NCLEX AQ- Fundamentals Skills

Use of standard formal nursing diagnoses serves several purposes:

1) provides a precise definition that gives all members of the health care team a common language for understanding patient needs 2) Allows nurses to communicate what they do among themselves, with other health care professionals, and with the public 3) Distinguishes the nurse's role from that of physicians and other health care providers 4) Helps nurses to focus on the scope of nursing practice 5) Fosters the development of nursing knowledge

Indirect care interventions

treatments performed away from the patient but on behalf of the patient or group of patients.

The Health Insurance Portability and Accountability Act (HIPAA)

has a privacy rule to set standards for the protection of health information, info in a patient's record is confidential. Requires patients to sign an authorization before you collect personal health data, unless in emergency

standard of care

minimum level of care accepted to ensure high quality of care to patients. patients with specific problems or needs.

Diagnostic Label

name of the nursing diagnosis within the NANDA-I taxonomy. describes the essence of a patient's response to a health condition in as few words as possible.

Data analysis

involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the patient's response to a health problem

Data clusters

organizations of all your data. during this, a cue or an individual sign, symptom, or finding will alert your thinking more than others.

3 phases of the interview

orientation working termination

4 categories of related factors:

pathophysiological, treatment-related, situational, and maturational

Critical Pathways

patient care management plans that provide the multidisciplinary health team with the activities and tasks to be put into practice sequentially; main purpose is to deliver timely care at each phase of the care process for a specific type of patient allows staff from all disciplines to develop integrated care plans for a projected length of stay. can use this to monitor a patient's progress and as a documentation tool (keeps care moving)

A patient who is in the terminal stages of cancer has moderate pain and severe dyspnea. Her husband informs the nurse that she believes in prayer and her last wish is to die while listening to prayer. What should the nurse do first? Perform a prayer. Administer pain medications. Administer oxygen. Arrange for a chaplain.

Administer oxygen.

What is the goal of Watson's theory? To develop interaction between the nurse and patient To promote health, restore the patient's health, and prevent illness To focus on caring as a means of coping with illness To facilitate the reparative processes of the body by manipulating the patient's environment

To promote health, restore the patient's health, and prevent illness

Etiology

always within the domain of nursing practice and a condition that responds to nursing interventions. nursing interventions CANNOT change a medical diagnosis. `

Clinical guideline or protocol

document that guides decisions and interventions for specific health care problems or conditions, such as the treatment for a patient who has had a stroke or the administration of chemotherapy.

Patient assessment occurs?

each time you interact with the patient

Purpose of assessment

establish a thorough database about a patient

North American Nursing Diagnosis Association (NANDA)

established with the purpose: "to develop, refine, and promote a taxonomy (model) of nursing diagnostic terms of general use for professional nurses" It was their intent to create a common language for nurses to be able to indentify patient health problems and thus provide similar therapies for each problem. includes 13 domains, 47 classes, and 188 nursing diagnoses

Medical diagnosis

identification of a disease condition based on evaluation of physical signs, symptoms, history, and diagnostic tests and procedures. Physicians and certified advanced practice nurses make these

Teaching

important nursing responsibility. focus of change is intellectual growth or the acquisition of new knowledge or psychomotor skills. as a nurse, you teach correct principles, procedures, and techniques of health care to inform patients about their health status and to prepare them for self-care

Instrumental Activities of Daily Living (IADLs)

include skills such as shopping, preparing meals, writing checks, and taking medications.

interdisciplinary care plans

includes contributions from all disciplines involved in patient care. improves the coordination of all patient therapies.

Planning

involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions

Defining characteristics

the clinical criteria or assessment findings that support and acutal nursing diagnosis

database

to store info

Related Factor

show some type of patterned relationship with the nursing diagnosis. comes from the patient's assessment data.

Risk Factors

Environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerabilty of an individual, family, or community to an unhealthy event.

Termination Phase

Give patient a clue that the interview is coming to an end. Gives patient a chance to ask questions. When ending the interview, summarize the important points and ask your patient if the summary is accurate

Who used anthropology to form a theory of cultural care diversity and universality? Leininger Roy King Orem

Leininger

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? Have the client void every 2 hours. Maintain the client in an isolation room. Spend time with the client to allow verbalization of feelings. Wear two pairs of gloves when touching the client during care.

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

Which developmental changes should be evaluated in girls around 12 years of age? Motor skills Visual acuity Skeletal growth Hormonal changes

Skeletal growth Rationale Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.

Which standards would the nurse explain are important for critical thinking? Select all that apply. Specific Fairness Relevant Confidence Independence

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

Scientific Rationale

The reason for the interventions.

syndrome diagnosis

a clinical judgment describing a specific cluster of nursing diagnoses that occur together.

Arrange the order of critical thinking for an existing problem. 1.Making a conclusion 2.Evaluating the information 3.Recognizing the existing issue 4.Analyzing information about the issue

1.Recognizing the existing issue 2.Analyzing information about the issue 3. Evaluating the information 4. Making a conclusion

steps to objectively evaluate the degree of success in achieving outcomes of care:

1. examine the outcome criteria to identify the exact desired patient behavior or response 2. measure the patient's actual behavior or response 3. compare the established outcome criteria with the actual behavior or response 4. judge the degree of agreement between outcome criteria and the actual behavior or response 5. if there is no agreement (or only partial) between outcome criteria and patient response, why did they not agree? identify any barriers?

Validation

comparison of data with another source to confirm accuracy

Seven guidelines when writing goals and expected outcomes:

1. patient centered 2. singular goal or outcome 3. observable 4. measurable 5. time limited 6. mutual factors (agreement between patient and nurse) 7. realistic

Evaluation

crucial to deciding whether, after interventions have been delivered, a patient's condition or well-being improves. you conduct evaluation to determine if expected OUTCOMES are met, NOT if nursing INTERVENTIONS were completed.

Actual nursing diagnosis

describes human responses to health conditions or life processes that exist in an individual, family, or community.

risk nursing diagnosis

describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community.

Wellness nursing diagnosis

describes human responses to levels of wellness in an individual, group, or community. supported by defining characteristics that cluster in patterns of related cues and or inferences.

Which of the following statements about a case manager is correct? "A case manager identifies and implements new and more effective approaches to problems." "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." "A case manager helps clients identify and clarify health problems and chooses appropriate courses of action to solve these problems." "A case manager applies a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families."

"A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." Rationale A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families. A change agent helps identify and implement new and more effective approaches to problems. A counselor helps clients identify and clarify health problems and choose appropriate courses of action. A caregiver applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families.

Before discharge after a myocardial infarction, a client asks the nurse when sexual activity can be resumed. What is the best response by the nurse? "Two weeks is the usual waiting time." "How long do you think you should wait?" "Have you discussed this with your primary healthcare provider?"" "You should wait until your heart feels stronger."

"Have you discussed this with your primary healthcare provider?"" Rationale The primary healthcare provider should be consulted, because the decision depends on the amount of damage to the heart muscle and extent of healing. It is false reassurance to determine an exact time and date; 2 weeks may be too early. Although the client's feelings should be considered, this is a medical decision that depends on the amount of damage to the heart muscle. Saying the client should wait for the heart to feel stronger is too vague and does not involve information from the primary healthcare provider.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? "You do not need to wear them while you are awake, but it is important to wear them at night." "You will need to apply them in the morning before you lower your legs from the bed to the floor." "If they bother you, you can roll them down to your knees while you are resting or sitting down." "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

"You will need to apply them in the morning before you lower your legs from the bed to the floor." Rationale Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

4 steps to modify the written care plan:

1. revise data in the assessment section to reflect the patient's currents status. Date any new data to inform other health team members of the time that the change occurred 2. revise nursing diagnoses. delete diagnoses that are no longer relevant, and add and date any new diagnoses. It is necessary to revise related factors, as well as the patients goals, outcomes, and priorities. 3. revise specific interventions that correspond to the new nursing diagnoses and goals. should reflect the patient's present status. 4. determine the method of evaluation to achieve outcomes

Which age is considered the phallic stage according to Sigmund Freud's developmental theory? Birth to 18 months 18 months to 3 years old 3 to 6 years old 6 to 12 years old

3 to 6 years old Rationale According to Sigmund Freud's developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage a. Six to 12 years of age is the latent stage. Eighteen months to 3 years of age is the anal stage.

The nursing student is studying Neuman's system model of nursing. Including the physiological, how many concepts interact with each other to form this system? Record your answer using a whole number.

5 Betty Neuman's theory is based on stress and the patient's reaction to it. This theory has five components: physiological, psychological, sociocultural, developmental, and spiritual. These concepts interact with internal and external factors at all levels of prevention and with each other to achieve optimal wellness.

According to State Nurse Practice Acts, independent nursing interventions pertain to?

ADLs, health education and promotion, and counseling

The nurse interviews a client about a current health problem. The nurse then obtains and documents the client's temperature, blood pressure, and heart rate. Which step of the nursing process is involved in this situation? Planning Diagnosis Assessment Implementation

Assessment Rationale The scenario is an example of the assessment phase of the nursing process. Assessment involves the collection of comprehensive data pertinent to the client's health. During the planning level of nursing care, the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The nurse analyzes the assessment data to determine the diagnoses during the diagnosis level of nursing practice. The nurse implements the health care plan identified for the client during the implementation level of the standards of nursing practice. This level may include administering prescribed medications or healthcare procedures.

Which statement is true for attachment in the newborn? Attachment occurs for the first 28 days. Attachment begins in the first week of birth. Attachment is the overlapping of soft skull bones. Attachment is the interaction between parent and child.

Attachment is the interaction between parent and child. Rationale Attachment is the interaction between the parent and child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns that had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what? Attempts to minimize the illness Lacks an emotional response to the illness Refuses to discuss the condition with the client's spouse Expresses displeasure with the prescribed activity program

Attempts to minimize the illness Rationale Attempts to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.

What should the nurse educator instruct a graduate nurse who is seeking employment? Select all that apply. Be a role model to the nursing staff Attend workshops and conferences Motivate other educators on the nursing unit Work on developing effective communication Approach institutions that provide mentoring

Attend workshops and conferences Work on developing effective communication Approach institutions that provide mentoring Rationale The nurse educator should instruct the graduate nurse to attend workshops and conferences to develop collaborative skills and communication. A graduate nurse should work on developing effective communication with peers and members of the healthcare team. The graduate nurse should seek employment in institutions that provide mentoring for new graduate nurses. The nurse manager can be an effective leader by being a role model for the nursing staff. The nurse manager should motivate others on the nursing unit to make an empowering work environment.

How does a nurse prepare a "factual" record when performing a client documentation? By providing a logical order for the communication By using exact measurements for each activity of the client By providing complete and appropriate information in each client record By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

By recording descriptive and objective information of what the nurse sees, hears, feels, and smells Rationale A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a complete and appropriate record that includes all essential information.

Last step of a complete assessment

Communication of assessment findings, either verbally or through documentation

A senior nurse is teaching nursing theories to a group of nursing students. What are the components of nursing theories that explain a nursing phenomenon? Concepts Definitions Corrections Assumptions Compositions

Concepts Definitions Assumptions Nursing theory contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon. These elements help to make the theory practice based and contribute to effective nursing care. Corrections and compositions are not nursing theory components.

What is content? Content is data entering the system. Content is the end product. Content is data related to system functioning. Content is product and information obtained from the system.

Content is product and information obtained from the system.

With reference to the nursing process as a system, what is content? Content is the end product of a system. Content serves to inform a system about how it functions. Content is the product and information obtained from the system. Content is the data or information that comes from a client's assessment.

Content is the product and information obtained from the system. Rationale With reference to the nursing process as a system, the content is the product and information obtained from the system. Output is the end product of a system. Feedback serves to inform a system about how it functions. Input is the data or information that comes from a client's assessment.

Which nursing intervention is performed for a middle-aged adult in restorative and continuing care? Establishing independence Focusing on problems related to sense of identity Reorganizing intimate relationships and family structure Determining the coping mechanisms of the client and the family

Determining the coping mechanisms of the client and the family Rationale The nurse should determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.

Taxonomy Domains (NIC)

Domain 1: Physiological: Basic. care that supports physical functioning Domain 2: Physiological: Complex. care that supports homeostatic regulation Domain 3: Behavioral. care that supports psychosocial functioning and facilitates life-style changes Domain 4: Safety. care that supports protection against harm Domain 5: Family. care that supports the family unit Domain 6: Health System. care that supports effective use of the health care delivery system Domain 7: Community. Care that supports the health of the community

Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation? Domain 1 Domain 2 Domain 3 Domain 4

Domain 2 Rationale Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

Which domain of the nursing intervention phase includes electrolyte and acid-base management? Domain 1 Domain 2 Domain 3 Domain 4

Domain 2 Rationale Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiologic complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

Which of these databases should the nurse use to obtain a broad view on biomedical and pharmaceutical studies? PubMed EMBASE MEDLINE PsycINFO

EMBASE So close! Rationale The EMBASE database is a good source of biomedical and pharmaceutical studies. PubMed is the health science library at the National Library of Medicine; this database offers free access to many journal articles. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. PsycINFO is a good resource for psychology and psychology-related healthcare disciplines.

