N524 Fundamental Hesi Study Cards + Explanations

Some facts about a client are missing. Arrange the actions performed by the lead nurse in chronological order. A) Looking for a pattern B) Talking to the client directly C) Bringing co-workers together D) Finding a solution

B, C, A, D If some facts about a client are missing, then the first step should be to talk to the client directly. If the problem still exists, then the lead nurse should bring the co-workers together and look for a pattern. After this, a solution for the existing problem should be created.

After a traumatic event, a client is extremely upset and exhibits pressured and rambling speech. What therapeutic technique can the nurse use when a client's communication rambles? A) Touch B) Silence C) Focusing D) Summarizing

C) Focusing Focusing is indicated when communication is vague; the nurse attempts to concentrate or focus the client's communication on one specific aspect. Touch invades the client's space and will not help focus the client's communication. Silence prolongs the rambling communication; the client needs to be focused. Until the concern is identified and explored, summarizing is impossible.

The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need? A) "The teachings of home self-care." B) "A psychological episode of an anxiety attack." C) "A physiological episode of an obstructed airway." D) "The measures required to decrease postoperative complications."

D) "The measures required to decrease postoperative complications." The nurse leader should have the ability to set the priorities of the client depending on the client's need. Intermediate priority needs includes non-emergency, non-life-threatening needs. An example of this need would be measures that are required to decrease postoperative complications. The teaching of home self-care is a low priority need. High priority needs include addressing a psychological episode of an anxiety attack and addressing a physiological episode of an obstructed airway.

The nurse is reviewing the data of clients with pre-hypertension. Which client is at risk of stage 1 hypertension based on the given data? A) Client A B) Client B C) Client C D) Client D

In pre-hypertension, the blood pressure will range from 120/80 to 139/89 mmHg. The blood pressure is mainly influenced by heart rate and cardiac output. When the cardiac output and hematocrit are increased, the blood pressure also increases. Client B, with an increased cardiac output and an increased hematocrit, is at a higher risk for stage 1 hypertension. In client A, only the hematocrit is increased. Client C may be at risk of hypotension because the cardiac output is decreased. Client D has a normal hematocrit and blood pressure.

A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? Select all that apply. A) Taking on parental roles B) Adjusting to a reduction in family size C) Development of intimate peer relationships D) Adjusting the marital system to make space for children E) Realigning relationships to in-laws and grandchildren

A & D A family with more young children undergoes an emotional transition of accepting a new generation of members. These changes include taking on parental roles and adjusting the marital system to make space for children to proceed developmentally. Adjusting to a reduction in family size is required for the family life-cycle stage of children leaving the family home. The development of intimate peer relationships is required for an unattached young adult. Realigning relationships to in-laws and grandchildren is required for the family life-cycle stage of children leaving the home to start their own lives.

While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? Select all that apply. A) "I have difficulty judging things." B) "I forget to take medicines." C) "I am unable to do financial calculations." D) "I get confused about the proper date and time." E) "I am unable to recall words during conversations with my family."

A) "I have difficulty judging things." C) "I am unable to do financial calculations." E) "I am unable to recall words during conversations with my family." Poor judgment, loss of the ability to calculate, and loss of language skills are related to cognitive impairment. These changes may develop due to an imbalance of neurotransmitters in brain. Forgetfulness and getting confused are symptoms that may be associated with normal aging changes.

A client who is scheduled for a muscle biopsy tells the nurse, "They better give me a general anesthetic. I don't want to feel anything." Which is the most therapeutic initial response by the nurse? A) "You seem to be worried about the test." B) "This test is done under local anesthesia." C) "Tell them when you have pain so they can take care of it." D) "You probably will not have pain so try not to think about it."

A) "You seem to be worried about the test." The response "You seem to be worried about the test" acknowledges the client's apprehension and encourages further communication. The response "This test is done under local anesthesia" does not address the client's feelings and may cause more anxiety. The response "Tell them when you have pain so they can take care of it" is perhaps true, but it does not foster communication; the client may focus on the word "pain." The response "You probably will not have pain so try not to think about it" negates the client's feelings and promotes false reassurance. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? A) Clear breath sounds B) Positive pedal pulses C) Normal potassium level D) Decreased urine specific gravity

A) Clear breath sounds Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate? A) Core rewarming with warm fluids B) Ambulation to increase metabolism C) Frequent oral temperature assessments D) Gastric tube feedings to increase fluid volume

A) Core rewarming with warm fluids Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? A) Orient the client to the unit environment. B) Have a copy of hospital regulations available. C) Explain that there is no reason to be concerned. D) Reassure the client that the staff is available if the client has questions.

A) Orient the client to the unit environment. Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available and reassuring the client that the staff is available to answer questions are part of orienting the client to the unit. Explaining that there is no reason to be concerned may be false reassurance because no one can guarantee that there is no reason to be concerned.

A nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process? Select all that apply. A) Slowed neurologic responses B) Lowered intelligence quotient C) Long-term memory impairment D) Forgetfulness about recent events E) Reduced ability to maintain an erection

A) Slowed neurologic responses D) Forgetfulness about recent events E) Reduced ability to maintain an erection Slowing of neurologic responses is part of the aging process. Memory for short-term situations and events is reduced. The ability of the male to attain and sustain an erection is reduced. There should not be a loss of intellectual ability. Memory of long-term experiences and events should not be impaired.

Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? A) Syncope B) Headache C) Tachycardia D) Hemiparesis

A) Syncope With complete (heart) atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow because the ventricular rhythm is not initiated by the SA node. Hemiparesis is associated with a brain attack (cerebrovascular accident).

