NRS100 FINAL

26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1. "A person with the educational background to solve problems." 2. "A person who finds the problem and does what is best to fix it." 3. "It's someone who uses the scientific method to solve problems." 4. "Someone who uses a system to work through and solve a problem."

"A person who finds the problem and does what is best to fix it."

3. A nurse is using a holistic approach when caring for a client. To incorporate all of the factors that may influence the client, which of the following nursing responses is most therapeutic? 1. "I would like you to perform this exercise once a day." 2. "Your physician has left orders that you are to follow." 3. "The laboratory tests reveal the need to reduce your daily percentage of fat intake." 4. "Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels."

"Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels."

22. A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional? 1. "After defining the client's symptomatology, eliminate those nursing diagnoses that are not supported by the database." 2. "Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics." 3. "After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable." 4. "With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process."

"After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."

29. Which of the following statement best reflects the nurse's appropriate attention to a client's need for self-efficacy? 1. "What can I do to help you lose the weight?" 2. "Are you really ready to start a regular exercise regimen?" 3. "After you watch me demonstrate this inhaler, you will have no problems using it at all." 4. "Come on; with all the self-help products out there, you will be able to stop smoking."

"After you watch me demonstrate this inhaler, you will have no problems using it at all."

19. Which of the following statements made by a family member of a client recently diagnosed with Alzheimer's disease is most reflective of an understanding of this disease process? 1. "Dad has always been a fighter; he'll fight this too. He won't give up." 2. "We have an appointment with his care provider to see about medication therapy." 3. "Good thing we found out about this early so steps can be taken to keep it from getting worse." 4. "It usually progresses gradually so we are hoping it will be a while before his memory is gone."

"We have an appointment with his care provider to see about medication therapy."

28. Which of the following statements made by the parents of a newborn best reflects an understanding regarding the diagnosis of postpartum depression? 1. "I helped my sister when she was depressed after the birth of her second child." 2. "I have a wonderfully supportive family who will be there if I start feeling depressed." 3. "We've read over the literature, and I'll be able to recognize any signs of depression in my wife." 4. "Most new moms get a little depressed, but we will be sure to pay attention to any real indications of a problem."

"We've read over the literature, and I'll be able to recognize any signs of depression in my wife."

18. In order to obtain the most information, which of the following is the most appropriate question asked of a 14-year-old female who is visiting the county health center for "birth control help?" 1. "Have you told your parents that you are sexually active?" 2. "Are any of your friends participating in sexual behaviors?" 3. "What can you tell me about any of your past sexual activities?" 4. "Have you been physically protecting yourself with safe sex measures?"

"What can you tell me about any of your past sexual activities?"

19. Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client's depression? 1. "Have you ever felt this depressed before?" 2. "What do you believe is the cause of your depression?" 3. "What makes you feel that you are experiencing depression?" 4. "What can we do to make you comfortable while you are here?"

"What do you believe is the cause of your depression?"

**Which of the following nursing statements has the greatest therapeutic value when counseling a "sandwich generation" client caring for a chronically ill parent? 1. "I can help you in finding assistance with the in-home care." 2. "What is the most stressful aspect of caring for your parent?" 3. "I'm sure your children love having grandmother in the house." 4. "What do you do for relaxation now that your mom lives with you?"

"What do you do for relaxation now that your mom lives with you?"

6. The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning? 1. "Is your pain worse or better than it was an hour ago?" 2. "Do you believe that your nausea is from the new antibiotic?" 3. "What do you think has been causing your current depression?" 4. "What have you done to alleviate the side effects from your medications?"

"What do you think has been causing your current depression?"

21. The nurse is caring for an older adult client who has reported symptoms suggestive of depression. Which of the following questions asked by the nurse is most therapeutic in assessing the client's perception of the impact depression has had on her life? 1. "What does it mean to be depressed?" 2. "How does being depressed make you feel?" 3. "Were you happy before becoming depressed?" 4. "What makes you think that you are depressed?"

"What does it mean to be depressed?"

12. A client who works in a dry cleaning establishment comes to the clinic for a regular check-up. Based on this information, the nurse assesses the client for: 1. Asbestosis 2. Dermatitis 3. Tendonitis 4. Raynaud's phenomenon

Dermatitis

7. The nurse recognizes that which one of the following statements about growth and development is correct? 1. Development ends with adolescence. 2. Growth refers to qualitative events. 3. Developmental tasks are age-related achievements. 4. Cognitive theories focus on emotional development.

Developmental tasks are age-related achievements.

13. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Diarrhea related to food intolerance 2. Alteration in comfort related to pain 3. Risk for impaired skin integrity related to poor hygiene habits 4. Potential complications related to insufficient vascular access

Diarrhea related to food intolerance

9. In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority? 1. Difficulty breathing 2. Financial problems 3. A nutritional deficit 4. An impending divorce

Difficulty breathing

30. A client has been recently told that the primary cancer has metastasized, and the cancer is considered terminal. When the nurse offers to discuss palliative care options, the client replies, "I'm going to have the reports reevaluated by another doctor; I feel fine and I think a mistake has been made." The nurse recognizes this response as: 1. Anger 2. Disbelief 3. Bargaining 4. Acceptance

Disbelief

32. The nurse defines ageism most accurately as: 1. The undervaluing of individuals based on their age. 2. Perception of a person's worth based on productivity 3. Biases directed towards individuals considered aged 4. Discrimination based on an individual's increasing age

Discrimination based on an individual's increasing age

19. The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure? 1. Assure the client that preoperative sedation will be administered. 2. Discuss the pre- and postprocedure care that will be provided. 3. Provide a detailed explanation of why the procedure is necessary. 4. Guarantee that family will be regularly updated during the procedure.

Discuss the pre- and postprocedure care that will be provided.

9. There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: 1. Giving medication at the time ordered 2. Following a procedure for catheterization step-by-step 3. Reviewing all clients' medical records thoroughly 4. Discussing various alternative pain management techniques

Discussing various alternative pain management techniques

3. The nurse established the following objective for the client who was unable to void: The client's intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is indicated by the client: 1. Voiding at least 1000 mL during the shift 2. Verbalizing abdominal comfort without pressure 3. Having adequate fluid intake and urinary output 4. Drinking 240 mL of fluid five or six times during the shift

Drinking 240 mL of fluid five or six times during the shift

**The nurse recognizes that the presence of an alcohol-abusing parent places a child at greatest risk for: 1. Homelessness 2. School truancy 3. Family violence 4. Accident-related injuries

Family violence

12. In applying Gould's developmental theory, the nurse anticipates that a client will have a greater concern for one's health within the following theme and age-group: 1. First theme (20s) 2. Second theme (early 30s) 3. Fourth theme (40s) 4. Fifth theme (50s)

Fifth theme (50s)

16. When the nurse offers to "just sit here with you" after a particularly painful procedure, a homeless client asks, "Why would you want to do that?" The nurse recognizes that the client most likely: 1. Prefers to be alone at this time 2. Does not have a need for companionship 3. Perceived the offer as being inappropriate 4. Finds it difficult to understand the nurse's concern

Finds it difficult to understand the nurse's concern

**The nurse can primarily affect the effectiveness of a family's ability to cope with stress by encouraging: 1. Flexible roles 2. Distinct task assignment 3. Individual independence 4. Variable parenting models

Flexible roles

11. The client who recently received a kidney transplant is worried about her husband since he has taken over the physical tasks of running their home. The client is in the process of adapting to a change in: 1. Body image 2. Self-concept 3. Illness behavior 4. Family dynamics

Family dynamics

8. A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse: 1. Validates the assessment information in the data base 2. Uses the NANDA International list of diagnoses as a primary source 3. Formulates a diagnosis too closely resembling a medical diagnosis 4. Distinguishes the nursing focus instead of other health care disciplines

Formulates a diagnosis too closely resembling a medical diagnosis

5. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement "Nurse will apply warm, wet soaks to the patient's leg while awake" lacks which of the following components? 1. Method 2. Quantity 3. Frequency 4. Performing staff

Frequency

12. The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults: 1. Require institutional care 2. Have no social or family support 3. Are unable to afford any medical treatment 4. Are capable of taking charge of their own lives

Are capable of taking charge of their own lives

21. In preparing to discuss safe sex practices with a 20-year-old, it is most important that the nurse shares with the client that in addition to physical symptoms of genital pain and discharge, sexually transmitted diseases: 1. Can lead to chronic illness and infertility 2. Are particularly common in young adults 3. Respond well to treatment when detected early 4. May be effectively controlled through the use of condoms

Are particularly common in young adults

18. As described by Freud, the nurse recognizes that a young adult best shows a well-developed superego when he: 1. Tells a friend that he'll help him stop smoking 2. Returns a lost wallet to a stranger who dropped it 3. Arranges for a cab ride home after consuming alcohol 4. Has 10% of his salary automatically transferred to savings

Arranges for a cab ride home after consuming alcohol

21. When caring for a client with a spouse and two adolescent children, the nurse knows that the family unit must first: 1. Be viewed as a client 2. Change traditional roles 3. Provide support for the ailing mother 4. Seek help to fulfill day-to-day needs

Be viewed as a client

23. The nurse is caring for a homeless client who recently emigrated from China. The client has a language barrier, and the hospital has been unsuccessful in locating any relatives. The health care provider is considering the option of placing the client on a respirator to manage a severe respiratory tract problem. To be a caring advocate for this client, the nurse must first: 1. Ask the hospital chaplain to arrange for appropriate religious support 2. Be sure that the client receives the best available care for his condition 3. Arrange for a Chinese interpreter to facilitate client-staff conversations 4. Become familiar with the Chinese culture's attitudes regarding life support

Become familiar with the Chinese culture's attitudes regarding life support

9. As an individual enters middle adulthood health problems generally become more prevalent. The middle adult may be influenced by chronic illness that results in: 1. Decreased health care tasks 2. Reinforcement of family roles 3. Changed sexual behavior habits 4. Improvement of family relationships

Changed sexual behavior habits

13. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated? 1. Taking vital signs 2. Providing support to a family 3. Changing a dressing 2 times each day 4. Measuring intake and output each shift

Changing a dressing 2 times each day

14. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Anxiety related to cardiac monitor 2. Pain related to difficulty ambulating 3. Chronic pain related to insufficient use of medication 4. Bedpan required frequently as a result of altered elimination pattern

Chronic pain related to insufficient use of medication

18. Which subjective assessment data are most supportive of a client's diagnosis of anxiety? 1. Diaphoretic and cool skin 2. An apical pulse rate of 120 beats per minute 3. Reports "needing to leave now" 4. Claims "something is terribly wrong"

Claims "something is terribly wrong"

11. The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the: 1. Client 2. Physician 3. Family member 4. Experienced unit nurse

Client

10. Clients give various responses to teaching sessions. For the nurse, an example of an evaluation of a psychomotor skill is: 1. Client states side effects of a medication 2. Client responds appropriately to eye contact 3. Client independently plans an exercise program 4. Client demonstrates the proper use of a walking cane

Client demonstrates the proper use of a walking cane

12. The nurse is evaluating the responses of clients to teaching sessions. An example of an evaluation of a client's attainment of a cognitive skill is: 1. Client explains that the medication should be taken with meals 2. Client looks at the surgical incision without requiring prompting 3. Client uses crutches appropriately to move both up and down stairs 4. Client independently capable of dressing self after eating breakfast

Client explains that the medication should be taken with meals

12. The process of data collection should begin with the nurse performing a: 1. Physical exam 2. Client interview 3. Review of medical records 4. Discussion with other health team members

Client interview

25. Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process? 1. Paternal family history of osteoarthritis has been reported. 2. Client is observed grimacing when walking to bathroom. 3. Right knee appears edematous when compared to left knee. 4. Client rated the pain felt after walking at a 6 on a scale of 1 to 10.

Client is observed grimacing when walking to bathroom.

13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the client's understanding of the need for therapy? 1. Client agrees to test blood glucose levels 4 times a day. 2. Client records blood glucose levels for a 3-week period. 3. Client is observed testing his blood glucose level before breakfast. 4. Client is able to demonstrate the proper technique for performing a finger stick.

Client records blood glucose levels for a 3-week period.

32. Which of the following client-centered goals best rest reflects singular focus? 1. Client will cough and deep breathe every hour while awake. 2. Client will be free of shoulder and elbow pain by discharge. 3. Client will adhere to a low-fat diet and lose 3 pounds in 30 days. 4. Client will ambulate to the bathroom for the purpose of showering daily.

Client will ambulate to the bathroom for the purpose of showering daily.

31. Which of the following goals best shows that the nurse understands the concept of a client-centered goal? 1. Client will consume at least 75% of each meal served. 2. ADLs will be completed before breakfast is served. 3. Pain will be managed so as to be rated at 3 or less out of 10. 4. Client will be transported to physical therapy by 9 AM daily.

Client will consume at least 75% of each meal served.

28. The expected outcome that best evaluates the presurgical goal of, "Client will understand purpose of coughing and deep breathing within 4 hours of returning to room" is: 1. Client will demonstrate proper technique for coughing and deep breathing 2. Client will cough and deep breathe every 1 hour while awake without staff prompting 3. Client is capable of restating the purpose of coughing and deep breathing in own words 4. Client's lungs will be free of abnormal breath sounds within 1 hour of being returned to room

Client will cough and deep breathe every 1 hour while awake without staff prompting

28. When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that correlates with the number of carbohydrates he is allowed for that meal, this is an example of: 1. Cognitive learning 2. Affective learning 3. Impaired learning 4. Psychomotor learning

Cognitive learning

2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age and height. This is an example of: 1. Defining the client problem 2. Recognizing gaps in data assessment 3. Comparing data with normal health patterns 4. Drawing conclusions about the client's response

Comparing data with normal health patterns

2. The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods? 1. Preventive measures 2. Assisting with ADLs 3. Preparing for special procedures 4. Compensation for adverse reactions

Compensation for adverse reactions

4. Upon evaluation of a 6-month-old infant's developmental status, the nurse expects that the child at this age will be able to: 1. Completely roll over 2. Pull self to a standing position 3. Creep on all four extremities 4. Assume a sitting position independently

Completely roll over

16. There are a variety of teaching methodologies that may be utilized to meet the client's needs. Which teaching method is best applied to a cognitive learning need? 1. Modeling of behavior 2. Discussion of feelings 3. Computer-assisted instruction 4. Demonstration of a procedure

Computer-assisted instruction

6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? 1. Impaired gas exchange 2. Decreased cardiac output 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

Impaired gas exchange

7. The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation

Implementation

29. The nurse is preparing an educational program for members of the local senior center. Which of the following topics would present the greatest learning challenge for this developmental group? 1. Exercising arthritic joints 2. Tips for living with GERD 3. Importance of the human touch 4. Principles of heart-healthy eating

Importance of the human touch

15. Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate. 1. Risk for injury 2. Excess fluid volume 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

Ineffective airway clearance

4. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Risk for change in body image related to cancer 2. Cardiac output decreased related to motor vehicle accident 3. Ineffective airway clearance related to increased secretions 4. Potential for injury related to improper teaching in the use of crutches

Ineffective airway clearance related to increased secretions

11. A nurse researcher has completed a study involving the use of intravenous analgesics for postsurgical discomfort. The description of the 16 clients used for the study would best be written in which part of the research report? 1. Results section 2. Methods section 3. Discussion section 4. Introduction section

Methods section

3. The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using? 1. Reassessing the client 2. Stating an expected outcome 3. Revising the nursing diagnosis 4. Modifying the nursing care plan

Modifying the nursing care plan

18. The nurse's initial responsibility in the management of a client's collaborative problem is to: 1. Monitor for changes 2. Advocate for the client 3. Implement interventions 4. Evaluate client outcomes

Monitor for changes

Which of the following is a current trend in families of family living? 1. People marrying earlier 2. Reduction in the divorce rate 3. People having more children 4. More people choosing to live alone

More people choosing to live alone

15. In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in their: 1. Client outcomes 2. Client assessment 3. Nursing interventions 4. Multidisciplinary approach

Multidisciplinary approach

what protection do you use for droplet precautions

N95 respirator

11. The nurse is alert to stressors that may have an influence on the young adult client. One example of a common stressor for this age-group is: 1. Occupational pursuits 2. Health-related matters 3. Coping with cognitive changes 4. Caring for the older adult parent

Occupational pursuits

16. In the assessment of older-adult clients, it is often difficult to discriminate between delirium and dementia. Delirium is characterized by: 1. A slow progression 2. Lasting months to years 3. A normal state of alertness 4. Occurrences at twilight or darkness

Occurrences at twilight or darkness

23. While discussing discharge plans for a client who recently experienced a stroke that resulted in right-sided weakness and communication problems, the daughter shares with the nurse that she has concerns regarding her role as caregiver. The most therapeutic response by the nurse is to: 1. Agree that her concerns are well-founded 2. Suggest that she consider home health aides 3. Offer to arrange for her to see the facility's grief counselor 4. Provide her with information about a caregiver support group

Offer to arrange for her to see the facility's grief counselor

14. The nurse observes a client scheduled for an invasive procedure crying while discussing the procedure with a family member. Which of the following therapeutic nursing interventions would be the most caring? 1. Arranging for the client's clergy to visit 2. Inquiring, "Why is your sister crying?" 3. Providing a detailed explanation of the procedure 4. Offering to "sit and talk" if the client has any questions

Offering to "sit and talk" if the client has any questions

**Post discharge, the client is returning to their home environment. In assisting the client with that, specifically in implementing family-centered care, the nurse: 1. Provides personal beliefs regarding problem-solving 2. Assists the family members to assume dependent roles 3. Works with the client to accept responsibility for role in discourse 4. Offers both client and family information about necessary self-care abilities

Offers both client and family information about necessary self-care abilities

6. Based on the following outcome criterion determined by the nurse: "Client will independently complete necessary assessments prior to administration of digoxin (cardiotonic)" the nurse will evaluate the client's ability to: 1. Assess the respiratory rate 2. Palpate the radial pulse 3. Review dietary habits 4. Inspect color of the skin

Palpate the radial pulse

6. In planning nursing care for an 18-month-old child, the nurse should know that the predominant developmental characteristic of children this age is: 1. Parallel play 2. Peer pressure 3. Mutilation anxiety 4. Imaginary playmates

Parallel play

11. In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is: 1. Realistic 2. Observable 3. Measurable 4. Client-centered

Realistic

3.The nurse recognizes that Freud's theory approaches development by looking at: 1. Moral reasoning. 2. Logical maturity 3. Psychosexual aspects 4. Cognitive development

Psychosexual aspects

7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories? 1. Family history 2. Psychosocial history 3. Biographical history 4. Environmental history

Psychosocial history

16. Which of the following should the nurse consider first when assessing the cognitive ability of an older adult? 1. A life-long bachelor 2. Orphaned at age 12 3. History of a chronic disease process 4. Recent immigration to the United States

Recent immigration to the United States

types of isolation requires a private room or cohort patients, gloves, gowns.

contact precautions

sanguineous exudate

containing red blood cells

The patient states that she has joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change? a. Precontemplation b. Contemplation c. Preparation d. Action

d. Action

Air born transmission of pathogens

droplet nuclei or residue or evaporated droplets suspended in air during coughing, sneezing, or carried on dust particles

type of isolation that requires a private room or cohort partiens; mask and respiratior is required

droplet precautions

signs of systemic inflammation

fever, increased WBCs, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure

Inflammatory exudate

fluid composed of plasma and white cells that escape from capillaries

whats the order in removing PPE protection

gloves, eyewear, gown, and mask

whats the order in putting on PPE protection

gown, mask, eye wear or googles, and gloves

10. The primary purpose of a nursing diagnosis, according to the nurses, is to: 1. Support the medical plan of care 2. Provide a standardized approach for all clients 3. Recognize the client's response to an illness or situation 4. Offer the nurse's subjective view of the client's behaviors

Recognize the client's response to an illness or situation

6. An example of a cognitive nursing skill is: 1. Providing a soothing bed bath 2. Communicating with the client and family 3. Giving an injection to the client per the physician's orders 4. Recognizing the potential complications of a blood transfusion

Recognizing the potential complications of a blood transfusion

21. The concept of nursing responsibility is best reflected in which of the following nursing actions? 1. Providing accurate and timely documentation regarding an incident resulting in a client fall 2. Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3. Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client 4. Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult

Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult

type of isolation that is a private room with positive airflow mask must be worn outside of the room by patient.

protective environment

14. The nurse is presenting an information session on nutritional guidelines at a senior living center. Incorporated into the discussion are the recommendations for nutritional intake for individuals of this age-group, which include a reduction in: 1. Fiber 2. Protein 3. Vitamin A 4. Refined sugars

Refined sugars

9. According to Piaget, the infant is in the first period of development, which is characterized by: 1. Concrete operations 2. Preoperational thought 3. Sensorimotor intelligence 4. Identity versus role confusion

Sensorimotor intelligence

4. There are a variety of teaching methodologies fro a nurse to choose from to use with clients. For a toddler, the nurse should use: 1. Role-playing 2. Problem-solving 3. Independent learning 4. Simple explanations and pictures

Simple explanations and pictures

9. Which one of the following client assessment findings indicates a lifestyle risk factor to the nurse? 1. Obesity 2. Sunbathing 3. Overcrowded housing 4. Industrial-based occupation

Sunbathing

Which of the following is a gerontological principle related to families? 1. Later-life families need not work on developmental tasks. 2. The caregivers are often not members of the client's family. 3. Role reversal is usually expected and well accepted by the older client. 4. Support systems are likely to be different than those of younger age-groups.

