NRSG 2200 NCLEX practice
A nurse evaluates that the care plan related to normal physiologic changes has been effective for a 70 year old client if he says: -I have an increased need for sleep. -I have lost some of my social support systems. -I have less joint cartilage that I used to. -I have more sebaceous gland activity.
I have less joint cartilage that I used to.
A toddler is admitted for severe anemia, which is found to be dietary in nature. To increase iron in the diet as a means of promoting healthy growth and development, the nurse recommends to the parents that they: -Limit milk to no more than 32 oz/day. -Increase fat-soluble vitamins in the diet. -nclude grains and legumes in the daily intake. -Limit foods that are high in protein in the daily caloric requirement.
Limit milk to no more than 32 oz/day.
While conducting an initial assessment on an infant, a home health nurse notices that he is wearing a soiled piece of braided yarn around his neck. Which action by the nurse is most appropriate? -Ask about its significance, and suggest that it be place more safely onhis body. -Remove the yarn because it is soiled and could lead to strangulation. -Leave the yarn in place, but wash it with a cloth and mild soap. -Explain that the yarn offers no benefit and ask the parents to remove it.
Ask about its significance, and suggest that it be place more safely onhis body. The action that demonstrates cultural sensitivity is the one that inquires about the significance of the braided necklace while taking into account issues of client safety (in case of strangulation).
A nurse threatens to restrain a verbally abusive client if the abuse continues. Which legal tort has the nurse committed?
Assault Assault is threatening to touch a person, such as by applying restraints, without consent. Sharing a client's confidential information without consent is an invasion of privacy. When a person performs an act that a reasonable person would not do under the same circumstance, it is negligence. Defamation of character occurs when one makes statements that damage another person's reputation.
The nurse receives a "do not resuscitate" (DNR) order for a dying client. What should the nurse do next?
Assess the client's spiritual needs Conducting a spiritual assessment is an essential aspect of maintaining health and providing holistic and sensitive nursing care especially in a DNR. Following the spirituality assessment, if the client has additional questions or concerns related to spirituality, the nurse may suggest follow-up with a chaplain or a priest, but there is no indication the client requested spiritual guidance. A nurse should not discuss suicide and its affects as that is inappropriate. The order may impact the nurse's interventions but this is not the priority at this point.
The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification Distractions to learning, such as the television being on or the client being at meal time, diminish the effectiveness of any education plan. An authoritarian style of teaching does not honor the client as a partner in the learning process. Age does not necessarily determine developmental stage. Assessing the client's developmental stage and understanding of the health problem, clarifying information that is difficult for the client to understand, and ensuring that the client is physically able to perform the task are all aspects of a well-planned education session for all clients.
A home care nurse is visiting an older adult who experienced a brain attack 2 years ago and now has a sacral pressure ulcer. The nurse identifies that the client and spouse both appear unkempt, and the spouse appears tired or irritated. The client is very quiet and avoids eye contact. Which nursing action is most appropriate? A Explore with the client and spouse their concerns. B Assess the client for signs of physical abuse and neglect. C Discuss with the client and spouse additional resources to help with the client's care. D Assess the client's pressure ulcer and report finding to the primary health-care provider.
B Assess the client for signs of physical abuse and neglect. Protecting the client from neglect or abuse is the priority. The client should be assessed further for signs of neglect or abuse. The client's behavior may indicate fear. The spouse's appearance and behavior may indicate caregiver role strain. Inadequate turning and positioning, nutritional intake, and bathing and skin care can precipitate a pressure ulcer. Reporting suspected elder abuse or neglect to appropriate authorities is legally required by health-care professionals in most states.
What word or phrase best describes an effective counselor?
Caring An effective counselor needs to be a caring individual with the interpersonal skills of warmth, friendliness, openness, and empathy. Having knowledge and being technically skilled are effective traits for teaching but not for counseling. Being practical is related to doing something or using something rather than to theory and ideas, which does not suit the compassionate functionality of an effective counselor.
A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf?
A surrogate decision maker Infants, young children, people with severe cognitve impairment or who are incapacitated, and people in a persistent vegetative state or coma do not have the capacity to participate in decision-making about their health care. For such people, a surrogate decision maker must be legally designated to act on their behalf. The surrogate decision maker may be any one of the individuals listed in the other answers, if properly identified by the hospital authorities.
A patient is admitted to the emergency department with difficulty breathing. Which patient response identified by the nurse causes the most concern? A Low pulse oximetry B Wheezing on expiration C Shortness of breath on exertion D Using accessory muscles of respiration
A. Low pulse oximetry If the reading is below the expected value of 95%, this is an indication of poor oxygenation and medical intervention is needed.
Which of the following statements reflect ethical nursing practice when providing end of life care? Select all that apply. -Clients in some states in the US can legally take their own life. -Euthanasia is acceptable if a client is suffering or has a terminal illness. -Withholding food and fluid is acceptable practice near end of life to allow a life to progress to its natural end. -Titration of pain medication is acceptable as long as it does not cause respirations to fall below 10 breaths per minute. -Discontinuing life support is acceptable if the client is dying and it is the decision of the client or the client's health proxy, or it is stated in the client's legal documents regarding end of life care.
-Clients in some states in the US can legally take their own life. -Euthanasia is acceptable if a client is suffering or has a terminal illness. -Withholding food and fluid is acceptable practice near end of life to allow a life to progress to its natural end. -Discontinuing life support is acceptable if the client is dying and it is the decision of the client or the client's health proxy, or it is stated in the client's legal documents regarding end of life care. assisted suicide is the taking of one's own life after seeking and receiving a prescription from a primary health-care provider for a medication that will cause death. Specific criteria must be met, such as having the ability to self-administer the medication that will end one's life, being at least 18 years of age, being terminally ill, and having received counseling regarding other options. A position statement on euthanasia by the ANA states that nurses are prohibited from participating in euthanasia. Euthanasia is the premeditated termination of the life of a person who is suffering from an incurable disease or terminal illness. Withholding food and fluid is acceptable practice near end of life to allow a life to progress to it's natural end. This is often a difficult decision for family members who equate providing food and fluid as nurturing and caring. Titration of pain medication to achieve comfort is acceptable even if it hastens death. It is considered an ethical, justified intervention. Discontinuing life support is acceptable if the client is dying and it is the decision of the client or the client's designated health-care proxy, or it is stated in the client's legal documents regarding end of life care.