In which process of Swanson's theory is the nurse engaging when explaining neonatal care to a parent? Enabling Knowing Doing for Being with

Enabling Rationale According to Swanson's theory, the nurse is engaging in enabling when explaining the care of a neonate to a parent. Enabling includes informing/explaining/supporting/allowing, focusing, generating alternatives, validating, and giving feedback. The process of knowing includes avoiding assumptions, centering on the one being cared for, assessing thoroughly, seeking cues, and engaging the self or both. The process of doing for includes comforting, anticipating, performing skillfully, protecting, and preserving dignity. The process of being with includes being there, conveying ability, sharing feelings, and not burdening.

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? Use the new product sample when changing the dressing. Cleanse the site with alcohol first and then with povidone-iodine. Cleanse the site with the new product first and then follow the agency's protocol. Follow the agency's policy unless it is contradicted by a primary healthcare provider's prescription.

Follow the agency's policy unless it is contradicted by a primary healthcare provider's prescription. Rationale Agency policy determines procedures; if the procedure is out of date or problematic, the nurse should contact the primary healthcare provider for a change in the prescription. The nurse cannot use another product without a primary healthcare provider's prescription. The nurse will be risking liability if agency policy is not followed unless the prescription is changed by the primary healthcare provider. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer to a multiple-choice item. If answer choices contain an absolute (e.g., none, never, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices.

Which statement is true about the nursing model "team nursing"? The registered nurse is responsible for all aspects of client care. Client care can be delegated to other healthcare team members. The registered nurse works directly with the client, family members, and healthcare team members. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. Rationale In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? Side-lying with head elevated 45 degrees Sims with head elevated 90 degrees Semi-Fowler with legs elevated High-Fowler using the bedside table to rest the arms

High-Fowler using the bedside table to rest the arms Rationale The high-Fowler position elevates the clavicles and helps the lungs to expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? Fatigue related to weight loss secondary to COPD Imbalanced nutrition: less than body requirements, related to fatigue Imbalanced nutrition: less than body requirements, related to COPD Ineffective breathing pattern, related to alveolar hypoventilation

Imbalanced nutrition: less than body requirements, related to fatigue Rationale The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation

Implementation Rationale The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

Which internal variable influences health beliefs and practices? Family practices Cultural background Socioeconomic factors Intellectual background

Intellectual background Rational Intellectual background is an internal factor that affects the client's health beliefs and practices. A client's knowledge, educational background, and past experiences influence how a client thinks about health. Family practices, cultural background, and socioeconomic factors are among the external factors that influence health beliefs and practices.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? Labeling Collecting Clustering Interpreting

Interpreting Rationale An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.

Which opposing conflict does a young adult face according to Erikson's theory of psychosocial development? Intimacy versus Isolation Identity versus Role Confusion Autonomy versus Sense of Shame and Doubt Generativity versus Self-Absorption and Stagnation

Intimacy versus Isolation Rationale According to Erikson's theory of psychosocial development, a young adult is likely to face Intimacy versus Isolation. An adolescent is likely to face Identity versus Role confusion. A toddler age 1 to 3 years of age is likely to face Autonomy versus Sense of Shame and Doubt. A middle-aged adult is likely to face Generativity versus Self-Absorption and Stagnation.

A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall? Labeling Collecting Clustering Interpreting

Labeling The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting level include inaccurate data, missing data, and disorganization. Errors at the clustering level include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the interpreting level, errors include failure to consider conflicting cues and failure to consider cultural influences or developmental stage.

Which theory emphasizes the facilitation of the body's reparative processes by manipulating the client's environment? Orem's theory Watson's theory Leininger's theory Nightingale's theory

Nightingale's theory Rationale Nightingale's theory is based on facilitating the body's reparative processes by manipulating the client's environment. Orem's self-care deficit theory focuses on the client's self-care needs. Watson's theory is based on promoting health, restoring the client to health, and preventing illness. Leininger's theory is based on providing care consistent with emerging science and knowledge, with caring as the central focus.

What are the phases of Peplau's theory? Orientation Termination Proposition Working phase Assumptions

Orientation Termination Working phase Peplau's theory states the importance of developing a good nurse-patient interpersonal relationship in caring for a patient. This theory has four phases including orientation, working phase, and termination. Propositions or assumptions are not phases of Peplau's theory. These refer to the taken-for-granted statements that explain the concepts, definitions, and purposes of a nursing theory.

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? Colitis Stomatitis Paralytic ileus Gastrocolic reflux

Paralytic ileus Rationale After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

Which of these is a part of health belief model? Behavioral outcomes Behavior-specific knowledge Perception of susceptibility to an illness Individual characteristics and experience

Perception of susceptibility to an illness Rationale The health belief model is divided into three components. The first component is an individual's perception of susceptibility to an illness. The second component is an individual's perception of seriousness of an illness. The third component is the preventive actions taken by a person. The health promotion model focuses on behavioral outcomes, behavior-specific knowledge and affect, and individual characteristics and experience.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? <p>A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what?</p> Suddenness of the change Obviousness of the change Extent of the change Perception of the change

Perception of the change Rationale It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

What are the demands of Roy's adaptation model that can be useful in helping the patient? Economical Pathological Physiological Psychological Dependence-independence

Physiological Psychological Dependence-independence Roy's adaptation model is an example of a grand theory and is based on the physiological, psychological, sociological, and dependence-independence adaptive modes. Economical and pathological adaptive modes are not part of Roy's theory.

A senior nurse is explaining the importance of nursing theory to a group of nursing students. What statements are true about prescriptive theories? Prescriptive theories are action-oriented. Prescriptive theories test the validity and predictability of a nursing intervention. Prescriptive theories are more limited in scope and less abstract. Prescriptive theories guide nursing research to develop specific nursing interventions. Prescriptive theories address a specific phenomenon and reflect practice.

Prescriptive theories are action-oriented. Prescriptive theories test the validity and predictability of a nursing intervention. Prescriptive theories guide nursing research to develop specific nursing interventions.

A senior nurse is explaining the importance of nursing theory to a group of nursing students. What statements are true about prescriptive theories? Prescriptive theories are action-oriented. Prescriptive theories test the validity and predictability of a nursing intervention. Prescriptive theories are more limited in scope and less abstract. Prescriptive theories guide nursing research to develop specific nursing interventions. Prescriptive theories address a specific phenomenon and reflect practice.

Prescriptive theories are action-oriented. Prescriptive theories test the validity and predictability of a nursing intervention. Prescriptive theories guide nursing research to develop specific nursing interventions.

What is the primary focus of the nurse when providing evidence-based care to the client? Practice trends Research studies Clinical experience Problem-solving approach

Problem-solving approach Rationale Evidence-based practice is first and foremost a problem-solving approach to care. This problem-solving approach incorporates application of current best practice along with knowledge from research studies and clinical expertise.

Which healthcare system is required after a physical or mental illness, injury, or chemical addiction? Rehabilitation Intensive care Psychiatric facilities Extended care facilities

Rehabilitation Rationale Clients require rehabilitation after a physical illness, mental illness, injury, or chemical addiction. An intensive care unit is required when a client needs close monitoring in addition to medical care. Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities.

A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence? Establish long-range goals for the client. Identify errors that the client can correct. Reinforce success in tasks accomplished. Demonstrate ways to promote self-reliance.

Reinforce success in tasks accomplished. Rationale Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death? Revising the client's will and planning a visit to a friend Alternately crying and talking openly about death Getting second, third, and fourth medical opinions Refusing to follow treatments and stating they won't help anyway

Revising the client's will and planning a visit to a friend Rationale Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time. Crying and talking openly about death are signs of depression. Going from healthcare provider to healthcare provider demonstrates disbelief, denial, or desperation. Refusing to follow treatments and stating that the client is going to die anyway indicates anger and hopelessness, not acceptance.

Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes? Neuman's system theory Swanson's theory of caring Orem's self-care deficit theory Mishel's theory of uncertainty in illness

Swanson's theory of caring Rationale Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.

What is the primary focus of nursing care in the "family as context" approach? The relationship among family members The health and development of an individual The ability of the family to meet their basic needs The family's process of caregiving for a sick member

The health and development of an individual Rationale In the "family as context" approach, the primary focus is the health and development of an individual in a specific environment. The relationship and family processes are the primary focus when the family is viewed as client. When the family is viewed as context, the focus is the ability of the family to meet the basic needs of the individual, not their own needs. The process followed by the family when caring for the sick family member is assessed when family is viewed as client.

Which feature according to Benner is observed in a nurse at the "proficient" level? The nurse learns by means of a set of rules. The nurse identifies the principles of nursing care. The nurse identifies problems related to the health care system. The nurse focuses on managing care rather than managing skills.

The nurse focuses on managing care rather than managing skills. The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills. The novice nurse learns by means of a set of rules, which are usually stepwise and linear. The advanced beginner has observational experience and is able to identify the principles of nursing care. The expert nurse is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse.

A nurse is in the process of conducting research. What action indicates that the nurse is designing the study? The nurse gathers all relevant articles and focuses on reviewing the literature. The nurse obtains approval from the proper authorities and enlists the research subjects. The nurse checks whether all investigators are following the appropriate study protocol. The nurse prepares questionnaires and selects the treatment plans necessary for the study.

The nurse prepares questionnaires and selects the treatment plans necessary for the study. Rationale The stage of designing the study is when the nurse chooses the instrumentation for conducting the study. In this stage, the nurse prepares questionnaires and selects physiological measures, interviews, and treatments necessary for the study. The first stage of the research process involves identifying of the problem. At this stage the nurse may gather all relevant articles and review literature for the purpose of conducting the research. The stage of conducting the study involves the nurse obtaining approval from the appropriate authorities and enlisting research subjects. The nurse also monitors whether all investigators are following the appropriate study protocol in order to ensure accuracy of the findings.

Which example indicates that the nurse is following evidence-based practice? The nurse documents client care in an electronic health record. The nurse reads current nursing journals and uses the latest scientific methods. The nurse uses flowcharts and diagrams to record the client's progress. The nurse encourages the hospitalized client's family to bring home-cooked food.

The nurse reads current nursing journals and uses the latest scientific methods. Rationale Evidence-based practice requires the nurse to read current nursing journals and use the latest scientific methods. It also requires the integration of best current evidence with clinical expertise and client preferences while providing health care. The nurse uses informatics to document client care in an electronic health record. The nurse uses flowcharts and diagrams to record the client's progress and monitor the outcomes of client care. This helps the nurse to improve the quality of care. The nurse provides client-centered care by encouraging the hospitalized client's family to bring home-cooked food.

Which nurse is using complex critical thinking skills when caring for a client? The nurse talks to the client to identify reasons for a particular behavior. The nurse seeks the assistance of a senior nurse to set up an insulin pump. The nurse follows the agency's manual to apply a Foley catheter to a client. The nurse takes action without involving others and accepts accountability.

The nurse talks to the client to identify reasons for a particular behavior. Rationale A nurse practicing complex critical thinking skills begins to analyze and examine choices more independently. Talking to a client to identify reasons for a particular behavior, such as refusal to take pain medication or use of alternative therapy for pain involves the use of complex critical thinking skills. An example of basic critical thinking skills is a nurse who depends on manuals or experts and a nurse who seeks the assistance of a senior nurse to set up an insulin pump. A nurse who takes action without involving others and accepts

What is the main focus of community health nursing? To meet the acute care needs of a population To improve the quality of health in a population To influence political processes affecting public policies To assess the healthcare needs of an individual or family

To improve the quality of health in a population Rationale Community health nursing is a nursing practice focusing on the healthcare of individuals, families and groups with a community. Its main focus is to improve the quality of life and health of a population by preserving, protecting, promoting, or maintaining health. The acute and chronic care of an individual or family is provided by community-based nursing. Instead of focusing on institutional care, community-based nursing brings healthcare within the reach of the community. Factors influencing health services such as political process affecting public policies are handled by public health nursing. Community-based nursing focuses on the fulfillment of the healthcare needs of an individual or family.

What is the purpose of block and parish nursing? To provide services to older clients To promote health throughout a school curriculum To provide nursing services with a focus on health promotion and education To provide primary care to a client population living in a community

To provide services to older clients Rationale In block and parish nursing, nurses living within a neighborhood provide services to older clients or those unable to leave their homes. Health promotion throughout a school curriculum is provided by school health. Nurse-managed clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. Community health centers are outpatient clinics that provide primary care to a client population living in a community.

A client with a leg fracture is hospitalized. The registered nurse instructs the nursing student to interrogate the client to ascertain the reason for the injury. Which question would help to determine an extrinsic factor? Do you have clear vision? Are you taking any sedatives or hypnotics? Were you wearing inappropriate shoes? Do you have a history of postural hypotension?

Were you wearing inappropriate shoes? Rationale Extrinsic factors include environmental hazards outside and within the home. Asking the client about his or her footwear will help to ascertain whether there was an extrinsic factor that may have caused the fall. Intrinsic factors include impaired vision, the taking of sedatives or hypnotics, and a history of a postural hypotension.