Support systems are likely to be different than those of younger age-groups.

purulent exudate

pus (WBC and bacteria)

semi critical items that need a high-level of disinfectant or sterilization

respriatory and anesthesia equipment, endoscopes, endotracheal tubes, GI endoscopes, diaphragm fitting rings

**The most important impact that truthful, timely communication between the nurse and the family of a critically ill client has is on the family's ability to: 1. Trust the nurse 2. Adjust to "bad news" 3. Be confident of the care the client is receiving 4. Make appropriate choices regarding client treatment

Trust the nurse

what causes temp. loss of function during inflammation

the pressure that is being put on the never endings from swelling

Vascular response to inflammation

vasodilation and increased capillary permeability, increased blood (warmth and redness), Increase fluid and protein (edema), increased pain (pressure on nerve endings), temp loss of function because of the increased pressure on nerve.

Vehicles transmission of pathogens

water, drug solutions, blood, food that's been improperly handled, stored, cooked

25. Which of the following teaching topics is an example of restoration of health? 1. Glucose monitoring at home 2. Living with rheumatoid arthritis 3. Stress management's impact on depression 4. What to expect after hip replacement surgery

What to expect after hip replacement surgery

13. A nurse understands that illness behavior means: 1. Each distinct illness will cause the client to behave in a specific manner 2. Nursing care provides interventions that are behavior oriented 3. The client's behaviors will have a direct impact on his illness 4. When ill, a client's perception of illness will result in unique behaviors

When ill, a client's perception of illness will result in unique behaviors

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Quaternary prevention

a. Primary prevention

risk factors for infection

chronic dz, high risk behaviors, occupation, diagnostic procedures, heredity, travel history, trauma, and nutrition.

serous exudate

clear, like plasma

asymptomatic

clinical signs and symptoms are not present

symptomatic

clinical signs and symptoms are present

26. Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? 1. "I can tell when my Hispanic clients are in pain." 2. "Moaning is a classic sign of pain in most cultures." 3. "All clients will tell you when they need pain medication." 4. "Chronic pain is difficult to manage especially for the stoic individual."

"All clients will tell you when they need pain medication."

27. Which of the following statements made by a new graduate nurse regarding a client's care needs requires follow-up by the mentor? 1. "No one really enjoys being hospitalized." 2. "Every client is offered a back rub at bedtime." 3. "All post surgery clients are reluctant to ambulate." 4. "I always spend extra time with new clients to help them relax."

"All post surgery clients are reluctant to ambulate."

17. Which of the following nursing questions is best directed towards the assessment of a normal finding regarding physiological changes in an older-adult client? 1. "Any difficulty driving at night?" 2. "Are you experiencing any loss of libido?" 3. "Do you see yourself as becoming forgetful" 4. "Have you had your cholesterol tested lately?"

"Any difficulty driving at night?"

17. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is the following: 1. "Take vital signs." 2. "Refer client to a therapist." 3. "Turn client as needed while in bed." 4. "Apply two 4 × 4 dry gauze dressing pads tid."

"Apply two 4 × 4 dry gauze dressing pads tid."

12. A nurse reads about a case study involving the potential positive effects of the early stimulation of post-head-injury clients. Which of the following questions should be a priority consideration before use of the research results? 1. "What was the cost of the study?" 2. "Were ethical principles maintained?" 3. "Were the results of this study published in other journals?" 4. "Are the clients in the study similar to clients I work with?"

"Are the clients in the study similar to clients I work with?"

32. Which of the following questions will provide the nurse with the best understanding of a terminally ill client's spiritual needs? 1. "Do you have a religious preference?" 2. "Have you given thought to your spiritual needs?" 3. "Is there a particular clergy you would like to visit with?" 4. "Are there any spiritual needs you have that I may help with?"

"Are there any spiritual needs you have that I may help with?"

23. Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the client's adjustment to the aging process? 1. "I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that it's hard to even walk." 2. "I've given my grandchildren money for college so they can live a better life than I had." 3. "Growing old certainly presents all sorts of challenges. I wish I knew then what I know now." 4. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."

"As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."

20. Which of the following situations/statements best depicts Gould's fourth theme of adult development? 1. "When I made that decision, I didn't expect it to turn out like it did." 2. "I have to take the opportunity to be my own boss and not rely on others." 3. "I think you can do anything if only you have your health and good friends." 4. "As much as I'd love to open my own shop, I just can't take that kind of chance."

"As much as I'd love to open my own shop, I just can't take that kind of chance."

15. Which of the following client statements best relates to the third component of the Health Belief Model? 1. "My blood cholesterol is only a little high." 2. "No one in my family is susceptible to the flu." 3. "I'll just avoid the food that causes the problem." 4. "By losing weight my blood pressure may come down."

"By losing weight my blood pressure may come down."

23. The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain? 1. "What makes the pain worse?" 2. "When did you first notice the pain?" 3. "What do you do to lessen the pain?" 4. "Can you rate your pain using the pain scale that we've discussed?"

"Can you rate your pain using the pain scale that we've discussed?"

4. The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the client's goal attainment? 1. "Client has no pain after ambulating." 2. "Client has no manifestations of nausea while up in hall." 3. "Client walked well and did not have any problem when up." 4. "Client has no evidence of respiratory distress when ambulating."

"Client has no evidence of respiratory distress when ambulating."

3. The nurse writes the following goal for a client who is hypertensive: "Client will maintain a blood pressure within acceptable limits." Which of the following would be the most appropriate outcome criterion? 1. "Client will request pain medication as needed." 2. "Client will experience no headache or dizziness." 3. "Client will identify at least two things that cause stress." 4. "Client will have a 7 AM blood pressure reading less than 140/90."

"Client will have a 7 AM blood pressure reading less than 140/90."

20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis and treatment needs. The most appropriate outcome statement based upon the established criteria is the following: 1. "Client will perform glucose measurements often." 2. "Client will appear less anxious regarding diagnosis." 3. "Urinary output will reach normal young adult levels." 4. "Client will independently perform subcutaneous insulin injection by 8/31."

"Client will independently perform subcutaneous insulin injection by 8/31."

6. In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is: 1. "Client will describe activity restrictions." 2. "Client will verbalize understanding of treatments." 3. "Client will be ambulated in hallway 3 times each day." 4. "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24."

"Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24."

28. Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care? 1. "Concept maps help me see the whole client, not just individual health problems." 2. "Concept maps can be easily edited to reflect a client's ever changing health needs." 3. "I need help organizing my assessment data and concept mapping is really good for that." 4. "I like concept mapping because it helps me focus on how the disease processes affect the client."

"Concept maps help me see the whole client, not just individual health problems."

7. The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility? 1. "Your shoulder pain is normal for your age." 2. "Continue to exercise your joints regularly to your tolerance level." 3. "Why don't you begin walking 3 to 4 miles a day, and we'll evaluate how you feel next week." 4. "Don't worry about taking that combination of medications since your doctor has prescribed them."

"Continue to exercise your joints regularly to your tolerance level."

14. The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication? 1. "I understand how you must feel." 2. "This medication is used to lower your blood pressure." 3. "You appear anxious. You're wringing your hands constantly." 4. "Could you give me an example of how you handle stressors?"

"Could you give me an example of how you handle stressors?"

21. When asked to define the purpose of diagnostic reasoning, the best nursing response is: 1. "Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis." 2. "The diagnostic reasoning process flows from the assessment process and includes decision-making steps." 3. "Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem." 4. "Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

"Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

32. Which of the following nursing assessment questions is best directed toward determining the presence of a normal physiological change experienced by a middle-aged client? 1. "Any problems with your teeth or gums?" 2. "Any family history of thyroid problems?" 3. "Do you have a skin-moisturizing routine?" 4. "Are you having a problem with driving at night?"

"Do you have a skin-moisturizing routine?"

21. The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse? 1. "How long have you been dealing with GERD?" 2. "Are you currently taking any medications for your GERD?" 3. "Do you follow a particular diet to help manage your GERD?" 4. "Do you have any other gastrointestinal problems besides GERD?"

"Do you have any other gastrointestinal problems besides GERD?"

33. Which of the following nursing assessment questions is best directed toward determining the presence of an occupational hazard-related condition specific for a client working in a dry cleaning establishment? 1. "Do you have any problems with rashes or itching?" 2. "How long have you worked in the dry cleaning business?" 3. "Do you treat the minor burns you experience?" 4. "Do you drive the company van to make deliveries?"

"Do you have any problems with rashes or itching?"

28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1. "I'm sure that friction and pressure have caused this problem." 2. "Please be sure that her ankles are well padded when you place her in bed." 3. "Do you have any suggestions on how we can minimize the pressure to her ankles?" 4. "It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour."

"Do you have any suggestions on how we can minimize the pressure to her ankles?"

8. A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying: 1. "Don't worry about the medication's name if you can identify it by its color and shape." 2. "Unless you have severe side affects, don't worry about the minor changes in the way you feel." 3. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." 4. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications."

"Feel free to ask your physician why you are receiving the medications that are prescribed for you."

29. Which of the following questions asked by the nurse best assesses for the signs of pregnancy most likely observed in the second trimester? 1. "Have you had any problems climbing steps?" 2. "Have you noticed any cramping in your abdomen?" 3. "Have you experienced any nausea in the morning?" 4. "Have you had any problems with shoes that don't seem to fit?"

"Have you noticed any cramping in your abdomen?"

4. A 49-year-old client is experiencing problems with depression. She has come to the clinic showing signs of malnutrition and fatigue. Which of the following is the best initial statement for the nurse to make in the assessment phase? 1. "How much weight have you lost over the past month?" 2. "Have you recently been experiencing menopausal symptoms?" 3. "Depression is something to expect at your age, and with assistance you will get better." 4. "Your depression is somewhat uncommon. Can you tell me what has happened recently to cause it?"

"Have you recently been experiencing menopausal symptoms?"

26. Which of the following client responses shows the best understanding regarding the management of risk factors for acquiring a sexually transmitted disease (STD) among young adults? 1. "I may want to have children someday, so I need to be careful." 2. "Even though there are treatments for STDs, I don't take chances." 3. "There is certainly enough literature out there on the use of condoms." 4. "Having unprotected sex with someone my age is very risky business."

"Having unprotected sex with someone my age is very risky business."

29. Which of the following statements made by the nurse best reflects an understanding of the client's role in goal setting? 1. "He knows what he needs better than anyone else." 2. "When he sets the goals he is more likely to follow the plan." 3. "He identifies the goals and then together we create the plan of action." 4. "He is best suited to determine the level of effort he is capable of providing."

"He is best suited to determine the level of effort he is capable of providing."

30. Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit's nurse manager? 1. "Mary and I were comparing foot wound dressing techniques." 2. "I've been caring for orthopedic clients for 10 years and I think I've seen it all." 3. "I can't believe that my client isn't improving after 2 weeks of physical therapy." 4. "I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4."

"I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4."

15. Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines? 1. "Clinical guidelines are so very helpful in providing the most up-to-date nursing care." 2. "I'm sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols." 3. "I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site." 4. "I'm told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site."

"I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site."

11. Which of the following statement's best expresses the client's definition of personal illness? 1. "I came to the emergency department when the pain got too bad to ignore." 2. "I have arthritis, but I continue to enjoy knitting, embroidery and other needle work." 3. "Sometimes my bad knee keeps me from the hiking, but I do it as much as I can." 4. "It will be a terrible blow when my heart condition keeps me stuck in the house."

"I came to the emergency department when the pain got too bad to ignore."

18. Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult? 1. "I call a cab if I want to go out after dark." 2. "I can't help worrying about becoming forgetful." 3. "I have my eyes checked regularly. Can't afford to fall." 4. "I really enjoy eating good vanilla ice cream, but I have cut way down."

"I can't help worrying about becoming forgetful."

12. Which of the following statements reflects the best understanding of cultural caring provided by professional nurses? 1. "Nurses must be open to learning the culture of our clients." 2. "Nurses need to attend to clients in a culturally sensitive manner." 3. "I care for my clients in ways that respect their culture and beliefs." 4. "Culture caring means allowing the client the freedom to be himself."

"I care for my clients in ways that respect their culture and beliefs."

36. Which of the following statements, made by the daughter of an older adult client concerning bring her mother home to live with her family, presents the greatest concern for the nurse? 1. "If this doesn't work out, she can always go to live with my sister." 2. "I don't think she will react very well to me making decisions for her." 3. "I'm afraid that mom will be depressed and really miss her home terribly." 4. "My children will just have to adjust to having their grandmother with us."

"I don't think she will react very well to me making decisions for her."

23. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults? 1. "Unprotected sex is just plain dangerous." 2. "Everyone riding in my car wears a seatbelt." 3. "I'm a vegetarian, but I eat nonanimal protein." 4. "I've never smoked and I drink only occasionally."

"I've never smoked and I drink only occasionally."

31. Which of the following client statements, made by a young adult regarding health promotion habits, reflects a need for further client education by the nurse? 1. "I go to the gym and work out 3 times a week with friends." 2. "My dad has high cholesterol, so I have mine checked yearly." 3. "Diabetes runs in my family, so I watch my carbohydrate intake." 4. "I drink alcohol only on weekends, when it doesn't interfere with work."

"I drink alcohol only on weekends, when it doesn't interfere with work."

25. Which statement made by an older adult would reflect the best understanding of the nutritional requirements of individuals at this developmental stage? 1. "An apple a day is my motto; always has been." 2. "I eat everything, but just a little a bit of things like sweets." 3. "Fiber is more important than ever to my digestive system." 4. "I don't need the fat so I've taken to drinking protein shakes."

"I eat everything, but just a little a bit of things like sweets."

21. Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse's mentor? 1. "My LPN is really good with dressings, so I usually delegate them to her." 2. "I always take the time to ambulate a post op client the first time out of bed." 3. "I always try to help my nursing assistant with the clients who require a total bed bath." 4. "I have my nursing assistant take and document all vital signs and intake and outputs."

"I have my nursing assistant take and document all vital signs and intake and outputs."

20. Which of the following statements best reflects the nurse's correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit? 1. "I'm going to do the client's history before his family leaves so they can help with the admission history questions." 2. "You are scheduled for some x-rays, so I'd like to complete this admission history interview before you have to leave." 3. "I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable." 4. "Please let me know when the blood lab is finished with the new client so I can complete his admission history interview."

"I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable."

26. Which of the following client statements made by an older adult best reflects an understanding of the decrease in physical strength and stamina in this developmental stage? 1. "I know I'm not as young as I use to be." 2. "I just hire help with jobs I can't do myself." 3. "You get older you can't do as much, that's life." 4. "I have to ask my son for help with the yard work."

"I just hire help with jobs I can't do myself."

27. Which of the following statements made by a 27-year-old client shows the greatest need for further nursing assessment regarding the potential use of illegal drugs? 1. Whether you wear a helmet or not should be the choice of the motorcyclist." 2. "I fractured my hand 3 years ago when I got so mad I hit a wall in my dorm room." 3. "I like to drink a bit too much, and I lost my license once for drinking and driving." 4. "My father suffered from depression when he lost his job, and he still takes medication for it."

"I like to drink a bit too much, and I lost my license once for drinking and driving."

31. Of the following client statements made by an older adult client which best reflects an understanding the educational materials on nutrition presented by the nurse? 1. "I'll keep this literature and read it again later." 2. "I love rye bread. It's good to know its high in fiber." 3. "Nutrition and cooking has always been passions of mine." 4. "Now I can see the connection between food and my health."

"I love rye bread. It's good to know its high in fiber."

30. Which of the following client statements would be the best evidence that this young adult has adopted a positive strategy to promote his own personal emotional health? 1. "I drink alcohol only on special occasions and then moderately." 2. "I run at least three times a week; it seems to help me stay relaxed." 3. "I watch for the signs of depression since my mother experienced it." 4. "I know stress can affect my blood pressure, so I have it taken regularly."

"I run at least three times a week; it seems to help me stay relaxed."

22. Which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse? 1. "I take all the pills ordered once a day at bedtime, so I'm less likely to forget them." 2. "I have one pill that needs cut in half. I am going to ask the pharmacist to do that for me." 3. "The pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet." 4. "My daughter comes over each morning and puts my pills into a container that sorts them by the time they are due."

"I take all the pills ordered once a day at bedtime, so I'm less likely to forget them."

14. Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1. "I feel it's good practice to always have alternative interventions in mind." 2. "I trust my feelings about a client's needs since I work hard at knowing my client." 3. "I always try to keep an open mind about what interventions my client will require." 4. "I will wait until my assessment is completed before determining the client's needs."

"I trust my feelings about a client's needs since I work hard at knowing my client."

35. Which of the following statements made by an older adult client best reflects a healthy adjustment to the aging process and its physical limitations? 1. "I use to run in marathons, but now I truly enjoy a 1 mile walk around the park." 2. "I see friends my age just rocking on the porch. Not me; I want to stay physically active." 3. "When I can't get around like I do now, I'll watch TV and catch up on my favorite programs." 4. "I'll miss working in my garden when the arthritis gets bad, but I'll find something else to keep me busy."

"I use to run in marathons, but now I truly enjoy a 1 mile walk around the park."

24. Which of the following statements made by a 75-year-old client shows the best understanding of how the aging process affects the musculoskeletal system? 1. "I drink milk and eat cheese to get my calcium." 2. "I walk 1 mile everyday to strengthen my bones." 3. "I wear sensible shoes so I won't sprain an ankle." 4. "At my age I might never fully recover from a hip fracture."

"I walk 1 mile everyday to strengthen my bones."

39. A nurse is preparing to perform an assessment on an older adult client newly admitted to a nursing center. Which of the following statements made by the nurse best reflects the unique needs of this client regarding the assessment process? 1. "I will be back after you are settled in and we can devote enough time to this assessment process." 2. "We will need to move you to the examination room so that you will be comfortable during the assessment." 3. "I have to perform an assessment as part of the admission process, is this a good time for you to help me with it?" 4. "Since this move has been both physical and emotionally stressful, I will make this assessment as concise and brief as possible."

"I will be back after you are settled in and we can devote enough time to this assessment process."

30. A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager? 1. "The client will certainly need frequent reorientation to the care plan goals." 2. "I will restate the goals I've created for him regularly so as to win his compliance." 3. "I'm not sure that his family will be able to support him with these goals but I will discuss it with them." 4. "He seems very willing to work towards achieving his goals but his condition will certainly create barriers."

"I will restate the goals I've created for him regularly so as to win his compliance."

21. An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications? 1. "I don't seem to have problems with side effects, but I'll let my doctor know if something happens." 2. "I'm lucky since my daughter is really good about keeping up with my medications." 3. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something." 4. "It shouldn't be too hard to keep it straight since I don't have any really serious health issues."

"I'll be sure to read the inserts and ask the pharmacist if I don't understand something."

33. Which of the following statements made by a nurse best reflects an understanding of the negative impact of ageism regarding client care? 1. "If I don't value the older client, I will never be able to provide the care they are entitled too." 2. "Everyone, regardless of age or position, always deserves effective, appropriate nursing care." 3. "As a society we lose so much valuable wisdom and knowledge when we devalue our older members." 4. "If older clients do not feel valued, they are less likely to seek the health care they need and deserve."

"If I don't value the older client, I will never be able to provide the care they are entitled too."

13. An example of a predictive type of question that a nurse might use for research is which of the following? 1. "What creates an increase in stress levels?" 2. "How often does the stress reaction occur?" 3. "What does guided imagery mean to clients?" 4. "If guided imagery is used, will stress levels be reduced?"

"If guided imagery is used, will stress levels be reduced?"

9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1. "Altered speech" 2. "As evidenced by" 3. "Recent neurological disturbances" 4. "Inability to speak in complete sentences"

"Inability to speak in complete sentences"

17. When asked to define "Nursing Diagnosis" the nurse's best response is: 1. "It is the second step in the Nursing Process." 2. "It is the process of defining a client's problems." 3. "It correlates a client's problem with a condition a nurse is competent to treat." 4. "It focuses care a licensed nurse can provide with the identified needs of a client."

"It correlates a client's problem with a condition a nurse is competent to treat."

20. The nurse can best discuss the impact of a known risk factor on a client's health by stating: 1. "It doesn't mean you'll get the disease just that the odds are greater for you." 2. "Now you know that the possibility is there, you can take steps to prevent it." 3. "The risk factor can be managed by making a change in your lifestyle." 4. "You're lucky because you have the benefit of being able to do something about it."

"It doesn't mean you'll get the disease just that the odds are greater for you."

9. A 4½-year-old child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort? 1. "Please try to not move your leg and that will make it feel better." 2. "I'll give you a shot of medicine that will help take the pain away." 3. "It's okay if you need to cry. Would you like to hold your favorite doll?" 4. "Would you like to tell me now where you want me to give you your shot?"

"It's okay if you need to cry. Would you like to hold your favorite doll?"

27. Which of the following statements made by an older adult regarding sexuality would be of greatest concern for the nurse? 1. "Will this new medication affect my libido?" 2. "What can I do to help with vaginal dryness?" 3. "I really miss the intimacy my husband and I shared." 4. "It's so nice not to have to worry about an unwanted pregnancy."