What are the major attributes of quality health care? Select all that apply. A) Safe B) Timely C) Effective D) Efficient E) Equitable

A, C & D The attributes of health care can be major and minor. The major attributes are indispensable to maintain the quality of health care and include safe, effective, and efficient care. Health care is said to be of high quality if the care is safe and does not harm the client. Health care is effective in reaching its client goals. Health care should be efficient in terms of time, energy, and resources engaged in providing the care. The minor attributes of quality care include timely and equitable care. Timely care helps in preventing errors and avoiding complications. High-quality care is provided to all people who deserve it, irrespective of any discriminating factor.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. A) Respiratory rate of 14 breaths/minute B) Blood pressure of 120/80 mmHg C) Oxygen saturation of 95% D) Temporal temperature of 37.4 °C E) Radial pulse rate of 72 and irregular

A,B and C In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. A) Whole grains B) Cooked fruits and vegetables C) Nuts and seeds D) Lean red meats E) Milk and eggs

A,B,C,E With diverticular disease, the client should avoid foods that may obstruct the diverticula; therefore, the fiber should be digestible, such as whole grains and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. Although it has been believed in the past that avoiding nuts and seeds would prevent diverticulitis, there is no evidence to support this claim and nuts and seeds can be consumed as long as they are thoroughly chewed. For clients with diverticular disease, the client should decrease intake of fats and red meats.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A) Dyspnea B) Flushed face C) Precordial pain D) Increased pulse rate E) Increased blood pressure

B & D Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client? A) Fair (F) B) Good (G) C) Trace (T) D) Normal (N)

B) Good (G) According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

Nurses should focus care for middle-aged adults around their need to be what, according to Erikson's psychosocial developmental tasks? A) Productive B) Controlling C) Independent D) Autonomous

A) Productive A psychosocial task for middle adulthood according to Erikson is generativity; this task is concerned with the sense of productivity and accomplishment. Controlling, being independent, and being autonomous are not involved in any task of middle adulthood identified by Erikson.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? A) Tell the neighboring client to stop singing. B) Close the doors to both clients' rooms at night. C) Give the complaining client the prescribed as-needed sedative. D) Move the postoperative client to a room at the end of the hall.

D) Move the postoperative client to a room at the end of the hall. Moving the postoperative client from the singing client's diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms, because they need to be monitored. The use of a sedative should not be the initial intervention.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? A) Arrangements will be made by the client and the client's family. B) The plan is formulated and implemented early in the client's care. C) The rehabilitation is minimal and short term, because the client will return to former activities. D) Arrangements will be made for long-term care, because the client is no longer capable of self-care.

B) The plan is formulated and implemented early in the client's care. To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the healthcare system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.

Which related factor is appropriate for a nursing diagnosis? A) Prostectomy B) Trauma of incision C) Acute renal failure D) Knee replacement surgery

B) Trauma of incision The related factor or etiology of a nursing diagnosis is always within the nursing domain. The nurse must ensure that the related factor is a condition that responds to nursing interventions. Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostectomy is a medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also a medical condition. Nursing interventions should be directed towards behaviors or conditions that can be managed or treated by the nurse. Knee replacement surgery is a medical condition that cannot be managed by nursing interventions.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. A) Difficulty in swallowing B) Increased sensitivity to heat C) Increased sensitivity to glare D) Diminished sensation of pain E) Heightened response to stimuli

C) Increased sensitivity to glare D) Diminished sensation of pain Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adult unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.

For what clinical indicator should a nurse assess a client who is having a gastric lavage? A) Decreased serum pH B) Increased serum oxygen level C) Increased serum bicarbonate level D) Decreased serum osmotic pressure

C) Increased serum bicarbonate level Gastric lavage causes an excessive loss of gastric fluid, resulting in excessive loss of hydrochloric acid (HCl), which can lead to alkalosis; the HCl is not available to neutralize the sodium bicarbonate (NaHCO3) secreted into the duodenum by the pancreas. The intestinal tract absorbs the excess bicarbonate, and alkalosis results. Gastric lavage will lead to alkalosis, which is associated with increased pH. Gastric lavage will not affect oxygen levels. Gastric lavage may lead to dehydration, which will increase osmotic pressure.

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss? A) Smiling while seeing the client B) Nodding head in front of the client C) Making eye contact with the client D) Leaning forward towards the client

C) Making eye contact with the client The nurse should make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help to build a positive relationship. Nodding in front of the client helps to regulate the conversation. Leaning forward towards the client shows attention and awareness.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? A) Respiratory rate B) Amount of oxygen in the blood C) Percentage of oxygen-carrying hemoglobin D) Amount of carbon dioxide in the blood

C) Percentage of oxygen-carrying hemoglobin The pulse oximeter measures the oxygen saturation of blood by determining the percentage of oxygen-carrying hemoglobin. A pulse oximeter does not measure respiratory rate, nor does it interpret the amount of oxygen or carbon dioxide carried in the blood.

The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished and severely underweight. Which statement leads the nurse to conclude that the client is experiencing secondary gains from her behavior? "I'm as big as a house." "I get straight A's in school." "My mother keeps trying to get me to eat." "My hair is beginning to fall out in clumps.""My hair is

"My mother keeps trying to get me to eat." The client's behavior has gotten attention for her; it provides a sense of power and control. "I'm as big as a house" reflects a disturbed perception about her body. Although clients with anorexia nervosa are concerned about social acceptance, perfectionism, and achievement and may obtain high grades in school, good grades are not a secondary gain related to the eating behaviors associated with anorexia nervosa. Hair falling out in clumps is a result of starvation, not a secondary gain.