A nurse is caring for an adult client who is scheduled for surgery. Which actions are associated with the nurse ensuring a valid, legal consent? Select all that apply. -Observe the client signing the consent form. -Ensure that the client has the capacity to make an informed consent. -Assess if the client has the capacity to make an informed consent. -Review with the client the risks and benefits of the surgery before the consent is signed. -Explore options other than surgery that may be beneficial in meeting the client's health needs.
-Observe the client signing the consent form. -Ensure that the client has the capacity to make an informed consent. -Assess if the client has the capacity to make an informed consent. It is the responsibility of the nurse to observe the consent being signed, ensure that the client is not being forced to sign, and that the client has the cognitive ability to sign. Explaining the risks and benefits of the surgery is the responsibility of the surgeon, not the nurse. Exploring options other than surgery is the responsibility of the primary health-care provider or surgeon, not the nurse.
Which actions are a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)? Select all that apply. -Talking about a client to another health professional in an elevator. -Telling a neighbor about a famous persons who currently is your client. -Documenting untrue information on purpose in a client's record. -Leaving client data on a computer screen in a hallway while administering medications. -Completing an incident report about a client situation and asking the nurse manager to review it.
-Talking about a client to another health professional in an elevator. -Telling a neighbor about a famous persons who currently is your client. -Leaving client data on a computer screen in a hallway while administering medications.
Which is the first action the home care nurse should employ to prevent falls by an older adult living at home? -Conduct a comprehensive risk assessment -Encourage the patient to remove throw rugs in the home -Suggest installation of adequate lighting throughout the home -Discuss with the patient the expected changes of aging that place one at risk
Conduct a comprehensive risk assessment Assessment is the first step of the Nursing Process. The best way to prevent falls is by identifying those at risk and instituting interventions that prevent falls. The other answers are just individual strategies. A thorough assessment must be conducted first.
A nurse is planning client care based on moral and ethical principles. Which nursing statement demonstrates an effort to implement the principle of fidelity? A"Let's talk about foods that are healthy and that you should include in your daily diet." B "I know you are out of work, so I have arranged for you to get follow-up care at our outpatient clinic." C "You said that your son wants you to have this surgery. What is important is what you believe is best for you." D "It's been half an hour, and I am back as promised to ensure the pain medication I gave you is providing relief."
D. "It's been half an hour, and I am back as promised to ensure the pain medication I gave you is providing relief."
A terminally ill client told her family, "I am ready to die." Her family is very upset that she has given up and wants the nurse to intervene. Which nursing intervention is most appropriate?
Explain to the family that acceptance is part of the grieving process. Acceptance (an attitude of complacency) occurs after clients have dealt with their losses and completed unfinished business. After tying up all loose ends, dying clients feel prepared to die. Some even happily anticipate death, viewing it as a bridge to a better dimension. Nurses can help clients to pass from one stage to another by providing emotional support and by supporting the client's choices concerning terminal care. Facilitating the client's directives helps to maintain the client's personal dignity and locus of control. Accepting that death will occur and giving up are not the same thing and giving up is not expected.
As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?
Have the client rate pain level, and reschedule the teaching session. The client is not ready or able to learn and is reporting a need that first must be met. Assessing the client's knowledge of self-care or redirecting the client to discuss self-care only delays the care that must be done before the client is able to learn. Although providing written materials is an excellent supplement to a teaching session, it does not replace teaching the client. It is best to address the physical needs before attempting to educate the client.
When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized?
Include educational strategies that encourage clients to be active participants. The teaching-learning relationship is a dynamic, interactive process that involves active participation from the nurse and client. Having clients read material after teaching, being sure that clients are formally engaged (rather than actively engaged), and administering tests to evaluate learning are not dynamic, interactive approaches and thus would not likely optimize the client's learning.
A nurse knows that the expression "Do not cause harm" refers to which ethical principle?
Nonmaleficence Nonmaleficence is conducting procedures and interventions in a safe manner so that no harm is caused to the client. Justice is the idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society. Fidelity is demonstrated by continuing loyalty and support to a client. Beneficence requires that the procedure be provided with the intent of doing good for the client involved.
A nurse is providing end-of-life care to a terminally ill client. Which action should the nurse take to remove mucus and saliva from the client's mouth?
Perform suction in the client's mouth. Suctioning helps to remove mucus and saliva that the client cannot swallow or expectorate. A lateral, not supine, position keeps the mouth and throat free of accumulating secretions. The lips may need periodic lubrication because they may become dried from mouth breathing or administration of oxygen.
A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?
Positive feedback Important keys to success when evaluating learning are consistent, immediate, and frequent positive reinforcement, and teaching a small number of skills at any one time, thus creating a high possibility that the learner will master them. Positive reinforcement is also known as positive feedback, which is what the nurse is providing in this case. Negative reinforcement or feedback would be attempting to change a client's behavior by pointing out and criticizing or even punishing mistakes or undesireable behaviors. Motivation refers to the client's desire to learn or make a change. Health promotion is a topic that may be covered in client teaching and that pertains to optimizing one's health through maintaining peroper nutrition, exercise, and hygiene.
A nurse has a duty of nonmaleficence. Which action would be considered a contradiction to that duty?
Refusing to administer pain medication as prescribed The duty not to inflict harm, as well as prevent and remove harm, is termed nonmaleficence. Refusing to administer pain medication is inflicting unnecessary pain and harm. Providing comfort measures for a terminally ill client and assisting a client with activities of daily living are examples of fulfilling the duty of beneficence. Providing information related to procedures is an example of fulfilling the duty of ensuring the client's autonomy.
While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements?
Religion is a collection of spiritual beliefs and practices. Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable, and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion; nor is it a recent development.
The nurse enters a client's room as the client and family are praying. Which is the most appropriate action of the nurse?
Step outside the door until the prayer is finished. By stepping outside the door, the family and client will not be rushed to finish the prayer. Stepping up to the bedside may distract the client and or family.
Which action would cause a charge nurse to have concerns about a nurse's moral agency?
The nurse was seen at a grocery store after calling in sick. The only option with an ethical component possibility is the nurse being seen at the grocery store after calling in sick. It may be that the nurse had no other choice but to go to the grocery store, even if sick, but it would cause the charge nurse to be suspicious. The other options do not reflect an ethical issue because they did not lead to other unethical behaviors, just job performance issues.