"It's so nice not to have to worry about an unwanted pregnancy."

17. Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation? 1. "Do you feel confident in the use of your glucometer?" 2. "Have you been following your low carbohydrate diet?" 3. "Any questions regarding the tests you are scheduled for today?" 4. "May we review what we discussed earlier about your medications?"

"May we review what we discussed earlier about your medications?"

15. Which of the following statements made by a client's family is the most reliable for use in the evaluation of a client's outcome? 1. "Mom has been eating 90% of all of her meals since she's been home." 2. "My daughter is in much less pain now that she is going to physical therapy." 3. "My husband has been less depressed since he's been on that antidepressant pill." 4. "Mom has been so much better since she's been able to get up and walk by herself."

"Mom has been eating 90% of all of her meals since she's been home."

34. Which of the following statements made by a nurse best reflects an understanding of the adaptation required of nursing to assure quality nursing care for the older adult client? 1. "Remember to ask the client when she prefers to have her bath." 2. "I hope that I am that alert and interested in life when I'm her age." 3. "My client is in her 90s, so I don't expect her to respond to the therapy like a 50-year-old does." 4. "I just finished reading a great article on caring for the client newly diagnosed with Alzheimer's disease."

"My client is in her 90s, so I don't expect her to respond to the therapy like a 50-year-old does."

18. Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse's mentor? 1. "Older clients with arthritis require additional time to complete to complete their own AM care." 2. "My client's wife says he loves chocolate milk so I will order his dietary supplement in chocolate." 3. "My client just received some bad news regarding her tests. I'll see if the chaplain can visit this evening." 4. "Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars."

"My client just received some bad news regarding her tests. I'll see if the chaplain can visit this evening."

27. Which of the following assessment data provided by a client's family will have the greatest impact on the client's care while hospitalized? 1. "Mom falls asleep fastest with the television on." 2. "Dad starts off the day with hot coffee; it regulates his bowels." 3. "My wife's sister died 4 months ago, and she is still grieving over her loss." 4. "My husband doesn't like to let people know his arthritis is bothering him."

"My husband doesn't like to let people know his arthritis is bothering him."

10. The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is the following: 1. "Vital signs will return to within normal levels for a middle aged adult." 2. "Nursing assistant will ambulate the client in the hallway 3 times each day." 3. "Lungs will be clear to auscultation and respiratory rate will be 20/minute." 4. "Output will be at least 100 mL/hour of clear yellow urine within 24 hours."

"Output will be at least 100 mL/hour of clear yellow urine within 24 hours."

14. Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided? 1. "Pressure ulcer located on left heel has shown improvement." 2. "Pressure ulcer located on left heel has responded to treatment." 3. "Pressure ulcer on left heel is no longer producing purulent drainage." 4. "Pressure ulcer on left heel has not enlarged in size within the last 24 hours."

"Pressure ulcer on left heel is no longer producing purulent drainage."

35. Which of the following statements concerning health promotion habits made by a young adult best reflects an understanding regarding the primary cause of death and injury among that age group? 1. "Eating a healthy, low-fat diet is very important to me." 2. "AIDS is nothing to mess with, so I always practice safe sex." 3. "Regardless of what my friends say, I always wear a seat belt." 4. "I enjoy mountain biking, but I always wear the right protection gear."

"Regardless of what my friends say, I always wear a seat belt."

29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client's care needs? 1. "That surgery is painful. I'll get her pain medication ready." 2. "She was sleeping when I checked 15 minutes ago. I'll go back in right now." 3. "I'll be responsible for her PM care so I can spend some uninterrupted time with her." 4. "A mastectomy is a blow to a woman's self image. I'll notify her provider that she is depressed."

"She was sleeping when I checked 15 minutes ago. I'll go back in right now."

23. Which of the following nursing responses is most therapeutic when made in response to a parent's concern about her 3-year-old child's tendency to "break the rules"? 1. "Just keep reminding her of the rules." 2. "Daycare will help her learn to play fair." 3. "She will begin to understand that concept in a year or so." 4. "Add an age appropriate punishment for breaking the rules."

"She will begin to understand that concept in a year or so."

14. Which of the following statements best reflects the nurse's understanding of the function of client reassessment? 1. "The client's blood pressure is lower this morning than it was yesterday morning." 2. "30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10." 3. "Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx." 4. "Since the client has been ambulating to the bedroom without difficulty, I'll walk with him to the dayroom after dinner."

"Since the client has been ambulating to the bedroom without difficulty, I'll walk with him to the dayroom after dinner."

16. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data? 1. "Client appears sleepy" 2. "No physical distress noted" 3. "Abdomen soft and non-tender" 4. "States feels anxious and tense"

"States feels anxious and tense"

25. Which of the following best describes a nurse thinking at stage 5 of Kohlberg's Moral Developmental Theory? 1. "The client has a right to decide whether or not to proceed with the treatment plan." 2. "The hospital's policies and procedures are excellent tools for making client oriented decisions." 3. "It won't be fair to expect to get every weekend and holiday off, so I'll certainly work my share." 4. "If you don't keep client information confidential you could be terminated immediately."

"The client has a right to decide whether or not to proceed with the treatment plan."

6. Which of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process? 1. "I believe that this client is getting depressed." 2. "The client doesn't look right to me; I think something is wrong." 3. "The client's husband told me that she is feeling very uncomfortable." 4. "The client reports more pain than yesterday and her blood pressure is elevated."

"The client reports more pain than yesterday and her blood pressure is elevated."

27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals? 1. "The client's A1C levels will be 7 or below at the first testing date." 2. "The client will experience no blood sugar readings below 60 mg/dL before first follow up visit." 3. "The client will be visited weekly by home health nursing staff beginning 1 week after discharge." 4. "The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit."

"The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit."

20. Which of the following statements made by a new graduate nurse regarding the modification of a client's care plan requires immediate follow-up by the nurse's preceptor? 1. "I will review the care plan before I do my charting." 2. "The client prefers to bathe at night, so that's what I'll do." 3. "I gave her a bed bath this morning, but she could really manage showering herself." 4. "The order reads clear liquids, but I hear good bowel sounds and she's really hungry."

"The order reads clear liquids, but I hear good bowel sounds and she's really hungry."

12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The nurse responds correctly by telling the client that: 1. "The sex of the baby can be determined." 2. "There is a fine hair that covers the body." 3. "Fingers and toes are differentiated clearly." 4. "The organ systems are beginning to develop."

"The organ systems are beginning to develop."

The nurse is preparing a new mother for discharge when the woman shares that she is "worried about going back to work and its effects on my infant." The most therapeutic response by the nurse is: 1. "Do you want to go back to work?" 2. "Just be sure you have an excellent baby sitter." 3. "There is no proof that working will harm your baby." 4. "Can your husband share in the child care reponsibilities?"

"There is no proof that working will harm your baby."

13. The nurse evaluates which of the following statements as an indication that the client is not ready to learn at this time? 1. "I need to understand more about the reason for the colostomy." 2. "I will find out more about that when the support group meets." 3. "There's no sense in showing me that now. I'm too sick right now." 4. "Please be sure to tell me if I am completing all the steps correctly."

"There's no sense in showing me that now. I'm too sick right now."

26. Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes? 1. "It gives the client something positive to strive towards." 2. "They are statements of how the client's behavior should change." 3. "They are measurable criteria by which I can evaluation whether a goal has been achieved." 4. "They provide the client with suggestions on how to achieve their long and short term goals."

"They are measurable criteria by which I can evaluation whether a goal has been achieved."

1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student? 1. "Think about several interventions that you could use with this client." 2. "Don't draw subjective inferences about your client—be more objective." 3. "Please think harder—there is a single solution for which I am looking." 4. "Trust your feelings—don't be concerned about trying to find a rationale to support your decision."

"Think about several interventions that you could use with this client."

8. A parent of a 3-year-old boy states that she is concerned because he was potty trained long before hospitalization but now refuses to use the toilet. What is the correct response by the nurse? 1. "Your son is probably feeling neglected, and you should make an effort to spend more time with him." 2. "This is common behavior that is expressed when the hospitalized child is stressed or anxious." 3. "You may need to include discipline because children easily lose the ability to be toilet trained during hospitalization." 4. "Your son was probably not ready to be potty trained, and you may want to continue the training for the next 6 months."

"This is common behavior that is expressed when the hospitalized child is stressed or anxious."

24. Which of the following responses best reflects an understanding of the purpose of the "related to" phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? 1. "To focus on the cause of the client's needs" 2. "To identify the etiology of the client's diagnosis" 3. "To provide for individualization of the nursing interventions" 4. "To communicate the client's deficits to the nursing staff"

"To provide for individualization of the nursing interventions"

34. Which of the following nursing assessment questions is best directed toward determining the presence of career stressors in a young adult? 1. "What do you do to relieve stress for yourself?" 2. "What is the most stressful part of your daily job?" 3. "Career-wise, where would you like to be in 2 years?" 4. "Do you miss much work as a result of injuries or illness?"

"What is the most stressful part of your daily job?"

37. A nurse is caring for an older adult client preparing for discharge to a nursing center after having hip surgery. Which of the following nursing responses is most therapeutic when dealing with the client's concern that she, "will never go back home"? 1. "What makes you think that this transfer to the nursing center will be permanent?" 2. "The reason for this transfer is only to support you while you continue to recuperate." 3. "The decision to stay in the nursing center is yours to make. When you want to leave no one will stop you." 4. "The nursing center is a lovely place with a wonderful staff of caring people. Just give it a chance. You may like it."

"What makes you think that this transfer to the nursing center will be permanent?"

26. Which statement made by an older adult would reflect the best understanding of the nutritional guidelines for this age-group? 1. "I can prepare grilled chicken at least 10 different, delicious ways." 2. "When I entertain, I serve healthy foods like veggies and low-fat dip." 3. "I know I need to eat nutritiously, and I have certainly been doing better." 4. "I take seriously the suggestions my health team gives me on healthy eating."

"When I entertain, I serve healthy foods like veggies and low-fat dip."

17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time? 1. "Can you describe your pain?" 2. "Have you had this problem before?" 3. "What have you done to ease the pain?" 4. "When did your abdominal pain begin?"

"When did your abdominal pain begin?"

**In assessing the roles and power structure of a client's nuclear family, the nurse should specifically ask the client: 1. "Who decides where to go on vacation?" 2. "What type of health care insurance do you have?" 3. "How many family members currently live in your home?" 4. "What types of social activities do you and your family enjoy?"

"Who decides where to go on vacation?"

2. To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client: 1. "Have you ever been married?" 2. "Where do you currently work?" 3. "Has anyone ever taught you about contraception?" 4. "Who do you have for support during this pregnancy?"

"Who do you have for support during this pregnancy?"

22. A new graduate nurse missed cues regarding the client's emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is: 1. "That is why we perform assessments at least daily; so we can catch missed cues." 2. "Everyone has missed cues; don't be too hard on yourself and just keep trying." 3. "You will be less likely to miss client cues as you acquire more experience with assessments." 4. "The positive side to making this mistake is that you won't miss those cues again in another client."

"You will be less likely to miss client cues as you acquire more experience with assessments."

1. Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.) 1. Effective care 2. Delivery of care 3. Client satisfaction 4. Exceeding the standard of care 5. Identification of 'missed' client needs 6. Multidisciplinary approach to client care

1. Effective care 2. Delivery of care 3. Client satisfaction 4. Exceeding the standard of care

incubation period for cold

1-2 days

incubation period for influenza

1-4 days

incubation period for mumps

16-18 days

1. Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.) 1. "You're answers will be kept confidential." 2. "My name is Susan Smith and I'm a registered nurse." 3. "We are here to make your hospitalization as pleasant as possible." 4. "I need to ask you some questions that will help with planning your care." 5. "Only those directly involved in your care will have access to this information." 6. "If there is anything you need or help you require simply use your call bell and someone will be right in."

1. "You're answers will be kept confidential." 2. "My name is Susan Smith and I'm a registered nurse." 4. "I need to ask you some questions that will help with planning your care." 5. "Only those directly involved in your care will have access to this information."

1. Which of the following would be considered positive health behaviors for a 40-year-old client? (Select all that apply.) 1. Eating a low-fat, low-salt diet 2. Getting 6 to 8 hours of sleep nightly 3. Spending quality time with his children 4. Limiting his smoking to 3 cigarettes daily 5. Having his blood pressure checked regularly 6. Walking for 30 minutes several times a week

1. Eating a low-fat, low-salt diet 2. Getting 6 to 8 hours of sleep nightly 5. Having his blood pressure checked regularly 6. Walking for 30 minutes several times a week

3. The goal of the orientation phase of a nursing interview is to: (select all that apply) 1. Initiate the nurse-client relationship 2. Begin identifying the client's needs 3. Earn the trust and confidence of the client 4. Assume the decision role for the client 5. Welcome the client to the nursing unit 6. Gather the client's demographic information

1. Initiate the nurse-client relationship 2. Begin identifying the client's needs 3. Earn the trust and confidence of the client

2. Which of the following client behaviors are examples of active strategies of health promotion? (Select all that apply.) 1. Losing 10 pounds 2. Walking 1 mile each evening 3. Drinking vitamin D fortified milk 4. Driving a car equipped with airbags 5. Having regular blood pressure checks 6. Having a company-required hearing exam

1. Losing 10 pounds 2. Walking 1 mile each evening 5. Having regular blood pressure checks

1. Which of the following characteristics are considered guidelines for the writing of appropriate goals and outcomes? (Select all that apply.) 1. Singular 2. Realistic 3. Practical 4. Observable 5. Measurable 6. Meaningful

1. Singular 2. Realistic 4. Observable 5. Measurable

1. The nurse is preparing to present an educational program to residences of an assisted-living facility. Which teaching strategies would be most appropriate for the learning needs of this age-group? (Select all that apply.) 1. Speak in a slow but well-articulated manner. 2. Present a variety of ideas so as to have broad appeal. 3. Speak in soft, low voice so as to help the audience focus. 4. Small groups allow for more speaker-listener interaction. 5. End the program if there are signs of poor concentration or fatigue. 6. Present the material in a fast-paced manner to keep hold their attention.

1. Speak in a slow but well-articulated manner. 4. Small groups allow for more speaker-listener interaction. 5. End the program if there are signs of poor concentration or fatigue.

incubation period for measles

10-12 days

incubation period for chicken pox

14-16 days

WBC count during inflammation

15,000-20,000

incubation period for ebola

2-21 days

1. Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.) 1. Client teaching related to health and wellness topics 2. Evaluation of client outcomes in regards to nursing care 3. Identification of patterns in the client's health assessment data 4. Recognition of relationships among the client's various health issues 5. Planning specialized nursing interventions to meet a client's health needs 6. Facilitating assessment data collection through observation and communication

2. Evaluation of client outcomes in regards to nursing care 3. Identification of patterns in the client's health assessment data 4. Recognition of relationships among the client's various health issues 5. Planning specialized nursing interventions to meet a client's health needs

1. The scope of a client's health problem is a result of which of the following factors? (Select all that apply.) 1. Religious beliefs 2. Life experiences 3. Lifestyle choices 4. Work environment 5. Family relationships 6. Educational background

2. Life experiences 3. Lifestyle choices 4. Work environment 5. Family relationships

18. Which of the following young adults is at greatest risk for experiencing death or injury? 1. An 18-year-old with a father who is an alcoholic 2. A 30-year-old who is a professional rodeo rider 3. A 20-year-old living in an urban housing project 4. A 26-year-old riding a motorcycle across the country

A 20-year-old living in an urban housing project

25. When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information? 1. A 50-year-old in the ED reporting chest pain 2. A 70-year-old admitted with fever of unknown origin 3. A 81-year-old receiving follow-up treatment for a hip replacement 4. A 22-year-old being treated at a clinic for a sexually transmitted disease

A 81-year-old receiving follow-up treatment for a hip replacement

2. The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.) 1. "My work environment would depress anyone." 2. "It seems like almost anything can make me cry." 3. "Being here away from my family makes me sad." 4. "I just can't seem to get excited about anything anymore." 5. "The family always thought that my father was depressed." 6. "I like winter because I can just cover up on the couch and sleep."

4. "I just can't seem to get excited about anything anymore." 5. "The family always thought that my father was depressed."

how long does someone going into surgery srub

5 minutes

Normal WBC count

5,000-10,000

18. Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1. A new admission admitted for swelling in the right ankle and knee 2. A second day postoperative client who received pain medication 30 minutes ago 3. A client who the nursing assistant found crying in the bathroom 4. A client ready for discharge who requires a final assessment and documentation

A client who the nursing assistant found crying in the bathroom

16. Research has shown that certain postpartum factors negatively affect a woman's general health status after pregnancy. Which of the following women has the greatest risk factor for poor postpartum health? 1. A mother with complaints of fatigue, loss of appetite, and insomnia 2. A practicing attorney who has reluctantly taken a 3-month maternity leave 3. A stay-at-home mom who gave birth 2 months ago and whose husband recently lost his job 4. A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas

A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas

1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of: 1. A realistic goal 2. A compliant client 3. A negative evaluation 4. A nonmeasurable goal

A negative evaluation

15. Which of the following is the best example of a nurse's use of reflection? 1. The nurse places a client experiencing respiratory difficulties in a high-Fowler's position. 2. The nurse calls the provider when a client reports feeling "chilled and achy" while having an oral temperature of 100.2° F. 3. While caring for a client with a history of asthma, the nurse assesses the client's pulse oximetry reading when he "doesn't sound right." 4. A nurse tells a client; "When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time."

A nurse tells a client; "When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time."

1. When formulating a definition of "health," the nurse should consider that health, within its current definition, is: 1. The absence of disease 2. A function of the physiological state 3. The ability to pursue activities of daily living 4. A state of well-being involving the whole person

A state of well-being involving the whole person

38. A nurse caring for older adults in an assistive living facility recognizes that a client's quality of life needs are best determined by: 1. Excellent physical, social, and emotional nursing assessments 2. A working knowledge of this age-group's developmental needs 3. A therapeutic nurse-client relationship that facilitates communication 4. The client's ever-changing physical, emotional, and cognitive abilities

A therapeutic nurse-client relationship that facilitates communication

The nurse is concerned about pulmonary aspiration when providing her patient with tube feedings. The nurse should a. Verify tube placement before feeding. b. Lower the head of the bed to a supine po-sition. c. Add blue food coloring to the enteral formula. d. Run the formula over 12 hours to decrease volume.

ANS: A A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. The addition of blue food coloring to enteral formula to assist with detection of aspi-rate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time.

A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit smoking. When approached by the nurse, he states that he would be "better off dead." He states that he has always supported his family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse should a. Develop a plan of care for the family. b. Contact psychiatric services. c. Assure the patient that things will work out. d. Focus the plan of care on maximizing patient function.

ANS: A Because of the effects of illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable.

A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit smoking. When approached by the nurse, he states that he would be "better off dead." He states that he has always supported his family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse should a. Develop a plan of care for the family. b. Contact psychiatric services. c. Assure the patient that things will work out. d. Focus the plan of care on maximizing patient function.

ANS: A Because of the effects of illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable.

Which situation will cause the nurse to intervene and follow up on the nurse aide's behavior? a. The nurse aide is calling the older adult patient "honey." b. The nurse aide is facing the older adult patient when talking. c. The nurse aide cleans the older adult patient's glasses. d. The nurse aide allows time for the older adult patient to respond.

ANS: A Communicate with older adults on an adult level, and avoid patronizing or speaking in a condescending manner. Avoid terms of endearment such as "honey," "dear," "grandma," or "sweetheart." Facing an older adult patient, making sure the older adult has clean glasses, and allowing time to respond facilitate communication with older adult patients and should be encouraged, not stopped.

The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations.

ANS: A Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient's family and friends and to become familiar with the patient's favorite topics for conversation. Asking for explanations is a nontherapeutic technique.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure

ANS: A In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient, but it is not the R in SOLAR. Reminisce is a therapeutic communication technique, especially when used with the elderly. Reassuring can be therapeutic if the nurse reassures patients that there are many kinds of hope, and that meaning and personal growth can come from illness experiences. However, false reassurance can block communication.

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Narrative b. Socializing c. Nonjudgmental d. SBAR

ANS: A In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation.

Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. An example of an internal variable would be a. Perception of functioning. b. Family practices. c. Socioeconomic factors. d. Cultural background.

ANS: A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

Nurses who make the best communicators a. Develop critical thinking skills. b. Like different kinds of people. c. Learn effective psychomotor skills. d. Maintain perceptual biases.

ANS: A Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques and communication involves more than psychomotor skills. Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators.

The patient has just started on enteral feedings but is complaining of abdominal cramping. The nurse should a. Slow the rate of tube feeding. b. Instill cold formula to "numb" the stom-ach. c. Place the patient in a supine position. d. Change the tube feeding to a high-fat formula.

ANS: A One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is use of cold formula. The nurse should warm the formula to room temperature. The nurse should maintain the head of the bed at least 30 degrees. High-fat formulas are also a cause of abdominal cramping.

The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to provide a. Primary prevention. b. Secondary prevention. c. Tertiary prevention. d. Diagnosis and prompt intervention.

ANS: A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to provide a. Primary prevention. b. Secondary prevention. c. Tertiary prevention. d. Diagnosis and prompt intervention.