A nurse is taking care of a client who has chronic back pain. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A) Ask the client about the acceptable level of pain. B) Eliminate all activities that precipitate the pain. C) Administer the pain medications regularly around the clock. D) Use a different pain scale each time to promote client education. E) Assess the client's pain every 15 minutes.

A) Ask the client about the acceptable level of pain. & C) Administer the pain medications regularly around the clock. The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires pain assessment at frequent intervals. (like every 15 minutes)

The nurse develops a goal that makes a client feel as if the client is engaging in a competition. Which type of motivation is the nurse using in this situation? A) Power motivation B) Affiliative motivation C) Avoidance motivation D) Achievement motivation

A) Power motivation People who tend to be motivated by power generally have more assertive and aggressive behavior. Therefore the nurse designs goals in such a way that makes these clients feel like they are in a competition even though the clients are only competing against themselves. Individuals who tend to be motivated by affiliative motivation are generally nonassertive and more dependent on others. Therefore the nurse can design the goal according to their mental behavior. Avoidance motivation requires the nurse to consider the client's anxiety, fear of failure, and other phobias. People who are motivated by achievement are not characterized by aggressive behavior with a need to engage in competition.

Which nursing actions reflect the carative factor of 'promoting and expressing positive and negative feelings' according to the Watson's transpersonal caring? Select all that apply. A) Supporting and accepting the client's feelings B) Learning together while educating the client to acquire self-care skills C) Creating a healing environment at the physical and nonphysical levels D) Applying the nursing process in systematic, scientific problem-solving decision-making E) Showing a willingness to take risks in sharing in the relationships when connecting with clients

A) Supporting and accepting the client's feelings E) Showing a willingness to take risks in sharing in the relationships when connecting with clients According to the Watson's transpersonal caring, there are ten carative factors that should be incorporated into the nursing practice. The nurse can include the carative factor "promoting and expressing positive and negative feelings" by supporting and accepting the client's opinions and feelings. It also includes showing a willingness to take risks in sharing in the relationship. Transpersonal teaching-learning is promoted by learning together while educating the client. This learning together session helps in acquiring self-care skills. A healing environment is created by providing supportive, protective, and corrective mental, physical, and spiritual environment. According to Watson's theory, the nursing process should be used as the creative, problem-solving caring process. It involves applying systematic, scientific problem-solving and decision-making in providing client-centered care. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation

What problems may a nurse come across when dealing with ethical issues related to end-of-life care? Select all that apply. A) Clients are unable to communicate effectively. B) All interventions for helping the clients seem futile. C) Clients are often unfamiliar with the concept of autonomy. D) Multiple medications affect the cognitive ability of the clients. E) Predictions regarding health outcomes are not always accurate.

A, B & E Older adults who need end-of-life care may be unable to communicate effectively. The nurse should evaluate the ability of the client to make important decisions about his or her care. During end of life care, all interventions for helping the clients may seem to be futile. As such, the caregivers, the client, and the healthcare workers should focus on providing palliative care. Predictions regarding health outcomes may not always be. There may also be differences of opinion regarding the worth of an outcome. Older adults are often unfamiliar with the concept of autonomy. As such, they may find it difficult to contradict primary healthcare providers and nurses. This problem is not restricted to end-of-life care situations. Older adults may also face problems such as diminished cognitive ability due to the intake of multiple medications. This problem is also not limited to end-of-life care.

A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client's family about recognizing caregiver role strain? Select all that apply. A) The caregiver has disturbed sleep patterns. B) The caregiver has reduced appetite and weight. C) The caregiver is more concerned about personal appearance. D) The caregiver engages in leisure activities as often as possible. E) The caregiver is fearful about administering medications to the client.

A, B and E A family should recognize that when the caregiver has disturbed sleep patterns, the caregiver is experiencing strain. Changes in appetite, weight, and sleep patterns are all indicative of caregiver role strain. A caregiver experiences strain while learning about new therapies and administering medications to the client. A caregiver experiencing role strain is not concerned about personal appearance and may withdraw from social groups. A caregiver also does not spend time in any leisure activities if overcome by strain.

Arrange the events of communication throughout the nursing process in chronological order. A) Assessing the medical records and diagnostic tests B) Intrapersonal analysis of the assessment findings C) Identifying the factors affecting the outcomes Incorrect D) Documenting expected outcomes Incorrect E) Performing verbal, visual, auditory, and tactile health teaching activities

A, B, D, E & C The first step of communication throughout the nursing process is assessment, which involves assessing medical records and diagnostic tests. The second step is nursing diagnosis, which involves the intrapersonal analysis of assessment findings. The third step is planning, which involves the documentation of expected outcomes. The fourth step is implementation, which involves performing verbal, visual, auditory, and tactile health teaching activities. The final step is evaluation, which involves identifying the factors affecting the outcomes.

Which warning signals should the nurse observe in a child suspected to be a victim of abuse? Select all that apply. A) The child doesn't want to be touched by anyone. B) The child sleeps for an average of 15 hours a day. C) The child frequently visits the emergency department. D) The child suffers from fever and tenderness in the abdomen. E) The child looks at the caregiver before answering any question.

A, C & E The child may become scared if touched. The physical abuse may cause injuries and the child may visit the emergency department frequently. An abused child may look at the caregiver before answering any question due to fear. The child sleeping for an average of 15 hours a day does not indicate abuse. Fever and tenderness in the abdomen are not signs of abuse; it could indicate an organic cause.