A client gets out of bed following hip surgery, falls, and re-injures the hip. The nurse caring for the client knows that it is the nurse's duty to make sure an incident report is filed. Which statement accurately describes the correct procedure for filing an incident report?c
The report should contain all the variables related to the incident. An incident report, also called a variance or occurrence report, is used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. The nurse responsible for a potentially (or actually) harmful incident or who witnesses an injury is the one who fills out the incident form. This form should contain the complete name of the person or people involved and the names of all witnesses; a complete factual account of the incident; the date, time, and place of the incident; pertinent characteristics of the person or people involved (e.g., alert, ambulatory, asleep) and of any equipment or resources being used; and any other variables believed to be important to the incident. These reports are used for quality improvement and should not be used for disciplinary action against staff members. The physician should be called to reassess the client and provide additional orders for care. The physician does not fill out the form.
A client scheduled for complex heart surgery has been reading the Bible for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client?
These behaviors are signs of spiritual distress. Many clients find it difficult to talk about their spiritual beliefs and problems but may have behavioral indicators of spiritual distress. Significant behavioral observations include sudden changes in spiritual practices, mood changes, sudden interest in spiritual matters, and disturbed sleep. The client may or may not have family available or be emotionally reactive.
A client has been diagnosed with a terminal illness and has made an appointment with an attorney to complete a will. How will the nurse document this stage of grief according the Kübler-Ross Model?
acceptance Acceptance (an attitude of complacency) occurs after clients have dealt with their losses and completed unfinished business. Completing a will shows that acceptance is occurring and does not demonstrate depression, bargaining, or denial.
A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an):
durable power of attorney. A durable power of attorney allows clients to designate another person to make decisions if they become incapacitated and cannot make decisions independently. Advanced estate planning typically involves estate tax reduction, Medicaid planning and/or special needs trust planning is for a client with a large estate. Exemplary representative and significant power are not related to health care.
The nurse needs to understand the teaching-learning process when administering
educational interventions. Educational interventions require the application of the teaching-learning process. The other interventions listed would not, as their primary goal is not to educate the client.
A new client is on the hospital unit. He was recently diagnosed with metastatic pancreatic cancer and was told that any treatment would be palliative. He tells a nurse that there is no God that he knows of who would subject someone to this. The client's statement is most reflective of:
spiritual crisis. A spiritual crisis can occur with an acute illness, sudden loss, or a new challenging diagnosis. These turning points often result in the questioning of one's beliefs.
The husband of a client who died of breast cancer is still grieving for his wife 2 years later. What type of grief is he experiencing?
unresolved Unresolved grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Maturational losses are losses that predictably occur during the life cycle. Situational losses are losses that are caused by unexpected or unusual circumstances.
The nurse determines a new mother is in greatest need of more education about infant care and safety when the mother states: -"I am pretty sure that I am going to breast-feed my baby." -"After feeding, the baby should be put on her tummy to prevent choking." -"Solid foods are not necessary during the baby's first 4 to 6 months." -"My baby will sleep frequently and should be awakened every three to four hours for feeding."
"After feeding, the baby should be put on her tummy to prevent choking." Infants should always be put to sleep on the back. The other options are correct statements related to infant care and therefore pose no risk to the infant and no concern to then nurse.
A nurse who provides care on the palliative unit of a hospital is aware of the importance of spiritual assessment and the integration of spirituality into clients' care. What assessment question should the nurse use in an effort to determine clients' spiritual beliefs?
"Are there any spiritual or religious beliefs or practices that are important to you?" An open-ended yet clear question about a person's spiritual beliefs is most likely to elicit information about the client in a thoughtful manner. Asking the client to choose between self-identifying as religious or spiritual is not an accurate dichotomy. Asking about the afterlife is not a direct way of assessing religion and spirituality. Not every religious or spiritual group situates their practices in a church.
A nurse confides in a nurse friend, "I never report minor incidents. The charge nurse always wants a variance report filled out and they take so much time." Which responses by the friend are indicated? Select all that apply.
"Having documentation might keep you out of trouble someday." "Reporting helps us fix problems that result in danger to clients." Incident or variance reports serve as a tool for trending to identify risk and avoid it in the future. Having correct documentation is very beneficial if error or injuries lead to litigation. Simply documenting problems in a client chart is not enough, as they may apply to more than just that client and may be overlooked. Injury is not always immediately obvious. Variance reports should not be used punitively.
A client tells the nurse, "I am an atheist. I do not believe in God." What would be an appropriate response by the nurse?
"I respect what you choose to believe in." An atheist is a person who denies the existence of God, guided by philosophies of living that do not include a religious faith. The atheist deserves respect for what he or she chooses to believe. Asking questions challenges the client and his or her beliefs; this not warranted by the nurse. The nurse should not dictate what the client should believe.
A nurse is conducting a spiritual assessment on a client recently admitted to the hospital unit. Which questions would be appropriate to ask the client about his religious and spiritual practices? Select all that apply.
"Is religion a significant part of your life?" "Does the present situation interfere with any spiritual or religious practice?" "Are there any spiritual practices that you would like to continue while hospitalized?" A spiritual and religious assessment attempts to identify and document any practices or beliefs that are important for the client to maintain or that may alter medical or nursing treatment.
When conducting a spiritual assessment, the nurse must be sensitive to the client's personal beliefs. Which questions should the nurse ask? Select all that apply.
"Is there anyone from your church you would like to talk to?" "Is religion or God significant to you?" "Do you feel your faith is helpful to you?" Several nurses have developed spiritual assessment tools. Stoll's (1979) Guidelines for Spiritual Assessment is an early widely recognized spiritual assessment tool. This tool is built around a definition of spirituality that encompasses religion and belief in a higher power. It identifies four areas and suggests questions for each: (a) concept of God or deity, (b) source of hope and strength, (c) religious practices and rituals, and (d) relationship between spiritual beliefs and state of health. "Is religion or God significant to you?" is a question asking about the concept of God or deity. "Do you feel your faith is helpful to you?" focuses on the relationship between spiritual beliefs and state of health. "Is there anyone from your church you would like to talk to?" asks about their source of hope and strength. Asking the client why they do not believe in God and why they will not share their belief are questions focusing on belittling and degrading the client.
Kübler-Ross defines five stages of psychosocial responses to dying and death. Which statement is characteristic of the bargaining stage?
"Just let me live to see my grandson born." In the bargaining stage of the psychosocial responses to dying and death, the client tries to bargain for more time to live. It is important to meet wishes for putting personal affairs in order and fulfilling last wishes during this time, if possible, because bargaining helps clients move into later stages of dying. Denial is recognized by the statement, "The doctors made a mistake." Anger is characterized by, "Why did this happen to me? I always exercised." Acceptance is the statement, "I've had a good life and I can die in peace."