ANS: A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

20. The nursing diagnosis of acute pain falls under which of the following comfort domain classifications? 1. Social comfort 2. Physical comfort 3. Interpersonal comfort 4. Environmental comfort

Physical comfort

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient who says that she wants to be "detoxified." It is important for the nurse to a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Instruct the patient that she will have to change her lifestyle. d. Instruct the patient that relapses are not tolerated.

ANS: A Processes of change, or nursing interventions, should be appropriately chosen to match the stage of change. Most behavior change programs are designed for those people who are ready to take action regarding their health behavior problems. Only a minority of people are actually in this action stage. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient who says that she wants to be "detoxified." It is important for the nurse to a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Instruct the patient that she will have to change her lifestyle. d. Instruct the patient that relapses are not tolerated.

ANS: A Processes of change, or nursing interventions, should be appropriately chosen to match the stage of change. Most behavior change programs are designed for those people who are ready to take action regarding their health behavior problems. Only a minority of people are actually in this action stage. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

In determining the nutritional status of a patient and developing a plan of care, it is important to evaluate the patient according to a. Published standards. b. Nursing professional standards. c. Absence of family input. d. Patient input only.

ANS: A Referring to professional standards for nutrition is especially important during this step because published standards are based on scientific findings. Nursing standards cannot be used alone. Other health care professionals must be consulted to adopt interventions that reflect the patient's needs. Family should be involved in evaluation and design of interventions. Although patient input is important, synthesis of patient information from multiple sources is necessary to devising an individualized approach to care that is relevant to the patient's needs.

The nurse is providing home care for a patient diagnosed with AIDS. In preparing meals for this patient, the nurse should a. Provide small, frequent nutrient-dense meals. b. Encourage intake of fatty foods to in-crease caloric intake. c. Prepare hot meals because they are more easily tolerated. d. Avoid salty foods and limit liquids to preserve electrolytes.

ANS: A Small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods are easier to tolerate. Patients benefit from eating cold foods and drier or saltier foods with fluid in between.

The nurse is preparing a smoking cessation class and is amazed at how many people still smoke even with the information on lung cancer so readily available. She believes that her class will convert many smokers to nonsmokers once they get all the latest information. The nurse is a believer in which of the following health care models? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: A The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model is more complex than the Health Belief Model in that it notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. Education is important but is not the sole determinant of change.

The nurse is preparing a smoking cessation class and is amazed at how many people still smoke even with the information on lung cancer so readily available. She believes that her class will convert many smokers to nonsmokers once they get all the latest information. The nurse is a believer in which of the following health care models? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: A The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model is more complex than the Health Belief Model in that it notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. Education is important but is not the sole determinant of change.

The energy needed to maintain life-sustaining activities for a specific period of time at rest is known as a. BMR. b. REE. c. Nutrients. d. Nutrient density.

ANS: A The basal metabolic rate (BMR) is the energy needed to maintain life-sustaining activities for a specific period of time at rest. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in rela-tion to kilocalories.

Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: A The time before the nurse meets the patient is called the pre-interaction phase. This phase can involve such things as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve such things as setting the tone for the relationship by adopting a warm, empathetic, caring manner; recognizing that the initial relationship is often superficial, uncertain, and tentative; or expecting the patient to test the nurse's competence and commitment. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. This phase can involve such things as encouraging and helping the patient express feelings about his or her health, encouraging and helping the patient with self-exploration, or providing information needed to understand and change behavior. The termination phase occurs during the ending of the relationship. This phase can involve such things as reminding the patient that termination is near, evaluating goal achievement with the patient, or reminiscing about the relationship with the patient.

Fats are composed of triglycerides and fatty acids. Triglycerides a. Are made up of three fatty acids. b. Can be saturated. c. Can be monounsaturated. d. Can be polyunsaturated.

ANS: A Triglycerides circulate in the blood and are made up of three fatty acids attached to a glycerol. Fatty acids (not triglycerides) can be saturated or unsaturated (monounsaturated or polyunsatu-rated).

A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid.

ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient.

When expected nutritional outcomes are not being met, the nurse should a. Revise the nurse measures or expected outcomes. b. Alter the outcomes based on nursing standards. c. Ensure that patient expectations are con-gruent with the nurse's expectations. d. Readjust the plan to exclude cultural be-liefs.

ANS: A When expected outcomes are not met, the nurse should revise the nursing measures or expected outcomes based on the patient's needs or preferences, not solely on the basis of nursing stand-ards. Expectations and health care values held by nurses frequently differ from those held by pa-tients. Working closely with patients enables the nurse to redefine expectations that are realisti-cally met within the limits of conditions and treatments and to identify their dietary preferences and cultural beliefs.

An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Speak clearly and loudly. b. Turn off the television. c. Chew gum. d. Use at least 14-point print.

ANS: B Patients who are hearing impaired benefit when the following techniques are used: Check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired.

8. The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for: 1. Coordination with the physician's visit 2. The time when the client's family are visiting 3. Immediately before the client's scheduled MRI testing 4. After the client has become comfortably oriented to the room

After the client has become comfortably oriented to the room

22. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult? 1. Alcohol and tobacco use 2. Ignoring seat belt and helmet laws 3. Unprotected sex with multiple partners 4. Poor nutrition and a lack of structured exercise

Alcohol and tobacco use

When developing a plan of care for a patient with altered nutritional needs, the nurse must assess the patient for which of the following? (Select all that apply.) a. What is the condition now? b. Is the condition stable? c. Will the condition get worse? d. Will the disease process accelerate deteri-oration? e. Which single objective measure will pre-dict the course of action?

ANS: A, B, C, D Nutritional screening tools must gather data based on four main principles: What is the condition now? Is the condition stable? Will the condition get worse? And will the disease process acceler-ate nutritional deterioration? Using a single objective measure is ineffective in predicting risk of nutritional problems.

According to the World Health Organization, what is the best definition for "health"? a. Simply the absence of disease b. Involving the total person and environment c. Strictly personal in nature d. Status of pathological state

ANS: B Nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not equally healthy. Views of health have broadened to include mental, social, and spiritual well-being, as well as a focus on health at family and community levels. Conditions of life, rather than pathological states, are what define health.

Models of health offer a perspective by which to understand the relationships between the concepts of health, wellness, and illness. Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health because nurses (Select all that apply.) a. Understand the challenges of today's health care system. b. Identify actual and potential risk factors. c. Have coined the term "illness behavior." d. Can minimize the effects of illness and assist to the return of optimal health

ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system and embrace the opportunity to use wellness activities to promote health and wellness and to prevent illness. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Medical sociologists call the reaction to illness "illness behavior."

Models of health offer a perspective by which to understand the relationships between the concepts of health, wellness, and illness. Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health because nurses (Select all that apply.) a. Understand the challenges of today's health care system. b. Identify actual and potential risk factors. c. Have coined the term "illness behavior." d. Can minimize the effects of illness and assist to the return of optimal health

ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system and embrace the opportunity to use wellness activities to promote health and wellness and to prevent illness. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Medical sociologists call the reaction to illness "illness behavior."

Dietary reference intakes (DRIs) present evidence-based criteria for an acceptable range of amounts of vitamins and nutrients for each gender and age group. Components of DRIs include which of the following? (Select all that apply.) a. Estimated average requirement (EAR) b. Recommended dietary allowance (RDA) c. The Food Guide Pyramid d. Adequate intake (AI) e. The tolerable upper intake level (UL)

ANS: A, B, D, E Dietary reference intakes (DRIs) present evidence-based criteria for an acceptable range of amounts of vitamins and nutrients for each gender and age group. DRIs have four components. The estimated average requirement (EAR) is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population based on age and gen-der. The recommended dietary allowance (RDA) indicates the average needs of 98% of the pop-ulation, not the exact needs of the individual. Adequate intake (AI) is the suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes and is used when evidence is insufficient to allow the RDA to be set. The tolerable upper intake level (UL) is the highest level that likely poses no risk of adverse health events. It is not a recom-mended level of intake. The food guide pyramid is not a component of the DRIs.

To create a new nutritional plan of care for a patient, the nurse needs to do which of the following? (Select all that apply.) a. Utilize the characteristics of a normal nu-tritional status. b. Evaluate previous patient responses to nursing interventions. c. Exclude established expected outcomes to evaluate patient responses. d. Design innovative interventions to meet the patient's needs. e. Follow through with evaluation and counseling.

ANS: A, B, D, E To create a new nutritional plan of care, the nurse must utilize characteristics of a normal nutri-tional status to gauge effectiveness of the plan. The nurse must be aware of previous patient re-sponses to nursing interventions for altered nutrition to determine the probability of success. The nurse must use established expected outcomes to evaluate the patient's response to care (e.g., patient's weight increases by 0.5 kg/week). The nurse must also be creative when designing in-novative nursing interventions to meet the patient's nutritional needs and must demonstrate re-sponsibility by following through with evaluation and counseling to successfully reach goals.

The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient that from a nutritional point of view, the patient should (Select all that apply.) a. Maintain body weight in a healthy range. b. Increase physical activity. c. Increase intake of meat and other high-protein foods. d. Keep total fat intake to 10% or less. e. Choose and prepare foods with little salt.

ANS: A, B, E According to the 2005 Dietary Guidelines for Americans, key recommendations include main-taining body weight in a healthy range; increasing physical activity and decreasing sedentary ac-tivities; increasing intake of fruits, vegetables, whole grain products, and fat-free or low-fat milk with less red meat; keeping fat intake between 30% and 35% of total calories, with most fats coming from polyunsaturated or monounsaturated fatty acids (most meats contain saturated fatty acids); and choosing prepared foods with little salt while at the same time eating potassium-rich foods.

According to the World Health Organization, what is the best definition for "health"? a. Simply the absence of disease b. Involving the total person and environment c. Strictly personal in nature d. Status of pathological state

ANS: B Nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not equally healthy. Views of health have broadened to include mental, social, and spiritual well-being, as well as a focus on health at family and community levels. Conditions of life, rather than pathological states, are what define health.

A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient? a. Hopelessness b. Impaired verbal communication c. Hearing loss d. Self-care deficit

ANS: B A patient with impaired verbal communication has defining characteristics such as an inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending. Hopelessness implies that the patient has no hope for the future. Hearing loss is not a nursing diagnosis. Just because a patient has garbled speech does not mean that a hearing loss has occurred; a physical problem such as a stroke could cause the garbled speech. Self-care deficit does not apply in this situation because this usually relates to bathing, grooming, etc.

The patient with cardiovascular disease must be taught how to reduce the risk of cardiovascular disease by balancing calorie intake with exercise to maintain a healthy body weight. In addition to this, the nurse instructs the patient to a. Eat fish at least 5 times per week. b. Limit saturated fat to less than 7%. c. Limit cholesterol to less than 200 mg/day. d. Avoid high-fiber foods.

ANS: B AHA guidelines recommend limiting saturated fat to less than 7%, trans fat to less than 1%, and cholesterol to less than 300 mg/day. Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber foods.

A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues.

ANS: B Allowing time for the patient to respond will facilitate communication, especially for an older confused patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired or cognitively impaired patients.

A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's personal space was violated. b. The patient's affect is inappropriate. c. The patient's vocabulary is poor. d. The patient's denotative meaning is wrong.

ANS: B An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and his wife refuse to talk about it and refuse to be taught about how to care for it. The nurse realizes that the patient and his wife are in which stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

ANS: B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment when they accept the loss, and rehabilitation when the patient is ready to learn how to adapt.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and his wife refuse to talk about it and refuse to be taught about how to care for it. The nurse realizes that the patient and his wife are in which stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

ANS: B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment when they accept the loss, and rehabilitation when the patient is ready to learn how to adapt.

A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right."

ANS: B Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." Giving personal opinions ("If I were you") is nontherapeutic and not assertive. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like should, good, bad, right) is not assertive or therapeutic.

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. To prevent this, the nurse a. Irrigates the tube with 60 mL of water af-ter all medications are given. b. Checks with the pharmacy to find out if liquid forms of the medications are avail-able. c. Instills nonliquid medications without di-luting. d. Mixes all medications together to decrease the number of administrations.

ANS: B Avoid crushed medication if liquid is available. Irrigate with 30 mL of water before and after each medication per tube. Dilute crushed medications if not liquid. Read pharmacological infor-mation on compatibility of drugs and formula before mixing medications.

Before giving the patient an intermittent tube feeding, the nurse should a. Make sure that the tube is secured to the gown with a safety pin. b. Have the tube feeding at room tempera-ture. c. Inject air into the stomach via the tube and auscultate. d. Place the patient in a supine position.

ANS: B Cold formula causes gastric cramping and discomfort because the mouth and the esophagus do not warm the liquid. Do not use safety pins. Safety pins can become unfastened and may cause harm to the patient. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach. Place the patient in high-Fowler's position, or elevate the head of the bed at least 30 degrees to help prevent aspiration.

When teaching a patient about current dietary guidelines for the general population, the nurse explains referenced daily intakes (RDIs) and daily reference values (DRVs), otherwise known as daily values. In providing this information, the nurse understands that daily values a. Have replaced recommended daily al-lowances (RDAs). b. Have provided a more understandable format of RDAs for the public. c. Are based on percentages of a diet con-sisting of 1200 kcal/day. d. Are not usually easy to find computer ex-perience is required.

ANS: B Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day; these values constitute the daily values used on food labels, which are easy for anyone to find. Computer ex-perience is not required.

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: B Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Pre-interaction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship.

In providing diet education for a patient on a low-fat diet, it is important for the nurse to understand that with few exceptions a. Saturated fats are found mostly in vegeta-ble sources. b. Saturated fats are found mostly in animal sources. c. Unsaturated fats are found mostly in ani-mal sources. d. Linoleic acid is a saturated fatty acid.

ANS: B Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans.

A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Intimate b. Personal c. Social d. Public

ANS: B Personal space is 18 inches to 4 feet and involves such things as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves such things as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. Social zone is 4 to 12 feet and involves such things as making rounds with a physician, sitting at the head of a conference table, or teaching a class for patients with diabetes. Public zone is 12 feet and greater and involves such things as speaking at a community forum, testifying at a legislative hearing, or lecturing.

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group

ANS: B Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Intrapersonal communication is a powerful form of communication that occurs within an individual. Transpersonal communication is interaction that occurs within a person's spiritual domain. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process.

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. What level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. What level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

Dysphagia refers to difficulty when swallowing. Of the following causes of dysphagia, which is considered neurogenic? a. Myasthenia gravis b. Stroke c. Candidiasis d. Muscular dystrophy

ANS: B Stroke is the only cause of dysphagia in this list that is considered neurogenic. Myasthenia gravis and muscular dystrophy are considered myogenic in origin, whereas candidiasis is considered obstructive.

The ChooseMyPlate program includes guidelines for a. Children younger than 2 years. b. Balancing calories. c. Increasing portion size. d. Decreasing water consumption.

ANS: B The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars. These guidelines have been put forth for Americans over the age of 2 years.

In providing diabetic teaching for a patient with type 1 diabetes mellitus, the nurse instructs the patient that a. Insulin is the only consideration that must be taken into account. b. Saturated fat should be limited to less than 7% of total calories. c. Cholesterol intake should be greater than 200 mg/day. d. Nonnutritive sweeteners can be used without restriction.

ANS: B The diabetic patient should limit saturated fat to less than 7% of total calories and cholesterol intake to less than 200 mg/day. Type 1 diabetes requires both insulin and dietary restrictions for optimal control. Nonnutritive sweeteners can be eaten as long as the recommended daily intake levels are followed.

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary

ANS: B The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication.

Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle. The presence of any of these risk factors means that a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. The disease is guaranteed not to develop if the risk factor is controlled. d. Risk modification will have no effect on disease prevention.

ANS: B The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor identification assists patients in visualizing those areas in life that can be modified or even eliminated to promote wellness and prevent illness.

Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle. The presence of any of these risk factors means that a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. The disease is guaranteed not to develop if the risk factor is controlled. d. Risk modification will have no effect on disease prevention.

ANS: B The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor identification assists patients in visualizing those areas in life that can be modified or even eliminated to promote wellness and prevent illness.

The patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. She is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. The nurse recognizes that the patient is in which stage of the change process? a. Precontemplation b. Contemplation c. Preparation d. Action

ANS: B These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). This patient is planning to make the change within the next 6 months and is in the contemplation stage.

The patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. She is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. The nurse recognizes that the patient is in which stage of the change process? a. Precontemplation b. Contemplation c. Preparation d. Action

ANS: B These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). This patient is planning to make the change within the next 6 months and is in the contemplation stage.

The nurse is assessing a patient for nutritional status. In doing so, the nurse must a. Choose a single objective tool that fits the patient's condition. b. Combine multiple objective measures with subjective measures. c. Forego the assessment in the presence of chronic disease. d. Use the Mini Nutritional Assessment for pediatric patients.

ANS: B Using a single objective measure is ineffective in predicting risk of nutritional problems. Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Chronic disease and increased metabolic requirements are risk factors for the development of nutritional problems; these patients may be in critical need of this assessment. The Mini Nutritional Assessment was developed to use for screening older adults in home care programs, nursing homes, and hospitals.

Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in a. Negative nitrogen balance. b. Positive nitrogen balance. c. Total dependence on protein for kcal pro-duction. d. Neutral nitrogen balance.

ANS: B When intake of nitrogen is greater than output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance occurs when the body loses more nitrogen than the body gains. Neutral nitrogen balance occurs when gain equals loss and is not optimal for tissue healing. Protein provides energy, but because of the essential role of protein in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources.

The nurse is caring for a patient who has been trying to quit smoking. She has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and never will quit smoking. b. The patient will return to the contemplation or precontemplation phase. c. The patient will need to adopt a new lifestyle for change to be effective. d. The patient must pick up her attempt right where she left off.

ANS: B When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up her attempt where she left off. It is believed that change involves movement through a series of stages. These stages range from no intention to change (precontemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintenance. The action phase indicates a desire to change and a potential to do so. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle.

The nurse is caring for a patient who has been trying to quit smoking. She has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and never will quit smoking. b. The patient will return to the contemplation or precontemplation phase. c. The patient will need to adopt a new lifestyle for change to be effective. d. The patient must pick up her attempt right where she left off.

ANS: B When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up her attempt where she left off. It is believed that change involves movement through a series of stages. These stages range from no intention to change (precontemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintenance. The action phase indicates a desire to change and a potential to do so. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle.

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed.

ANS: C The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R).

Which types of patients can cause challenging communication situations? (Select all that apply.) a. A male patient who is cooperative with treatments b. A female patient who is outgoing and flirty c. An older adult patient who is demanding d. An elderly patient who can clearly see small print e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed

ANS: B, C, E, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations.

6. Nurses need to become familiar with the elements of a research publication. A brief explanation of the type of measurement to be used is found in which section of a study? 1. Results 2. Methods 3. Conclusion 4. Introduction

Methods

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a nonjudgmental attitude. Why does the nurse do this? a. Noncompliant patients thrive on the disapproval of authority figures. b. External variables have little effect on compliance. c. A person's compliance is affected by economic status. d. Employment status is an internal variable that impacts compliance.

ANS: C A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices. Internal and external variables influence how a person thinks and acts toward health care. Employment status is an external variable, not an internal variable.

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a nonjudgmental attitude. Why does the nurse do this? a. Noncompliant patients thrive on the disapproval of authority figures. b. External variables have little effect on compliance. c. A person's compliance is affected by economic status. d. Employment status is an internal variable that impacts compliance.

ANS: C A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices. Internal and external variables influence how a person thinks and acts toward health care. Employment status is an external variable, not an internal variable.

To counter obesity in adolescents, increasing physical activity is often more important than curbing intake. Sports and regular, moderate to intense exercise necessitate dietary modifications to meet increased energy needs for adolescents. The nurse understands that these modifications include a. Decreasing carbohydrates to 25% to 30% of total intake. b. Decreasing protein intake to .75 g/kg/day. c. Ingesting water before and after exercise. d. Providing vitamin and mineral supple-ments.

ANS: C Adequate hydration is very important for all athletes. They need to ingest water before and after exercise to prevent dehydration, especially in hot, humid environments. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocal-ories. Protein needs increase to 1.0 to 1.5 g/kg/day. Vitamin and mineral supplements are not re-quired, but intake of iron-rich foods is required to prevent anemia.

At present, the most reliable method for verification of placement of small-bore feeding tubes is a. Auscultation. b. Aspiration of contents. c. X-ray. d. pH testing.

ANS: C At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. Aspiration of contents and pH testing are not infallible. The nurse would need a more precise indicator to help differentiate the source of tube feeding aspirate. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inad-vertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach.

The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." The nurse needs to explain that a. Fats have no significance in health and the incidence of disease. b. All fats come from external sources so can be easily controlled. c. Deficiencies occur when fat intake falls below 10% of daily nutrition. d. Vegetable fats are the major source of saturated fats and should be avoided.

ANS: C Deficiency occurs when fat intake falls below 10% of daily nutrition. Various types of fatty acids have significance for health and for the incidence of disease and are referred to in dietary guidelines. Linoleic acid and arachidonic acid are important for metabolic processes but are manufactured by the body when linoleic acid is available. Most animal fats have high proportions of sat

The nurse is caring for a patient who will be receiving PN. To reduce the risk of developing sepsis, the nurse a. Takes down a running bag of TPN after 36 hours. b. Runs lipids for no longer than 24 hours. c. Wears a sterile mask when changing the CVC dressing. d. Wears clean gloves when changing the CVC dressing.

