intro final (review questions)
The nurse is caring for a woman with terminal breast cancer. Which statement made by the client reflects the bargaining stage of grief? "Why is this happening now? I will never see my grandchild." "I may not see my grandchild here on Earth,but I will in the afterlife." "Please, let me live long enough to see my grandchild." "I do not care about anything. Just let me sleep."
"I do not care about anything. Just let me sleep."
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."
"I will use clean gloves to handle the catheter and other equipment."
A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know what is an advanced directive?" What is the nurse's best response? "I will contact the hospital social worker to come and discuss the development of an advance directive with you." "It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition." "It is a document created by you and your attorney naming a beneficiary to handle your estate if you become terminally ill." "It is an agreement that authorizes the hospital to make decisions on your behalf, if you become incapacitated."
"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."
A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? "Let me tell you what I will be doing. It should not be painful" "I have to do this, so just relax and it won't last long" "This is nothing to worry about. I won't hurt you" "Some of the examination may be painful, but I will be gentle"
"Let me tell you what I will be doing. It should not be painful"
A nurse interviews a patient who was abused by her partner and is staying at a shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? "Patient displays moderate anxiety related to her situation." "Patient manifests panic related to feelings of impending doom." "Patient describes severe anxiety related to her situation." "Patient expresses fear of her husband."
"Patient expresses fear of her husband."
A female client tells the nurse, "I try to consume 2000 calories daily by eating a variety of proteins, carbohydrates, and fats." What is the appropriate nursing response? "That is a healthy amount of daily calorie intake" "It doesn't matter which foods you eat, as long as you consume 2,000 calories daily" "Your diet should be richer in nutrients, vitamins, and minerals". "You are eating too many calories for an adult woman".
"That is a healthy amount of daily calorie intake"
Which is the proper way to document midnight in a clients record? 1201 2401 0000 1200
0000
How much water, at a minimum, should be consumed daily? 120 oz of fluid 64 oz of non caffeinated fluid 80 oz of non caffeinated fluid 1200 oz of fluid
64 oz of non caffeinated fluid
Older adults are considered to be what age? 40-65 years old 80+ years old 50-85 years old 65+ years old
65+ years old
Who is the most likely person to commit errors and be a factor in adverse events? The teenager who sleeps in until 12pm An older gentleman in a retirement home A nurse who has just worked a a 16 hour double shift. The lawyer who has a fixed schedule, 40 hour work week.
A nurse who has just worked a a 16 hour double shift.
A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? Cognitive Psychomotor Affective Physical changes
Affective
A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? Personal Identity Disturbance Body Image Disturbance Self-Esteem Disturbance Altered Role Performance
Altered Role Performance
Which of these is NOT true of Alzheimer's disease? Alzheimer's is a form of dementia The cause of Alzheimer's is unknown Alzheimer's can be cured There are treatments for Alzheimer's
Alzheimer's can be cured
A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? An infant who learns to turn over A school-aged child who learns how to add and subtract An adolescent who is a "loner" A young adult who has a variety of friends
An adolescent who is a "loner"
A nurse is performing an assessment of a woman who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? Ineffective Coping related to the new parenting role Ineffective Denial related to ability to care for a newborn Anxiety related to change in role status Situational Low Self-Esteem related to fear of parenting
Anxiety related to change in role status
A 35 year old female is being discharged today after an infection caused by an external fixation device. The nurse who works with her all day created a bond with the patient. When it is time to assist the patient to her car, the nurse is concerned because they (the nurse) have not been fully educated on how to safely complete the task. What should the nurse do next? Transfer the patient on their own anyway, got to learn sometime. Ask a family member to assist with the transfer of the patient. Ask a nurse with experience with transferring patients to assist. Call the physician to have the discharge held until the next shift.
Ask a nurse with experience with transferring patients to assist.