Which questions should the nurse ask to elicit psychosocial issues in a client with cancer? Select all that apply. A) "Do you feel fatigue or restlessness?" B) "How is your family dealing with your condition?" C) "How do you rate your distress on a scale of 0 to 10?" D) "Have you noticed any problem in remembering things?" E) "Do you see yourself as a different person since you've had cancer?"

B) "How is your family dealing with your condition?" C) "How do you rate your distress on a scale of 0 to 10?" Cancer affects a client's social relationships. Therefore, the nurse should ask about the family's concern regarding the client's condition. The client's sorrow and pain regarding cancer is important to know. Asking the client to score his or her distress will give the nurse insight into the client's perception of the illness. Symptomatic problems can be identified if the nurse asks the client about fatigue or restlessness. The client may sometimes have trouble remembering things or finding words after chemotherapy. These are symptomatic problems. A person who has cancer may see himself or herself as a different person, which may cause problems in personal relationships—for instance, with a spouse. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options are likely related to the situation, but only some of the options may be related directly to the situation.

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower? A) "Would you like a shower?" B) "I'll help you take your shower now." C) "When do you want your shower, now or later?" D) "You'll feel so much better if you have a shower."

B) "I'll help you take your shower now." The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client's physiologic and psychological needs. The client may or may not be capable of making a decision; if the client says no, the nurse will be confronted with a dilemma: meeting the client's physiologic needs will contradict the client's wish not to bathe. The client may not be able to tell the nurse when the shower is desired, because the client may be incapable of making a decision. "You'll feel so much better if you have a shower" may be false reassurance; the client may not be able to process cause and effect.

Which statements related to initial assessment of hypertension by the nurse requires correction? Select all that apply. A) "Deflating the cuff too slowly will show false-high diastolic readings." B) "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." C) "If the blood pressure in the left arm is 110/80 mm Hg and in the right arm it is 130/80 mm Hg, it is reportable." D) "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure." E) "It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80 mm Hg in the right arm."

B) "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." D) "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure." False low diastolic readings are obtained in clients if the stethoscope is held too firmly against the antecubital fossa. Keeping the arm unsupported while assessing blood pressure results in false high blood pressure values. False high diastolic readings are obtained when the cuff is deflated too slowly. Pressure differences greater than 10 mm Hg between the two arms should be reported because it indicates vascular problems. Normally there is a difference of 5 to 10 mm Hg of blood pressure between the arms.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? A) "Wear sterile gloves when doing the procedure." B) "Wash your hands before performing the procedure." C) "Perform the self-catheterization every 12 hours." D) "Dispose of the catheter after you have catheterized yourself."

B) "Wash your hands before performing the procedure." To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? A) Care that supports physical functioning B) Care that supports homeostatic regulation C) Care that supports psychosocial functioning D) Care that provides immediate short-term help in physiological crises

B) Care that supports homeostatic regulation Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation. If interventions are provided to support the client in doing daily activities, they are considered a physiological basic domain that supports physical functioning. Providing behavioral and cognitive therapies helps to support psychosocial functioning and facilitates lifestyle changes. Providing immediate short-term help in physiological crises helps to support protection against harm.

The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying? A) Risk taking B) Confidence C) Thinking independently D) Responsibility and authority

B) Confidence The critical thinking attitude of confidence grows with experience and the nurse is able to shift the focus from remembering the procedure to caring for the client's needs. The nurse builds a bond of trust by displaying confidence while performing a procedure. Risk taking involves recommending alternative methods to client care or questioning a primary healthcare provider's order. A nurse who reads nursing literature and shares ideas about nursing interventions with other nurses uses independent thinking. Responsibility and authority are critical thinking attitudes. A responsible nurse follows procedure manuals while caring for the client and reports problems immediately.

An unemancipated pediatric client is to undergo a routine medical procedure. Who is the appropriate authority to provide consent? A) The court B) Either of the child's parents C) One of the child's grandparents D) The pediatric client

B) Either of the child's parents For unemancipated pediatric clients, the parents are required to provide consent. Either parent may do so. The court intervenes in situations where the parents refuse to allow a child to undergo treatment. A grandparent may provide consent only if the situation is an emergency and the parents are not present. The client is underage and unemancipated; therefore if at all possible, consent must be obtained from one of the child's parents in a non life-threatening situation. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify an incorrect answer.

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. What could be the cause for this condition? A) Loss of elasticity of the lens B) Impairment of the extraocular muscles C) Obstruction of the aqueous humor outflow D) Progressive degeneration of the center of the retina

B) Impairment of the extraocular muscles Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. A) After reporting severe pain B) On admission to the hospital C) Upon entering the operating room D) Before transfer to a rehabilitation facility E) At time of scheduling for the surgical procedure

B) On admission to the hospital & D) Before transfer to a rehabilitation facility Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the healthcare provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status (Severe pain) does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission. Medication reconciliation takes place when the client is admitted.

As a nurse plans to teach a 9-year-old boy with a learning disability about his diabetes, the parents intervene and state, "That won't be necessary. With our son's learning issues, we recognize that he can't care for himself." What is the best response by the nurse? A) "Then I will teach you what he needs to have done." B) "He seems bright enough to me. I think he can learn this." C) "Including your son now will help him take on more of his own care in the future." D) "This material is not difficult. Even a slow child can learn how to care for himself."

C) "Including your son now will help him take on more of his own care in the future." The parents need to recognize that their child must be given increasing responsibility for self-care. Giving the parents total responsibility for managing their son's diabetes supports their need to keep the child dependent. Announcing that their son can learn about his care denigrates the parents and does not permit further expression of feelings. Stating that even a slow child can learn demeans the child and inhibits the parents from expressing additional feelings.