ANS: C During CVC dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection, change the TPN infusion tubing every 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours.

A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend

ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses such standards as humility, self-confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient.

To provide successful nutritional therapies to patients, the nurse must understand that a. Patients will have to change diet prefer-ences drastically to be successful. b. The patient will tell the nurse when to change the plan of care. c. Expectations of nurses frequently differ from those of the patient. d. Nurses should never alter the plan of care regardless of outcome.

ANS: C Expectations and health care values held by nurses frequently differ from those held by patients. Successful interventions and outcomes depend on recognition of this concept, in addition to nursing knowledge and skill. If ongoing nutritional therapies are not resulting in successful out-comes, patients expect nurses to recognize this fact and alter the plan of care accordingly. Work-ing closely with patients enables the nurse to redefine expectations that are realistically met within the limits of conditions and treatments and to identify their dietary preferences and cultural beliefs.

In providing prenatal care to a patient, the nurse teaches the expectant mother that a. Protein intake needs to decrease to pre-serve kidney function. b. Calcium intake is especially important in the first trimester. c. Folic acid is needed to help prevent birth defects and anemia. d. The mother should take in as many extra vitamins and minerals as possible.

ANS: C Folic acid intake is particularly important for DNA synthesis and growth of red blood cells. In-adequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. Protein intake throughout pregnancy needs to increase to 60 g daily. Calcium intake is especially critical in the third trimester, when fetal bones are mineralized. Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts.

To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is a. Allowing people to continue current behaviors to reduce the stress of change. b. Focusing only on individual health changes that will lead to better communities. c. Creating social and physical environments that promote good health. d. Focusing on illness treatment to provide fast recuperation.

ANS: C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The other three include (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; and (3) promote quality of life, healthy development, and healthy behaviors across all life stages.

To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is a. Allowing people to continue current behaviors to reduce the stress of change. b. Focusing only on individual health changes that will lead to better communities. c. Creating social and physical environments that promote good health. d. Focusing on illness treatment to provide fast recuperation.

ANS: C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The other three include (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; and (3) promote quality of life, healthy development, and healthy behaviors across all life stages.

An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2020 goal of a. Increasing quality of life in America. b. Prolonging healthy life in America. c. Eliminating health disparities in America. d. Promoting healthy behaviors.

ANS: C Healthy People 2020 promotes a society in which all people live long, healthy lives. This program has four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages. Providing health care to all would eliminate disparities in health care by ensuring access. Perhaps the best way to increase quality and years of healthy life is to promote healthy behaviors. However, providing access to health care would not guarantee changes in behaviors, increased quality of life, or prolonged healthy life.

An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2020 goal of a. Increasing quality of life in America. b. Prolonging healthy life in America. c. Eliminating health disparities in America. d. Promoting healthy behaviors.

ANS: C Healthy People 2020 promotes a society in which all people live long, healthy lives. This program has four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages. Providing health care to all would eliminate disparities in health care by ensuring access. Perhaps the best way to increase quality and years of healthy life is to promote healthy behaviors. However, providing access to health care would not guarantee changes in behaviors, increased quality of life, or prolonged healthy life.

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. The most likely cause of the diarrhea would be a. Clostridium difficile. b. Antibiotic therapy. c. Formula intolerance. d. Bacterial contamination.

ANS: C Hyperosmolar formulas can cause diarrhea. If that is the case, the solution is to lower the rate, dilute the formula, or change to an isotonic formula. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allowing for Clostridium difficile toxin buildup. However, this takes time, and no indication suggests that this patient was on antibiotics. Proximity to the start of the enteral feedings is more suspicious. Bacterial contamination of the feeding usually occurs when feedings are left hanging for longer than 8 hours.

In general, when energy requirements are completely met by kilocalorie (kcal) intake in food a. Weight increases. b. Weight decreases. c. Weight does not change. d. Kilocalories are not a factor.

ANS: C In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person's energy demands, the indi-vidual gains weight. If kilocalories ingested fail to meet a person's energy requirement, the indi-vidual loses weight. Kilocalories are a factor.

Which person is the best referral for a patient who speaks a foreign language? a. A family member b. A speech therapist c. An interpreter d. A mental health nurse specialist

ANS: C Interpreters are often necessary for patients who speak a foreign language. A family member can lead to legal issues, speech therapists help patients with aphasia, and mental health nurse specialists help angry or highly anxious patients to communicate more effectively.

In creating a plan of care to meet the nutritional needs of the patient, the nurse needs to explore the patient's feelings about weight and food. The nurse must do this to a. Determine which category of plan to use. b. Set realistic goals for the patient. c. Mutually plan goals with patient and team. d. Prevent the need for a dietitian consult.

ANS: C Mutually planned goals negotiated by patient, registered dietitian, and nurse ensure success. In-dividualized planning cannot be overemphasized. Preplanned and categorical care plans are not effective unless they are individualized to meet patient needs. It is important to explore patients' feelings about weight and food to help them set realistic and achievable goals. The nurse does not set goals for the patient. The plan should reflect the combined effort of patient, nurse, and dietitian, so a dietitian consult is required.

The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately.

ANS: C Nurses who use critical thinking skills interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationales for communication techniques used, and self-examine personal communication skills. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic phrases that communicate that the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues.

The patient is on PN and is lethargic. He has been complaining of thirst and headache and has had increased urination. Which of the following problems would cause these symptoms? a. Electrolyte imbalance b. Hypoglycemia c. Hyperglycemia d. Hypercapnia

ANS: C Signs and symptoms of hyperglycemia are thirst, headache, lethargy, and increased urination. Electrolyte imbalance is marked by changes in Na, Ca, K, Cl, PO4, Mg, and CO2 levels. These have to be monitored closely when patients are on PN. Hypercapnia increases oxygen consump-tion and increases CO2 levels. Ventilator-dependent patients are at greatest risk for this. Hypo-glycemia is characterized by diaphoresis, shakiness, confusion, and loss of consciousness.

The patient is having at least 75% of his nutritional needs met by enteral feeding, so the physician has ordered the PN to be discontinued. However, the nurse notices that the PN infusion has fallen behind. The nurse should a. Increase the rate to get the volume caught up before discon-tinuing. b. Stop the infusion and hang a normal saline drip in place. c. Taper the PN infusion gradually. d. Hang 5% dextrose if the PN runs out.

ANS: C Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. The same is true if the PN runs out. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an at-tempt to catch up.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses, and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses, and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

what are some problems that cause a person to be put in a protective environment

allogeneic hematopoietic, stem cell transplants.

The health care model that utilizes Maslow's hierarchy as its base is the _____ Model. a. Health Belief b. Health Promotion c. Basic Human Needs d. Holistic Health

ANS: C The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy.

The health care model that utilizes Maslow's hierarchy as its base is the _____ Model. a. Health Belief b. Health Promotion c. Basic Human Needs d. Holistic Health

ANS: C The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy.

The nurse is providing nutrition teaching to a Korean patient. In doing so, the nurse must understand that the focus of the teaching should be on a. Changing the patient's diet to a more conventional American diet. b. Discouraging the patient's ethnic food choices. c. Food preferences of the patient, including racial and ethnic choices. d. Comparing the patient's ethnic preferences with American dietary choices.

ANS: C The nurse needs to make sure to consider the food preferences of different racial and ethnic groups, vegetarians, and others when planning diets. Initiation of a balanced diet is more im-portant than conversion to what may be considered an American diet. Ethnic food choices may be just as nutritious as "American" choices. Foods should be chosen for their nutritive value and should not be compared with the "American" diet.

A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Pre-interaction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship.

The patient is an 80-year-old male who is visiting the clinic today for his routine physical examination. The patient's skin turgor is fair, but he has been complaining of fatigue and weak-ness. The skin is warm and dry, pulse rate is 126 beats per minute, and urinary sodium level is slightly elevated. After assessment, the nurse should recommend that the patient a. Decrease his intake of milk and dairy products to decrease the risk of osteopo-rosis. b. Drink more grapefruit juice to enhance vitamin C intake and medication absorp-tion. c. Drink more water to prevent further de-hydration. d. Eat more meat because meat is the only source of usable protein.

ANS: C Thirst sensation diminishes, leading to inadequate fluid intake or dehydration. Symptoms of de-hydration in older adults include confusion, weakness, hot dry skin, furrowed tongue, and high urinary sodium. Milk continues to be an important food for older woman and men, who need adequate calcium to protect against osteoporosis. After age 70, osteoporosis equally affects men and women. Caution older adults to avoid grapefruit and grapefruit juice because these will de-crease absorption of many drugs. Some older adults avoid meats because of cost, or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein.

6. Individuals at the young adult point in their life are generally expected to, according to developmental patterns: 1. Continue physical growth 2. Experience severe illnesses 3. Ignore physical symptoms 4. Seek frequent medical care

Ignore physical symptoms

Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.) a. Faith b. Supportiveness c. Self-confidence d. Humility e. Independent attitude f. Spiritual expression

ANS: C, D, E A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith, supportiveness, and spiritual expression are attributes of caring, not critical thinking standards.

Just as health and health behavior are affected by internal and external variables, so are illness and illness behavior. Which external variables can affect illness and behavior? (Select all that apply.) a. Perception of the seriousness of the illness b. Patient's coping skills c. Cultural background d. Social support e. Socioeconomic status

ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.

Just as health and health behavior are affected by internal and external variables, so are illness and illness behavior. Which external variables can affect illness and behavior? (Select all that apply.) a. Perception of the seriousness of the illness b. Patient's coping skills c. Cultural background d. Social support e. Socioeconomic status

ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.

A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.

ANS: D "I don't feel good" is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. "How are you doing?" is the message.

When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"

ANS: D "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them.

The patient has a calculated body mass index (BMI) of 34. This would classify the patient as a. Unclassifiable. b. Normal weight. c. Overweight. d. Obese.

ANS: D BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI less than 25 is considered normal or underweight. All patients can be classified by dividing their weight in kilograms by their height in meters squared.

In teaching mothers-to-be about infant nutrition, the nurse instructs patients to a. Give cow's milk during the first year of life. b. Supplement breast milk with corn syrup. c. Add honey to infant formulas for in-creased energy. d. Remember that breast milk or formula is sufficient for the first 4 to 6 months.

ANS: D Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. Infants should not have regular cow's milk during the first year of life. Cow's milk causes gastrointesti-nal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin and should not be used in the infant diet.

Patients who are unable to digest or absorb enteral nutrition benefit from parenteral nutrition (PN). However, the goal to move toward use of the GI tract is constant because PN a. Can be given only in the hospital setting. b. Cannot be used in patients in highly stressed situations. c. Can be given only by way of a peripheral IV line. d. Can lead to villous atrophy and cell shrinkage.

ANS: D Disuse of the GI tract has been associated with villous atrophy and generalized cell shrinkage. Translocation of bacteria from the local gut to systemic regions has been noted in relation to GI cell shrinkage, resulting in gram-negative septicemia. PN is administered in a variety of settings, including the patient's home. Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therapy. Safe administration of this form of nutrition de-pends on meticulous management of a central venous catheter.

The patient that will cause the greatest communication concerns for a nurse is the patient who is a. Alert, has strong self-esteem, and is hungry. b. Oriented, pain free, and blind. c. Cooperative, depressed, and hard of hearing. d. Dyspneic, has a tracheostomy, and is anxious.

ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, a tracheostomy, and anxiety all contribute to communication concerns.

In determining kcal expenditure, the nurse knows that carbohydrates and proteins provide 4 kcal of energy per gram ingested. The nurse also knows that fats provide _____ kcal per gram. a. 3 b. 4 c. 6 d. 9

ANS: D Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal per gram.

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. In doing so, the nurse is fostering the concept of a. Illness prevention. b. Active health promotion. c. Wellness education. d. Passive health promotion.

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. In doing so, the nurse is fostering the concept of a. Illness prevention. b. Active health promotion. c. Wellness education. d. Passive health promotion.

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

The patient is elderly and has been diagnosed with Imbalanced nutrition: less than body requirements. Her treatment regimen should include having the nurse a. Encourage weight gain as rapidly as pos-sible. b. Encourage large meals three times a day. c. Decrease fluid intake to prevent feeling full. d. Encourage fiber intake.

ANS: D Increasing fiber intake deters constipation and enhances appetite. Weight gain should be slow and progressive. Frequent small meals should be encouraged to increase dietary intake and to help offset anorexia. Older adults need eight 8-ounce glasses of fluid per day from beverage and food sources.

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, the nurse measures from the a. Tip of the nose to the xiphoid process of the sternum. b. Earlobe to the xiphoid process of the sternum. c. Tip of the nose to the earlobe. d. Tip of the nose to the earlobe to the xiph-oid process.

ANS: D Measure distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. This approximates the distance from the nose to the stomach in 98% of patients. For duodenal or jejunal placement, an additional 20 to 30 centimeters is required.

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. Given this information, which of the following tubes is appropriate for this patient? a. Nasogastric tube b. Percutaneous endoscopic gastrostomy (PEG) tube c. Nasointestinal tube d. Jejunostomy tube

ANS: D Patients with gastroparesis or esophageal reflux or with a history of aspiration pneumonia may require placement of tubes beyond the stomach into the intestine. The nasogastric tube and the PEG tube are placed in the stomach, and placement could lead to aspiration. The nasointestinal tube and the nasogastric tube may be contraindicated by facial trauma and the broken nose. The jejunostomy tube is the only tube in the list that is beyond the stomach and is not contraindicated by facial trauma.

The ChooseMyPlate program was developed to replace MyFoodPyramid as a basic guide for buying food and meal preparations. This system was developed by the a. Food and Drug Administration. b. 1990 Nutrition Labeling and Education Act. c. Referenced daily intakes (RDIs). d. U.S. Department of Agriculture.

ANS: D The ChooseMyPlate program was developed by the U.S. Department of Agriculture to replace the MyFoodPyramid program. ChooseMyPlate serves as a basic guide for making food choices for a healthy lifestyle. The Food and Drug Administration (FDA) created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act (NLEA). The FDA first es-tablished two sets of reference values: referenced daily intakes (RDIs) and daily reference values (DRVs).

The patient is describing moderate incisional pain that was not relieved by the last dose of hydromorphone (Dilaudid) given 90 minutes earlier. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music she likes, and puts on the music channel on the television, setting it to play that type of music. The nurse is attempting to utilize which health care model? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: D The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

The patient is describing moderate incisional pain that was not relieved by the last dose of hydromorphone (Dilaudid) given 90 minutes earlier. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music she likes, and puts on the music channel on the television, setting it to play that type of music. The nurse is attempting to utilize which health care model? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: D The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

In measuring the effectiveness of nutritional interventions, the nurse should a. Expect results to occur rapidly. b. Not be concerned with physical measures such as weight. c. Expect to maintain a course of action re-gardless of changes in condition. d. Evaluate outcomes according to the pa-tient's expectations and goals.

ANS: D The nurse should measure the effectiveness of nutritional interventions by evaluating the pa-tient's expected outcomes and goals of care. Nutrition therapy does not always produce rapid results. Ongoing comparisons need to be made with baseline measures of weight, serum albumin or prealbumin, and protein and kilocalorie intake. Changes in condition may indicate a need to change the nutritional plan of care.

Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as a. Amino acids. b. Dispensable amino acids. c. Triglycerides. d. Indispensable amino acids.

ANS: D The simplest form of protein is the amino acid. The body does not synthesize indispensable amino acids, so these need to be provided in the diet. The body synthesizes dispensable amino acids. Triglycerides are made up of three fatty acids attached to a glycerol

The nurse is teaching the patient about dietary guidelines. In discussing the four components of dietary reference intakes (DRIs), it is important to understand that a. The estimated average requirement (EAR) is appropriate for 100% of the population. b. The recommended dietary allowance (RDA) meets the needs of the individual. c. Adequate intake (AI) determines the nu-trient requirements of the RDA. d. The tolerable upper intake level (UL) is not a recommended level of intake.

ANS: D The tolerable upper intake level (UL) is the highest level that likely poses no risk of adverse health events. It is not a recommended level of intake. The EAR is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population based on age and gender. The RDA reflects the average needs of 98% of the population, not the exact needs of the individual. AI is the suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes and is used when evidence is insufficient for setting of the RDA.

The patient has quit smoking and has been smoke free for the past 2 years. Of the following stages, which best fits her current stage of change? a. Contemplation b. Preparation c. Action d. Maintenance

ANS: D These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). Because she has been smoke free for 2 years, she is in the maintenance stage.

The patient has quit smoking and has been smoke free for the past 2 years. Of the following stages, which best fits her current stage of change? a. Contemplation b. Preparation c. Action d. Maintenance

ANS: D These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). Because she has been smoke free for 2 years, she is in the maintenance stage.

Which technique will be most successful in ensuring effective communication? The nurse uses a. Interpersonal communication to change negative self-talk to positive self-talk. b. Small group communication to present information to an audience. c. Intrapersonal communication to build strong teams. d. Transpersonal communication to enhance meditation.

ANS: D Transpersonal communication is interaction that occurs within a person's spiritual domain. Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power." Interpersonal communication is one-on-one interaction between the nurse and another person that often occurs face to face. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. Small group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Intrapersonal communication is a powerful form of communication that occurs within an individual. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions

A nurse uses SBAR during hand-offs. The purpose of SBAR is to a. Use common courtesy. b. Establish trustworthiness. c. Promote autonomy. d. Standardize communication.

ANS: D When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, a risk of miscommunication arises. Accurate communication is essential to prevent errors. SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others.

2. A 70-year-old client asks the nurse to explain her hypertension as she is to have her blood pressure checked each shift. An appropriate response by the nurse as to why older clients often experience hypertension is because of: 1. Myocardial muscle damage 2. Reduction in physical activity 3. Ingestion of foods high in sodium 4. Accumulation of plaque on arterial walls

Accumulation of plaque on arterial walls

15. When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as: 1. Respiratory 2. Activity and exercise 3. Sleep and rest pattern 4. Self-care deficit: activities of daily living

Activity and exercise

15. The nurse has completed an assessment on the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned? 1. Activity intolerance related to pain 2. Ineffective management of treatment regimen 3. Noncompliance with prescribed exercise plan 4. Knowledge deficit regarding impending surgery

Activity intolerance related to pain

5. For an older adult client, an example of a common behavioral task or critical event is: 1. Selecting a mate 2. Rearing children 3. Finding a congenial social group 4. Adjusting to decreasing physical strength

Adjusting to decreasing physical strength

4. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated? 1. Teaching a client to administer his or her insulin injection 2. Assisting a new mother with learning the art of breast-feeding 3. Notifying the nutritionist of a client's specific dietary preferences 4. Administering a cleansing enema in preparation for radiological testing

Administering a cleansing enema in preparation for radiological testing

5. Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult? 1. 50% of older adults have two chronic health problems. 2. Cancer is the most common cause of death among older adults. 3. Nutritional needs for both younger and older adults are essentially the same. 4. Adults older than 65 comprise the greatest users of prescription medications.

Adults older than 65 comprise the greatest users of prescription medications.