The nurse is caring for a patient who was admitted for abdominal pain, in which she reports the pain as an 9 on a pain scale of 1 to 10. The nurse notes that the patient is laughing and chatting with staff. Which action will the nurse perform prior to initiating treatment? Contact the pain clinic for further assessment Discuss observations with the client. Request a lower dose of medication from the health care provider. Assess for nonverbal cues to pain
Assess for nonverbal cues to pain
A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk? Assess the client's level of consciousness. Assess the client for nausea. Inspect, auscultate and palpate the client's abdomen. Inspect the integrity of the client's oral mucosa.
Assess the client's level of consciousness.
The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take? Call code blue Ask another nurse to observe the patients sleep patterns Review the patient's medical records Assess the clients sleep vital signs and pulse oximetry
Assess the clients sleep vital signs and pulse oximetry
You are caring for a 76-year-old patient who is having trouble hearing your instructions. You suggest the use of a hearing aid. What sensory receptor is impaired in the patient? Olfactory Gustatory Auditory Stereognosis
Auditory
Which channels do nurses use to communicate with patients and other health care providers? Select all that apply. Auditory Visual Kinesthetic Communication Receiver
Auditory Visual Kinesthetic
A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which has the nurse committed? Assault Battery False imprisonment Negligence
Battery
A client in the emergency room is being assessed. When performing an assessment, the nurse notes that the client guards his fractured arm to protect it. When offered to sit in a chair, the patient refuses to get up from his bed and turns his head to face the wall. How would the nurse note this reaction? Physiologic Behavioral Psychosomatic Affective
Behavioral
The nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on patient care? Higher nurse retention Improved job satisfaction score Longer patient stays Better patient outcomes
Better patient outcomes
A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume? Egg Yolks Ice cream Brown Rice Cheese
Brown Rice
Which of the following is NOT a function of the electrolyte calcium? Nerve Impulses Muscle Contraction B12 Absorption Carbohydrate metabolism
Carbohydrate metabolism
A nurse is teaching a female client who must provide a urine specimen. Which is the proper method to instruct the client to use in order to obtain a clean-catch urine specimen? Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. Catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. Catch the urine in the cup after cleansing the perineum.
Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.
A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse incur the clients safety? Check that the grab bars are at shoulder level Give the client a damp towel for bathing Check that the bathroom has a non skid floor Keep a bottle of bathing oil near the tub
Check that the bathroom has a non skid floor
Before providing care to an older patient with dementia, the nurse will check the MD orders. What would the next priority action be? Check the patient's blood glucose Check the patient's identification band Get help from a colleague that is familiar with the patient Ask the patient his name before care
Check the patient's identification band
A nurse takes the pulse of a patient, and finds it to be 138 bpm. What should the nurse do next? Check the pulse again and report the rate to the physician Record the rate Assess BP and respirations Ask the patient if they are in pain
Check the pulse again and report the rate to the physician
The MOLST form needs to be signed by which two parties? Clinician and patient Patient and family Clinician and nurse The charge nurse and nurse
Clinician and patient
The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which conflict resolution style does the nurse manager display? Avoiding Competing Collaborating Smoothing
Collaborating
A nurse asks a patient: "How important is it to you to believe that your work has value to others?" Which of the following aspects of self- esteem might this nurse be assessing? Socialization and communication Competence Virtue Power
Competence
What is the leading cause of residential building fires? Space Heaters Heating Smoking Cooking
Cooking
An 81-year-old patient was admitted to the hospital and is showing signs of confusion, disorientation, and restlessness. What state of conscious arousal is this patient perceived to be in? Dementia Confusion Somnolence Delirium
Delirium
The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying? Quantum Autocratic Democratic Laissez-faire
Democratic
If a nurse is preparing to give a client a transdermal medication, how should it be accomplished? Below the dermis By mouth By eyes Directly to the skin
Directly to the skin
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? Document the findings and continue to monitor the patient. Administer antipyretics, as prescribed. Increase the frequency of assessment to every hour and notify the patient's primary care provider. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.