What is exploratory research? It is a study that tests how well a program, practice, or policy is working. It is a study designed to develop a hypothesis about the relationships among phenomena. It is a study that explores the interrelationships among variables of interest without any active intervention by the researcher. It is a study that measures characteristics of situations, or groups, and the frequency with which certain events or characteristics occur.

it is a study designed to develop a hypothesis about the relationships among phenomena. Rationale Exploratory research is an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena. Evaluation research is a study that tests how well a program, practice, or policy is working. Correlational research is a study that explores the interrelationships among variables of interest without any active intervention by the researcher. Descriptive research is a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur.

What is a stressor? A stressor is any stimuli that can produce tension and cause instability within the system. A stressor exists within the client system, such as the physiological and behavioral responses to illnesses. A stressor exists outside the client system; external stressors include changes in healthcare policies or increased the crime rates. A stressor is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

A stressor is any stimuli that can produce tension and cause instability within the system. Rationale A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

Which critical thinking skill does the nurse associate with the concept of maturity? Eagerness to acquire knowledge Being tolerant of different views Trust in own reasoning processes Ability to reflect on own judgments

Ability to reflect on own judgments Rationale Maturity is the ability of a critical thinker to reflect on his or her own judgments. A critical thinker realizes that multiple solutions are acceptable. Inquisitiveness is the eagerness to acquire knowledge. A critical thinker is considered open-minded if he or she respects the right of others to have different opinions and is tolerant of different views. The critical thinker possesses self-confidence and trusts in his or her own reasoning process.

3 areas of competency to select interventions

1. knowing the scientifc rationale, or reason for the interventions 2. possessing the necessary psychomotor and interpersonal skills to perform the interventions 3. being able to function within a particular setting to use the available health care resources effectively

A nurse is recalling Piaget's theory of cognitive development. Which statement is a characteristic of the concrete operations stage? "A child is able describe a process without actually doing it." "A child faces difficulty in conceptualizing time." "A child believes that everyone experiences the world exactly as they do." "A child believes that his or her actions and appearance are constantly being scrutinized."

"A child is able describe a process without actually doing it." Rationale In the concrete operations stage, a child is able to perform mental operations and describe a process without actually doing it. In the preoperational stage, a child faces difficulty in conceptualizing time, and he or she believes that everyone experiences the world exactly as they do. In the formal operations stage, an individual believes that his or her actions and appearances are scrutinized constantly.

Which approach is a comforting approach that communicates concern and support? 1. Touch 2. Listening 3. Knowing the client 4. Providing a positive presence

1. touch

A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain? "Can you describe your pain to me?" "Is your pain associated with movements?" "Can you rate your pain on a scale of 0 to 10?" "Do you notice your pain worsening with any activity?"

"Can you describe your pain to me?" Rationale The nurse may ask the client to describe the pain or to point the area that hurts. It may help to assess the nature of the pain. Asking about effect on pain with movement may help to assess precipitating factors. The severity of a pain could be identified by asking the client to rate it on a scale from 0 to 10. The precipitating factors can be identified by asking the client about worsening of the pain with a particular activity.

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse? "Why are you always laughing?" "Your laughter is a cover for your fear." "Does it help to joke about your illness?" "The person who laughs on the outside cries on the inside."

"Does it help to joke about your illness?" Rationale The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

A registered nurse is teaching a nursing student about systems theories with a specific reference to Neuman's systems theory. Which statements made by the nursing student post teaching are accurate? Select all that apply. "Factors that change the environment also affect an open system." "The components are interrelated and share a common purpose to form a whole." "A system is composed of separate components and the components can be open or closed." "Neuman's systems theory defines a total-person model of holism and a closed-systems approach." "An open system interacts with the environment, with an exchange of information between the system and the environment."

"Factors that change the environment also affect an open system." "The components are interrelated and share a common purpose to form a whole." "An open system interacts with the environment, with an exchange of information between the system and the environment." Rationale Factors that change the environment also affect an open system. The components are interrelated and share a common purpose to form a whole. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. A system is composed of separate components, and there are two types of system, open or closed. Neuman's systems theory defines a total-person model of holism and an open-systems approach.

During the initial interview you have the opportunity to:

1. introduce yourself to the patient, explain your role, and explain the role of others during care 2. establish a caring therapeutic relationship with the patient 3. gain insight about the patients concerns and worries 4. determine the patient's goals and expectations of the health care delivery system 5. obtain cues about which parts of the data collection phase require in-depth investigation

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? "I would, but my back hurts today." "Okay. It will be my good deed for the day." "Of course. I want to do whatever I can for you." "I would like to, but it is not in my job description."

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.

A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family? "Please do not worry, everything will be alright." "I am sorry; I do not have any information about the client." "You will have to wait for the primary healthcare provider." "Please wait; I will update you as soon as I have any information."

"Please wait; I will update you as soon as I have any information." Rationale The nurse should update the client's relatives once he or she receives relevant information. This action helps the nurse to maintain the nurse-client relationship. The nurse must not provide false reassurances because this action affects the family's ability to adjust to any bad news. If the nurse does not have any information about the client, the nurse must find out details and inform the client's family. The nurse should not avoid the situation by asking the relatives to speak to the primary healthcare provider.

A registered nurse is teaching a nursing student about Maslow's hierarchy of needs. Which statement made by the nursing student needs correction? "The hierarchy of basic human needs includes five levels of priority." "The second level includes safety and security needs, which involve physical and psychological security." "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life."

"The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." Rationale The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization.

A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? "Let me get my preceptor." "Wash your hands before and after any client care." "Clean all instruments and work surfaces with an approved disinfectant." "Ensure proper disposal of all items contaminated with blood or body fluids."

"Wash your hands before and after any client care." Rationale The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? "No, try to be in your sense of reality." "Yes, today is the day that you just mentioned." "You should try improving your awareness level." "Try to recall your past memories associated with the day."

"Yes, today is the day that you just mentioned." Rationale Validation therapy an approach to communication with a confused client with dementia. In this approach, the nurse accepts the description of the time and place as stated by the client. Therefore, the statement "Yes, today is the day that you just mentioned" represents the use of validation therapy. Asking the client to reorient himself or herself to reality and asking him or her to improve his or her awareness level are examples of the reality orientation approach. Reminiscence is an approach that asks the client to recall his or her past experience.

Sources of data

(primary)patient,(secondary) family and significant others, health care team, medical records, and other records and the literature

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? 1 "I will ask the client to move his or her arm towards the body." 2 "I will ask the client to bend his or her limb by decreasing the angle." 3 "I will ask the client to move his or her hand so that the ventral surface faces downward." 4 "I will ask the client to move his or her head beyond its normal resting extended position."

1 "I will ask the client to move his or her arm towards the body." Adduction is moving the arm towards the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surface downwards indicates pronation. The movement of the head beyond the normal resting extended position indicates hyperextension.

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1. Lactated Ringer solution 2. 5% dextrose and water 3. 0.9% normal saline 4. 0.45% normal saline

0.9% normal saline

six factors to consider when choosing interventions:

1. characteristics of the nursing diagnosis 2. expected outcomes and goals 3. evidence base for the intervention 4. feasibility of the intervention 5. acceptability to the patient 6. your own competency

Steps in a consult

1. identify general problem area 2. direct the consultation to the appropriate professional 3. provide the consultant with relevant information and resources about the problem area 4. do not prejudice or influence consultants. 5. be available to discuss the consultant's findings and recommendations. 6. include the consultant's recommendations in the care plan

Evaluation process includes 5 elements:

1. identifying evaluative criteria and standards 2. collecting data to determine if you met the criteria or standards 3. interpreting and summarizing findings 4. documenting findings 5. terminating, continuing, or revising the care plan

Which statement regarding Roy's theory of nursing needs correction? 1 The Roy adaptation model views the environment as an adaptive system. 2 The need for nursing care occurs when the client cannot adapt to internal and external environmental demands. 3 The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. 4 All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

1. The Roy adaptation model views the environment as an adaptive system.

How many levels of critical thinking exist for nursing judgment? Record your answer using a whole number.

3 Rationale There are three levels of critical thinking in nursing judgment. The first level is basic critical thinking, in which the nurse has faith that the expert has the right answer to each problem. The second level is complex critical thinking. The nurse examines and analyzes information provided by the expert. A nurse engaging in this critical thinking may discover that another option is available with which to solve an issue. The third level of critical thinking is commitment. A nurse at this level can make choices without help from others. The nurse at this level of critical thinking takes full responsibility for every action in which he or she engages.

A registered nurse is teaching a nursing student about Erikson's theory of psychosocial development. To which age group does Industry versus Inferiority apply? 3 to 6 years 1 to 3 years 6 to 11 years Birth to 1 year

6 to 11 years Rationale According to Erikson's theory of psychosocial development, Industry versus Inferiority applies to the 6 to 11 years of age group. Initiative versus Guilt applies to the 3 to 6 years of age group. Autonomy versus Sense of Shame and Doubt falls in the 1 to 3 years of age group. The Trust versus Mistrust stage applies to the birth to 1 year age group.

A registered nurse is teaching a nursing student about Piaget's theory of cognitive development that includes four periods, which are related to age. Which age group corresponds with concrete operations? 2 to 7 years 7 to 11 years Birth to 2 years 11 years to adulthood

7-11 years According to Piaget's theory of cognitive development, the concrete operations period applies to the age group of 7 to 11 years of age. The preoperational period is during the age group of 2 to 7 years. The sensorimotor period applies to the age group of birth to 2 years. The formal operations period applies to the age group of 11 years to adulthood.

A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? Authority Autonomy Accountability Responsibility

Accoiuntability Rationale Accountability means being answerable for one's actions. The nurse's action of admitting the mistake and seeking instructions to correct it indicates accountability. Authority is the legitimate power to give instructions and make final decisions in a situation. Autonomy is freedom of choice and responsibility for the choices. Responsibility indicates the duties and activities that an individual is employed to perform.

Which is used for determining the hours of care and staff required for a group of clients? Flow sheets Acuity records Standardized care plans Discharge summary forms

Acuity records Rationale An acuity record is used to determine the hours of care and staff required for a given group of clients. A client's acuity level is based on the type and number of nursing interventions. Accurate acuity ratings justify overtime and the number and qualifications of staff needed to safely care for clients. A flow sheet helps to assess data about a client; this data includes vital signs and routine repetitive care. Standardized care plans based on an institution's standards of nursing practice are preprinted and established guidelines used to care for clients who have similar health problems. Discharge documentation includes medications, diet, community resources, follow-up care, and medical contact information in case of an emergency or query.

A patient is admitted to an acute care area. The patient is a businessman who is worried about getting back to work. He has had severe diarrhea and vomiting for the last week. He is weak, and his breathing is labored. Using Maslow's hierarchy of needs, what is this patient's immediate priority? Self-actualization Air, water, and nutrition Safety Esteem and self-esteem needs

Air, water, and nutrition

While working in a community health clinic, it is important to obtain nursing histories and get to know the patients. Part of history taking is to develop the nurse-patient relationship. Which statements apply to Peplau's theory when establishing the nurse-patient relationship? An interaction between the nurse and patient must develop. The patient's needs must be clarified and described. The nurse-patient relationship is influenced by the patient's and the nurse's preconceptions. The nurse-patient relationship is influenced only by the nurse's preconceptions. The nurse-patient relationship should not establish trust.

An interaction between the nurse and patient must develop. The patient's needs must be clarified and described. The nurse-patient relationship is influenced by the patient's and the nurse's preconceptions.

The leader is advising the nursing student to avoid making careless assumptions. Which critical thinking skill does the leader wants the nursing student to learn? Analysis Inference Evaluation Explanation

Analysis Rationale The leader is advising the nursing student to adopt an analysis skill. Analytical skills involve a nurse being open-minded while looking at the client's information and avoiding the making of careless assumptions. Inference skills focus on the meaning of the findings and its significance. Evaluation involves looking at all situations objectively and using criteria to determine the results of nursing actions. Explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? <p>The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?</p> Red blood cell count Sputum culture Arterial blood gas Total hemoglobin

Arterial blood gas Rationale Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

A nurse questions the staff about a change in a client's plan of care. What does this demonstrate? Authority Autonomy Responsibility Accountability

Authority Rationale The nurse asking questions about a change in a client's plan of care shows that the nurse has the power to make decisions. This is an example of the nurse's authority over other staff members. Independence in making choices about client care and work is autonomy. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability means that individuals are answerable for their actions. The nurse demonstrates accountability by checking on the client and family after discharge.

Which theory is based on the model of primacy of caring? Roy's Theory Watson's Theory Betty Neuman's Theory Benner and Wrubel's Theory

Benner and Wrubel's Theory Rationale The model of primacy of caring is the basis of Benner and Wrubel's Theory. This theory focuses on client's need for caring as a means of coping with stressors of illness. CARING IS CENTRAL According to Roy's theory, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. This theory promotes health, restoring the client to health, and preventing illness. Neuman's theory is based on stress and the client's reaction to the stressor.