17. Which of the following nursing actions is most likely a result of the nurse's clinical experience? 1. Placing an immobile client on a turning schedule 2. Always assessing a client's IV site before hanging a new bag of fluid 3. Requesting that the nursing assistant have vital signs recorded by 0815 4. Administering a pain medication 30 minutes before changing a burn dressing

Always assessing a client's IV site before hanging a new bag of fluid

1. A client thinks that she might be pregnant. Which first trimester physiological changes would most likely indicate this? 1. Amenorrhea and nausea 2. Braxton Hicks contractions 3. Increased urinary frequency 4. Edematous ankles and dyspnea

Amenorrhea and nausea

17. A client who is re-learning to walk asks the nurse, "to come with me today to physical therapy." The nurse realizes that the client is most likely expressing: 1. A need for emotional support 2. A need for familiar companionship 3. An appreciation of the nurse's caring 4. An interest in validating her progress

An appreciation of the nurse's caring

19. Which of the following statements best defines quality improvement (performance improvement)? 1. The assessment of the delivery system responsible for the implementation of client-oriented interventions 2. Integration of evidence-based practice research into the delivery process used to implement client-oriented interventions 3. High-priority evaluation process directed towards differentiating between good and poor intervention delivery by providers 4. An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client's needs

An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client's needs

31. A client has been recently told that the primary cancer has metastasized and the cancer is considered terminal. When the nurse offers to discuss palliative care options the client replies, "I can't understand why you all want to upset me by bringing the topic up. Now please just leave me alone." The nurse recognizes this response as: 1. Anger 2. Disbelief 3. Bargaining 4. Acceptance

Anger

6. A client, after being taught of the clinical manifestations of inflammation to enable early detection of a complication of a surgical wound states, "I will look at the wound four times a day and tell my surgeon if it looks red or swollen." Her statement is an example of: 1. Attitudes 2. Application 3. Analysis 4. Evaluation

Application

12. Use of the intellectual standard of critical thinking implies that the nurse: 1. Questions the physician's order 2. Recognizes conflicts of interest 3. Listens to both sides of the story 4. Approaches assessment logically

Approaches assessment logically

6. The nurse is aware that the majority of older adults: 1. Live alone 2. Live in institutional settings 3. Are unable to care for themselves 4. Are actively involved in their community

Are actively involved in their community

12. Client assessment provides the nurse with necessary information for the development of an effective plan of care. When determining the influence of an internal variable on the client's health status, the nurse will specifically look for: 1. Anxiety level present 2. Family remedies used 3. Location and type of occupation 4. Available health insurance coverage

Anxiety level present

29. A client expresses concern over a scheduled intravenous pyelogram by stating, "I don't know what to expect." Which of the following nursing diagnoses is most appropriate for this client need? 1. Anxiety related to scheduled diagnostic testing 2. Knowledge deficit regarding need for diagnostic testing 3. Knowledge deficit related to need for intravenous pyelogram 4. Anxiety related to lack of knowledge concerning intravenous pyelogram

Anxiety related to lack of knowledge concerning intravenous pyelogram

Aerobic bacteria

Bacteria that require oxygen for survival

21. With which of the following interventions does the nurse best reflect caring by maintaining belief in a client? 1. Offering a client with cancer pain medication before a family visit 2. Explaining to a client what to expect during a bone marrow aspiration 3. Arranging for a burn client to talk with others who survived similar burns 4. Explaining to a client that he may select from a variety of entrees for dinner

Arranging for a burn client to talk with others who survived similar burns

8. Which of the following nursing activities is an example of tertiary level caregiving? 1. Teaching a client how to irrigate a new colostomy 2. Providing a class on hygiene for an elementary school class 3. Informing a client that her infant can be immunized at the health department 4. Arranging for a hospice nurse to visit with the family of a client with lung cancer

Arranging for a hospice nurse to visit with the family of a client with lung cancer

21. The nurse is preparing the discharge teaching materials on newly prescribed drugs to a client diagnosed to be in the early stage of Alzheimer's disease. The nurse best deals with the client's cognitive deficits by: 1. Providing written material to supplement the discussion 2. Arranging for family to be present during the discussion 3. Presenting the material in two short but focused sessions 4. Requiring the client to restate the information in her own words

Arranging for family to be present during the discussion

22. Which of the following interventions made by a new graduate nurse reflects the best understanding of knowing her client? 1. Asking the client, "What do you need to be more comfortable?" 2. Offering the client's family a sleeper chair for use in the client's room 3. Providing an extra blanket for a client who often complains of being cold 4. Awakening the client for a phone call from her son who lives out of town

Asking the client, "What do you need to be more comfortable?"

7. To best improve the bathing care provided by a particular staff member, the nurse manager should: 1. Tell the staff member how to correctly give baths to clients 2. Provide the staff member with good resources to read on bathing clients 3. Ask another staff member to provide the unit's bathing care in the afternoon 4. Assist and observe the staff member in the bathing care of a client on the unit

Assist and observe the staff member in the bathing care of a client on the unit

8. For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention? 1. Teaching 2. Counseling 3. Compensating for adverse reactions 4. Assisting with activities of daily living (ADLs)

Assisting with activities of daily living (ADLs)

7. A nurse is preparing an education program on safety for a young adult group. Based on the major cause of mortality and morbidity for this age-group, the nurse should focus on: 1. Birth control 2. Automobile safety 3. Occupational hazards 4. Prevention of heart disease

Automobile safety

2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month well-baby visit? 1. Moro 2. Startle 3. Babinski 4. Extrusion

Babinski

20. The nurse is preparing to present a teaching session on skin protection for a group of older adults at a senior center. A principle that has been found to be most effective in teaching older adults is: 1. Moving the group along at a predetermined pace 2. Providing information in longer teaching sessions 3. Speaking very slowly and in a louder tone of voice 4. Beginning and ending each session with important information

Beginning and ending each session with important information

3. In evaluating an infant's physical status and growth, the nurse expects to find: 1. Birth weight triples by 6 months 2. Anterior fontanel closes 4 to 8 weeks after birth 3. Chest circumference is larger than head circumference at 12 months 4. Birth height increases 1 inch each month for the first 6 months

Birth height increases 1 inch each month for the first 6 months

19. A client reports to the nurse that the room is "too hot." Which of the following nursing actions best reflects the nurse's understanding of the therapeutic manipulation of the client's environment? 1. Bringing a portable fan into the room 2. Assisting the client in the removal of excess clothing 3. Offering to ambulate the client into the visiting lounge 4. Closing the blinds to minimize the sunshine through the windows

Bringing a portable fan into the room

**A nurse who is sensitive to the care of families recognizes that the term "family" is primarily defined: 1. As individuals legally bound to the client 2. As people with biological connections to the client 3. In terms generally accepted by the majority of clients 4. By the client as individuals important to the client

By the client as individuals important to the client

13. When facilities strive to improve client satisfaction, the area of primary focus should be: 1. Holistic client care 2. Caring nursing staff 3. Expert care providers 4. State-of-the-art technology

Caring nursing staff

25. Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals? 1. Client will properly clean the hearing aid ear piece daily with soap and water. 2. Client will state 3 positive effects of wearing his hearing aid at follow-up appointment. 3. Client will wear hearing aid while awake to help improve his ability to understand instructions. 4. Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.

Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.

12. Which of the following outcomes best reflects a nurse-sensitive client outcome? 1. Client will consume 75% of all meals. 2. Client will perform personal hygiene daily. 3. Client will experience no falls during hospitalization. 4. Client will report lessened anxiety regarding surgical procedure.

Client will experience no falls during hospitalization.

23. Which of the following would be the most appropriate outcome criterion for the goal, "Client's pain will be managed to within an acceptable level within 30 minutes of receiving pain medication." 1. Client will deny presence of any pain or discomfort. 2. Client will rate pain at a level of 3 or less out of a possible 10. 3. Client will demonstrate ability to request pain medication as needed. 4. Client will identify two external factors that decrease presence of pain.

Client will rate pain at a level of 3 or less out of a possible 10.

34. Which of the following goals concerning client anxiety is the best example of measurability? 1. Client will be less anxious by discharge. 2. Client will appear less anxious by discharge. 3. Client will report anxiety at less than 3 out of 5 by discharge. 4. Client pulse rate and blood pressure will be within normal limits by discharge.

Client will report anxiety at less than 3 out of 5 by discharge.

35. Which of the following goals best reflects measurability? 1. Client's emotional state will be stable by time of discharge. 2. Client will experience normal sensations in feet by discharge. 3. Client will report being free of shoulder pain by discharge. 4. Client will have acceptable range of motion in elbow by discharge.

Client will report being free of shoulder pain by discharge.

11. Which of the following statements best reflects a goal based on a clinical standard of practice? 1. Client will lose 10 pounds in 90 days. 2. Client will walk 30 feet with minimal assistance. 3. Client's peripheral intravenous site will be free of redness. 4. Client's chronic pain will be managed with oral medication by discharge.

Client's peripheral intravenous site will be free of redness.

9. Caring enables a nurse to know the client and thereby focus on identifying the client's specific needs. This ability is most typically impacted by a nurse's: 1. Assessment skills 2. Sense of compassion 3. Clinical experience 4. Communication proficiency

Clinical experience

13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the client's health problem. To obtain these data most efficiently, the nurse should use: 1. Channeling 2. Open-ended questions 3. Closed-ended questions 4. Problem-seeking responses

Closed-ended questions

6. The nurse can best demonstrate caring behavior by: 1. Updates the family about the client's condition 2. Asks to address the client by the client's first name 3. Closes the door and covers the client during morning care 4. Shares with the client's roommate that she is scheduled for tests

Closes the door and covers the client during morning care

4. A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as: 1. Clustering data 2. Validating data 3. Peer reviewing 4. Problem statement

Clustering data

5. The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill? 1. Cognitive 2. Interactive 3. Psychomotor 4. Communication

Cognitive

10. A child's understanding of the concept of ice becoming water, Piaget's stage of cognitive development, is seen in: 1. Sensorimotor 2. Preoperational 3. Formal operations 4. Concrete operations

Concrete operations

8. The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved? 1.The problem area should be totally delegated to the consultant. 2. Consultation is often used when the exact problem remains unclear. 3. The problem area is identified by any member of the health care team. 4. Feelings about the problem should be described to the consultant by the nurse.

Consultation is often used when the exact problem remains unclear.

5. A client is discharged following a heart attack. In using the Stages of Health Behavior Change as a guide, the nurse recognizes that the client is most likely to begin to accept information on diet changes and an exercise program during which stage? 1. Action 2. Preparation 3. Maintenance 4. Contemplation

Contemplation

8. A sample of orthopedic clients varies greatly in their requests for postsurgical analgesics. Which type of nursing research would best examine a prospective group of clients in determining what factors affect their alterations in comfort? 1. Historical research 2. Evaluation research 3. Correlational research 4. Experimental research

Correlational research

15. A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization? 1. Crayons and a coloring book 2. A 1000-piece puzzle to complete 3. A CD player with soothing CDs 4. A Nerf football to throw around the room

Crayons and a coloring book

7. The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client? 1. Nursing Kardex 2. Computerized care plan 3. Critical pathway 4. Standardized care plan

Critical pathway

25. The primary factor that distinguishes a professional nurse's care from care provided by ancillary nursing staff is: 1. Critical thinking 2. Years of education 3. Professional licensure 4. Complexity of the task

Critical thinking

24. With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1. The veteran nurse has a varied history of client care experiences 2. Critical thinking improves with experience, longevity, and interest 3. Today's short hospital stays minimize the opportunity to develop critical thinking skills 4. New graduates often lack the self-confidence to take the risks often required of critical decision making

Critical thinking improves with experience, longevity, and interest

3. The nurse begins to auscultate the client's lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of: 1. Performing a nursing assessment 2. Reorganizing the nursing diagnoses 3. Implementing nursing interventions 4. Critically analyzing client assessment data

Critically analyzing client assessment data

19. Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1. Determining that the client's ankle edema is worse after he ambulates 2. Asking the client to rate his ankle pain after receiving oral pain medication 3. Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 4. Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

10. The nurse is performing a physical examination on a 58-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging? 1. Palpable thyroid lobes 2. Decreased skin turgor 3. Reduced pupillary reaction 4. Increased range of joint motion

Decreased skin turgor

3. The nurse is performing a physical examination on a 40-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging? 1. Decreased hearing acuity 2. Decreased sense of smell 3. Decreased strength of abdominal muscles 4. Decreased function of the various cranial nerves

Decreased strength of abdominal muscles

3. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Acute pain related to left mastectomy 2. Impaired gas exchange related to altered blood gases 3. Deficient knowledge related to need for cardiac catheterization 4. Need for high protein diet related to alteration in client nutrition

Deficient knowledge related to need for cardiac catheterization

20. The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure: 1. Effective use of both nursing time and resources 2. Delivery of both timely and relevant nursing care 3. Concrete evidence of successful outcome achievement 4. Minimal ineffective communication among the nursing staff

Delivery of both timely and relevant nursing care

1. Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy? 1. Detection of fetal movement 2. Observation that the uterus is below the pubis 3. Confirmation of the desire to breast- or bottle-feed 4. Determination of the presence of morning sickness

Detection of fetal movement

10. The primary purpose of the nursing evaluation process is to: 1. Determine the effectiveness of the nursing care provided 2. Identify interventions that are ineffective in achieving client goals 3. Establish the progress the client is making towards health and wellness 4. Critique the nurse's ability to implement appropriate nursing interventions

Determine the effectiveness of the nursing care provided

5. The nurse, trying to promote positive health habits regarding stress management is aware of the external influences on young and middle adult clients. With this knowledge, the nurse recognizes that an effective strategy for this age-group is: 1. Teaching clients to abstain from all alcohol consumption 2. Demonstrating how to take an accurate blood pressure measurement 3. Determining an effective daily exercise schedule for stress reduction 4. Describing the types of medications commonly used for treating depression

Determining an effective daily exercise schedule for stress reduction

Initially, the nurse should begin by doing what in completing a client's family assessment? 1. Collecting health data from all the family members 2. Testing the family's ability to cope with normal stressors 3. Evaluating the family's interpersonal communication patterns 4. Determining the client's definition of familiar structure and attitudes

Determining the client's definition of familiar structure and attitudes

10. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data? 1. Pain in the left leg 2. Elevated blood pressure 3. Fear of impending surgery 4. Discomfort upon breathing

Elevated blood pressure

2. Which one of the following is the main, overarching goal for Healthy People 2010? 1. Reduction of health care costs 2. Elimination of health disparities 3. Investigation of substance abuse 4. Determination of acceptable morbidity rates

Elimination of health disparities

9. Which of the following research topics best lends itself to the experimental research process method? 1. The effects of therapeutic touch on a geriatric client diagnosed with Alzheimer's disease 2. Prioritizing three nursing diagnoses for a newly admitted client with diabetes mellitus 3. Employing humor as an intervention with clients who are recovering from orthopedic surgery 4. Determining the blood pressure patterns of a client who recently experienced a cerebrovascular accident (i.e., stroke)

Employing humor as an intervention with clients who are recovering from orthopedic surgery

20. The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group? 1. Suggest that he purchase an emergency in-home alert system. 2. Arrange for the client to receive meals delivered to his home daily. 3. Encourage the client to use a compartmentalized pill storage container for his daily medications. 4. Provide a written document describing the medications the client is currently prescribed.

Encourage the client to use a compartmentalized pill storage container for his daily medications.

19. While teaching the client about management of his heart disease, a nurse might use a strategy that is implemented to promote learning in the affective domain such as: 1. Asking the client what he believes he needs to know about the diagnosis 2. Providing brochures both on current exercises and on nutrition guidelines 3. Encouraging the client to personally discuss his feelings about his health status 4. Having the client return-demonstrate self-measurement of his own blood pressure

Encouraging the client to personally discuss his feelings about his health status

2. The nurse using Erikson's theory to assess a 20-year-old client's developmental status expects to find which of the following behaviors? 1. Coping with physical and social losses 2. Enjoys participating in the community 3. Applying self to learning skills 4. Overcoming a sense of guilt or frustration

Enjoys participating in the community

30. The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to: 1. Facilitate the exchange of information between appropriate parties 2. Minimize the opportunity for this information to be assessed inappropriately 3. Ensure the client's right to have his medical information regarded as personal and confidential 4. Guarantee that the information will be shared with only those requiring it for client care purposes

Ensure the client's right to have his medical information regarded as personal and confidential

5. The nurse should realize that the most important aspect of knowing the client involves: 1. Establishing a relationship 2. Gathering assessment data 3. Treating discomforts quickly 4. Assuming the client's emotional needs

Establishing a relationship

14. In accordance with Erikson's theory, it is expected by the nurse that a middle-aged adult client will be involved in the process of: 1. Developing a sense of identity 2. Searching for meaning in life 3. Enhancing one's capability to love others 4. Expanding personal and social involvement

Expanding personal and social involvement

13. A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1. Curiosity 2. Experience 3. Perseverance 4. Scientific knowledge

Experience

2. The second component of critical thinking in the "critical thinking model" is: 1. Experience 2. Competencies 3. Specific knowledge 4. Diagnostic reasoning

Experience

26. A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse's mentor? 1. Conducting the interview with the client's boyfriend present 2. Stopping the interview to answer a page from the nursing station 3. Frequently checking the time while waiting for the client to answer 4. Heard asking the client, "Am I correct; you've rated your pain a 9 out of 10?"

Frequently checking the time while waiting for the client to answer

19. Which of the following nursing interventions is the best example of a primary care prevention strategy regarding the flu? 1. Staffing a flu immunization clinic at a senior citizen's center 2. Providing flu prevention literature for distribution to visitors 3. Reminding client care personnel of the importance of the flu shot 4. Getting a drug manufacturer to donate flu vaccine for the homeless

Getting a drug manufacturer to donate flu vaccine for the homeless

2. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be: 1. Goal met; client able to state three symptoms 2. Goal not met; client able to list three symptoms 3. Goal not met; client unable to list five symptoms 4. Goal partially met; client able to state three symptoms

Goal partially met; client able to state three symptoms

9. The nurse has completed an assessment and found that the client has "an activity and exercise abnormality." This type of wording indicates that which of the following organizing formats has been used? 1. Review of systems 2. Nursing health history 3. Gordon's functional health patterns 4. Biographical information database

Gordon's functional health patterns

6. The nurse working in an adult medical clinic wishes to learn more about a developmental theory that focuses on the adult years. The nurse investigates different possibilities and selects the theory proposed by: 1. Gould 2. Piaget 3. Freud 4. Chess and Thomas

Gould

15. The nurse is presenting an information session on nutritional guidelines at a senior living center. Which of the following foods meets the recommended nutritional guidelines for older adults? 1. Grilled chicken 2. Hamburger and french fries 3. Hot dog with dill pickle relish 4. Baked potato with cheese and bacon bits

Grilled chicken

7. The client continues to ask questions about a surgical wound. The client states, "I think I would like help the first time I look at my wound." This is an example of: 1. Adaptation 2. Perception 3. Organizing 4. Guided response

Guided response

17. The nurse knows that the greatest internal factor to consider when educating an adult client concerning health promotion activities is the client's: 1. Emotional wellness 2. Developmental stage 3. Professed spirituality 4. Intellectual background

Intellectual background

7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was admitted to the surgical center to have his tonsils removed to: 1. Perform his own preoperative hygienic care 2. Have alone time to relax before the procedure 3. Handle the equipment when taking his blood pressure 4. Have access to age-appropriate magazines and puzzles for diversion

Handle the equipment when taking his blood pressure

8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1. Has a documented blood pressure of 90/50 2. Was medicated for back pain 10 minutes ago 3. Has an order to be out of bed and ambulated 4. Requires instructions for wound care before discharge

Has a documented blood pressure of 90/50

17. The nurse is preparing to discuss postpartum depression as a part of discharge teaching with the parents of a newborn. Which of the following nursing actions would be most therapeutic regarding early detection of this postpartum condition? 1. Helping the couple understand the importance of social interaction with other adults 2. Providing the couple with a video that tells the story of a new mother's experience with depression 3. Encouraging the couple to attend parenting classes designed to minimize the stressors of parenting an infant 4. Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression

Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression

14. A client tells the nurse that his illness is a result of his failure to "live a good life." The nurse recognizes this statement as an example of the client's: 1. Risk factor 2. Health belief 3. Illness behavior 4. Negative health behavior

Health belief

19. What is the single greatest factor that contributes to the struggle of today's nurses to "know" the client? 1. Nursing shortage 2. High client acuity 3. Shorter hospital stays 4. Increasing client loads

High client acuity

**Of the following trends, which one represents the greatest current health care challenge to nurses? 1. Homelessness 2. Single parent families 3. Alternative relationship patterns 4. "Sandwiched" or middle geration

Homelessness

17. A nurse caring for a 78-year-old client recently diagnosed with pneumonia will find Erikson's psychosocial development theory most helpful in determining: 1. Which needs the client will typically develop 2. Which coping mechanisms the client will likely use 3. How the client will respond to the respiratory problem 4. How the client and his family will adjust to the stressors

How the client will respond to the respiratory problem

2. The Health Information Portability and Accountability Act (HIPAA), implemented in 2003, may influence nursing research in the area of: 1. The cost of the study 2. Where the study may be published 3. What type of study may be conducted 4. How the data will be obtained and protected

How the data will be obtained and protected

19. The purpose and distinction of a concept map, which a nurse may use when implementing a plan of care, are for: 1. Multidisciplinary communication 2. Quality assurance in the health care facility 3. Provision of a standardized format for client problems 4. Identification of the relationship of client problems and interventions

Identification of the relationship of client problems and interventions

3. The expected research role for the baccalaureate-prepared nurse is to: 1. Assume the role of a clinical expert 2. Acquire funding for research projects 3. Identify clinical nursing problems in practice 4. Develop methods of inquiry relevant to nursing

Identify clinical nursing problems in practice

15. The primary purpose for the nurse to understand human growth and development is to be best able to: 1. Identify deviations from normal 2. Select effective nursing interventions 3. Be sensitive to age-appropriate needs 4. Enhance nurse-client communication

Identify deviations from normal

1. The nurse uses nursing diagnoses after completion of the client assessment, because they: 1. Are required for accreditation purposes 2. Identify the domain and focus of nursing 3. Assist the nurse to distinguish medical from nursing problems 4. Make all client problems become more quickly and easily resolved

Identify the domain and focus of nursing

What do microbes need to thrive

PH, Food, Water, O2, Light

16. The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to: 1. Implement care that has its basis in evidence-based practice 2. Produce care plans that are specific to the individual client needs 3. Improve the standard of care provided to the clients cared for on that unit 4. Provide the staff on that unit with guidelines to ensure the delivery of quality care

Improve the standard of care provided to the clients cared for on that unit

12. Which of the following is an appropriate etiology for a nursing diagnosis? 1. Incisional pain 2. Poor hygienic practices 3. Need to offer bedpan frequently 4. Inadequate prescription of medication

Incisional pain

28. What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift? 1. Document the request in the nursing notes. 2. Include the client's request in the shift report. 3. Place instructions regarding the client's wishes above the client's bed. 4. Verbally inform the unit clerk of the client's request.

Include the client's request in the shift report.