Document the findings and continue to monitor the patient.
Which of the following would be considered an advantage of the nasal cannula? Dislodges frequently Does not impede eating or speaking Useful for mouth breathers Higher flow rates than a simple mask
Does not impede eating or speaking
A nurse caring for older adults in a long-term care facility encourages an older adult to reminisce about past life events. This life review, according to Erikson, is demonstrating what developmental stage of the later adult years? Ego integrity Generativity Intimacy Initiative
Ego integrity
A nurse is teaching a 5-year-old boy who was recently diagnosed with type 1 diabetes. The client's mother, who is the primary caregiver, informs the nurse of having a fear of needles. What actions are appropriate for the nurse to take to ensure a successful education session? Select all that apply. Ensuring 20 minutes of uninterrupted teaching time Using a doll to demonstrate giving an insulin injection Providing the client's mother with an informational pamphlet about insulin injection Asking the client's mother to leave the room to avoid distractions.
Ensuring 20 minutes of uninterrupted teaching time Using a doll to demonstrate giving an insulin injection Providing the client's mother with an informational pamphlet about insulin injection
A client with cancer has a family member who is emotionally supportive of the client. Having a supportive family member is which type of resource? External resource Financial resource Internal resource Professional resource
External resource
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: Vomiting and nausea Fluid and electrolyte imbalance Ability to reposition Pain level during infusion
Fluid and electrolyte imbalance
When a pt is taking their wisdom teeth out, what type of anesthesia will be administered? Regional General Local Moderate
General
Which of the following is correct about the difference in therapeutic effects of heat and cold applications? Heat decreases inflammation, cold relaxes muscles Heat increases blood flow, cold reduces bleeding Heat decreases velocity of nerve conduction, cold diminishes muscle spasms Heat prevents swelling, cold eases joint stiffness and pain
Heat increases blood flow, cold reduces bleeding
A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client? Impaired Skin Integrity related to functional incontinence Urinary Incontinence related to urinary tract infection Impaired Skin Integrity related to urinary bladder infection and dehydration Risk for Urinary Tract Infection related to dehydration
Impaired Skin Integrity related to urinary bladder infection and dehydration
What should a patient do if they consented to participate in a study, but have since changed their mind and no longer feel comfortable continuing in the study? Inform the nurse; patients are allowed to drop out of studies at anytime without jeopardizing their quality of care. Inform the nurse of their concerns, but know that they will have to continue on until the research has finished. Keep their concerns to themselves; no healthcare professional would do unethical research, so it's silly to worry. Patients are never involved in studies, so this would never happen.
Inform the nurse; patients are allowed to drop out of studies at anytime without jeopardizing their quality of care.
A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? Collaborative problem Nursing problem Interdisciplinary problem Medical problem
Interdisciplinary problem
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? Hypotonic Hypertonic Isotonic Osmosis
Isotonic
A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which ethical principle is the nurse attempting to practice? Nonmaleficence Beneficence Fidelity Justice
Justice
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: Soft Semi-formed Liquid Consistency Hard stool Firm stool
Liquid Consistency
Which action most clearly demonstrates a nurse's commitment to social justice? Ensuring that a hospital client's diet is culturally acceptable Answering a client's questions about care clearly and accurately Lobbying for an expansion of healthcare resources and benefits to those in poverty Documenting client care in a timely, honest, and thorough manner
Lobbying for an expansion of healthcare resources and benefits to those in poverty
Which natural chemical does the body produce at night to decrease wakefulness and promote sleep? Serotonin Melatonin Dopamine Endorphins
Melatonin
A nurse is interviewing a 42-year-old patient who is visiting an internist for a blood pressure screening. The patient states: "I'm currently a sales associate, but I'm considering a different career and I'm a little anxious about the process." According to Levinson, what phase of adult life is this patient experiencing? Entering the adult world Settling down Midlife transition Entering middle-adulthood
Midlife transition
While assessing breathing sounds, a nurse hears crackles. What causes these abnormal sounds? Air in the lungs A narrowing of the upper airway Narrowed small air passages Moisture in air passages
Moisture in air passages
A nurse works in a nursing care facility that has a policy of regularly using restraints on clients that the nurse believes is unethical. However, the nurse feels obligated to follow the policy because of a fear of being fired. This is an example of which type of ethical situation? Moralizing Moral distress Ethical dilemma Conscientious objection
Moral distress