During the second group meeting of regressed long-term clients, one of the members asks the nurse, "What do you want us to do today?" What is best response by the nurse? A)"Whatever you want to do is all right with me." B) "Despite what you might wish, you seem to feel that you must do what I say." C) "It is the group's responsibility, which includes me, to make that decision together." D) "You seem more interested in pleasing me than participating in the group's activity."

C) "It is the group's responsibility, which includes me, to make that decision together." Involvement in decision making promotes acceptance and commitment to group goals. All members of the group should be involved with setting group goals. When the nurse states, "Whatever you want to do is all right with me" it is promoting autonomy as a client, rather than utilizing group involvement. The response "Despite what you might wish, you seem to feel that you must do what I say" focuses on therapist-client communication rather than group communication. The response "You seem more interested in pleasing me than participating in the group's activity" is hostile and confrontational and will put the client on the defensive.

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? A) Procedures for a client's benefit do not require a signed consent. B) Clients who are aphasic are incapable of signing an informed consent. C) A separate signed informed consent for routine treatments is unnecessary. D) A specific intervention without a client's signed consent is an invasion of rights.

C) A separate signed informed consent for routine treatments is unnecessary. This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

While assessing a client who experienced an accident, the nurse found that the client is unable to move eyeballs laterally. Which nerve damage led to this condition in the client? A) Optic nerve B) Facial nerve C) Abducens nerve D) Oculomotor nerve

C) Abducens nerve The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs. Damage to this nerve limits lateral movement of the eyeball. Injury to the optic nerve causes changes in visual acuity. Injury to the facial nerve results in loss of facial expressions and loss of taste perception from the anterior one third of the tongue. Injury to the oculomotor nerve limits the extraocular movements and pupillary responses.

A nurse performs lung assessments of four clients. The details are given below. Which client has inflamed pleura? Client A: Overall Lung = Inspiratory & Expiratory wheezes Client B: Trachea & Bronchi = Coarse crackles Client C: Right and Left Lung bases = Fine crackles Client D: Anterior Lateral Lung = Frictional rub

Client D: The breathing sounds in a pleural rub or an inflamed pleura are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung, as observed in client D. High-pitched, continuous musical sounds heard all over the lung are wheezing breath sounds heard when there is a high-velocity airflow through severely narrowed or an obstructed airway. Loud, low-pitched, rumbling coarse sounds heard in the trachea and bronchi are rhonchi, which are observed during muscular spasm or when fluid or mucus is present the in larger airways. Fine crackles, medium crackles, and coarse crackles heard in client C are heard in lung bases due to random and sudden re-inflation of groups of alveoli, which causes a disruptive passage of air through the small airways.

A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction? A) Putting both legs in traction keeps one leg from becoming longer than the other. B) Putting both legs in traction keeps the baby from turning over in bed and breaking his leg again. C) As a means of ensuring counter-traction, both legs are placed in traction, and the buttocks are suspended off the bed. D) When the leg was x-rayed, the healthcare practitioner apparently discovered that the other leg was broken as well.

C) As a means of ensuring counter-traction, both legs are placed in traction, and the buttocks are suspended off the bed. In young infants the body weight doesn't provide adequate countertraction to overcome the spasm of the muscles. With both legs in traction and the buttocks suspended off the bed, countertraction is sufficient to realign the femur. Putting both legs in traction does not keep the child from having one leg longer than the other. A bed jacket could keep the child from turning over in bed; keeping the baby from turning over in bed is not the reason for putting both legs in traction. This type of traction can be used for one fractured femur; it is not reserved for bilateral fractures.

A nurse is caring for a client who has been admitted to a healthcare facility for the treatment of sinus disorders. The nurse discovers that the client is a cocaine addict. What task followed by the nurse is the best way to deal with the situation? A) Teach the client about safe medication storage and the danger of polypharmacy. B) Educate the client about his or her correct body mechanics and promote stress management. C) Assess the client's drug intake and ensure that the individual does not leave the healthcare facility. D) Assist with adequate personal hygiene, nutrition, and hydration and provide emotional support to the family.

C) Assess the client's drug intake and ensure that the individual does not leave the healthcare facility. When dealing with a client with substance abuse issues, the nurse should assess the client's drug intake in terms of the amount, frequency, and type of use to obtain useful information. Clients with substance abuse problems tend to avoid healthcare facilities for fear of judgmental attitudes and worries over being arrested by the police. In this case, the nurse should ensure that the client does not prematurely leave the facility. When dealing with a client with medication use and abuse issues, the nurse should provide proper education about safe medication storage and the danger of polypharmacy. When dealing with a client with arthritis, the nurse should educate the client about correct body mechanics and should also promote stress management. When dealing with clients in a confused state, the nurse should assist him or her with adequate personal hygiene, nutrition, and hydration and provide emotional support to the family.

A primigravida is admitted with a ruptured fallopian tube (resulting from an ectopic pregnancy), and surgery is performed to remove the fallopian tube. Which intervention should be included in the postoperative nursing care plan? A)Counseling on how to prevent another tubal pregnancy B) Administering Rho (D) immune globulin to prevent isoimmunization C) Explaining that the client may still be capable of becoming pregnant D) Telling the client to avoid douching after intercourse, because this may dislodge a fertilized egg

C) Explaining that the client may still be capable of becoming pregnant Removing a fallopian tube does not impair the ovaries' ability to release an egg, which may be fertilized in the remaining tube if it is undamaged. There is no known way to prevent future tubal pregnancies. There is no information to indicate that the client is Rh negative, requiring the administration of Rho (D) immune globulin. Liquid from a douche does not reach the fallopian tube or dislodge a fertilized egg; in addition, douching is no longer recommended at any time.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what? A) Diminished B) Normal C) Full D) Bounding

C) Full The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.