6. When assessing the external variables that influence a client's health beliefs and practices, the nurse must consider his: 1. Income status 2. Religious practices 3. Educational background 4. Reaction to the heart disease

Income status

17. For a functionally illiterate client, the nurse particularly focuses on: 1. Using intricate analogies and examples 2. Avoiding lengthy return demonstrations 3. Incorporating familiar nonmedical terminology 4. Providing longer learning sessions with the client

Incorporating familiar nonmedical terminology

what cause redness and warmth during inflammation

Increase blood pressure

10. In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging? 1. Increased perspiration 2. Increased airway resistance 3. Increased salivary secretions 4. Increased pitch discrimination

Increased airway resistance

11. Which one of the following is an appropriate etiology for a nursing diagnosis? 1. Myocardial infarction 2. Cardiac catheterization 3. Abnormal blood gas levels 4. Increased airway secretions

Increased airway secretions

1. A nurse is performing a physical examination on an older-adult client in an assisted living facility. On completion of the examination, the nurse compares the results to findings expected for individuals in this age-group. An expected finding for this client is: 1. Increased tactile responsiveness 2. Increased sensitivity to visual glare 3. Increased hearing acuity for higher tones 4. Increased thoracic expansion during ventilation

Increased sensitivity to visual glare

4. When a nurse researcher distributes an explanatory information sheet to subjects solicited for participation in her study, which of the following ethical principles that guide research is this researcher using? 1. Informed consent 2. Freedom from harm 3. Protection of subjects 4. Confidentiality of subjects

Informed consent

19. A nurse is preparing to discharge an 11-month-old child after a hospitalization for a viral infection. The nurse uses anticipatory guidance most effectively when: 1. Encouraging the parents to limit visitors for 14 days 2. Providing the parents with written discharge instructions 3. Arranging the follow-up pediatrician appointment for the parents 4. Informing the parents that the child may cry when taken to daycare

Informing the parents that the child may cry when taken to daycare

**A client is unable to independently perform colostomy care due to arthritis. The nurse should first: 1. Offer to assist the client to learn to manage the care 2. Arrange for home care services to care for the colostomy 3. Inquire as to family members who may be able to assist with the care 4. Suggest that the client attend a colostomy self-help support group

Inquire as to family members who may be able to assist with the care

7. The nurse has determined the following outcome for a client with a skin impairment: "Erythema will be reduced in 3 days." Evaluation will specifically focus on: 1. Selection of appropriate wound care 2. Notation of the odor and color of drainage 3. Inspection of the color and condition of the area 4. Measurement of the diameter of the ulceration daily

Inspection of the color and condition of the area

18. In preparing a teaching plan for adult clients in a cancer support group, the nurse incorporates evidence-based information. The nurse recognizes that evidence obtained about adult learners has identified that this group prefers: 1. Computer-assisted instruction 2. Traditional classroom settings 3. Long sessions with plenty of technical information 4. Interesting personal communication techniques

Interesting personal communication techniques

infections process: prodromal stage

Interval from onset of non specific signs and symptoms to more specific symptoms

21. Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: "Client will lose 10 pounds in 3 months?" 1. Interview the client to identify reasons why the goal was not met. 2. Assess the client for possible physical reasons for failure to lose the weight. 3. Discuss with the client whether they were truly motivated to lose the weight. 4. Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months.

Interview the client to identify reasons why the goal was not met.

3. The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is "not right" with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology

Intuition

16. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is: 1. Offer fluids to the client q2h 2. Observe the client's respirations 3. Change the client's dressing daily 4. Irrigate the nasogastric tube q2h with 30 ml normal saline

Irrigate the nasogastric tube q2h with 30 ml normal saline

16. Which one of the following statements is correct regarding the preadolescence developmental stage? 1. It appears 2 years earlier in boys than in girls. 2. Intimate feelings are confided in the parents. 3. Interest in the opposite sex is not a factor for this group. 4. It signals the development of secondary sex characteristics.

It signals the development of secondary sex characteristics.

4. A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that: 1. Diet and exercise can slow the process considerably 2. Few clients live more than 3 years after the diagnosis 3. Many individuals can be cured if the diagnosis is made early 4. It usually progresses gradually with a deterioration of function

It usually progresses gradually with a deterioration of function

14. In planning to teach an older adult client, the nurse should incorporate which teaching method or principle into the plan? 1. Keep teaching sessions short. 2. Teach in the early morning or late evening. 3. Put as much as possible into each teaching session. 4. Focus on teaching a family member or caregiver instead.

Keep teaching sessions short.

1. A nurse who wants to apply a theory that relates to moral development should read more from the work of: 1. Gould 2. Freud 3. Erikson 4. Kohlberg

Kohlberg

The gratest risk to a child of adolescent parents comes from the: 1. Increased family stressors resulting in domestic violence 2. Lack of appropriate parenting resources and role models 3. Statically high potential for physical and emotional abuse 4. Parents inability to provide health care and economc support

Lack of appropriate parenting resources and role models

8. A nurse is working in the health office at a local college where most of the students are young adults. Being aware of the major concerns for this age-group, the nurse includes assessment of these clients': 1. Current marital history status 2. Lifestyle and leisure activities 3. Experience with chronic disease 4. History of childhood accidents

Lifestyle and leisure activities

1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request? 1. Low priority 2. An unmet need 3. Intermediate priority 4. A safety and security need

Low priority

8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the client's: 1. Respiratory rate 2. Complaint of chest pain 3. Lungs clear bilaterally on auscultation 4. Ability to perform incentive spirometry

Lungs clear bilaterally on auscultation

11. The nurse in a pediatric health care setting is using Kohlberg's developmental theory. A child is evaluated as having reached level I, the preconventional level, if the child: 1. Makes sure that he or she is not late for school 2. Cleans the blackboards after school for the teacher 3. Runs for school council in order to change policies 4. Stays away from peer groups that harass other children

Makes sure that he or she is not late for school

13. The nurse is working with a new mother who will require surgery. The follow-up treatment will interfere with bonding. In applying Freud's theory, the nurse recognizes that the stage of development that may be affected is the: 1. Oral stage 2. Anal stage 3. Phallic stage 4. Latent stage

Oral stage

24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority? 1. Inventory of clothes and other personal belongings 2. Orientation to the nursing unit and individual room 3. Interview regarding medications currently being taken 4. Assessment of body systems for presurgery checklist

Orientation to the nursing unit and individual room

1. A client interview consists of three phases. The nurse recognizes that those phases are: 1. Orientation, working, termination 2. Introduction, controlling, selection 3. Introduction, assessment, conclusion 4. Orientation, documentation, database

Orientation, working, termination

5. When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should: 1. Redevelop the entire client care plan 2. Focus on changing the nursing diagnoses and goals 3. Perform a complete reassessment of all client factors 4. Add more nursing interventions from a standardized plan of care

Perform a complete reassessment of all client factors

2. The nurse knows that according to Benner, caring is defined as a: 1. New consciousness and moral idea 2. Nurturing way of relating to a valued other 3. Person, event, project, or thing that matters to a person 4. Central, unifying, and dominant domain necessary for health and survival

Person, event, project, or thing that matters to a person

10. A client with chronic respiratory problems tells the nurse, "I haven't felt this good in a long time." The nurse realizes that the statement most reflects the client's: 1. Willingness to share his feelings 2. Acceptance of his physical limitations 3. Personal definition of his individual health 4. Acknowledgment of his chronic health problems

Personal definition of his individual health

8. In Kohlberg's Moral Development theory, an individual who reaches level II (conventional thought) is expected to exhibit: 1. Absolute obedience to authority 2. Reasoning based on personal gain 3. Personal internalization of other's expectations 4. Self-chosen ethical principles, universality, and impartiality

Personal internalization of other's expectations

15. Because young adults are less likely to experience serious illness, which of the following nursing interventions is most effective in determining risk for illness in this age-group? 1. Health screenings 2. Personal lifestyle assessment 3. Full body systems assessment 4. Cardiopulmonary focal assessment

Personal lifestyle assessment

4. Riemen's study of nurses' caring behaviors (1986) found which one of the following as a similarity between male and female clients' perceptions of nursing caring behaviors? 1. Physical presence 2. Promotion of autonomy 3. Knowledge of injection technique 4. Speed in the completion of treatment

Physical presence

22. Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1. Performing a head-to-toe assessment on a new admission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client's allergy to an ordered medication

Placing a client experiencing shortness of breath on oxygen

13. The nurse assists the family of a 9 year old with nutritional information. A recommended after-school snack for a child this age is: 1. Milk shakes 2. Potato chips 3. Plain popcorn 4. Bite-size candy

Plain popcorn

37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to: 1. Facilitate the intervention in a timely manner 2. Evaluate the client's response to the intervention 3. Possess the technical skills required to implement the intervention 4. Provide client education regarding the implementation of the intervention

Possess the technical skills required to implement the intervention

28. Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? 1. Poor client compliance resulting from generalized diminished capacity 2. Inadequate health insurance coverage for the group as a whole 3. Insufficient research to provide a basis for effective geriatric health care 4. Preconceived assumptions regarding the lifestyles and attitudes of this group

Preconceived assumptions regarding the lifestyles and attitudes of this group

15. A client has confided to the nurse that she would prefer hospice care to receiving further radical treatment for terminal pancreatic cancer. The nurse observes that the client fails to share her wishes with her family during a discussion regarding future treatment plans. Ethically, the nurse should first: 1. Tell the family of the client's expressed wishes 2. Privately ask the client if her wishes have changed 3. Inform the client's health care provider of her wishes 4. Share with the client the importance of expressing her wishes

Privately ask the client if her wishes have changed

what microbe cause gang green

clostridium perfringens

**The optimum goal of effective communication within the family, according to the nurse observing the family members and their interaction, is: 1. Problem solving and psychological support 2. Role development of individual members 3. Socialization among individual members 4. Better financial conditions for the family

Problem solving and psychological support

15. The dressing covering the pressure ulcer on a client's heel frequently becomes loosened and requires repeated reinforcement. The nurse asks, "What can be done to improve the adhering properties of this type of dressing?" The nurse has just formulated a: 1. PICO-formatted question 2. Research question (hypothesis) 3. Problem-focused triggered question 4. Knowledge-focused triggered question

Problem-focused triggered question

5. The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1. Inference 2. Management 3. Problem-solving 4. Diagnostic reasoning

Problem-solving

13. The primary reason for the establishment of standing orders is to: 1. Provide appropriate nursing autonomy in settings where client needs can change rapidly 2. Facilitate adequate care when direct contact with a primary health care provider is not immediately possible 3. Allow nurses to provide certain routine therapies without first notifying the primary health care provider 4. Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider

Provide appropriate nursing autonomy in settings where client needs can change rapidly

**The primary goal of family-centered nursing is to: 1. Promote the wellness of the family and its members 2. Implement appropriate care for the family and its members 3. Provide support and care for the family and its individual members 4. Identify physical and emotional problems affecting the family as a unit

Provide support and care for the family and its individual members

26. Which of the following actions is the primary nursing responsibility regarding client education? 1. Providing accurate, current, relevant information 2. Answering the client's questions regarding health-related issues 3. Assessing the individual client's readiness and motivation to learn 4. Identifying areas where clients are in need of educational information

Providing accurate, current, relevant information

12. Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse-initiated intervention is: 1. Providing client teaching 2. Administering medication 3. Ordering a liver CAT scan 4. Referring a client to physical therapy

Providing client teaching

**The mother of a child receiving immunizations at a health clinic shares with the nurse that she and the child have not eaten today. Which of the following nursing interventions is best directed at impacting the immediate problem while being sensitive to the mother's sense of self-worth? 1. Notifying family services of the problem 2. Taking both mother and child to the cafeteria 3. Informing the mother that she is eligible for food stamps 4. Providing her with contacts at the neighborhood food bank

Providing her with contacts at the neighborhood food bank

21. Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity? 1. Applying adequate clothing to ensure the client's warmth 2. Providing sufficient quantities of an aloe-based skin lotion 3. Helping the client select her favorite foods from the menu form 4. Dressing the client's feet in non-skid soled slippers when ambulating

Providing sufficient quantities of an aloe-based skin lotion

7. An enterostomal nurse shows a client's significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the client's significant other, the nurse is using what type of nursing skill? 1. Affective 2. Cognitive 3. Interactive 4. Psychomotor

Psychomotor

27. When a client newly diagnosed with type 2 diabetes mellitus assumes responsibility for checking her blood glucose level four times a day, this is an example of: 1. Cognitive learning 2. Affective learning 3. Impaired learning 4. Psychomotor learning

Psychomotor learning

1. Which of the following research approaches is an example of an exploratory type of research? 1. Establishing facts and relationships of past events 2. Testing how well a program, practice, or policy is working 3. Refining a hypothesis on the relationships among phenomena 4. Portraying the characteristics of persons, situations, or groups

Refining a hypothesis on the relationships among phenomena

24. To help a comatose client's family make a moral decision regarding the termination of life support, the nurse must first: 1. Refrain from expressing his/her personal beliefs concerning the life support issue 2. Provide the family with information regarding the process of terminating life support 3. Determine whether the client had expressed any written or oral wishes regarding the issue 4. Facilitate the family's decision-making process by providing them with a quiet, private space for discussion

Refrain from expressing his/her personal beliefs concerning the life support issue

9. Which of the following behaviors shows the greatest risk to an older adult as they attempt to minimize the effects of the aging process? 1. Increased cosmetic use 2. Refusing to share their actual ages 3. Spending less time with age-related peers 4. Refusing assistance with certain activities

Refusing assistance with certain activities

10. In the Health Belief Model, the nurse recognizes that the focus is placed on the: 1. Basic human needs for survival 2. Functioning of the individual in all dimensions 3. Relationship of perceptions and compliance with therapy 4. Multidimensional nature of clients and their interaction with the environment

Relationship of perceptions and compliance with therapy

1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client's environment. This involves the nurse: 1. Repositioning the client q2h 2. Removing clutter from the client's room 3. Delegating ambulation of clients to the nursing assistant 4. Providing pain medication to the client before a dressing change

Removing clutter from the client's room

10. When teaching basic infant safety to the parents of a 3 month old, the nurse should emphasize: 1. Placing gates at stairways 2. Keeping bathroom doors closed 3. Giving large, hard teething biscuits 4. Removing feeding bibs at bedtime

Removing feeding bibs at bedtime

22. When a client goal is unmet, which of the following nursing actions is most appropriate? 1. Reevaluation of the original client goal 2. Selection of new but appropriate interventions 3. Evaluation of the client's ability and motivation to be compliant 4. Repetition of the entire nursing process regarding the nursing diagnosis

Repetition of the entire nursing process regarding the nursing diagnosis

11. Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1. Reporting client difficulties 2. Offering an alternative approach 3. Looking for a different treatment option 4. Sharing ideas about nursing interventions

Reporting client difficulties

14. A nurse routinely uses therapeutic touch when caring for postoperative clients with incisional pain. Occasionally a client will show reluctance when the intervention is offered. The nurse's best response in such a situation is to: 1. Research for alternative interventions that will be better received by the client 2. Suggest that the client allow the intervention just once before making a final decision 3. Respect the client's wishes and rely on pain medication to help with managing the pain 4. Inform the client that the intervention has been found to be effective during several research projects

Research for alternative interventions that will be better received by the client

3. In reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true? 1. Delirium is usually easily distinguished from irreversible dementia. 2. Therapeutic drug intoxication is a common cause of senile dementia. 3. Reversible systemic disorders are often implicated as a cause of delirium. 4. Cognitive deterioration is an inevitable outcome of the human aging process.

Reversible systemic disorders are often implicated as a cause of delirium.

14. Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)? 1. Maintaining regular bowel elimination 2. Promoting the health of the entire family 3. Managing severely restricted body movement 4. Restoring tissue integrity to areas damaged by friction

Restoring tissue integrity to areas damaged by friction

9. The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is: 1. Administering analgesics 2. Restraining a violent client 3. Initiating stress-reduction therapy 4. Teaching the client how to take his/her pulse rate

Restraining a violent client

2. Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include: 1. Returning to sewing 2. Preventing ocular infection 3. Administering eye drops on time in the hospital 4. Performing independent hygienic care in the hospital

Returning to sewing

29. While discussing a client's medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation? 1. Note the allergy on the client's Kardex. 2. Inform the provider of the client's possible allergy. 3. Review the client's medical record for confirmation of the allergy. 4. Tell the client to have all medications identified before taking them.

Review the client's medical record for confirmation of the allergy.

7. After identifying the problem, the next step in the research process is to: 1. Select the population 2. Review the literature 3. Obtain approval to conduct the study 4. Identify the instrument to use for data analysis

Review the literature

22. The nurse observes signs of depression in a client who has been hospitalized for several weeks because of injuries sustained in an automobile accident. The client confirms his fears of never, "Being able to work and support my family as I did before." The nurse's initial intervention is to: 1. Offer to arrange for him to speak with the facility's chaplain 2. Assure the client that physical therapy will help him tremendously 3. Revise his care plan to include interventions to assist him with coping 4. Tell his health care provider of his need for antidepressant medication

Revise his care plan to include interventions to assist him with coping

4. The client states, "Heart disease runs in our family. My blood pressure has always been high." The nurse determines that this is an example of the client's: 1. Risk factors 2. Active strategy 3. Health beliefs 4. Negative health behavior

Risk factors

16. Which one of the following is a NANDA International nursing diagnosis label? 1. Frequent urination 2. Coughing and dyspnea 3. Risk for impaired parenting 4. Abnormal hygienic care practices

Risk for impaired parenting

4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1. Humility 2. Risk-taking 3. Accountability 4. Independent thinking

Risk-taking

18. Care plans created by nursing students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the student's care plan but not in the client's record is: 1. Client outcomes 2. Nursing diagnoses 3. Scientific rationales 4. Nursing interventions

Scientific rationales

7. A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of: 1. Health promotion 2. Primary prevention 3. Tertiary prevention 4. Secondary prevention

Secondary prevention

4. The nurse notes that a narcotic is to be administered "per epidural cath." The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed? 1. Seek assistance 2. Reassess the client 3. Use interpersonal skills 4. Critical decision making

Seek assistance

1. The best way for a new graduate to demonstrate caring behavior towards the client is by: 1. Seeking assistance before attempting a new procedure 2. Attempting to do new treatments as quickly as possible 3. Informing the client when performing a treatment for the first time on an actual client 4. Avoiding situations with clients that may be uncomfortable for either the nurse or the client

Seeking assistance before attempting a new procedure

16. A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process? 1. IV is discontinued. 2. Warm compress applied to IV site. 3. Site reinspected for presence of swelling. 4. IV site observed as having significant swelling.

Site reinspected for presence of swelling.

23. The nurse is best demonstrating perseverance by: 1. Having a perfect attendance record 2. Completing a lengthy course on current chemotherapies 3. Repeatedly irrigating the nasogastric tube until it is patent 4. Sitting with a client until she is ready to discuss why she is crying

Sitting with a client until she is ready to discuss why she is crying

11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to: 1. Say Da-da 2. Smile responsively 3. Differentiate strangers 4. Play social peekaboo games

Smile responsively

10. To provide optimum care, a nursing intervention should be based on: 1. An appropriate nursing diagnosis 2. Subjective and objective client data 3. Sound clinical judgment and knowledge 4. Identified physical and psychosocial needs of the client

Sound clinical judgment and knowledge

The nurse suspects that there is physical abuse present after visiting the client in the home. In recognition of the pattern of family violence, the nurse knows that: 1. Child abuse is declining in frequency 2. Spouses are the most frequent abusers 3. Mental illness is a major cause of abuse 4. Abuse is primarily seen in lower income families

Spouses are the most frequent abusers

11. Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance/illness prevention, the nurse should select a topic on: 1. Use of assistive devices, such as canes 2. Self-help devices for post-CVA clients 3. Stress management techniques for working parents 4. Environmental alterations for clients in wheelchairs

Stress management techniques for working parents

9. A client shares with the nurse that they have, "almost reached the goal of smoking only one-half pack of cigarettes a day." The best example of a nursing intervention to correct this unmet outcome is: 1. Discuss with the client the desire to comply with the ordered therapy 2. Suggest that the client use another smoking cessation tool to achieve the goal 3. Reevaluate the time frame originally decided upon for achievement of the goal 4. Suggest that the strength of the prescribed nicotine patches be increased to 21 mg

Suggest that the strength of the prescribed nicotine patches be increased to 21 mg

16. The goal of Pender's Health Promotion theory is best reflected in which of the following nursing interventions? 1. Suggesting the client experience a variety of exercise routines before settling on the one to adapt 2. Arranging for a client to attend a support group for individuals who also have severe burn scars 3. Playing soft, classical music when a client diagnosed with Alzheimer's becomes physically agitated 4. Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care

Suggesting the client experience a variety of exercise routines before settling on the one to adapt

19. The most serious risk for death for a young adult living in rural poverty is: 1. Suicide 2. Homicide 3. Poor health maintenance practices 4. Family history of chronic illnesses

Suicide

17. The nurse is teaching parents about probable warning signs that a teenager is considering suicide and tells parents to be alert to: 1. An increase in appetite 2. A sudden interest in school activities 3. An unexplained increase in sleepiness 4. Talking about death and personal harm

Talking about death and personal harm

12. Which of the following interventions best reflects the nurse's understanding of direct care interventions regarding a cognitively impaired client's need for social interaction? 1. Arranging for the client to attend a "sing along" in the dayroom 2. Helping the client place a long distance telephone call to his daughter 3. Turning the client's television on when his or her favorite program is playing 4. Talking about the client's favorite sport's team while redressing his or her wound

Talking about the client's favorite sport's team while redressing his or her wound

1. The client has been informed that he can be discharged once he can irrigate his colostomy independently. The client requests the nurse to observe his irrigation technique. Which of the following learning motives is the client displaying? 1. Physical need 2. Social activity 3. Task mastery 4. Evaluation stance

Task mastery

3. Which one of the following nursing activities is an example of Swanson's "enabling" in the caring process? 1. Staying with the client before surgery 2. Performing a urinary catheterization skillfully 3. Assessing the client's health history 4. Teaching the client how to inject fast-acting insulin

Teaching the client how to inject fast-acting insulin

5. The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is: 1. Telling 2. Trusting 3. Participating 4. Group teaching

Telling

20. Which of the following nurse-family interactions is most reflective of caring for the family? 1. Offering to arrange for a sleep chair for the family's use 2. Notifying the family that the client has returned from surgery 3. Telling the family when the client's surgeon will be on the unit 4. Always being available to spend time answering the family's questions

Telling the family when the client's surgeon will be on the unit

10. The nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands? 1. Defining the problem 2. Making final decisions 3. Testing possible options 4. Considering consequences

Testing possible options

**When caring for a terminally ill client, the nurse must also assess the family, because the primary benefit will be: 1. Effective use of time and resources in the end-of-life care of the client 2. Appropriate attention to the cultrual beliefs and expectations of the family 3. Added information regarding the care needs and preferences of the client 4. The ability to respond effectively to the familly unit during the dying process

The ability to respond effectively to the familly unit during the dying process

14. The elementary school nurse is responsible for evaluating each child's overall physical development. During the school-age years, the nurse anticipates that: 1. The child's body weight will almost triple 2. There will be few physical differences among children 3. The child will grow an average of 1 to 2 inches per year 4. Body fat will gradually increase, contributing to a heavier appearance

The child will grow an average of 1 to 2 inches per year

24. When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be: 1. The client tearing when being ambulated to the chair 2. A report from the ancillary staff that the client is reporting pain 3. The client observed grimacing when positioning self in the bed 4. Overhearing the client discuss hip pain with family on the phone

The client observed grimacing when positioning self in the bed

22. Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery? 1. The client will show no systemic or local signs of infection by time of discharge from hospital. 2. The client will demonstrate an understanding of the proper use of patient-controlled analgesia (PCA). 3. The client will demonstrate effective coughing and deep-breathing techniques within 2 hours of surgery. 4. The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.