An ICU patient with an amputated leg informs the nurse that sometimes she experiences pain in the amputated leg. How would the nurse describe this kind of pain that the patient is experiencing? Chronic pain Cutaneous pain Visceral pain Neuropathic Pain
Neuropathic Pain
Which belief statement is an example of ageism? Older adults are not interested in sex Older adults may have a slowed reaction time Older adults can still live very fulfilled lives Older adults can learn new things
Older adults are not interested in sex
A RN is taking the axillary temperature of a 6 year old patient during their annual physical. The patient is visibly uncomfortable and is moving too much. What is an alternative form of getting an accurate temperature? Rectal Oral Forehead Tympanic
Oral
A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"? Oriented person, situation, and time Oriented to hospital, person, and date Oriented to person, place, and time Oriented to person, place, and situation
Oriented to person, place, and time
A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply. Pale, cool skin Regular deep respirations Decreased urine output Irregular heart rate Strong, bounding pulse
Pale, cool skin Decreased urine output Irregular heart rate
A school nurse is studying Kohlberg's theory of moral development to prepare a parent discussion addressing the problem of bullying. According to Kohlberg, which factor initially influences the moral development of children? Parent/caregiver-child communications Societal rules and regulations Social and religious rules A person's beliefs and values
Parent/caregiver-child communications
The following statement is documented in a client's health record: " Patient c/o severe h/a upon arising this morning" Which interpretation of this statement is most accurate? Patient reports waking up with a severe cough this morning. Patient reports waking up this morning with a severe headache. Patient reports waking up this morning with complaints of a heart attack. Patient reports waking up this morning with severe heartburn.
Patient reports waking up this morning with a severe headache.
A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is most appropriate? Correct the initial assessment form. Redo the initial assessment and document current findings. Conduct and document an emergency assessment. Perform and document a focused assessment of skin integrity.
Perform and document a focused assessment of skin integrity.
A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? Incubation period Prodromal stage Full stage of illness Convalescent period
Prodromal stage
The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? Pulling the razor against the direction of hair growth Applying direct pressure to an area that is bleeding Washing the skin with soap and water prior to shaving Rinsing the razor after each stole of the razor
Pulling the razor against the direction of hair growth
A nurse is researching the relation between patients who do puzzles with nurses in hospitals improving their cognitive abilities quicker than those who do them alone. They will be conducting most of the research in a clinical setting. What type of research is this? Correlational research Experimental research Descriptive research Quasi-experimental research
Quasi-experimental research
What are some of the most important nursing actions to implement on a pt that is post-op? Select all that apply. Registering pain meds Deep breathing Ambulating in the PACU Coughing Sneezing
Registering pain meds Deep breathing Coughing
Which of the following are EARLY symptoms of Hypoxia? Select all that apply. Restlessness Bradycardia Tachycardia Anxiety Dyspnea
Restlessness Tachycardia Anxiety
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? Imbalanced Nutrition: More Than Body Requirements related to immobility Impaired Physical Mobility related to pain and discomfort Chronic Pain related to immobility Risk for Infection related to altered skin integrity
Risk for Infection related to altered skin integrity
A nurse may attempt to help a client solve a situational crisis during what type of counseling session? Short-term counseling Long-term counseling Motivational counseling Professional counseling
Short-term counseling
A nurse observes some involuntary muscle jerking a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? Stage 1 NREM Sleep Stage 4 NREM Sleep REM Sleep Stage 2 NREM Sleep
Stage 1 NREM Sleep
After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: Stage 1 Stage 2 Stage 3 Stage 4
Stage 2
A client who had an asthma attack was recently admitted to the facility. The nurse has an order for a medication that needs to be prescribed immediately. What is the proper abbreviation that would mean immediate action for a medication? Stat PRN AC PC
Stat
Which of the following are reputable sources of evidence in evidence-based practice? Select all that apply. Systemic reviews Controlled cohort studies Uncontrolled cohort studies Wikipedia articles
Systemic reviews Controlled cohort studies Uncontrolled cohort studies
Who is most responsible for promoting safety and preventing injury in the hospital setting? The Patient The Nurse The patient's family The hospital security
The Nurse
A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? The client describes signs and symptoms of hypoglycemia. The client expresses a desire to improve nutritional intake and lose weight. The client prepares the skin for the administration of an insulin injection. The client demonstrates proper technique for injecting insulin.