While assessing a client, the nurse finds bluish coloration of the skin. The nurse finds that this discoloration is due to cyanosis. Which condition may be suspected? A) Anemia B) Liver disease C) Heart disease D) Autoimmune disease

C) Heart disease A bluish discoloration of the skin indicates cyanosis. This condition may be caused by increased amounts of deoxygenated hemoglobin, which may lead in heart disease or lung disease. In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin. In clients with liver disease, the skin appears yellow or orange due to increased deposits of bilirubin. In autoimmune diseases, the skin will lose its pigmentation.

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve? A) Aortic B) Mitral C) Pulmonic D) Tricuspid

C) Pulmonic The second left intercostal space (ICS) along the sternal border reflects sounds from the pulmonic valve. The correct landmark for auscultating the aortic valve is at the right second ICS at the sternal border; for the mitral valve (apical pulse) at the left fifth ICS in the mid-clavicular line; and for the tricuspid valve at the left fifth ICS at the sternal border.

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion? A) The nurse shares constructive criticism with his or her team members. B) The nurse meets with colleagues regularly to discuss work experience. C) The nurse recalls, thinks, analyzes and learns from day-to-day work situations. D) The nurse organizes or connects information in a way so the diverse information about a client forms meaningful patterns.

C) The nurse recalls, thinks, analyzes and learns from day-to-day work situations. Reflective practice is a conscious process of recalling, thinking, analyzing, and learning from work situations. This practice may also include journaling work experiences for self-evaluation. Meeting with colleagues to share constructive criticism and discuss work experiences is an important part of critical skill development. The use of concept mapping requires the nurse to organize and collect the client's information in a way that forms meaningful patterns. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse is interested in obtaining information about the medical and genomic data of the people in a U.S. state to conduct a research study on the predictive health of the population. Which domain of informatics should the nurse refer to? A) Public health informatics B) Clinical research informatics C) Translational bioinformatics D) Clinical health care informatics

C) Translational bioinformatics Translational bioinformatics refers to the type of informatics that would help the nurse to use biomedical and genomic data of a large group of individuals to assess the predictive, preventive, or proactive health of the population. Thus the nurse should use translational bioinformatics to perform research on the predictive health of the people in the state. Clinical health care informatics includes the development of approaches for clients and their families who wish to use information and communications technology support to improve their health status. Clinical research informatics focuses on the application of informatics to gather new information about health and disease. Public health informatics focuses on the use of informatics to improve the general health of the population.

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? A) Reminiscence B) Reality orientation C) Validation therapy D) Therapeutic communication

C) Validation therapy Validation therapy is the psychosocial concern involved in accepting the descriptive statements made by a confused older client. Reminiscence is recalling the past. Reality orientation involves helping a confused older client agree with the nurse's statements. Therapeutic communication enables the nurse to perceive and respect the older client's uniqueness and healthcare expectations.

The nurse assists in the care of four older clients whose clinical features are mentioned below. Which client may have dementia?

Client 1 has normal psychomotor behavior. The attention of the client is also featured to be normal. Moreover, misperceptions are absent. Therefore, client 1 may likely have dementia. Hypokinetic psychomotor behavior, impaired attention, and a difficulty in distinguishing between reality and perceptions may signify delirium. Hyperkinetic behavior and inattention with hallucinations may also signify delirium. Psychomotor retardation, easily distractible attention, and illusions may be caused by depression.

A healthcare provider prescribes an upper gastrointestinal (GI) series and a barium enema. The client asks, "Why do I have to have barium for these tests?" Which explanation by the nurse of barium's function is the best? A) "It gives off visible light, illuminating the alimentary tract." B) "It provides fluorescence, thereby lighting up the alimentary tract." C) "It dyes the structures of the alimentary tract, making them more visible." D) "It gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."

D) "It gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays." Barium salts used in a GI series and barium enemas coat the inner lining of the GI tract and then absorb x-rays passing through. Thus, they outline the surface features of the tract on a photographic plate. Barium has no light-emitting properties. Barium does not give off visible light or provide fluorescence. Barium does not have the properties of a dye.

A client with borderline personality disorder receives the wrong tray for lunch and scolds the dietary staff regarding this mistake. What is the most appropriate response by the nurse? A) "Getting angry is inappropriate; your behavior must stop." B) "Yelling is unacceptable and will only get you placed in seclusion." C) "You have to eat the first tray of food; then I'll get another tray for you." D) "It must be frustrating to get the wrong tray. I'll order another tray for you."

D) "It must be frustrating to get the wrong tray. I'll order another tray for you." When working with clients with personality disorders it is important that nurses empathize with their emotions and then offer constructive solutions to issues. Anger is not always inappropriate; it is how it is expressed that is important. Although yelling is not desirable, it is inappropriate to threaten seclusion. Telling the client that he must eat the first tray of food before getting another is punitive. Clients have a right to receive the tray they ordered unless it is unavailable.

A female client terminally ill with cancer says to the nurse, "My husband is avoiding me. He doesn't love me anymore because of this awful tumor!" What is the nurse's most appropriate response? A) "What makes you think he doesn't love you?" B) "Avoidance is a defense. He needs your help to cope." C) "Do you think he's having difficulty dealing with your illness?" D) "You seem very upset. Tell me how your husband is avoiding you."