The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.

38. The primary function of a care plan is to provide: 1. The client with continuity of care 2. The staff with written client-centered nursing interventions 3. An established criteria for the evaluation of nursing outcomes 4. An organized means of exchanging information between caregivers

The client with continuity of care

When working with families, the nurse may view the family as context or client. Which one of the following examples demonstrates the view of the family as context? 1. The family's ability to support the client's dietary and recreational needs 2. The client's ability to understand and manage his own personal dietary needs 3. The family's demands on the client that are based on the client's role performance 4. The adjustment of both the client and the family to changes in diet and exercise

The client's ability to understand and manage his own personal dietary needs

22. The nurse recognizes that the client's teaching plan is most directly driven by: 1. The client's identified learning needs 2. The complexity of the client's health needs 3. The client's readiness and motivation to learn 4. The presence of cultural or physical barriers

The client's identified learning needs

18. The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention? 1. No additional pressure ulcers are noted over a 1-week period. 2. Client expresses a decrease in pressure ulcer related pain within 1 week. 3. The client's pressure ulcer shows a decrease in size over a 1-week period. 4. The turning schedule is initiated to reflect appropriate positioning for a 1-week period.

The client's pressure ulcer shows a decrease in size over a 1-week period.

7. The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses? 1. The diagnosis should identify a "cause and effect" relationship. 2. The diagnosis must remain constant during the client's hospitalization. 3. The etiology of the diagnosis must be within the scope of the health care team's practice. 4. The diagnosis should include the problem and the related contributing conditions.

The diagnosis should include the problem and the related contributing conditions.

2. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about: 1. The onset and duration of his present breathing problem 2. His personal smoking, alcohol use, and exercise practices 3. Any extended family members who have diagnosed heart disease 4. Changes in other body systems that the client perceives as problematic

The onset and duration of his present breathing problem

20. Which of the following nursing actions best reflects the consequence stage of the decision-making process? 1. Being physically present when a client is given the results of a tissue biopsy 2. Witnessing the client sign consent for surgery forms before cardiac surgery 3. The client is informed of the various treatments available for his condition. 4. The nurse explains to the client the risks of leaving the hospital against medical advice.

The nurse explains to the client the risks of leaving the hospital against medical advice.

18. Which of the following client reactions reflects the greatest positive response to the nurse's use of caring touch in the form of a backrub? 1. The nurse observes the client smiling. 2. The client falls asleep shortly after the backrub. 3. The nurse feels the client's back muscles relaxing. 4. The client tells his wife that, "the nurse is so nice."

The nurse feels the client's back muscles relaxing.

16. Which of the following nursing situations best reflects accountability? 1. The nurse takes the oncology nursing certification examination. 2. The nurse files an incident report regarding a medication error. 3. The nurse assesses the client for the possible cause of his pain. 4. The nurse tells the client, "I don't know but I will find out for you."

The nurse files an incident report regarding a medication error.

33. The nurse realizes that goals should be singular in focus primarily because: 1. The nurse will find it difficult to modify the plan of care if the goals are not met. 2. The client may not have the strength to accomplish multiply behavioral changes. 3. The client may have difficulty focusing on more than one behavioral modification at a time. 4. The nurse will find it difficult to identify appropriate interventions to address multiple behaviors.

The nurse will find it difficult to modify the plan of care if the goals are not met.

3. The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about: 1. A family history of heart problems 2. Medications currently being taken at home 3. Questions or concerns about hospitalization 4. The onset, severity, and duration of the chest pain

The onset, severity, and duration of the chest pain

What can mess with normal flora?

The overuse or not finishing all broad spectrum antibiotics if all the normal flora is killed then the body lowers it's defenses for infections

14. When discussing the stressors felt by a single mother in her 30s, the nurse recognizes that the greatest financial impact on this family is caused by: 1. The ever-rising cost of living in the United States 2. The realization that a female earns 25% less than her male co-worker 3. Court-ordered child support is often times inadequate. 4. Daycare expenses are a strain on a single wage earner family

The realization that a female earns 25% less than her male co-worker

36. When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain, the nurse must first consider: 1. The institution's policies and procedures 2. The state's defined scope of nursing practice 3. The client's physiological and psychological needs 4. The scientific rationale for the proposed nursing action

The state's defined scope of nursing practice

Infections process: incubation period

interval between entrance of pathogen into body and appearance of first symptoms

infections process: convalescence

interval when acute symptoms of infection disappear

5. The client recently became febrile and stated he "felt hot." The nurse takes the client's temperature and finds it to be 38.2° C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data? 1. Pulse rate of 88 beats per minute 2. Blood pressure of 168/80 mm Hg 3. The statement regarding his feeling hot 4. The supported fact that he became febrile

The statement regarding his feeling hot

**What would a nurse expect to find in an assessment of a healthy family? 1. Change is viewed as detrimental to the family 2. There is a passive response to most stressors 3. The structure is flexible enough to adapt to crises 4. Minimum influence is being exerted on the environment

The structure is flexible enough to adapt to crises

30. When presenting information to the older adult, the client will be most likely to engage with the nurse in the learning process if: 1. Client feedback is encouraged and valued 2. Physical disabilities are accommodated for 3. The topic or information is valued by the learner 4. New knowledge is connected to knowledge already processed

The topic or information is valued by the learner

13. To assist older adults to meet their needs for sexuality, the nurse should recognize that the greatest impact on the sexuality of older adults is: 1. Therapeutic medications may alter sexual function 2. Sexual interest declines and then fades completely with age 3. Physiological changes do not adversely influence sexual activity 4. Prevention of sexually transmitted diseases is no longer an issue

Therapeutic medications may alter sexual function

23. The nurse recognizes that the primary goal of a client's teaching plan is to: 1. Facilitate a knowledge-based client decision-making process 2. Provide information that brings about informed client consent 3. Enhance the client's sense of personal control regarding his or her health care 4. Therapeutically affect the client's health, wellness, and independence

Therapeutically affect the client's health, wellness, and independence

8. The nurse knows that a key element in Leininger's theory of caring is that it includes: 1. Five categories of caring 2. Connectedness with others 3. Transcultural perspectives 4. Spiritual dimensions and healing

Transcultural perspectives

4. According to Piaget, a preschool child (3 to 5 years old) who comes to the clinic is expected by the nurse to exhibit which of the following behaviors? 1. Far-reaching problem-solving 2. Exploration of the environment 3. Cooperation and sharing with others 4. Thinking with the use of symbols and images

Thinking with the use of symbols and images

23. A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, "what the diagnosis means." Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge? 1. The client initiated the question. 2. This is a new diagnosis for the client. 3. The client identified a lack of understanding. 4. Type 2 diabetes mellitus is a complicated disease process.

This is a new diagnosis for the client.

9. The nurse is demonstrating to the client how to put on anti-embolitic stockings. In the middle of the lesson the client asks, "Why have my feet been swelling?" The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should follow? 1. Timing 2. Setting priorities 3. Building on existing knowledge 4. Organizing the teaching materials

Timing

27. Which of the following statements best reflects the nurse's understanding of the primary nursing-related purpose of a concept map? 1. To facilitate holistic nursing care 2. To provide visualization of the client's health problems 3. To assist in the identification of client-oriented nursing diagnoses 4. To demonstrate the relationship between the client's various health problems

To demonstrate the relationship between the client's various health problems

5. The nurse has diagnosed the client's problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except: 1. Poor fiber intake 2. Limited fluid intake 3. Total hip replacement 4. Lower abdominal discomfort

Total hip replacement

10. The nurse is looking at different strategies for learning and incorporating new information into practice. A strategy that uses problem-solving is demonstrated by: 1. Repeatedly practicing vital signs until competence is achieved 2. Seeking information from the nurse manager on the client's status 3. Reviewing Maslow's hierarchy either in a textbook or on the internet 4. Trying different types of colostomy dressings for maximum therapeutic effect

Trying different types of colostomy dressings for maximum therapeutic effect

17. Which of the following nursing actions is the best example of problem solving? 1. Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2. Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3. Trying several difficult wound dressings to determine which one the client can apply the most effectively 4. Calling for another pain medication order when the current drug results in the client experiencing nausea

Trying several difficult wound dressings to determine which one the client can apply the most effectively

11. Which of the following interventions is the best example of an indirect intervention directed towards client safety? 1. Checking on a restrained client every 15 minutes 2. Performing hand hygiene between client contacts 3. Including the diagnosis at risk for injury related to falls to a client's care plan 4. Turning on a night light to illuminate the path to the bathroom

Turning on a night light to illuminate the path to the bathroom

2. An industrial nurse is planning to give an informative talk on hypertension to employees in honor of "heart month." He plans to teach individuals how to take their blood pressure measurements. Which information is important for him to ask the planning committee before this presentation? 1. Ages of all employees involved 2. Names of employees who are married 3. Number of employees with high blood pressure 4. Type of room available and number of participants

Type of room available and number of participants

18. The nurse is caring for a terminally ill client who recently immigrated to the United States. To provide quality end-of-life care, the nurse must initially: 1. Make every effort to involve the client and his family in the end-of-life care 2. Understand the client's personal and cultural views regarding death and dying 3. Arrange for end-of-life care to be provided by personnel familiar with the client's culture 4. Share the client's concerns regarding the dying process with his interdisciplinary care team

Understand the client's personal and cultural views regarding death and dying

20. During a routine physical assessment a 27-year-old client acknowledges the suspension of his driver's license because of an arrest for driving under the influence of alcohol. This admission should prompt the nurse to discuss which of the following in detail with the client? 1. Use of illegal drugs 2. History of depression 3. Unprotected sexual experiences 4. Tendency toward violent behavior

Use of illegal drugs

5. The nurse takes on ethical responsibilities when conducting research with human subjects. Which of the following violates an ethical responsibility associated with informed consent? 1. Adhering to verbal and written agreements 2. Using data obtained before the initiation of the study 3. Explaining the possibility of unknown risks when appropriate 4. Providing alternatives, including the right of refusal and standard practices

Using data obtained before the initiation of the study

22. The nurse is caring for a 6-year-old child who is scheduled for outpatient surgery. Piaget's theory of cognitive development suggests that the nurse can help the child cope with the stressors of this hospital experience best by: 1. Arranging for the parents to be with the child until the anesthetic takes affect 2. Explaining the entire process with the child using age-appropriate language 3. Using play as a means of familiarizing the child with the events he will experience 4. Providing the child with a coloring book that shows the events he will be experiencing

Using play as a means of familiarizing the child with the events he will experience

5. For a 2-year-old child, cognitive development is characterized by: 1. Recognizing right and wrong 2. Initiating play with other children 3. Having a vocabulary of at least 1000 words 4. Using short sentences to express independence

Using short sentences to express independence

31. The nurse recognizes that a client's hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle? 1. Speaking slowly, clearly, and in a normal tone 2. Using various forms of nonverbal communication 3. Relying heavily on touch to convey caring and interest 4. Involving family in discussions concerning meeting client's needs

Using various forms of nonverbal communication

13. The nurse is completing a physical exam for a 45-year-old client who has come to the family practice office. In evaluating the observations made during the examination, the nurse recognizes that an expected finding for a client in this age-group is: 1. Hepatomegaly 2. Visual acuity below 20/50 3. An oral temperature of 39° C 4. Increased amount of skin turgor

Visual acuity below 20/50

11. There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age: 1. Men have the greatest incidence of osteoporosis 2. Muscle fibers increase in size and become tighter 3. Weight-bearing exercise reduces the loss of bone mass 4. Muscle strength does not diminish as much as muscle mass

Weight-bearing exercise reduces the loss of bone mass

infections process: illness stage

interval when patient manifests signs/ symptoms specific to type of infection

When attempting to meet the needs of the family, the nurse recognizes the central concept of the theory of family developmental stages is that: 1. Over time all families progress through developmental stages 2. Needs differ as the family progresses through the various stages 3. While each family is unique, they all tend to progress through similar stages 4. The family will progress only when all the challenges of a particular stage are met

While each family is unique, they all tend to progress through similar stages

8. There are many factors are assessed before teaching the client to learn insulin injection sites, but the most important factor for the nurse to assess first is the: 1. Previous knowledge level of the client 2. Willingness of the client to want to learn the injection sites 3. Financial resources available to the client for the equipment 4. Intelligence and developmental level of the individual client

Willingness of the client to want to learn the injection sites

**Needing assistance with daily living activities, an older adult with two grown children is being discharged home. Although both children live nearby, the daughter is expressing concern about handling her parent's physical needs. The nurse's initial response is to: 1. Work with the family on delegating responsibility 2. Suggest short-term nursing home placement to the client 3. Arrange for the client to remain hospitalized in the medical center 4. Make decisions for the family on how to manage the care at home

Work with the family on delegating responsibility

Iatrogenic infections

a type of HAI from a diagnostic or therapeutic procedure

Which activity represents secondary prevention? a. A home health care nurse visits a patient's home to change a wound dressing. b. A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked. c. The school health nurse provides a program to the first year students on healthy eating d. The patient attends cardiac rehabilitation sessions weekly

a. A home health care nurse visits a patient's home to change a wound dressing.

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) a. Difficulty paying his bills b. Seeing his pastor as a mean of support c. Family practice of not routinely seeing a health care provider d. Stress from the divorce and the loss of a job

a. Difficulty paying his bills c. Family practice of not routinely seeing a health care provider d. Stress from the divorce and the loss of a job

When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? a. Holistic b. Health belief c. Transtheoretical d. Health promotion

a. Holistic

Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. An example of an internal variable would be a. Perception of functioning. b. Family practices. c. Socioeconomic factors. d. Cultural background.

a. Perception of functioning. Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

which microbe causes more infections in humans anerobic or aerobic bacteria

aerobic bacteria

type of isolation negative pressure room

airborne precuations

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individuals perception of susceptibility to an illness? a. "I don't have time to exercise because I have to work after school every night." b. "I am worried about becoming overweight and getting diabetes because my father has diabetes." c. "The statistics of how many teenagers are overweight is scary." d. "I've decided to start a walking club at school for interested students."

b. "I am worried about becoming overweight and getting diabetes because my father has diabetes."

A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise? a. "Walking is OK. I really think running is better. b. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" c. "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables." d. "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good"

b. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?"

what are some examples of droplet precautions problems

diphtheria, rubella, streptococcal pharyngitis, pneumonia, scarlet fever in infants or young children, pertussis,mumps, mycoplasma pneumonia, meningococcal pneumonia or sepsis

The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic and physiological? (Select all that apply.) a. Sedentary lifestyle b. Father died from CAD at age 50 c. History of hypertension d. Eats diet high in sodium e. Elevated cholesterol level f. Age is 44 years

b. Father died from CAD at age 50 c. History of hypertension e. Elevated cholesterol level f. Age is 44 years

When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness? a. Health belief b. Illness behavior c. Health promotion d. Illness prevention

b. Illness behavior

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow? a. Physiological b. Safety and security c. Love and belonging d. Self-actualization

b. Safety and security

anerobic bacteria

bacteria that do not require oxygen to survive

normal during infection

basophils

noncritical items that only need to be disinfected

bedpans, blood pressure cuffs, bedrails, linens, stethoscopes, beside trays, food utensils

How is Ebola transmitted?

bodily fluids & blood also droplets (splashes or sprays) of respiratory secretions

Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, exercise? I haven't done that since junior high gym class, and I hated it then!" a. "That's fine. Exercise is bad for you anyway." b. "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month." c. "I understand. Can you think of one reason why being more active would be helpful for you?" d. "I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day."

c. "I understand. Can you think of one reason why being more active would be helpful for you?"

A patient experienced a myocardial infarction 2 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Quaternary prevention

c. Tertiary prevention

exogenous infections

caused by organisms that enter the patient from the environment

inflammation

cellular response of the body to injury, infection, or irritation

A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image? a. "I just don't have the energy to get out of bed in the morning." b. "I've been attending church regularly with my wife since I got out of the hospital." c. "My wife has taken over paying the bills since I have been in the hospital." d. "I don't go out very much because everyone stares at me."

d. "I don't go out very much because everyone stares at me."

A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statements reflects that the patient is in what stage of the health belief model? a. Perceived threat of the disease b. Likelihood of taking preventative health action c. Analysis of perceived benefits of prevention action d. Perceived susceptibility to the disease

d. Perceived susceptibility to the disease

A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having the difficultly communicating with the father. What action does the nurse take? a. Care for the boy as she would any other patient b. Ask the manager to talk with the father and keep him out of the unit c. Have another nurse care for the boy because maybe that nurse will do better with the father d. Search or help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

d. Search or help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

Where are normal floras found?

deep layers of the skin, saliva, oral mucosa, GI, GU tracts

suprainfection

develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection

increased in parasitic infections

eosinophils

vector transmission of pathogens

external mechanical transfer (fly), internal transmission (vector, and host): mosquito, louse, flea, tick

Chemical agents that cause inflammation

external/ internal irritants poison, or gastric acid

what causes edema during inflammation

increased fluid, proteins and blood flow to site from capillary permeability

what cause increased pain during inflammation

increased pressure on the never endings from the swelling and edema

chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

reservoir

is a place where microorganisms survive, multiply, and await transfer to a susceptible host.

Droplet transmission of pathogens

large particles that travel up to 3 feet coughing, sneezing, talking and come in contact with susceptible host

Cellular response to inflammation

leukocytes drawn to area of injury neutrophils and monocytes preform phagocytosis and eat dead cells and bacteria

increased in chronic bacterial and viral infection, decreased in sepsis

lymphocytes

what are examples airborne precautions problems infections

measles, chickenpox, varicella, pulmonary or laryngeal TB

Physical agents that cause inflammation

mechanical trama, extreme temps, radiation,

whats the difference between medical and surgical aspesis

medical is breaks the chain of infection used with all patients even when a patient is not diagnosed (hand hygiene , barrier technique) surgical aspesis prevents contamination of an open wound, severs to isolate an operative area from the unsterile environment and maintains a sterile field for surgery.

increased in protozoan, rickettsial, and tb infections

monocytes

what are some examples of contact precautions problems

multi drug resistance such as VRE or MRSA, C-diff, shigella, major wound infections herpes simplex, scabies, varicell zoster; respiratory syncytial virus in infants, young children or immunocompromised adults

WBC increased in acute suppurative infection, decreased in overwhelming bacterial infection

neutrophils

endogenous infection

occurs when part of the patients flora becomes altered and an overgrowth results ex straphylococci

direct transmission of pathogens

person to person physical contract with susceptible host

Indirect contact transmission of pathogens

personal contact of susceptible host with contaminated object (needle, dressing, environment)

colonization

presence and growth of microorganisms within a host without tissue invasion or damage

critical items that require sterilization

surgical instruments, cardiac or intramuscular catheters

signs of normal inflammation

swelling, heat, redness, pain or tenderness, lost of function to affected body part

communicable disease

the infection process transmitted from one person to another

Infection

the invasion of a susceptible host by pathogens or microorganisms results in disease