Which statement is true about Betty Neuman's theory? Betty Neuman's theory is based on anthropology. Betty Neuman's theory views the client as an adaptive system. Betty Neuman's theory is based on stress and the client's reaction to the stressor. Betty Neuman's theory defines the outcomes of the nursing based on humanistic aspects of life.

Betty Neuman's theory is based on stress and the client's reaction to the stressor. Rationale Betty Neuman's theory is based on stress and the client's reaction to the stressor. In this model, the client is the individual, group, family, or community. The system is composed of five concepts that interact with one another: physiologic, psychologic, sociocultural, developmental, and spiritual. Leininger's theory is based on anthropology. Roy's adaptation model views the client as an adaptive system. Jean Watson's theory of transpersonal caring defines the outcome of the nursing activity with regard to the humanistic aspects of life.

The nurse is caring for a patient admitted to the hospital after complaints of chest pain and shortness of breath. She remained in ICU for two days due to her elevated blood pressure of 190/100 mm Hg but has since been placed on a medical floor. According to systems theory, what factors constitute the input component? Blood pressure of 190/100 mm Hg Antihypertensive drugs administered in the ICU History of chest pain History of shortness of breath Improvement from health interventions given in the ICU

Blood pressure of 190/100 mm Hg History of chest pain History of shortness of breath According to systems theory, the nursing process has four components including input, output, feedback, and content. Input is any information or data obtained after assessing the patient's health. This includes information about the patient's physiological function or information about the interaction between the patient and the environment. Therefore, the information about blood pressure, history of chest pain, and breathlessness constitute input data. Antihypertensive drugs and the interventions that were given to the patient are the data included in the content information.

The nurse is using Orem's theory while delivering care to a patient. According to this theory, what should be the goal of the nursing interventions? Care for and help the patient attain complete self-care. Help the patient adapt to changes in physiological needs. Communicate with the patient to establish positive adaptation to the environment. Assist the patient to do activities independently and to gain strength.

Care for and help the patient attain complete self-care. Different theories of nursing have different goals. Orem's theory focuses on patient self-care needs and its goal is to care for and help the patient attain complete self-care. Helping a person to adapt to changes in physiological needs is the goal of Roy's theory. According to King's theory, the nurse should use communication skills to help a patient reestablish positive adaptation to the environment. Henderson believed that nurses should work with other health care workers to assist the patient to do activities independently and help to gain strengths that the patient is lacking.

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? Mask Clean gloves Sterile gloves Shoe covers

Clean Gloves Rationale Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Mask, sterile gloves, and shoe covers are not required for this situation.

A registered nurse is teaching a nursing student about the concepts that make up a theory. Which point noted by the nursing student needs correction? Concepts consist of interrelated theories. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences.

Concepts consist of interrelated theories. Rationale A theory consists of interrelated concepts. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences.

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? Risk taking Confidence Thinking independently Responsibility and authority

Confidence Rationale 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.

A client is ambivalent about making a change in health behavior. Which stage of health behavior does the nurse suspect? Preparation Maintenance Contemplation Precontemplation

Contemplation Rationale The nurse suspects that the client is in the stage of contemplation. This stage of health behavior is characterized by the client's attitude toward a change, and the client is most likely to accept that change over the next 6 months. In the preparation stage, the client believes that a change in behavior will be advantageous. The client may need assistance to bring about the change in behavior. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to receive any information about changes in behavior and may become defensive and confrontational.

A client is in a state of ambivalence. Which of these stages of health behavior will the nurse suspect? Preparation Maintenance Contemplation Precontemplation

Contemplation Rationale The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude towards a change; the client is most likely to accept that change in the next six months. The stage of preparation is when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about the changes in the behavior.

What type of research explores the interrelationship among variables of interest without any active intervention by a researcher? Historical research Evaluation research Exploratory research Correlation research

Correlation research Rationale Correlation research involves the exploration of the interrelationship among variables of interest without any active intervention by a researcher. Historical studies are designed to establish facts and relationships concerning past events. Evaluation research tests how well a program, practice, or policy is working. Exploratory research is an initial study designed to develop or refine the dimensions of phenomena.

Which step in the research process is similar to the assessment step of the nursing process? Analyzing the results Conducting the study Developing hypothesis Identifying the problem

Identifying the problem Rationale Identifying the problem, which includes reviewing literature, formulating a theoretical framework, and identifying the study variables is similar to assessment in the nursing process. Analyzing the results of research is similar to the evaluation phase of the nursing process. Conducting the study is similar to the implementation phase of the nursing process. Developing the hypothesis coincides with the diagnosis phase of the nursing process.

What is the definition of descriptive research? Descriptive research tests how well a program, practice, or policy is working. Descriptive research measures the characteristics of persons, situations, or groups. Descriptive research is designed to establish facts and relationships concerning past events. Descriptive research explores the interrelationships among variables of interest without any active intervention.

Descriptive research measures the characteristics of persons, situations, or groups. Rationale Descriptive research is defined as a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. Evaluation research tests how well a program, practice, or policy is working. Historical research is designed to establish facts and relationships concerning past events. Correlational research explores the interrelationships among variables without any active intervention by the researcher.

Which theory describes the phenomenon of grief or caring? Grand theories Descriptive theories Prescriptive theories Middle-range theories

Descriptive theories Rationale Descriptive theories describe a phenomenon such as grief or caring. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories discuss interventions and expected outcomes for a specific phenomenon. They describe phenomena, speculate on why they occur, and describe their consequences. Middle-range theories have a more narrow scope than grand theories; these theories integrate theory-based research with nursing practices.

Which theories describe the life processes of an older adult facing chronic illness? Systems theories Developmental theories Interdisciplinary theories Health and wellness models

Developmental theories

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with patient care, remove the gown first and then remove the gloves.

Don an N95 respirator mask before entering the room. Rationale A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

Which psychophysiological factors can influence communication between a nurse and a client? Select all that apply. Privacy level Emotional status Information exchange Level of caring expressed Growth and development

Emotional status Growth and development Rationale Growth and development and emotional status are two psychophysiological factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

A nurse changing the dressing on the client's perineum would fall into which zone? Public zone Intimate zone Personal zone Vulnerable zone

Intimate zone Rationale Changing a client's dressing on the perineum falls under the intimate zone. For this action, the appropriate interpersonal distance between the nurse and the client should be between 0 and 18 inches. A nurse lecturing a class of students or speaking at a community forum lies within a public zone. A personal zone refers to a nurse sitting on the client's bedside, taking a client's history, or teaching a client individually. The vulnerable zone is where special care is needed.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? Discharge in am Blood glucose monitoring ac and bedtime Erythromycin 250 mg TIW Dalteparin 5000 international units Sub-Q BID

Erythromycin 250 mg TIW Rationale TIW, indicating three times a week, is an unacceptable abbreviation. It may be mistaken for "three times a day" or "twice weekly." The abbreviation am for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of ac (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation Sub-Q, indicating the subcutaneous route, is an acceptable abbreviation. BID, indicating twice a day, is an acceptable abbreviation. International units must be completely spelled out instead of "IU" because it may be mistaken as a four.

As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, what does nursing rely on? Experimental research Nonexperimental research Research from other disciplines Professional opinions

Experimental research Nonexperimental research Research from other disciplines

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? Evaluation Explanation Interpretation Self-regulation

Explanation Rationale Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

Which nursing interventions enhance comfort in an imminently dying client in the hospital? Select all that apply. Frequently repositioning the client Maintaining oral hygiene in the client Limiting frequent visits of the family members Measuring the vital signs of client frequently Applying body lotion to the client's skin daily

Frequently repositioning the client Maintaining oral hygiene in the client Applying body lotion to the client's skin daily Rationale The nurse provides comfort care to the client who is in the process of dying to ensure client comfort. Prolonged bed rest may cause back pain and skin issues; to reduce the pain, the nurse frequently repositions the client on the bed. Poor oral and skin hygiene may cause discomfort to the client, so the nurse carefully maintains the client's oral and skin hygiene. The nurse does not limit the visitation of family members because these visits may reduce the client's emotional stress. There is no need to measure the vital signs regularly in an imminently dying client, and doing so may increase discomfort in the client.

Arrange in order the items of personal protection equipment (PPE) removed after performing a surgical procedure. Gown, mask, gloves, face shield

Gloves face shield gown mask

2 Approaches for a comprehensive assessment :

Gordon's 11 functional health patterns problem-focused approach

A nursing student is listing the points that are applicable to grand theories of nursing. Which point mentioned by the nursing student needs correction? Grand theories require further specification through research. Grand theories are systematic and broad in scope and complex. Grand theories include Mishel's theory of uncertainty in illness. Grand theories do not provide guidance for specific nursing interventions.

Grand theories include Mishel's theory of uncertainty in illness. Rationale Mishel's theory of uncertainty in illness is not an example of a grand theory; it is a middle-range theory. Neuman's systems model is a grand theory. Grand theories require further specification through research. Grand theories are systematic and broad in scope and complexity. Grand theories do not provide guidance for specific nursing interventions; instead they provide the structural framework for broad and abstract ideas about nursing.

Which statement about Henderson's theory of nursing care is correct? Henderson's self-care deficit theory focuses on the client's self-care needs. Henderson's theory is based on stress and the client's reaction to the stressor. Henderson's concept of the environment includes the suggestion that nurses do not need to know all about the disease process differentiated nursing from medicine. Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental.

Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental. Rationale Henderson's theory comprises 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental. Orem's self-care deficit theory focuses on the client's self-care needs. The Neuman systems model is based on stress and the client's reaction to the stressor. Nightingale's concept of the environment includes the suggestion that nurses do not need to know all about the disease process differentiated nursing from medicine.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? Heredity Hypertension Cigarette smoking Diabetes mellitus

Heredity Rationale Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.

Which healthcare system focuses solely on palliative care? Hospice Rehabilitation Assisted Living Extended care facilities

Hospice Rationale A hospice is a system of family-centered care that allows clients to live and remain at home with comfort, independence, and dignity while easing the pain of terminal illness. The focus of hospice care is palliative care, not curative treatment. Rehabilitation restores a person to his or her fullest physical, mental, social, vocational, and economic potential possible. Assisted living offers an attractive long-term care setting with an environment reminiscent of home and with some resident autonomy. An extended care facility provides intermediate medical, nursing, or custodial care to clients recovering from acute illnesses or clients with chronic illnesses or disabilities.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? Hypernatremia Hyponatremia Hyperkalemia Hypokalemia

Hyponatremia Rationale The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? Binder Ice bag Elastic bandage Warm compress

Ice Bag Rationale Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage on the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain.

Which is an example of an actual nursing diagnosis? Risk for acute confusion Impaired social interaction Readiness for enhanced nutrition Readiness for increased family coping

Impaired social interaction Rationale Impaired social interaction is an example of an actual nursing diagnosis. Actual nursing diagnoses are the responses of a person to a health condition. "Risk for" nursing diagnoses define human responses to conditions that have not occurred yet. Risk for acute confusion is an example of this kind of diagnosis. A health promotion nursing diagnosis is the clinical judgment of an individual's or family's willingness to improve health. Readiness for enhanced nutrition and Readiness for enhanced family coping are examples of health promotion nursing diagnoses.

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? Diagnosis Evaluation Assessment Implementation

Implementation Rationale The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

nursing model "team nursing"

In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? Increase oral fluid intake to 2 to 3 L/day. Maintain bed rest after discharge. Limit fluid intake to 1 L/day. Void at least every hour.

Increase oral fluid intake to 2 to 3 L/day. Rationale Increasing oral fluid intake to 2 to 3 L/day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? Plasma Interstitial Dense tissue Body secretions

Interstitial Rationale Interstitial fluid constitutes about 16% of body weight, which is 10 to 12 L in an adult male of 68 kg (150 lb). Plasma is 4% of body weight. Dense tissue is part of the intracellular component. Body secretions are derived from extracellular fluid and are calculated as part of the 20% of the total body weight.

Orientation Phase

begins with introducing yourself and your position and explaining the purpose of the interview. during this phase you establish trust and confidence with a patient.Gather less personal info such as date of birth, gender, address, family members' names and addresses

What is middle-range theory? It addresses specific phenomena and reflects practice. It is the first level in theory development and describes a phenomenon. It provides a structural framework for broad concepts about nursing. It is linked to outcomes (consequences of specific nursing interventions).

It addresses specific phenomena and reflects practice. A middle-range theory focuses on a specific field or phenomenon rather than the broad scope of nursing. A grand theory is systematic and broad in scope and provides a structural framework for nursing practice. A descriptive theory is the first level of theory development and describes the phenomena under study. A prescriptive theory details nursing interventions for a specific phenomenon and the expected outcome of the care. These theories help guide research.

Which statement about Orem's theory needs to be corrected? 1. It determines self-care needs. 2. It explains the types of nursing care. 3. It aids in the design of nursing interventions. 4. It describes factors supporting the health of the family.

It describes factors supporting the health of the family. Orem's theory explains the factors within a client's living situation. These factors may support or interfere with the client's self-care abilities, but they do not refer to the family's health. This theory interprets data that determine a client's self-care needs, self-care deficits, and self-care abilities. Orem's theory explains, predicts, or describes nursing care that will help the client in bettering his or her health. The theory also aids in the design of nursing interventions for the promotion of self-care by the client during times of illness, such as asthma, diabetes mellitus, or arthritis

A theory is a set of concepts, definitions, relationships, and assumptions. What does a theory do? It formulates legislation. It explains a phenomenon. It measures nursing functions. It reflects the domain of nursing practice.