On admission, a 78-year-old client states he uses laxatives three times a week for constipation. The nurse would respond: -"As people age, they need laxatives to stimulate defecation." -"Eat a balanced diet if you use laxatives." -"Long-term use of laxatives can cause constipation." -"Please use laxatives two times a week at night."
"Long-term use of laxatives can cause constipation." The gastrointestinal system is the system that most older adult clients have complaints about, yet it remains the most healthy system over time with proper diet and care. Prolonged use of laxatives can lead to dependence on them for stimulation of the defecation and can actually lead to uncontrollable defecation.
Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety?
"Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." Worry about one's spiritual condition is indicative of the nursing diagnosis of Spiritual Anxiety. Unfamiliarity with the religious character of a care setting suggests Spiritual Alienation, while questions of suffering often indicate Spiritual Pain or Spiritual Despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of Spiritual Guilt.
A recently graduated nurse is talking to the charge nurse about spirituality and tells the charge nurse that it is difficult to understand why people have a hard time giving spiritual care to clients. The charge nurse identifies the new nurse's lack of understanding when the new nurse makes which statement?
"Spirituality and religion are the same thing." Although some people use the words spirituality, faith, and religion interchangeably, there are distinctions. Spirituality is anything that pertains to a person's relationship with a higher power. Religion may be defined as a cultural system of designated behaviors and practices, worldviews, texts, sanctified places, prophecies, ethics, or organizations, that relates humanity to supernatural, transcendental, or spiritual elements. Faith is a strong belief in God or in the doctrines of a religion, based on spiritual apprehension rather than proof.
A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate?
"What do you know about support groups?" By asking the client an open-ended question the nurse can find out what the client knows about support groups. With the client's permission, the nurse can further educate on this topic. The nurse should acknowledge the client's ability to accept or reject the material to empower the client and lead to more healthy decision-making. The nurse cannot make the decision for the client by signing the client up for a support group. Although frustrating, the choice to follow suggestions in the end is the client's and the nurse must respect it as such. The nurse who states emphatically that the nurse is correct and that the client's views are misguided and skewed loses all credibility and influence. The nurse should be nonjudgmental and nonthreatening and should not be more assertive than the client. However, the nurse should listen carefully to what the client values and work from there. Each type of support group has different goals and values.
The nurse has taken a position in an ambulatory care clinic in a Hispanic neighborhood. The nurse would use knowledge of which of the following practices to provide culturally sensitive care to this population? Select all that apply -Herbal medicines are just as important as Western medicines in treating illness. -The client may want a caregiver of the same gender to enhance privacy. -Staring at a client who is a child will help to prevent or ward off "the evil eye". -Mourners are likely to be hired by a family to demonstrate grief after a death.
-Herbal medicines are just as important as Western medicines in treating illness. -The client may want a caregiver of the same gender to enhance privacy. -Depending on the specific illness, either hot or cold foods would be used in the treatment.
The nurse attempts to notify a health care provider about a client's elevated temperature but does not get a response. Which statement, if documented by the nurse, would indicate that the nurse is following proper protocol for nursing documentation?
1300: Client temperature elevated. Telephoned health care provider's service 3 times without a response. Tepid sponge bath given and nursing supervisor notified. Documentation must have the correct, factual, and timely information. The nurse must document when the health care provider was called and response or lack of response; what nursing action was done, if any, and notification of appropriate personnel. The nurse cannot administer medication without an order. The nurse should be careful to not make incriminating statements, such as, "as usual, health care provider did not respond." The nurse should not wait until rounds are made to inform the supervisor.
Which statement describes the person who is likely the most motivated to learn?
A 70-year-old female who is the client's spouse and is learning the care so the client can come home Adults learn best when the information given to them is something they need to use immediately, when they are strongly motivated to learn, and when they have an internal motivation to learn the topic. When the adult learner does not see the importance of the topic or has no emotional need to learn (such as the client who appears to be undergoing the education only at the insistence of the client's significant other), motivation is low. Motivation to learn may also be lacking if the adult learner has just reached completion of a major task, such as the client who just completed a course of physical therapy. The adult learner who is seeking knowledge to assist a loved one may be the most motivated. On the other other hand, a stranger to the client who has just been hired to bring the client home from the clinic is the least likely to be motivated to learn.
A nurse has permission from the homebound client to educate any of the family members about providing care for the client. Which family member is the most appropriate choice? -
A brother who visits daily, does laundry, and cooks all meals for the client The son is not available while at work, the sister lives physically close but is maintaining distance from the client, and the daughter lives too far away to be the person to provide care for the client. The client's brother shows interest in helping the client and would be the best choice to assess for readiness to learn to provide client care.
A woman has had a breast removed to treat cancer. What type of loss will she most likely experience?
Actual loss Loss occurs when a valued person, object, or situation is changed or made inaccessible so that its value is diminished or removed. Actual loss can be recognized by others as well as by the person sustaining the loss. Perceived loss is internal and identified only by the person experiencing it. Maturational loss are losses that predictably occur during the life cycle. Anticipatory loss occurs when a person displays loss and grief behaviors for a loss that has yet to take place. It is often seen in the families of clients with serious or life-threatening illnesses, and serves to lessen the effect of the actual loss of a family member.
A nurse is working with a group of postpartum women. Using culturally based practices as a guide, which of the following is at greatest risk of depression? -A Hispanic client -A Hindu client -A Chinese client -An American client
An American client Because American women tend to be more autonomous and have fewer relatives who assist in the postpartum period, American women are more at risk for postpartum depression. Many non-Western cultures will have family involvement in the care of the mother and infant for up to 50 days after delivery. This prolonged support helps to prevent the new mother from feeling overwhelmed with new responsibilities or feeling abandoned.
Which action constitutes battery?
An older adult client refuses an intramuscular injection, but the nurse administers it. If the client refuses a procedure or medication and the nurse proceeds with it, it is battery. Threatening to touch a client without consent is assault. Discussing a client within earshot of others is an invasion of privacy. Keeping a client against the client's wishes, regardless of health status, is false imprisonment.
A nurse is preparing to assist a Jewish client with eating lunch. A kosher meal is delivered to the client. Which nursing action is most appropriate in assisting the client with the meal? -Carefully placing the food from the paper plates to glass plates. -Unwrapping eating utensils for the client. -Replacing the plastic utensils with metal eating utensils. -Asking the client to unwrap the eating utensils and allowing the client to prepare the meal for eating.
