in this critical thinking may discover that another option is available with which to solve an issue. The third level of critical thinking is commitment. A nurse at this level can make choices without help from others. The nurse at this level of critical thinking takes full responsibility for every action in which he or she engages.
What is the role of a case manager in a healthcare organization?
To follow up with the client after discharge
What does a nurse understand by the quality improvement competency, according to Quality and Safety Education (QSEN)?
Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
What are the goals of care when working with families according to the family health system? Select all that apply.
When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.
According to King's theory, the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. According to Peplau's theory, the goal of nursing is to develop an interaction between nurse and client. According to Nightingale's theory, the goal of nursing is to facilitate the reparative processes of the body by manipulating a client's environment. According to Benner and Wrubel, the goal of nursing is to focus on a client's need for caring as a means of coping with stressors of illness.
Which theorist suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptations to their environments?
Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?
explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.