It explains a phenomenon.

What is true about a prescriptive theory? It addresses specific phenomena and reflects practice. It is the first level in theory development and describes a phenomenon. It provides a structural framework for broad concepts about nursing. It is linked to outcomes (consequences of specific nursing interventions).

It is linked to outcomes (consequences of specific nursing interventions).

Which statement about theory-based nursing practice is incorrect? It contributes to evidence-based practice. It provides a systematic process for designing nursing interventions. It is not linked to nursing outcomes. It guides the nurse's assessment.

It is not linked to nursing outcomes. Theory-based nursing practice does reflect nursing outcomes. For example, prescriptive theories address specific nursing interventions and predict the patient response.

What is descriptive theory? It addresses specific phenomena and reflects practice. It is the first level in theory development and describes a phenomenon. It provides a structural framework for broad concepts about nursing. It is linked to outcomes (consequences of specific nursing interventions).

It is the first level in theory development and describes a phenomenon. A descriptive theory is the first level of theory development and describes the phenomena under study. A grand theory is systematic and broad in scope and provides a structural framework for nursing practice. A middle-range theory focuses on a specific field or phenomenon rather than the broad scope of nursing. A prescriptive theory details nursing interventions for a specific phenomenon and the expected outcome of the care. These theories help guide research.

Which statement defines "information" gathered by the nurse? It is an individual piece of reality. It is a combination of pieces of reality. It is the organization and interpretation of data. It is the identification of relationship of various data.

It is the organization and interpretation of data. Rationale Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge.

Which statement is true regarding the nursing process? It is the end product of a system. It is the product and information obtained from a system. It is the information that comes from a patient's assessment. It is the information provided to a system about its functions.

It is the product and information obtained from a system. The nursing process includes the product and information obtained from the system. It is the information about the nursing interventions for patients with specific health problems. Output is the end product of a system. Input is the information that comes from a patient's assessment. Feedback serves to provide information to a system about its functions.

Which theorist suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptations to their environments? King Peplau Nightingale Benner and Wrubel

King Rationale According to King's theory, the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. According to Peplau's theory, the goal of nursing is to develop an interaction between nurse and client. According to Nightingale's theory, the goal of nursing is to facilitate the reparative processes of the body by manipulating a client's environment. According to Benner and Wrubel, the goal of nursing is to focus on a client's need for caring as a means of coping with stressors of illness.

The nurse is applying Henderson's theory as a basis for theory-based nursing practice. Which other elements are important for theory-based nursing practice? Knowledge of nursing science Knowledge of related sciences Knowledge about current health care issues Knowledge of standards of practice Knowledge of bias

Knowledge of standards of practice Knowledge of nursing science Knowledge of related sciences Henderson's theory is an example of a grand theory. Regardless of which particular nursing theory is selected, the nurse must use knowledge from nursing and related sciences, experience, and standards of practice when providing care.

A 70-year-old client needs to undergo heart surgery but cannot afford it. The client seeks the assistance of a nurse. Which is the preferred program that the nurse may suggest? Medicaid Medicare Managed care organization Preferred care organization

Medicare Rationale The nurse should discuss the Medicare program to this client. This health insurance program is designed for clients 65 years of age and older. There are four parts of Medicare; part A takes care of the medical, surgical, and psychiatric costs. Medicaid is a state-operated program that provides long-term care to low-income families and disabled older clients. The nurse may suggest this program in case of disabilities, but Medicare is the preferred choice. Managed care organizations (MCO) provide comprehensive preventive and treatment services to a specific group of voluntarily enrolled people. Preferred care organizations (PCO) narrow down the list of hospitals, physicians, and healthcare providers preferred by the member. PCO and MCO members need to pay from his or her own pocket in order to afford these facilities.

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? Assess the resources available to the family Meet the client's family's comfort and nutritional needs Meet the client's comfort, hygiene and nutritional needs Determine the family's need for rest and their stage of coping

Meet the client's comfort, hygiene and nutritional needs Rationale When viewing family as context, the nurse mainly focuses on the client's comfort, hygiene, and nutritional needs. Family as context means focusing on the health and development of a client. When viewing family as a system, the nurse mainly focuses on assessing the resources available to the family. Family as system includes both family as context and family as a client. When viewing family as a client, the client's family comfort and nutritional needs are focused on, and the nurse determines the family's needs for rest and their stage of coping.

A nursing student notes the characteristics of middle-range theories. Which points noted by the nursing student are accurate? Select all that apply. Middle-range theories are systematic and broad in scope and complexity. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Middle-range theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching. Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, qualit

Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Rationale Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Mishel's theory of uncertainty in illness is an example of a middle-range theory; it focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories are more limited in scope and less abstract than grand theories. Middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching.

Intermediate Priorities

involve the nonemergent, non-life threatening needs of a patient (fatigue).

A patient with leukemia is admitted to a hospital. The nurse is developing strategies to help the patient cope with the prognosis. Which theory could help the nurse in developing the strategies? Grand theory Mishel's theory Peplau's theory Descriptive theory

Mishel's theory Mishel's theory on uncertainty focuses on dealing with uncertainty in disease processes such as cancers. Therefore, this theory can assist the nurse in developing strategies to help the patient deal with the uncertainty of the prognosis of leukemia. A grand theory does not guide the nursing interventions but provides a structural framework for broad, abstract ideas about nursing. They are extremely comprehensive. They do not specifically help in developing strategies to increase coping. Peplau's theory focuses on the nurse-patient interpersonal relationship; increasing coping skills is just one aspect of the theory. Descriptive theories explain phenomena that would be helpful to explain in nursing assessments. They are not useful for guiding nursing actions. However, they would be helpful in explaining the phenomena of stress and coping but may not be helpful to the nurse in developing strategies for coping.

The nurse finds that an elderly patient is underweight, malnourished, and cachexic. The patient does not have a family but does have a close friend who visits often. The patient appears depressed and complains about not achieving enough during life. Which of the patient's needs falls under the third level of Maslow's hierarchy? Need for nutrition Need for the visiting friend Need for a sense of achievement Need for a sense of usefulness

Need for the visiting friend Maslow's hierarchy involves five levels. The first level involves basic needs including food, air, and water. The second level includes safety and security needs. The third level includes love and belonging needs such as friendship. The fourth level includes self-esteem needs such as self-confidence, sense of achievement, usefulness, and self-worth. The final level includes the need of self-actualization. Therefore, the need for meeting the friend comes under the third level of hierarchy. Nutritional needs come under the first level and the need for a sense of achievement and usefulness are fourth-level needs.

A registered nurse is teaching a nursing student about Nightingale's theory of nursing. Which statements have been correctly stated by the nursing student as a result of the teaching? Select all that apply. Nightingale's theory states that the focus of nursing is caring through the environment. Nightingale's theory limits nursing to the administration of medications and treatment. Nightingale's theory suggests that every nurse should know all about the disease process. Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness.

Nightingale's theory states that the focus of nursing is caring through the environment. Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Rationale Florence Nightingale's theory of nursing focuses on nursing by caring through the environment. Nightingale's theory is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Nightingale's theory does not limit nursing to the administration of medications and treatment. Nightingale's theory suggests that nurses do not need to know all about the disease process, which differentiates nursing from medicine.

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where? In the axillae On the hands On the right side On the side that the client prefers

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

Physical care techniques

involve the safe and competent administration of nursing procedures. Common methods appropriately include protecting you and the patient from injury, using proper infection control practices, staying organized, and positioning patients correctly.

Which nursing theory focuses on the client's self-care needs? Roy's theory Orem's theory Watson's theory Leininger's theory

Orem's theory Rationale Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.

The nurse is discussing Orem's nursing theory with a colleague. Which statements about this theory are true? The goal of nursing care is to provide culturally competent care. Orem's theory focuses on interpersonal relations between the nurse, the patient, and the patient's family. Orem's theory focuses on the patient's self-care needs. The goal is to help the patient perform self-care and manage his or her health problems. Nursing care aims to increase the patient's ability to independently meet his or her own needs.

Orem's theory focuses on the patient's self-care needs. The goal is to help the patient perform self-care and manage his or her health problems. Nursing care aims to increase the patient's ability to independently meet his or her own needs. Orem's theory was developed by Dorothea Orem. The theory focuses on the patient's self-care needs. In this theory, the goal is to help the patient perform self-care and manage his or her own health problems. According to the theory, the nurse helps the patient to increase the ability to meet his or her needs independently. The goal of Leininger's theory is to provide culturally competent care. Peplau's theory focuses on interpersonal relations between the nurse, the patient, and the patient's family.

The nurse is caring for a patient who has electively terminated a pregnancy. During the caring process, the patient shares her feelings and emotions with the nurse, which results in the nurse developing a bond with the patient. Which nursing theory would be most appropriate to help develop an interpersonal relationship? Nightingale's theory Peplau's theory Neuman's theory Henderson's theory

Peplau's theory Peplau's theory is to develop interactions between the nurse and the patient. This theory mainly focuses on the nurse developing a therapeutic relationship with the patient to help promote health and prevent sickness. Although Nightingale's theory does promote a relationship between the patient and the nurse, its primary focus is to facilitate the reparative processes of the body by doing manipulations in the environment. Neuman's theory also promotes a therapeutic relationship between the nurse and the patient, but its primary focus is attaining total wellness by much needed interventions. Henderson's theory mainly focuses on working independently with other health care providers and helping the patient to gain independence. A secondary area of concern may be to promote a patient-nurse relationship.

What are the demands of Roy's adaptation model that can be useful in helping the patient? Economical Pathological Physiological Psychological Dependence-independence

Physiological Psychological Dependence-independence Roy's adaptation model is an example of a grand theory and is based on the physiological, psychological, sociological, and dependence-independence adaptive modes. Economical and pathological adaptive modes are not part of Roy's theory.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family? Orem's theory Peplau's theory Leininger's theory Henderson's theory

Peplau's theory Rationale Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? Fairness Humility Discipline Perseverance

Perseverance Rationale Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, he or she demonstrates perseverance. Fairness requires the nurse to listen to both the sides in any discussion. Humility is associated with recognizing the need for more information for making a decision. When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.

What are the links of the meta-paradigm of nursing? Person Nursing Research Environment Knowledge development

Person Nursing Environment A paradigm is a pattern of thoughts that describes the domain of a particular discipline such as nursing. The meta-paradigm of nursing has four links including person, health, nursing, and environment or situation. Research and knowledge development are not links of the nursing meta-paradigm; they are elements of the nursing paradigm that direct the activity of the nursing profession.

The Magnet Recognition Program for health care organizations is based on fourteen forces of magnetism related to five magnet model components. Which force of magnetism is assessed to review the structural empowerment of the organization? Quality of care Quality improvement Interdisciplinary relationships Personnel policies and programs

Personnel policies and programs Rationale Health care organizations that apply for Magnet status must demonstrate innovations in professional practice. One of the forces of magnetism that impacts the structural empowerment of the organization is its personnel policies and programs. Personnel policies of an organization should provide an innovative environment in which the staff are developed and empowered. Empirical quality outcomes are reviewed by assessing the quality of care. New knowledge, innovations, and improvements are reviewed by assessing the quality improvement of the health care organization. Interdisciplinary relationships are assessed to review exemplary professional practice.

A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain? Domain Paradigm Phenomenon Environment or situation

Phenomenon Rationale A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon. The domain is the perspective of a profession. A paradigm is a pattern of thought that is useful in describing the domain of a discipline. Environment or situation includes all possible conditions affecting clients and the settings in which their health care needs occur.

Closed-ended questions

limit the patient's answers to one or two words such as "yes" or "no" (did you eat today)

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? Place a surgical mask on the client. Other than standard precautions, no additional precautions are needed. Minimize close physical contact. Cover the client's legs with a blanket.

Place a surgical mask on the client. Rationale Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

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

Postural drainage Rationale 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.

Which statement is true about prescriptive theories? Prescriptive theories are action-oriented. Prescriptive theories help to explain client assessment. Prescriptive theories focus on a specific field of nursing. Prescriptive theories are the first level of theory development.

Prescriptive theories are action-oriented. Rationale Prescriptive theories are action-oriented. They test the validity and predictability of a nursing intervention. These theories address nursing interventions for a phenomenon, describe the conditions under which the prescription occurs, and predict the consequences. Descriptive theories help to explain client assessment. A middle-range theory tends to focus on a specific field of nursing. Descriptive theories are the first level of theory development.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Maintain immobilization of a client's leg to prevent dislodging a skin graft. Keep an older adult client from falling out of bed following a surgical procedure.

Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Rationale Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

The nurse is studying the theories of nursing. Which would the nurse categorize as phenomena of nursing? Self-care Nursing care Pathophysiological processes Client response to stress Sociocultural factors affecting health

Self-care Nursing care Client response to stress Nursing theories focus on the phenomena of nursing and nursing care. A phenomenon is the term, description, or label given to describe an idea or response to or about an event, situation, process, group of events, or group of situations. Examples of nursing phenomena include caring, self-care, and patient responses to stress. Pathophysiological processes and sociocultural factors affecting health are not phenomena but concepts that help describe a phenomenon.

What interventions should the nurse perform while caring for an actively dying client? Select all that apply. Admit the client in hospice care. Perform aggressive laboratory tests. Provide client and family reassurance. Keep the client undisturbed for a long time. Perform symptom management in the client.

Provide client and family reassurance. Perform symptom management in the client. Rationale The nurse should provide comfort care in an actively dying client. In comfort care, the nurse should reassure the client and family to reduce their emotional anxiety. The nurse should perform symptom management to improve the client's quality of life. The client should not be admitted into hospice care if he or she is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? Provide perineal care. Turn and position the client. Give a complete bed bath. Document the bowel movement.

Provide perineal care. Rationale Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

A client with bone cancer is receiving hospice care at home. The hospice program also provides respite care. What is the purpose of respite care? Assisting the client with meals and personal care Providing short-term relief to the family caregiver Providing skilled nursing interventions for the client Providing counseling and treatment for behavioral problems

Providing short-term relief to the family caregiver Rationale Hospice programs are focused at providing pain relief to the client. Some hospice programs also provide short-term relief or "time-off" to the family caregiver. This enables the caregiver to leave the home to attend to other activities while the client is looked after by a responsible person. Services in an assisted living facility provide meals and personal care to the clients. A skilled nursing facility or an intermediate care facility provides skilled interventions such as intravenous administration of fluids, wound care, or long-term ventilator management. Psychiatric facilities provide counseling and treatment to clients for behavioral problems.

The plan of care for the client was to lose 7 lbs (3.2 kg) by the end of the month. The client only lost 3 lbs (1.4 kg). How should the nurse respond? Assume that the client has been cheating on the diet. Increase the goal for next month to keep the client on track. Reevaluate the plan of care for appropriateness. Discontinue the plan of care because it did not work.

Reevaluate the plan of care for appropriateness. Rationale If client outcomes have not been met, the process is reviewed from the beginning. The nurse evaluates whether the outcomes and nursing interventions were realistic, measurable, and achievable. If not, revision of client outcomes and interventions are necessary to determine whether the plan should be maintained, modified, discontinued, or referred to another healthcare professional. Assuming the client has been cheating on the diet, increasing the goal for next month, and discontinuing the plan of care are not positive steps to help the client reach the goals realistically.

Why is nursing research important in the profession of nursing? Research can lead to new theories. Research helps to test all components of a theory. Research is not done in nursing. Research determines the accuracy of a theory. Research helps in testing a theory before it is implemented.

Research can lead to new theories. Research determines the accuracy of a theory. Research helps in testing a theory before it is implemented. Research that tests nursing theories determines how accurately a theory describes a nursing phenomenon. Testing helps to develop evidence for describing or predicting patient outcomes. The researcher has a theoretical idea of how patients describe or respond to a phenomenon and subsequently generates research questions or hypotheses to test the assumptions of the theory. Research is useful to test a theory before it is implemented. No single study tests all components of a theory.

Which component of decision-making refers to the duties and activities an individual is employed to perform? Authority Autonomy Responsibility Accountability

Responsibility Responsibility refers to all duties and activities an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? Right task Right person Right supervision Right communication

Right communication Rationale Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations while delegating a task. Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person is delegating a task to the correct person who has the ability to perform said task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.

What should the community nurse teach about the risk of adolescent pregnancy? Risk for premature birth Risk for having a large baby Risk for chromosomal defects Risk for increased weight gain

Risk for premature birth Rationale The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply. Self-worth Achievement Security needs Belonging needs Self-actualization

Self-worth Achievement Rationale Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? Prioritize psychosocial needs over physical needs. Use the Nursing Outcomes Classification (NOC) only. Use nursing knowledge to plan outcomes and disregard client and family desires. Set priorities and outcomes using the client's and family input.

Set priorities and outcomes using the client's and family input. Rationale Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? Nuclear family Extended family Single-parent family Skip-generation family

Skip-generation family Rationale A skip-generation family form is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

nursing-sensitive outcome

measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions.

Which statement made by a nursing student about Swanson's theory of caring needs correction? The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.

Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. Rationale Swanson's theory of caring provides a basis for identifying and testing nurse caring behaviors to determine if caring will improve client health outcomes. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? The baby has a head lag when pulled to sit. The baby can turn from the side to the back. The baby can turn from the abdomen to the back. The baby supports much of his own weight when he or she is pulled to stand.

The baby has a head lag when pulled to sit. Rationale A normal five-month-old infant should be able to sit up without a head lag. This finding should cause the nurse to conduct a further assessment. A baby should be able to turn from the side to the back by four months of age. At five months of age, the baby should be able to turn from the abdomen to the back. The baby should be able to support much of his own weight when pulled to stand by the age of five to six months.

A nurse is teaching a parent about the different temperaments that a child may display. What characteristics does a slow-to-warm up child display? Select all that apply. The child adapts slowly with frequent communication. This child is regular and predictable in his or her habits. The child is highly active, irritable, and irregular in his or her habits. The child reacts with mild but passive resistance to novelty. The child reacts negatively and with mild intensity to new stimuli.

The child adapts slowly with frequent communication. The child reacts with mild but passive resistance to novelty. The child reacts negatively and with mild intensity to new stimuli. Rational A slow-to-warm up child adapts slowly with frequent communication and reacts to novelty with mild but passive resistance. A slow-to-warm up child also reacts negatively and with mild intensity to new stimuli. An easy child is regular and predictable in his or her habits. A difficult child is highly active, irritable, and irregular in his or her habits.

During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding? The nurse restores the client's sense of reality. The nurse builds self-esteem by asking about a client's previous achievements. The nurse agrees to a confused client's incorrect statement. The nurse meets the expressed and unexpressed needs of the client.

The nurse builds self-esteem by asking about a client's previous achievements. Rationale Reminiscence theory involves helping the client to recall past experiences to help resolve current conflicts. A nurse who builds a client's self-esteem by asking about his or her previous achievements is using the theory. Reality orientation is associated with the restoration about the sense of reality. Validation therapy is associated with agreeing with a confused older client's incorrect statement. The nurse may use therapeutic communication to address the expressed and unexpressed needs of the client.

Which characteristic indicates that nursing is a profession? The nurse is trained to perform specific tasks. The nurse is required to follow a code of ethics. The nurse is required to have a collection of specific skills. The nurse has limited autonomy in decision making and practice

The nurse is required to follow a code of ethics. Rationale Nursing is a profession because it follows a code of ethics, which are the philosophical ideals of right and wrong that define the principles the nurse uses to care for the clients. Nursing is not just a collection of specific skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner. Nursing is a profession because nurses have autonomy in decision making and practice in accordance with the state and federal laws and regulations. Nursing is a profession because its members must not only possess basic nursing education but extended education to explore new methods of health care.

functional health patterns

method of patient care delivery in which each staff member is assigned a task that is completed for all pts on the unit

A patient is bedridden after an accident and she needs to adapt to her surroundings for physiological, sociological, and psychological needs. The nurse has decided to apply Roy's theory to the patient's condition. Which statements apply to Roy's theory when establishing patient adaptations? The nurse will determine which demands are causing problems for the patient. The nurse assesses how well the patient is adapting to problems. Adaptation to the basic physiological need should be the only goal of the nurse. Nursing care should be directed toward helping the patient adapt to changes. The need for nursing care arises only when the person cannot adapt to internal environmental demands.

The nurse will determine which demands are causing problems for the patient. The nurse assesses how well the patient is adapting to problems. Nursing care should be directed toward helping the patient adapt to changes. According to Roy's theory, the goal of nursing care should be to help the patient adapt to changes. The nurse should determine which demands are causing the problem and should assess the patient's response to the changes that need to be adapted to. The nurse should directly care for the patient and help her adapt to the changes. The goal of nursing should not be limited to adaptation of basic physiological needs. It should also include developing a positive self-concept, performing social roles, and achieving balance between dependence and independence. The need for nursing care arises when the person cannot adapt to either internal or external environmental demands.

What are components of the nursing paradigm? The person, health, the environment, and theory Health, theory, concepts, and the environment Nurses, physicians, health, and patient needs The person, health, the environment/situation, and nursing

The person, health, the environment/situation, and nursing The nursing paradigm focuses on the person, health, the environment/situation, and nursing. All the elements interact with one another with the patient being central.`

A client with colon cancer is receiving hospice care at home. What is the focus of hospice care? To ease the pain from illness To provide curative treatment To assist with activities of daily living To adapt to the limitations due to illness

To ease the pain from illness Rationale The focus of hospice care is palliative care to ease the pain caused by the illness. It is a system of family-centered care that allows clients to live at home with dignity. Hospice care does not provide curative treatment. The health care team follows an individualized plan of care for the client. Assisted living facilities offer long-term care for the older client in settings with a home-like environment. These facilities assist the client with activities of daily living. Rehabilitation facilities provide restorative care that helps the client to adapt the limitations caused by the illness.

What is the function of the Professional Standards Review Organizations (PSROs) set up by the federal government? To identify "Never Events" in health care To set national priorities to transform healthcare To review the quality, quantity, and cost of hospital care To eliminate overuse of diagnostic and treatment services

To review the quality, quantity, and cost of hospital care That's right! Rationale The federal government set up PSROs to review the quality, quantity, and cost of hospital care. The National Quality Forum defined a list of 28 "Never Events" in health care. Death or injury due to medication error is an example of a "Never Event." The National Priorities Partnership is a group of 28 organizations from a variety of health care disciplines that work together to transform health care on a national level. Medicare-qualified hospitals have utilization review committees to review admissions and identify and eliminate overuse of diagnostic and treatment services for clients on Medicare.

To prevent septic shock in the hospitalized client, what should the nurse do? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures. Rationale Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

Which statement is applicable to Watson's theory of transpersonal caring? Watson's theory views the client as an adaptive system. Watson's theory is based on stress and the client's reaction to the stressor. Watson's theory focuses on providing the client with culturally specific nursing care. Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life.

Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life. Rationale Watson's theory of transpersonal caring defines the outcome of nursing activity in relation to the humanistic aspects of life. The Roy adaptation model views the client as an adaptive system. The Neuman systems model is based on stress and the client's reaction to the stressor. Leininger's theory focuses on cultural diversity; the goal of nursing care should be to provide the client with culturally specific nursing care.

health promotion nursing diagnosis

a clinical judgment of a person's, family's, or community's motivation, and readiness to increase well-being.

Patient-centered goal

a specific and measurable behavior or response that reflects the patient's highest possible level of wellness and independence in function

Activities of daily living (ADLs)

activities usually performed during a normal day; include ambulation, eating, dressing, bathing, and grooming.

Collaborative problem

actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status. nurses intervene in collaboration with personnel from other health care disciplines, such as social workers and dietitians. manage these using both physician-prescribed and nursing-prescribed interventions

5 Types of nursing diagnoses:

actual, health promotion, risk, syndrome, and wellness

collaborative interventions

also called interdependent nursing interventions. therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

Nursing intervention

any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes. include both direct and indirect care measures

5 steps of the nursing process (ADPIE)

assessment diagnosis planning/goals implementation/intervention evaluation

Patients first line of defense

careful monitoring and early detection of problems

Nursing Outcomes Classification (NOC)

classification system of nursing-sensitive outcomes. one purpose is to identify, label, validate, and classify nursing-sensitive patient outcomes.

Nursing diagnosis

clinical judgement about individual, family, or community responses to actual and potential health problems or life processes.

Health promotion diagnosis

clinical judgement of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential to enhance specific health behaviors, such as nutrition and exercise. Do not require a patient to have a high level of wellness

Sydrome diagnosis

cluster or group of signs and symptoms that almost always occur together.

2 steps in nursing assessment

collection and verification of data from a primary source (patient) and secondary sources (family, friends, health professionals, medical records) Analysis of all data as a basis for the second step of the nursing process, developing nursing diagnoses and identifying collaborative problems

Risk nursing diagnosis

describes human responses to health conditions or life processes that have a chance of developing in a vulnerable individual, family, or community. supported by risk factors.

Nursing interventions classification (NIC)

developed by the Univeristy of Iowa, helps to differentiate nursing practice from that of other health care professionals by offering a language that nurses can use to describe sets of actions in delivering nursing care.

2-part format of nursing diagnosis

diagnostic statement followed by a statement of a related factor

Counseling

direct care method that helps patients use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships. involves emotional, intellectual, spiritual, and psychological support. examples are behavior modification, bereavement counseling, biofeedback, and crisis intervention

Nursing diagnostic process

flows from the assessment process and includes data clustering, interpretation and analysis, identifying patient needs, and formulating the nursing diagnosis or collaborative problem

Problem-focused approach

focus on patient's situation and begin with problematic areas.