Asking the client to unwrap the eating utensils and allowing the client to prepare the meal for eating. A kosher meal arrives on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils or transfer the foodstuffs to another serving dish. Although the nurse may want to be helpful in assisting the client with the meal, the only appropriate option for this client is option d.
A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee?
Assist in decision making based on the client's best interests. One reason an ethics committee convenes is when a client is unable to make an end-of-life decision and the family cannot come to a consensus. In this case, the committee members are there to advocate for the best interest of the client and to promote shared decision making between the client (or surrogates, if the client is decisionally incapacitated) and the clinicians. The committee would not convince, decide, or present options about the type of care. This is not the role of an ethics committee.
Which of the following health care practices may be influenced by a young woman's religion?
Birth-control measures Certain practices associated with health care may have religious significance for a client. For example, acceptable birth-control measures are determined by some religious faiths. Yearly mammograms, annual physicals, and health assessments are not determined by religious faiths but may be impacted by health insurance coverage.
A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?
Blocking 30 minutes of time for skill teaching Preschool age children (2 to 5 years) have short attention spans. Five- to ten-minute blocks of time are age appropriate. A 30-minute block is more appropriate for an older client. The other answers are developmentally appropriate for a 4-year-old.
The nurse and a nursing assistant (unlicensed assistive personnel) are working together on a surgical unit. Which nursing activity should the nurse assign to the nursing assistant? A Assessing the results of blood glucose monitoring B Explaining to a patient how to use an incentive spirometer C Emptying a urine collection bag that is attached to continuous bladder irrigation D Assisting the post-anesthesia care unit nurse to help a patient to make the transition to the surgical unit.
C Emptying a urine collection bag that is attached to continuous bladder irrigation Emptying and recording the volume of output collected from a urine collection bag is within the legal role of unlicensed assistive personnel. The nurse will then calculate the volume of irrigating solution instilled from the total output. Calculating the actual urine output is an assessment that requires the skill of a licensed nurse. Monitoring blood glucose levels requires the skills of a licensed nurse. Patient teaching is in the legal scope of a licensed nurse, not unlicensed assistive personnel. PACU nurse should be assisted by the primary nurse responsible for the patient. This nurse will need a thorough report of the patient status to assume cares.
The nurse's client states that his pastor is coming in a few hours to pray with him and offer sacrament. The nurse plans to do the following things in preparation for this. Select all that apply.
Clear the room of unnecessary items. Clear the bedside table; cover with clean towel. Have a chair available near the bed. When expecting a visit from a client's spiritual counselor, preparations may vary, but the following are usually recommended: • The room should be orderly and free of unnecessary equipment and items. • There should be a seat for the religious counselor at the bedside or near the client so that both can be comfortable. • The bedside table should be free of items and covered with a clean, white cover if a sacrament is to be administered. • The bed curtains should be drawn for privacy if the client can't be moved to a more private setting.The nurse should not expect or plan to join a private group such as described.
A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education?
Cognitive, affective, and psychomotor "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin" is an example of the cognitive, affective, and psychomotor domains, respectively. Pedagogy is the science of teaching children and is not a domain of learning. Andragogy is the principle of teaching adults and is not a domain of learning. Gerogogy enhances learning among older adults and is not a domain of learning.
A nurse educator is describing the yin and yang theory of ancient Chinese philosophy of Tao to a group of nursing students. The nurse educator explains that foods are classified as hot and cold in this theory and are transformed into yin and yang energy when metabolized by the body. The nurse educator informs the students that a client who practices this belief: -Consumes cold foods when a "hot" illness is present. -Consumes hot foods when a "hot" illness is present. -Believes that yin foods are hot. -Believes that yang foods are cold.
Consumes cold foods when a "hot" illness is present. In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Foods are classified as hot or cold in this theory and are transformed into yin and yang energy when metabolized by the body. Yin foods are cold, and yang foods are hot. Cold foods are eaten when one has a hot illness, and hot foods are eaten when one has a cold illness.
A native American client who has a low-grade fever tells the nurse on the reservation that he will only use a sweat lodge to treat his illness. Which approach by the nurse should be most therapeutic? -Explain to the client that the sweat lodge is likely to worsen the fever. -Continue to monitor the client's status. -Ask the client's family to convince him not to use the sweat lodge. -Alert the physician and ask him or her to talk to the medicine man of the tribe.
Continue to monitor the client's status.
A faculty member of a nursing program is conducting an informational session for potential nursing students. The faculty member included the information that at the completion of the program, licensure to practice is: A responsibility of the American Nurses Association B Granted on graduation from a nursing program C Approved by the National League for Nursing D Required by state law
D. Required by state law The Nurse Practice Act in a state stipulates the requirements for licensure within a state. ANA has Standards of Clinical Practice, but they do not address licensure. Graduation from a school of nursing indicates completion of education requirements and the diploma will allow students to register to take the licensing exam in the state. NLN promotes nursing service and nursing education; it is not involved in licensure.
The nurse who is explaining the pathophysiology of COPD to a client includes that the alveolar destruction results in which of the following? -Decreased surface area for gas exchange -Increased dead space air -Pulmonary emboli -Chronic dilation of bronchioles
Decreased surface area for gas exchange The impaired gas exchange occurring with COPD is caused by the loss of alveolar surface area available for gas exchange. Destruction of alveoli is not related to increased dead space air, pulmonary emboli, or chronic dilation of bronchioles. With COPD there is progressive narrowing of bronchioles.
A nurse is teaching a class about aging at a senior citizen center. The nurse would know that a client needed further instruction if he or she made which of the following statements? -Free radicals influence the quality of growing old. -Through nutrition and exercise, we can modify the rate of aging. -Some of the physical changes within our bodies arethe result of disuse. -Deterioration of body systems occurs at the same rate.
Deterioration of body systems occurs at the same rate.
A nurse pulls the curtains closed before changing the dressing of the surgical wound on the abdomen of a postsurgical client. What value is served?
Dignity The nurse values the dignity of the client and provides the client with privacy before changing the wound dressing. This incident does not serve the values of accountability, freedom, or altruism. A nurse values accountability when documenting nursing care accurately and honestly. The nurse values freedom when the client's right to refuse treatment is honored. The nurse shows value for altruism when showing concern for the client's welfare.