The client describes signs and symptoms of hypoglycemia.
A nursing student is learning about blood pressure and asks her professor for the definition. What would the professor answer with? The rhythmic throbbing of the arteries as blood is propelled through them. The movement of blood through the blood vessels of the body. A problem with the rate or rhythm of the heartbeat. The force of circulating blood on the walls of the arteries
The force of circulating blood on the walls of the arteries
A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? The nurse puts on PPE after entering the patient room. The nurse works from "clean" areas to "dirty" areas during bath. The nurse personalizes the care by substituting glasses for goggles. The nurse removes PPE prior to leaving the patient room.
The nurse works from "clean" areas to "dirty" areas during bath.
A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. The patient takes time to think about responses to questions. The patient is 86 years old. The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty. The patient reports increased pain in right hip when repositioning in bed or chair.
The patient is 86 years old. The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty. The patient reports increased pain in right hip when repositioning in bed or chair.
Which of the following is NOT a normal respiratory function? Removal of Carbon Dioxide from blood Oxygenation of venous blood Transporting nutrients and wastes to and from body cells To produce increased levels of Carbon Dioxide in the lungs
To produce increased levels of Carbon Dioxide in the lungs
A patient has requested a translator to help understand questions the nurse is asking during the patient interview. The nurse knows what is most important when working with a patient translator? Translator may need additional explanation of medical terms. Use a family member to help interpret. Speak loudly to better help the patient and translator understand. Direct all information to translator and not the patient.
Translator may need additional explanation of medical terms.
An older patient with lower extremity weakness has trouble moving and turning and turning in bed, as well as trouble transferring in and out of bed. What assistive device would be used to best help this patient? Trapeze device Transfer chair Lateral assist device Gait belt
Trapeze device
A patient is experiencing sensory overload in the ICU setting. They are complaining of a headache, their eyes hurt, and are overwhelmed by the sounds of the alarms connected to their machines. What are some actions you can take to relieve the patient of their sensory overload? (select all that apply) Turn off the lights Shut the blinds on the windows Turn on music you think the patient might like Provide an eye mask Turn off any unnecessary alarms Turn off all alarms
Turn off the lights Shut the blinds on the windows Provide an eye mask Turn off any unnecessary alarms
In which situation would it be appropriate to shave the beard of an unconscious client without his permission? When inserting an endotracheal tube To facilitate use of a nebulizer When the beard becomes tangled To facilitate skin care
When inserting an endotracheal tube
In which phase of a helping relationship would the patient express feeling and concerns to the nurse? Orientation phase Termination phase Working phase Introduction phase
Working phase
Which of the following are examples of malpractice? Select all that apply. failure to communicate failure to document failure to follow standards of care allowing patient to self advocate
failure to communicate failure to document failure to follow standards of care
Silence should never be used during communication between the nurse and the patient.
false
Nurses complete incident reports as dictated by the agency protocol. What is the primary reason for this? to get people in trouble to improve quality of care to make a court case to add to medical order
to improve quality of care