Working Phase

gather information about patient's health status. begin by obtaining health history. First interview is most extensive of all

An assessment moves from

general to specific

Nursing care plan

generally includes nursing diagnoses, goals and/or expected outcomes, and specific nursing interventions so that any nurse is able to quickly identify a patient's needs and situation. communicates nursing care priorities to other health care professionals and indentifies and coordinates resources for delivering nursing care.

adverse reaction

harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. can possibly follow any nursing interventions, so learn to anticipate them and know what to expect.

Health History

includes information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. reasons for seeking health care present illness or health concern heatlh history family history environmental history psychosocial and cultural history review of systems

Cue

information that you obtain through use of the senses

independent nursing interventions

nurse-initiated interventions. nurses initiate on their own to act on a patient's behalf. DO NOT require direction or an order from another health care professional. examples: elevating an edematous extremity, offering counseling on coping, and instructing patients about medication side effects.

often the first ones to detect changes in patients' conditions

nurses

short-term goal

objective behavior or response that you expect the patient to achieve in a short time, usually less than a week

long-term goal

objective behavior or response that you expect the patient to achieve over a longer period, usually over several days, weeks, or months

Expected outcomes

observable effects that are the result of an intervention.

objective data

observations or measurements of a patient's health status.

Positive evaluations

occur when you achieve expected outcomes that lead you to conclude that the nursing interventions effectively met the patient's goals

how to communicate a patients progress toward meeting outcomes and goals:

on assessment flow sheet and summary progress notes, and by sharing information between nurses during change-of-shift reports

Priority Setting

ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing actions always important to include the patient

Low priorities

patient needs that are usually directly related to a specific illness or prognosis but may affect the patient's future well-being.

Assessment data reveals

patient's current and past health status, functional status, and present and past coping patterns

Implementation

performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care.

Lifesaving measures

physical care technique that you use when a patient's physiological or psychological state is threatened. purpose is to restore physiological and psychological balance. include administering emergency medications, performing cardiopulmonary resuscitation, and protecting a violent patient.

dependent nursing interventions

physician-initiated interventions. actions that require an order from a physician or another health care professional.

Back-channeling

practice of giving positive comments such as "all right," "go on," or "uh-huh" to the speaker. indicate that you have heard what the patient says and are attentive to hear the full story

Standing order

preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.

Consultation

process by which you seek the expertise of a specialist, to identify ways to handle problems in patient care management or in the planning and implementation of therapies.

Nursing Process

professional nurse's approach to identifying, diagnosing, and treating human responses to health and illness.

Preventive measures

promote health and prevent illness to avoid the need for acute or rehabilitative health care. All patients need this.

Open-Ended questions

prompts patients to describe a situation in more than one or two words. (how are you feeling today)

Gordon's 11 functional health patterns

provide a holistic framework Health perception-health management pattern, nutritional-metabolic pattern, elimination pattern, activity-exercise pattern, sleep-rest pattern, cognitive-perceptual pattern, self-perception--self-concept pattern, role-relationship pattern, coping--stress-tolerance pattern, and value-belief pattern

Goal

realistic and based on patients needs and resources. must also be time limited.always partner with your patient.

High Priorities

sometimes both psychological and physiological. avoid classifying only physiological nursing diagnoses as high priority. For example, "death anxiety" would be a high-priority diagnosis because it has the potential for impacting the patients ability to become a participant in her own care.

Goals and Expected outcomes are:

specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem. serve two purposes: to provide clear direction for the selection and use of nursing interventions and to provide focus for evaluating the effectiveness of the interventions

Family resiliency

the ability of the family to cope with expected and unexpected stressors

Level of Function

the physical, developmental, psychological, and social aspects of everyday living.

Direct care interventions

treatments performed through interactions with patients. examples are medication administration, insertion of an intravenous catheter, and counseling during a time of grief.

Negative evaluations

undersired results, indicate that the interventions were not effective in minimizing or resolving the actual problem or avoiding a potential problem. as a result, change the care plan and try different therapies

Concept Mapping

way to graphically represent the connections between concepts that relate to a central subject. forms a picture of each patient's diagnoses and the interconnections between the assessment data and nursing interventions associated with the patient problems.

Inference

your judgement or interpretation of cues

subjective data

your patients' verbal descriptions of their health problems. usually includes feelings of anxiety, physical discomfort, or mental stress

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? "I should carry objects about 18 inches from my body." "I should sleep on my stomach with a firm mattress." "I should carry objects close to my body." "I should pull rather than push when moving heavy objects."

"I should carry objects close to my body." Rationale By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give? Select all that apply. 1 "A nurse's documentation is the evidence of care that a client receives." 2 "Nurses' notes should not be given to attorneys in the event of a lawsuit." 3 "The nurse should note down assessments and significant changes in the client's health." 4 "In case an occurrence report is filed, nurses should enter the information the client's charts." 5 "Nurses should always document the primary healthcare providers' responses whenever they are contacted.

1 "A nurse's documentation is the evidence of care that a client receives." 3 "The nurse should note down assessments and significant changes in the client's health." 5 "Nurses should always document the primary healthcare providers' responses whenever they are contacted. To perform risk management, nurses should always complete documentation in the appropriate manner. A nurse's documentation is considered to be an evidence of care received by a client. Documenting assessments and significant changes in the client's health are essential because this information helps to defend nurses in lawsuits. Nurses should document that the primary healthcare provider was contacted and document the provider's response to the situation at hand. Attorneys often review nurses' notes first if a lawsuit is filed. Nurses should never document that an occurrence report has been completed in a client's chart.

What is the difference between risk nursing diagnoses and actual nursing diagnoses? 1 Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. 2 Actual nursing diagnoses are present in NANDA-I classification; risk nursing diagnoses are absent in NANDA-I classification. 3 Actual nursing diagnoses are associated with environmental and physiological factors; risk nursing diagnoses are not associated with these factors. 4 Actual nursing diagnoses are least likely to be established in a vulnerable population; risk nursing diagnoses are established in vulnerable population.

1 Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. Actual nursing diagnoses have related factors that show a causality relationship between the diagnosis and the etiology. Risk nursing diagnoses have a risk factor which may predispose a client to a disease. Both the types of diagnoses are mentioned in the NANDA-I classification. Both types of diagnoses may have associations with environmental and physiological factors. Both types of diagnoses can be established in vulnerable population.

A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease? 1 Avoid exercises to the involved joints. 2 Engage in passive exercises to the involved joints. 3 Increase isometric exercises to the involved joints slowly. 4 Participate in progressive, resistive exercises to the involved joints

1 Avoid exercises to the involved joints. During the acute phase, immobilization of the joints reduces pain and inflammation. Passive exercises are contraindicated during the acute inflammatory phase; joints need to be immobilized. Isometric exercises involve muscles, not joints. Progressive, resistive exercises are contraindicated during the acute inflammatory phase because joints need to be immobilized to reduce pain and inflammation.

A nurse is demonstrating to a client how to manipulate the ankles through full range of motion. Which movements should the nurse use during this process? Select all that apply. 1 Eversion 2 Inversion 3 Abduction 4 Dorsiflexion 5 Plantar flexion

1 Eversion 2 Inversion 4 Dorsiflexion 5 Plantar flexion Eversion is turning the ankle inward toward the midline of the body. The ankle can evert. Inversion is turning the ankle outward away from the midline of the body. The ankle can invert. Dorsiflexion occurs when the toes and the distal part of the foot are bent upward toward the abdomen. The ankles can dorsiflex. Plantar flexion occurs when the toes and the distal part of the foot are bent downward away from the abdomen. The ankles can plantar flex. The ankle cannot be abducted; abduction is moving an extremity away from the midline of the body.

Which image shows the Trendelenburg position? 1 Head down, feet down 2. Flat faciing up 3. Head down, legs down and straight/bent, arms out straight. 4. Flat on stomach

1 Head down, feet down 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.

A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall? 1 Labeling 2 Collecting 3 Clustering 4 Interpreting

1 Labeling The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting level include inaccurate data, missing data, and disorganization. Errors at the clustering level include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the interpreting level, errors include failure to consider conflicting cues and failure to consider cultural influences or developmental stage.

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. 1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems.

1 Nursing diagnoses involve the client when possible. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems. Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

1 Planning The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

Which feature is characteristic of a risk nursing diagnosis? 1 The diagnosis does not have related factors. 2 The diagnosis can be used in any health state. 3 The defining characteristics support the diagnostic judgment. 4 The defining characteristics are supported by a client's readiness.

1 The diagnosis does not have related factors. A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident 2 A listing of facts related to the incident as witnessed by the nurse 3 The name of the nurse who was responsible for implementing the restraints 4 The potential reasons why the restraints were not in place at the time of the fall

2 A listing of facts related to the incident as witnessed by the nurse PP Table 26-1 The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report, fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? 1 Have the prescription renewed every 48 hours. 2 Assess the client's condition every hour. 3 Provide range of motion to the client's elbows every shift. 4 Document output from the tube and catheter every 2 hours

2 Assess the client's condition every hour. A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.

How does a nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client record 4 By recording descriptive and objective information of what the nurse sees, hears, feels and smells

2 By using exact measurements for each client's activity The use of exact measurements establishes accuracy. A nurse follows the principle of organization by communicating the information in a logical order. The nurse incorporates the guideline completion by providing a complete and appropriate record with all the essential information. A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1 Fatigue related to weight loss secondary to COPD 2 Imbalanced nutrition: less than body requirements, related to fatigue 3 Imbalanced nutrition: less than body requirements, related to COPD 4 Ineffective breathing pattern, related to alveolar hypoventilation

2 Imbalanced nutrition: less than body requirements, related to fatigue The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

Which is an example of an actual nursing diagnosis? 1 Risk for acute confusion 2 Impaired social interaction 3 Readiness for enhanced nutrition 4 Readiness for increased family coping

2 Impaired social interaction Impaired social interaction is an example of an actual nursing diagnosis. Actual nursing diagnoses are the responses of a person to a health condition. "Risk for" nursing diagnoses define human responses to conditions that have not occurred yet. Risk for acute confusion is an example of this kind of diagnosis. A health promotion nursing diagnosis is the clinical judgment of an individual's or family's willingness to improve health. Readiness for enhanced nutrition and readiness for enhanced family coping are examples of health promotion nursing diagnoses.

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. What should the nurse be aware of when using the problem-etiology-signs and symptoms (PES) format? 1 Signs and symptoms come last in the diagnostic process. 2 Nursing interventions are derived from the etiology statement. 3 The only allowable diagnoses are nursing diagnoses. 4 Nursing diagnoses deal only with actual or potential illness problems

2 Nursing interventions are derived from the etiology statement. The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the signs and symptoms, or "S" in the acronym, comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses handle most commonly with other healthcare providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? 1 Supine 2 Orthopneic 3 Low-Fowler 4 Semi-Fowler

2 Orthopneic The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume. The supine position does not permit the diaphragm to descend by gravity, and pressure of the abdominal organs against the diaphragm limits its movement. Low-Fowler and semi-Fowler positions do not maximize lung expansion to the same degree as the orthopneic position. the position assumed by patients with orthopnea, namely sitting propped up in bed by several pillows.

A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? 1 Asking that the prescription indicate the type of restraint 2 Recognizing that PRN prescriptions for restraints are unacceptable 3 Implementing the restraint prescription when the client begins to act out 4 Ensuring that the entire staff is aware of the prescription for the restraints

2 Recognizing that PRN prescriptions for restraints are unacceptable A new prescription must be written each time a client requires restraints. When a client is acting out, the nurse may use restraints or a seclusion room and then obtain the necessary prescription. Less restrictive interventions should be used when the client begins to act out; restraints are used as a last resort.

Which client is likely to have a health promotion nursing diagnosis? 1 The client with acute pain due to appendicitis. 2 The client who is willing to take a 30-minute walk daily. 3 The elderly client with dementia admitted to the healthcare facility. 4 The client with reduced cognitive ability while recovering from surgery.

2 The client who is willing to take a 30-minute walk daily. A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client's response to a particular health condition. A risk nursing diagnosis describes an individual's response to health conditions that may develop in a vulnerable individual. The elderly client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls

Which related factor is appropriate for a nursing diagnosis? 1 Prostectomy 2 Trauma of incision 3 Acute renal failure 4 Knee replacement surgery

2 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.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. 1 Heart 2 Vagina 3 Rectum 4 Female genitalia 5 Musculoskeletal system

2 Vagina 3 Rectum 4 Female genitalia Sims' position is indicated to examine vagina, rectum, and female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system

The nurse finds that a client with bilateral oral swelling, pain, and trismus had undergone a surgical extraction of an impacted tooth five days ago. What type of nursing diagnosis does the documentation of acute pain refer to? 1 Syndrome diagnosis 2 Risk nursing diagnosis 3 Actual nursing diagnosis 4 Health promotion nursing diagnosis

3 Actual nursing diagnosis According to the given information, the pain is secondary to the surgical procedure. In this case, the nurse has sufficient assessment data to establish the nursing diagnosis. This is an example of an actual nursing diagnosis. A syndrome diagnosis is a clinical judgment describing a specific cluster of nursing diagnoses that occur together. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, and readiness to increase well-being.