The nurse is caring for a 7-year-old child scheduled for surgery in the morning. While conducting preoperative teaching, the nurse would choose which of the following visual aids to enhance the child's learning about the perioperative experience? -Videotapes -Colorful brochures -Dolls and puppets -A visit from the surgeon
Dolls and puppets The use of dolls may decrease a child's anxiety and fear of the nurse uses such aids to explain what is expected.
A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?
Fidelity Fidelity is keeping one's promises and never abandoning a client entrusted to one's care without first providing for the client's needs. Autonomy respects the rights of clients or their surrogates to make healthcare decisions. Nonmaleficence is preventing harm from being done to a client. Justice involves meeting the needs of each client equitably and acting fairly.
A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability?
Filling out an occurrence report and notifying the healthcare provider Accountability means that when an error occurs, the nurse takes the proper actions to address it. In this instance, the nurse should fill out an occurrence form for follow-up and notify the provider, as the error may change outcomes in the client's condition. Administering the missed medications with the other evening medications may double up the dose or cause unexpected adverse effects with the other medications. Telling the client that the medication will be administered the following day is not acceptable, as the nurse is suggesting next actions without the provider's knowledge. Documenting in the chart in a narrative about the occurrence does not allow for the health care provider to be notified and aware of a change in the client's condition.
A nurse who obtains a license to practice nursing through self-misrepresentation is guilty of what tort?
Fraud Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. A nurse obtaining a license to practice through misrepresentation is committing fraud. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Slander is one form of defamation of character. Defamation of character is an intentional tort in which one party makes derogatory remarks about another, remarks that harm the other party's reputation. Slander is spoken defamation of character; libel is written defamation.
A client who is on hospice care and has no immediate family has been given less than 1 week to live. The nurse caring for the client recognizes that providing presence is most important, especially when a client is dying. What would be the best way for this nurse to provide presence to this client?
Hold the client's hand and sit by the bedside as often as possible. The nurse can offer supportive presence by holding the patient's hand to show that he or she is sincerely concerned, or simply by being present to communicate value and respect. The other options do not show that the nurse truly cares. Checking on the client every hour demonstrates the nurse wanting to take care of physical needs rather than spiritual needs. Sitting in the chair on the other side of the room is not a caring behavior. Telling a client who is close to death to use the call bell demonstrates a nurse's inability to give caring behaviors.
A client who is scheduled to begin chemotherapy for cancer is overheard telling a family member that everything will eventually be okay and the cancer will be in remission. This client is demonstrating which of the following?
Hope Hope is demonstrated by a positive outlook. It enables a person both to consider a future and to work to actively bring that future into being. Fatalism involves an emotional resignation in light of the inevitability of the future. Love is an intense feeling of deep affection. Spirituality is the quality of being concerned with the human spirit or soul as opposed to material or physical things.
While caring for an infant, the nurse hears another child screaming in the next room and rushes there, forgetting to put the side rails up on the infant's crib. The nuse returns to the room to find that the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for?
Malpractice The nurse did not ensure the safety of the infant by pulling up the side rails before leaving the infant unattended. Therefore, the nurse may be charged with malpractice because the nurse had a duty and breached it, which resulted in harm to the infant. Assault occurs when a person threatens to touch a client without consent. Battery is actually touching the client without consent. Defamation occurs when one makes a statement about another person that can damage the person's reputation.
A hospice nurse in a small Appalachian community is caring for a client at home who is an active member of his church. As death nears, the minister and several members of the congregation come together in the home for a "death watch". Which action by the nurse is most therapeutic? -Ask the minister to have church members come in scheduled time blocks to avoid overcrowding. -Observe the client's religious beliefs and allow the family and minister unlimited access to the client. -Explain that the watch will not be a problem as long as it does not conflict with medical care. -Allow the family and three other visitors at a time tostay with the client, but keep everyone else in the next room.
Observe the client's religious beliefs and allow the family and minister unlimited access to the client. the nurse should respect the client and family wishes, since medical care is ineffective at this point in time.
A client informs the nurse that the heatlh care provider has planned a procedure that may be in conflict with the client's personal spiritual belief. The client asks the nurse for assistance. The nurse is aware that his or her role should include assisting the client to take which action?
Obtain accurate information in order to make a good decision. The nurse's role is to assist the client in obtaining the information needed to make an informed decision, and to support the client's decision making. The best way this can occur is if the nurse obtains accurate information in order to make a good decision. The nurse should never interfere between a client and the client's health care provider. Polling other providers is not appropriate nor is exploring and researching alternative medicine therapies.
The nurse is assessing an older adult client who is at risk for shock. The nurse will effectively assess for cyanosis on the: -Nail beds of the fingers or toes -Skin of the forehead -Oral mucous membranes -Sclera of the eye
Oral mucous membranes
An older adult client is admitted to an extended care facility for follow-up care of a total hip replacement. The nurse assesses a BMI of 20, lackluster hair, and pallor. Which laboratory assessments will the nurse review to obtain the most sensitive information about the client's nutritional status? -Total cholesterol -Prealbumin -Serum albumin -Complete blood count and differential
Prealbumin Prealbumin is a sensitive indicator of changes in nutritional protein status. Prealbumin can also alert the nurse to clients at risk for pressure ulcer development.
The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply.
Provide for stability and safety. Talk openly about death and the feelings associated with it. Encourage expression of feelings. In preparing children for death, encourage expression of feelings, provide for stability and safety, talk openly about death, and encourage expression of feelings. Do not praise stoicism, nor encourage forgetting of the deceased, nor force the child to participate in mourning rituals.
A nurse is caring for a young client who is dying of acute renal failure. What care should the nurse take when helping dying clients to cope?
Provide opportunities for the client to express his feelings freely. The nurse should provide opportunities for the client to express his feelings freely, as it demonstrates attention to meeting individual needs. The nurse should not avoid discussing death with the client, nor ask the client's family not to disturb him. The Dying Person's Bill of Rights states that the client has a right to have his questions answered honestly, so the nurse should inform the client of his actual health status if he wishes to know.
When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?
Psychomotor Because the client learns better by practicing the self-administration of the insulin injection alone, the client's learning style falls in the psychomotor domain. The psychomotor domain is a style of processing that focuses on learning by doing. The client's learning style does not fall in the cognitive, affective, or interpersonal domain. The cognitive domain is a style of processing information by listening to, or reading, facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values. The interpersonal domain is a style of processing that focuses on learning through social relationships.
A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?