D) "You seem very upset. Tell me how your husband is avoiding you." The response "You seem very upset. Tell me how your husband is avoiding you" validates the client's feelings and encourages the client to look at the basis or reality of the expressed concern. The response "What makes you think he doesn't love you?" ignores the client's statement; the client has already told the nurse the basis for the feelings. The response "Avoidance is a defense. He needs your help to cope" puts the responsibility for the husband's behavior on the client, who may not be able to handle it. The husband may or may not be having difficulty dealing with the client's illness, and this question does not focus on the client's feelings.

One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse? A) "I don't see a devil; why do you see a devil?" B) "Let's go to the mirror to see what you look like." C) "When I look at you I see a person, not a devil." D) "You're not a devil; why do you talk about yourself like that?"

D) "You're not a devil; why do you talk about yourself like that?" The response "When I look at you, I see a person, not a devil" points out reality while attempting to let the client understand that the nurse sees the client as a person of worth. The statement "I don't see a devil; why do you see a devil?" asks the client to explain his feelings, which may be unrealistic. The client may indeed view himself as a devil. The statement "You're not a devil; why do you talk about yourself like that?" is a somewhat belittling response; it cuts off communication. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg? A) 130/80 mm Hg B) 150/100 mm Hg C) 140/100 mm Hg D) 130/100 mm Hg

D) 130/100 mm Hg Deflating the cuff too quickly will result in false low systolic and false high diastolic readings. Therefore the client's systolic readings decreased to 130 mm Hg while the diastolic readings increased to 100 mm Hg. If the bladder or cuff is too wide, it results in false low readings in the client, as in the blood pressure of 130/80 mm Hg. If the bladder or cuff is too narrow or too short or if the cuff is wrapped too loosely or unevenly, the result is a false high, as in the blood pressure of 150/100 mm Hg. Deflating the cuff too slowly results in false high diastolic readings, such as the blood pressure of 140/100 mm Hg.

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? A) Anger B) Denial C) Bargaining D) Acceptance

D) Acceptance Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial.The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.

Upon arriving in the birthing room the nurse finds the client lying on her back with her head on a pillow and the bed in a flat position. The nurse explains that it is important to avoid lying in the supine position because of what reason? A) It may precipitate a severe headache. B) It can impede the progression of labor. C) It may cause nausea as labor progresses. D) It will prevent adequate blood flow to the fetus.

D) It will prevent adequate blood flow to the fetus. When the pregnant woman lies supine, pressure of the uterus against the vena cava reduces circulation; decreased perfusion of the placenta results in decreased blood flow to the fetus. The supine position should not precipitate a headache, although it can lead to supine hypotension. Although the supine position can prolong labor, it is not the primary reason for a position change. As labor progresses toward the transition phase, nausea may occur; this is unrelated to the client's position.

The nurse is caring for a client diagnosed with a rare genetic disorder. Which domain of informatics would the nurse use to gather information about this condition to provide good quality client care? A) Public health informatics B) Clinical research informatics C) Translational bioinformatics D) Clinical health care informatics

D) Clinical health care informatics Optimal health care can be delivered only if the clinician has in-depth knowledge of the client's condition. The nurse uses clinical health care informatics for gathering information about the client's condition. Clinical research informatics uses computer and information science to discover new knowledge relating to health and disease. Public health informatics uses information technology for improving the health of populations. Translational bioinformatics refers to the development of storage, analytic, and interpretive methods to assess the proactive, predictive, preventive, and participatory health of a population.

A nurse notes that a client is refusing a vital life-saving surgery due to financial constraints. The client's insurance has lapsed and the healthcare facility's policies do not allow surgeries to be performed free of cost. What should the nurse do first to deal with the situation? A) Identify all possible courses of action to help the client. B) Verbalize the problem by writing a simple, clear statement. C) Negotiate a plan with other members of the healthcare team. D) Collect information relevant to the issue from multiple sources.

D) Collect information relevant to the issue from multiple sources. The nurse identifies the situation to be an ethical dilemma. When resolving the ethical dilemma, the nurse should first gather all relevant information related to the situation from multiple sources, such as the client, family, the institution, etc. The nurse may identify all possible courses of action after gathering information, clarifying values, and verbalizing the problem at hand. It is essential to verbalize the problem by agreeing to a simple, clear statement. This helps the team of healthcare workers to conduct a discussion. However, this step is performed after gathering relevant information and performing value clarification. Negotiation of a plan is possible only after identifying all possible courses of action. This step is not performed first by the nurse.

A client is admitted to the hospital because of multiple chronic health problems. What is the priority intervention at this time? A) Advising the client to join a support group immediately after discharge B) Assuring the family that staff members will take care of the client's needs C) Reminding the client to keep medical follow-up appointments after discharge D) Conducting a multidisciplinary staff conference early during the client's hospitalization

D) Conducting a multidisciplinary staff conference early during the client's hospitalization Collaboration of all team members involved in the client's care early during hospitalization will allow for efficient planning of care and help prepare for discharge. The client may or may not be ready to join a support group at this time. Assuring the family that staff members will take care of the client's needs may promote dependence. The client should be encouraged to assume self-care gradually. Although this should be done eventually, it is not the priority at this time.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? A) Postural drainage B) Cupping the chest C) Nasotracheal suctioning D) Frequent changes of position

D) Frequent changes of position Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a healthcare provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, but will not prevent their accumulation.

A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions, the client says, "That sounds gross. I don't think I can do it." What does the nurse conclude from this statement? A) The client is unduly fastidious. B) The client feels that having a baby is not that important. C) Some women are uncomfortable with touching their genitals. D) Some women are afraid that they are the cause of the infertility.