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client? 1 Eversion 2 Supination 3 Opposition 4 Circumduction

3 Opposition Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip

Elbow restraints are prescribed for an 18-month-old toddler who just had surgery for a cleft palate. The nurse explains to the parents that the restraints are used to keep the child from doing what? 1 Playing with unsterile toys 2 Rolling to a supine position 3 Putting fingers into the mouth 4 Removing the nasogastric tube

3 Putting fingers into the mouth The suture lines in the mouth must be protected. Because the toddler uses the mouth to explore the environment, elbow restraints are needed to keep the child from placing fingers or objects in the mouth. The child should have time to play with toys, but with supervision to prevent mouthing activities that could disrupt the suture line. The supine position is acceptable; the toddler should be able to move freely when asleep. A nasogastric tube is not used.

In which positions should the nurse place a client who has just had a right pneumonectomy? 1 Right or left side-lying 2 High-Fowler or supine 3 Supine or right side-lying 4 Left side-lying or low-Fowler

3 Supine or right side-lying Supine or right side-lying permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. Although the high-Fowler position promotes ventilation, it may be tiring for a postoperative client. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain

3 The nurse asks the client to explain the surgery. The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

A client with a high fever, chills, and a severe body ache reports to a healthcare unit. What is the correct order for the nursing diagnosis procedure? 1. Interpreting and analyzing the data obtained 2 Defining characteristics and related factors 3. Collecting information about the client's health status 4. Identifying client needs and formulating nursing diagnoses 5. Organizing the data according to signs and symptoms

3, 1, 5, 2, 4 1. Collecting information about the client's health status 2. Interpreting and analyzing the data obtained 3. Organizing the data according to signs and symptoms 4. Defining characteristics and related factors 5. Identifying client needs and formulating nursing diagnoses For the nursing diagnosis procedure, the nurse should first assess the client's health status by collecting information from the client, family, or hospital health record. Next, the nurse should interpret and analyze the data obtained. This data should be clustered according to signs and symptoms. The nurse should also define and explain the characteristics and factors related to the illness. Finally, the nurse should identify the client's needs and compose a nursing diagnosis for the client.

According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance? 1 scale of 1 2 scale of 2 3 scale of 3 4 scale of 4

4 According to the common scale for grading muscle strength, a client who can complete range of motion with some resistance is given the rating 4. Rating 1 is given to a client with no joint motion and slight evidence of muscle contractility. Rating 2 is given to a client who can complete range of motion with gravity eliminated. Rating 3 is given to a client who can complete range of motion against gravity.

After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond? 1 "They're used routinely on infants who have had lip surgery." 2 "Legally we're required to put them on infants after lip surgery." 3 "The staff can't be with your baby continuously to prevent touching of the mouth." 4 "Because we're keeping the arms straight, your baby won't be able to touch the mouth."

4 "Because we're keeping the arms straight, your baby won't be able to touch the mouth." An explanation of how the restraints work and why they are used may reassure the parents. Touching the suture line may cause a separation of the wound edges, predisposing the infant to infection and compromised wound healing. Explaining routine use of restraints does not explain why they are being used now. Restraints are not a legal requirement; applying elbow restraints is a postoperative prescription. Stating that the nurse cannot be with the infant continuously may give the parents the feeling that their baby's needs are not being met.

How does a nurse prepare a "factual" record when performing a client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each activity of the client 3 By providing complete and appropriate information in each client record 4 By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

4 By recording descriptive and objective information of what the nurse sees, hears, feels, and smells A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells.

A nurse preparing to apply restraints to a client should understand which of the following principles? 1 The law prohibits restraining clients until a written prescription is obtained. 2 A felony charge may be leveled against nurses who use restraints improperly. 3 Nurses are not obligated to report institutions that use restraints unlawfully. 4 Charges of assault and battery may be leveled against nurses who use restraints improperly

4 Charges of assault and battery may be leveled against nurses who use restraints improperly Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid primary healthcare provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint prescriptions may differ from state to state and in different settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to report institutional misuse of restraints, because this may constitute false imprisonment and abuse.

A preschool child with a spinal cord injury will be on prolonged bed rest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan? 1 Fish 2 Fruit 3 Beef 4 Cheese

4 Cheese Cheese contains calcium, which is excreted by the kidneys and may contribute to the formation of kidney stones; it adds to the child's risk because immobility causes bone decalcification. Fish contains protein, which is needed for wound healing and growth. Fruit contains some fiber, which will help decrease the risk of constipation. Beef contains protein, which is needed for wound healing and growth.

The nurse is caring for a nonambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included in the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force

4 Impaired skin integrity, related to the effects of pressure and shearing force The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force. This is supported by the data provided that the client is nonambulatory and has a reddened sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's problem is not being "at risk" because the client already has an actual problem. Not enough information is provided to make the assumption that the impaired skin integrity is related to infrequent turning and repositioning.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? 1 Labeling 2 Collecting 3 Clustering 4 Interpreting

4 Interpreting An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? 1 NANDA-I label, related factor, and etiologies 2 NANDA-I label, risk factor, and nursing interventions 3 NANDA-I label, related factor, and nursing interventions 4 NANDA-I label, related factor, and defining characteristics

4 NANDA-I label, related factor, and defining characteristics The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions

Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? 1 Restraints can be used when less restrictive interventions are not successful. 2 Restraints can be used when all other alternatives have been tried and exhausted. 3 Restraints can be used only to ensure the physical safety of the resident or other residents. 4 Restraints can be used anytime without a written order from the healthcare provider

4 Restraints can be used anytime without a written order from the healthcare provider Restraints can be used only on the written order of a healthcare provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents.

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1. Activity theory 2. Continuity theory 3. Disengagement theory 4. Gerotranscendence theory

4. Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.

A nurse is assessing a client during a regular checkup. The client complains of a moderate decrease in food intake over the past 3 weeks, a 4-kilogram weight loss, and a decrease in mobility. The client had a bout of acute bronchitis 1 month ago and has recently been diagnosed with mild dementia. The body mass index of the client is 21. What is the total score of the client according to the mini nutritional assessment (MNA)? Record your answer as a whole number. ___________

5 The mini nutritional assessment (MNA) is a tool used to identify malnutrition. It measures the nutritional status and assigns a numerical score for each of the questionnaire areas. The score for a moderate decrease of food intake over the past 3 weeks is 1. The score assigned for a weight loss of 4 kg is 0. A score of 1 is assigned for the decrease in mobility (chair or bed bound). The score for a history of acute bronchitis is 0. A score of 1 is assigned to mild dementia, and a score of 2 is assigned to a body mass index of 21. Therefore, the total score of the client according to the MNA is 5.

Which description is most appropriate for the family centered care approach? The nursing care is focused on the client as an individual. A collaborative plan of care is developed to achieve optimal health. The healthcare provider is the expert in developing a plan of care. The nursing care is based solely on standards of practice.

A collaborative plan of care is developed to achieve optimal health. Rationale Family-centered care is commonly used to describe optimal health care as experienced by families. The term is frequently accompanied by terms such as "partnership," "collaboration," and families as "experts" to describe the process of care delivery. Family care addresses the family versus one individual. The healthcare provider collaborates with the family to develop a plan of care. Evidence based standards of practice are incorporated into a collaborative family centered care plan. Standards are not the only guidelines considered in a family centered plan of care.

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? Blended family Extended family Alternative family Single-parent family

Blended family Rationale The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. A single-parent family is formed when one parent cares for the children following the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.

How can a nurse best evaluate the effectiveness of communication with a client? Client feedback Medical assessments Health care team conferences Client's physiologic responses

Client feedback Rationale Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's Correct3 End-stage renal 4 Gastroesophageal reflux

Correct3 End-stage renal One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

A nurse helps a client to clarify health problems and choose appropriate courses of action. What competency in community-based practice is the nurse exercising? Educator Caregiver Counselor Epidemiologist

Counselor Rationale When a nurse is helping a client to identify and clarify health problems and choose appropriate courses of action to solve those problems, the nurse is acting as a counselor. The nurse acts as an educator by establishing relationships with community service organizations. The nurse acts as an epidemiologist when he or she is involved in case finding, health teaching, and tracking incident rates of an illness. The nurse acts as a caregiver when he or she provides appropriate, individualized nursing care for specific clients and their families.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? Knowing Enabling Doing for Being with

Enabling Rationale The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? Administer the prescribed as needed (PRN) sedative. Encourage the client to express feelings. Explain the postprocedure course of treatment. Reassure the client that there are others with this problem.

Encourage the client to express feelings. Rationale Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus should be on the client, not others. Reassurance may cut off communication and deny emotions.

Which professional standard does the nurse feel is most important for critical thinking? Logical thinking Evaluation criteria Accurate knowledge Relevant information

Evaluation criteria Rationale An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which statement defines the term family resiliency? Family resiliency is the uniqueness of each family. Family resiliency is the ability of the family to cope with stressors. Family resiliency is the intrafamilial system of support and structure. Family resiliency is the ability of the family to transcend.

Family resiliency is the ability of the family to cope with stressors. Rationale Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.

The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? 94.2 85.3 89.4 91.5

Hypothermia is classified as mild hypothermia (body temperature of 34 °C to 36 °C/93.2 °F to 96.8 °F), moderate hypothermia (body temperature of 30 °C to 34 °C/86 °F to 93 °F), and severe hypothermia (body temperature below 30 °C/86 °F). Client B, with a body temperature of 85.3 °F, is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 86 °F. Clients A, C, and D do not have a temperature less than 86 °F; therefore, they may not need rewarming through cardiopulmonary bypass.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? Primary Secondary Superinfection Nosocomial

Nosocomial Rationale A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

While assessing a client's joint for mobility, the primary healthcare provider moved the client's first and fifth metacarpals anteriorly from the flattened palm. Which type of synovial joint movement is this termed? 1 Flexion 2 Extension 3 Abduction 4 Opposition

Opposition Opposition is a synovial movement that involves moving the first and fifth metacarpals anteriorly from the flattened palm (cupping position). Flexion involves bending the joint as a result of muscle contractions that result in decreasing the angle between two bones. Extension involves the straightening of the joint that increases the angle between two bones. Abduction involves the movement of a part away from the midline of the body.

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? <p>Which stage of Piaget&#x2019;s theory of cognitive development does the nurse observe in a preschooler?</p> Sensorimotor Preoperational Formal operations Concrete operations

Preoperational Rationale The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed form birth to 2 years. During this stage, the child learns about himself and his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client? Touch Reminiscence Reality orientation Validation therapy

Reality orientation Rationale A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? Encouraging frequent naps Strengthening the concept of ageism Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high-carbohydrate diet

Reinforcing the client's strengths and promoting reminiscing Rationale Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? Potassium Sodium bicarbonate Carbon dioxide Sodium chloride

Sodium bicarbonate Rationale Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H 2CO 3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.

Which theories are most relevant to development in adults? Select all that apply. Piaget's theory Erikson's theory Kohlberg's theory Stage-Crisis theory Life Span approach

Stage-Crisis theory Life Span approach Rationale The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with the psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse? The client's gag reflex has returned. The client is confused due to anesthesia. The client is nauseated and wants to vomit. The client's airway is becoming obstructed.

The client's gag reflex has returned. Rationale The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not obstruct the airway.

Which assessment finding is associated with depression? The client has islands of intact memory. The client has impaired recent and remote memory. The client has impaired recent and immediate memory. The client needs step-by-step instructions for simple tasks.

The client has islands of intact memory Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? All nursing functions will be completed by discharge. All invasive intravenous lines will remain patent. The client will remain awake, alert, and oriented at all times. The client will be free of signs and symptoms of infection by discharge.

The client will be free of signs and symptoms of infection by discharge. Rationale Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

What are the goals of care when working with families according to the family health system? Select all that apply. To improve family health or well-being To help the family prepare for later transitions To assist in family management of illness conditions To promote positive family behaviors to achieve essential tasks To achieve health outcomes related to the family's areas of concern

To improve family health or well-being To assist in family management of illness conditions To achieve health outcomes related to the family's areas of concern Rationale When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

Why does the nurse establish "moderately hard" client-centered goals? Select all that apply. To decrease the cost of treatment during therapy To decrease the number of follow-up visits by the client To achieve the goal in a shorter period of time with less effort To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal

To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal Rationale Healthcare providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.

Which approach is a comforting approach that communicates concern and support? Touch Listening Knowing the client Providing a positive presence

Touch Rationale Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Listening is a critical component of nursing care and is necessary for meaningful interactions with clients. Knowing the client comprises both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that conveys a closeness and sense of caring.

Which intervention reflects the nurse's approach of "family as a context"? Trying to meet the client's comfort Evaluating the client family's coping skills Evaluating the client family's energy level Trying to meet the client family's nutritional needs

Trying to meet the client's comfort Rationale In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply. <p>Which fine-motor skills may be observed in an 8 to 10 month-old infant? <b>Select all that apply.</b> </p> Using pincer grasp well Picking up small objects Showing hand preference Crawling on hands and knees Pulling oneself to standing or sitting

Using pincer grasp well Picking up small objects Showing hand preference Rationale The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? Attention span Primary language Coping mechanisms Activity and coordination

attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.