Return demonstration The nurse is evaluating psychomotor skills; thus, a return demonstration, which is a method of testing skill performance, would be the most appropriate method for evaluating the client's learning. Written tests are time-consuming, intimidating, and not always specific to the client. Oral tests can be useful in testing cognitive learning. Simulation evaluates whether the client can apply learning in different situations, but not the ability to perform the exercises.
The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?
Role-playing Role-playing allows the learner to experience, relive, or anticipate an event. The nurse explains the scenario and then allows the individual to play out the scene. Role modeling involves a nurse's behaviors and the client observing and learning from these behaviors. Programmed instruction incorporates the use of books as the instructor, independent of study with a teacher. A panel discussion involves a presentation of information by two or more people.
A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse says that the surgeon is rude and that the surgeon's clients always end up with infections. The nurse is at risk of being accused of which?
Slander Slander involves words communicated verbally to a third party that harm or injure the personal or professional reputation of another person. Libel involves words communicated in writing to a third party that harm or injure the personal or professional reputation of another person. Negligence is performing an act that a reasonably prudent person under similar circumstances would not do or, conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do. Assault a threat or an attempt to make bodily contact with another person without that person's consent.
In comparison with licensure, which measures entry-level competence, what does certification validate?
Specialty knowledge and clinical judgment Whereas licensure measures entry-level competence, certification validates specialty knowledge, experience, and clinical judgment. Certification does not validate innocence, years of practice, or ability in multiple practice areas.
The nurse caring for a bedridden hospitalized client who states that this will be the first time that he has missed a Methodist church service in 50 years plans care based on which of the following NANDA-I diagnoses?
Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt Persons suffering spiritual dysfunction or distress may verbalize such distress or express a need for help. Developing a three-part nursing diagnosis consists of data analysis, problem identification, and the formulation of the nursing diagnosis. There are four different types of nursing diagnoses: actual nursing diagnosis, wellness (or health promotion) nursing diagnosis, risk nursing diagnosis, and syndrome diagnosis. The other three statements are missing part of the nursing diagnosis.
A college foreign exchange student is living with a family in England and is confused about the daily Catholic prayers and rituals of the family. The student longs for the comfort of her fundamentalist Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?
Spiritual alienation Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.
When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply.
Stages occur at varying rates among people. Some people actually skip some stages of grief altogether. People vary widely in their responses to loss. In reality, the stages of the grief cycle model are not as discrete as the model indicates. However, it is helpful to use the model as a general guide, while keeping in mind that people may vary greatly in their responses to loss and still fall within the normal response range. Grieving persons may go through the stages at varying rates, go back and forth between stages, or skip stages.
When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?
Talk with animation and vocal inflection to stimulate the client aurally. Talking with animation and vocal inflection to stimulate the client is effective for keeping the client's attention when the client loses focus. It is not appropriate to request family members to serve as translators, provide less teaching due to communication barriers, or elongate the teaching session.
What is the best method for the nurse to use to encourage the use of bicycle helmets by school-aged children? -Advocate for legislation on helmet laws. -Teach parents to role-model helmet use while riding bicycles. -Verbally reprimand children who report not wearing helmets while riding. -Recommend the parents purchase stylish helmets to increase compliance.
Teach parents to role-model helmet use while riding bicycles. Parent role models of behavior are the best method to develop good habits in children. The other options, although possibly valid (except c), are not the best answer.
A nurse is preparing a plan of care for a client whose religion is Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: -Surgery is prohibited in this religious group. -The administration of blood and blood products is forbidden. -Medication administration is not allowed. -Faith healing is practiced primarily.
The administration of blood and blood products is forbidden. Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. Administration of medication is an acceptable practice except if the medication is derived from blood products. Faith healing is forbidden in this religious group.
A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?
The client describes signs and symptoms of hypoglycemia. The client's ability to describe the signs and symptoms of hypoglycemia demonstrates cognitive learning (the storing and recalling of new knowledge in the brain). Demonstrating a skill, such as insulin injection, is an example of psychomotor learning. Affective learning includes changes in attitudes, values, and feelings (e.g., desire to lose weight).
The principle of autonomy by a client is applied in which situation?
The client has decided to stop chemotherapy treatments. The principle of autonomy respects the client's right to make the client's own decisions, and is reflected in the client who decides to stop chemotherapy treatments. The family of a client discussing care does not reflect autonomy, because the client is not making the decisions but the family. An order for an antibiotic is placed by a prescriber and does not reflect the client's right to make the client's own decision about taking the prescribed antibiotic. A hospice consult is placed by the nurse and reflects the nurse's autonomy, not the client's, to make a decision about the client.
When a nurse is planning for learning, who must decide who should be included in the learning sessions?
The nurse and the client The nurse and the client should be the individuals who decide who should be included in the learning sessions. The nurse cannot assume that family members are wanted by the client to be included. The client must always be included in the learning session.
A nurse gives the 400 IU of a vitamin supplement that was in the client's medications instead of the 200 IU that was prescribed. The dosage was given when the unit was busy admitting three clients and another client was in crisis. Which action(s) by the nurse demonstrate the professional value of integrity? Select all that apply.
The nurse documents the dose given. The nurse completes a variance or incident report. A nurse with integrity would document care correctly and would seek to remedy the error. The nurse would be accountable for the error rather than complaining about fairness or blaming others.
On finding multiple bruises on a client's arms and back, the nurse suspects that the client is being abused by a daughter who lives with the client. When questioned, the client denies any abuse. Despite the client's denial, the nurse should report the suspected abuse on the basis of which rationale?
The nurse has a legal and ethical responsibility to report the suspected abuse. Nurses are legally and ethically responsible to report suspected abuse. Because nurses are legally obligated, the client's fear or reluctance to report the abuse is irrelevant. Being labeled a hero is not the correct rationale for reporting suspected abuse.
While walking through a park, the nurse encounters a child with a swollen and reddened arm that hurts to move due to being struck with a baseball bat. The nurse splints the arm using two baseball bats. The child is transported to the hospital and later develops compartmental syndrome in the arm. Which statement regarding the nurse's liability in this case is accurate?
The nurse is protected by the Good Samaritan Act, which states that the nurse may give emergency care using good judgment. The nurse is protected by the Good Samaritan Act, which states the health practitioner may give emergency care in a prudent manner using good judgment. The nurse used two sturdy objects to immobilize the child's arm; therefore, the nurse was not grossly negligent. A prudent nurse would have done the same. The Good Samaritan Act states that the health care practitioner is not obligated to assist; however, it protects the practitioner if the practitioner decides to render emergency care.