D) Some women are uncomfortable with touching their genitals. Some women find it emotionally stressful to handle their genitals and discharges. The nurse does not have data to support whether the client is unduly fastidious. The nurse should not pass judgement on whether or not the client desires having a baby. Although many women in this situation feel that they are the cause of infertility, this has no bearing on either the nurse's instruction or the client's response. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem (The part of the question that presents the specific question being asked) is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? A) Weak upper arm strength and impaired stamina B) Weight bearing as tolerated and unilateral paralysis C) Partial weight bearing on the affected extremity and kyphosis D) Strong upper arm strength and non-weight bearing on the affected extremity

D) Strong upper arm strength and non-weight bearing on the affected extremity A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? A) The nurse understands that the client has pain due to a tracheostomy. B) The nurse identifies that the client is anxious about the cardiac catheterization. C) The nurse realizes that the client has diarrhea and needs the bedpan frequently. D) The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

D) The nurse identifies that the client is not aware of perineal care and has impaired skin integrity. The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.

Which action of the nurse would be inappropriate in the context of critical thinking skills for making clinical decisions in nursing practice? A) The nurse should observe changes in clients. B) The nurse should identify new problems when they arise. C) The nurse should follow direction in completing identified aspects of care. D) The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan.

D) The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan. Clinical decision-making in nursing practice is based on critical thinking skills. The nurse uses knowledge and experience in critical thinking to plan and implement care plans for client care. The nurse would observe changes in clients to help detect problems early These new problems, if identified early, may help in prompt treatment. Following the direction of the higher authority in completing the identified care aspects may not necessarily need knowledge and experience. Notifying the primary healthcare provider about a client's condition does not involve critical thinking skills.

The Surgeon General used the data from the 2000 census classification system to identify disparities in mental health care along racial-ethnic lines. What is the secondary use of this data? A) To provide culturally relevant care to the required ethnic group B) To identify all racial and ethnic groups in the United States C) To determine why there are disparities in the United States D) To determine when and how the health care needs of the ethnic populations are being met

D) To determine when and how the health care needs of the ethnic populations are being met The census classification system categorized individuals according to racial and ethnic descriptions. In addition to identifying health disparities, recording these classifications helps to determine when and how the health care needs of ethnic populations are being met. Nurses should practice culturally relevant nursing in order to meet the needs of culturally diverse clients of a specific ethnic group; the census has nothing to do with this. Because each racial group contains multiple ethnic cultures, the census does not succeed in identifying all of them in the United States, and it doesn't include them all as options. Although the census helps identify health disparities, it does not attempt to examine and determine why they exist.

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

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

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? Heat stroke Heat exhaustion Accidental hypothermia Malignant hyperthermia

Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

Describe Trendelenberg, Supine, Lateral and Prone position.

Image 1 shows the Trendelenburg position, in which the client is supine with the legs below the level of the heart. Image 2 shows the supine position, in which the client is on his or her back. Image 3 shows lateral position, in which the client is on his or her side. Image 4 shows prone position, in which the client is on his or her stomach.

Which client is suspected of having hypertension based on the given data? A) Patient A: Cardiac output (Decreased), peripheral resistance (Normal), and hematocrit (Decreased) B) Patient B: Cardiac output (increased), peripheral resistance (increased), and hematocrit (increased) C) Patient C: Cardiac output (Decreased), peripheral resistance (Normal), and hematocrit (Normal) D) Patient D: Cardiac output (Normal), peripheral resistance (increased), and hematocrit (Normal)

Patient B The blood pressure (BP) in a client rises when the client's cardiac output, peripheral resistance, and hematocrit are increased. Because all of these parameters are increased in client B, then that client is suspected to have hypertension. The BP falls when cardiac output is decreased. So, clients A and C may be at risk of hypotension. Client D's cardiac output may not be at risk of hypertension.

Which assessment finding of the nail indicates the risk of anemia in the client?

The second figure depicts the concave curving of a nail, which is known as koilonychia. This condition may indicate anemia. Beau's lines (option 1) are deep grooved transverse lines on the nail (as depicted in the first figure); this condition may be caused by a severe infection or a nail injury. Paronychia is the inflammation of the skin at the edge of the fingernail, as shown in the third figure. The fourth figure depicts clubbing, which is the softening of the nail bed and a change in the angle between nail and nail base. This condition may be due to a chronic lack of oxygen, heart disease, or lung disease.

A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond? A) By reminding the nurse that once the content is known, there is no need to focus on the hallucinations, because doing so reinforces them B) By giving positive feedback for the nurse's attempt to explore the content of the client's hallucinations and reinforcing the need to continue this approach C) By recognizing this as a positive intervention and helping the nurse develop a plan of care that calls for a contract to refrain from acting on command hallucinations D) By suggesting that the nurse use an open-ended approach and asking the nurse to discuss the correlation between positive behaviors observed and prescribed antipsychotics

Wasn't a hard question but STUPIDLY PHRASED A) By reminding the nurse that once the content is known, there is no need to focus on the hallucinations, because doing so reinforces them Once the content of the hallucination is known and it is not a command to harm the self or others, focusing on the hallucinations is not therapeutic; recognizing feelings, pointing out reality, and learning to use strategies to push aside hallucinations are therapeutic. Giving positive feedback reinforces the nurse's inappropriate approach with the client; continuing this approach reinforces the value of the hallucinations for the client, which is undesirable. This is a negative, not a positive, intervention; also, no data support the fact that the client is experiencing command hallucinations. Clear, concise, direct communication is more desirable when clients are experiencing hallucinations, which are usually frightening; although positive behaviors are a response to antipsychotic medications, these should not be the primary focus of this supervisory session.