A nurse in a physician's office has noted on several occasions that one of the physicians frequently obtains forms for writing prescriptions for controlled substances. The physician reports that the physician's spouse has chronic back pain and requires pain medication. One day the nurse enters the physician's office and sees the physician take a pill out of a bottle. The physician mentions having migraines and that the spouse's pain medication alleviates the pain. What type of nurse-physician ethical situation is illustrated in this scenario?
Unprofessional, incompetent, unethical, or illegal physician practice The physician is demonstrating unprofessional, incompetent, unethical, or illegal physician practice. Claims of loyalty and conflicts regarding the nurse's role are not included in this situation. There is no disagreement with the medical regimen as the physician is not supporting the spouse in obtaining prescriptions from a different provider.
What is the term for the beliefs held by the individual about what matters?
Values Values are ideals and beliefs held by an individual or group about what matters; values act as a standard to guide one's behavior. Ethics are moral principles and values that guide the behavior of honorable people. A moral is a standard for right and wrong. Bioethics is related to ethical questions surrounding life and death, as well as questions and concerns regarding quality of life as it relates to advanced technology.
The nurse should explain to the client's family member that a comfort-measures-only order is being implemented to obtain which expected outcome?
a comfortable, dignified death for the client A comfort-measures-only order indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. It does not have any bearing on organ donation. Comfort measures provide clear guidelines as the nursing care to be provided, which eliminates additional life-sustaining measures that the family has agreed upon.
Some religious beliefs may conflict with prevalent health care practices. For example, which type of treatment is prohibited by the doctrine of Jehovah's Witnesses?
administering blood transfusions Sometimes religious beliefs conflict with prevalent health care practices. The doctrine of Jehovah's Witnesses prohibits blood transfusions. Nurses should be aware of Jehovah's Witnesses' literature which teaches that their refusal of transfusions of whole blood or its four primary components—red cells, white cells, platelets and plasma—is a non-negotiable religious stand. The doctrine does allow use of narcotics for pain, minor surgical procedures, and diagnostic examinations such as an x-ray.
To practice ethically, the nurse should avoid:
allowing the nurse's own judgment to guide practice. Personal convictions apply only to situations and decisions pertaining to the individual. In ethical professional practice, nurses should avoid allowing personal judgments to bias their treatment of clients. It is appropriate for nurses to allow an ethics committee, past cases, and the views of clients and their families to guide nursing practice.
A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing?
anticipatory loss Anticipatory loss occurs when a person displays loss and grief behaviors for a loss that has yet to take place. It is often seen in the families of clients with serious or life-threatening illnesses, and serves to lessen the effect of the actual loss of a family member. Maturational losses are losses that predictably occur during the life cycle. Bereavement is a state of intense grief, as after the loss of a loved one. Dysfunctional grieving is prolonged grief.
An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:
critical thinking. Cognitive learning refers to rational thought or critical thinking. Affective learning is influenced by emotions or feelings. Psychomotor learning refers to the muscular movements learned to perform new skills and procedures; for example, when a mother successfully and independently breastfeeds an infant, the mother has physically demonstrated psychomotor learning.
The nurse is assessing a client recently diagnosed with terminal lung cancer who states, "This can't be happening to me. Maybe the doctor made a mistake." Which stage of death and dying is the client exhibiting?
denial In the denial stage, the client denies the reality of death and may repress what is discussed. The client may think the doctor made a mistake in the diagnosis or that his or her records were mixed up with another client's records. In the anger stage, the client demonstrates rage and hostility. In the bargaining stage, the client tries to barter for more time. In the depression stage, the client demonstrates a period of grief before death characterized by crying and not speaking much.
A nurse working on a critical care unit was informed by a client with multiple sclerosis that the client did not wish to be resuscitated in the event of cardiac arrest. Now the client is no longer able to express wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may involve:
ethical distress. The nurse is involved in a situation that involves ethical distress. Ethical distress occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action. Paternalism is acting for clients without their consent to secure good or prevent harm. Deception and confidentiality can result in ethical problems for nurses when there is a conflict between the client's and nurse's values/interests. In this scenario, the nurse is aware of the client's wishes, but the conflict lies with the family and thus the nurse will experience ethical distress.
A group of nurses working in a long-term care facility fails to keep the narcotic medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in disciplinary action against the:
nurses' licenses. In institutions, most controlled substances must be kept secure and monitored closely in accordance with institutional and state regulations. Failure to do so may lead to disciplinary action against the nurse's license. The pharmacist's license is not pertinent to the stem of the question. State regulatory body is a public authority or government agency responsible for exercising autonomous authority over professions. The institution is not at fault because it had appropriate policies and procedures in place regarding the management of narcotics.
A nurse shows client advocacy by:
offering a hospice consultation to a client who is terminally ill. The definition of advocacy is to ensure that the client's best interests are being met. A hospice consult is an appropriate example. Insisting that a client take a medication does not reflect advocacy for the client because it violates the client's autonomy. Sending a client home with verbal discharge instructions is normal and customary practice and does not ensure that the client's best interests are being met. Refusing to allow a spouse to stay by the client's bedside is not likely to be in the best interests of the client.
A client strongly refuses to be admitted to a long-term facility despite having no family to assist him with his needs at home. The client states, "If I go, I won't be able to go to church every Sunday!" The nurse understands that this statement is reflective of which issue?
separation from Spiritual ties Experiences of being hospitalized or becoming a resident in an assisted living facility or nursing home can initially be frightening. To some extent, such individuals are isolated from personal freedoms, personal privileges, and social support systems. They may be in private rooms with unfamiliar surroundings and may feel insecure. Daily habits may change. Some people are unable to attend formal services, have the accouterments of faith, or receive regular support from familiar groups or their faith community. This separation from spiritual ties places people at risk for altered spiritual function. The client is not experiencing fear of inadequate care as he comments about missing church if admitted. There not a moral issue or a previous experience with the care facility.
An older adult who identifies herself as a devout Catholic has recently relocated to an assisted-living facility. The client is pleased with most aspects of the living situation but laments the fact that the church is not nearby, so attending daily mass is not an option. She is quite upset by this restriction and states, "Going to daily mass was my life." The nurse recognizes that this client is suffering:
spiritual distress. Spiritual distress involves the inability to integrate meaning and purpose in life, while spiritual pain involves angst over the nature and actions of a higher power. The woman's statements do not directly reflect an outlook of hopelessness. A diagnosis of depression does not apply to this situation.
