NUR 111 Final Exam Review

Which term should the nurse know describes the primary purpose of the​ ribs? A. Protection B. Inspiration C. Exhalation D. Deflation

A. Protection Rationale: The main job of the ribs is protecting the more fragile lungs and heart from injury during daily activity. Each set of ribs assists with​ respiration, but the primary purpose of ribs is to protect the lungs from​ puncture, bruising, and injury.

The nurse is working on a committee to develop emergency department policies for the administration of antipyretics. Which should be​ included? A. Administer antipyretics as soon as possible. B. Wait until a fever reaches 101degreesF before administering an antipyretic. C. Avoid antipyretics until clients are admitted to the hospital. D. Admit the client to the hospital if a second dose of an antipyretic is required.

A. Administer antipyretics as soon as possible. ​Rationale: In all​ ages, antipyretics should be administered as soon as possible after the client enters the emergency department. It is important for the staff to remember​ that, if the fever is successfully treated with​ antipyretics, there may still be an infection present. It is not appropriate to admit the client to administer an antipyretic or because a second dose of an antipyretic medication is required.

The nurse is caring for a client who is exhibiting extremely low​ self-esteem. Which factor should the nurse assess that could be affecting the​ client's self-esteem?​ (Select all that​ apply.) A. Age B. Sex C. Ethnicity D. Level of education E. Socioeconomic status

A. Age D. Level of education E. Socioeconomic status ​Rationale: Two studies on​ self-esteem and behavior concluded that​ age, personality​ (extravert versus​ introvert), low​ risk-taking behaviors, high sense of​ mastery, better health​ status, level of​ education, and socioeconomic status factor into​ self-esteem. Sex and ethnicity do not factor into​ one's self-esteem.

The nurse suspects a client has​ Prader-Willi syndrome. Which specific manifestation has led to the​ nurse's suspicion?​ (Select all that​ apply.) A. Poor muscle tone B. Mental retardation C. Regurgitation of food D. Incessant desire to eat E. Consumption of nonfood items

A. Poor muscle tone B. Mental retardation D. Incessant desire to eat Rationale: Prader-Willi syndrome is characterized by mental​ retardation, poor muscle​ tone, and an incessant desire to eat. Regurgitation is a characteristic of a rumination​ disorder, not​ Prader-Willi syndrome. The consumption of nonfood items is a characteristic of​ pica, not​ Prader-Willi syndrome.

The nurse is evaluating teaching provided to the parents of​ 2-year-old twins regarding temperature measurement devices in the home. Which observation indicates that teaching has been​ effective? (Select all that​ apply.) A. An electronic thermometer with disposable covers is available for use. B. Mercury glass thermometers are removed from the home. C. Pad and pencil are placed next to the​ temperature-measuring device. D. There is no evidence of a​ temperature-measuring device in the home. E. Separate mercury glass thermometers are available for each child.

A. An electronic thermometer with disposable covers is available for use. B. Mercury glass thermometers are removed from the home. C. Pad and pencil are placed next to the​ temperature-measuring device. Rationale: The parents should have been instructed to remove mercury glass thermometers from the home. Paper and a pencil should be near the thermometer so that the measurement can be documented after taking. An electronic thermometer with disposable covers is an appropriate and safe measuring device to use with children. There should not be mercury glass thermometers in the​ house, so their presence indicates that teaching was not effective. The absence of a​ temperature-measuring device in the home indicates that teaching has not been effective.

The nurse is working with a team of healthcare professionals to care for a client with a personality disorder. Which type of medication that might be prescribed by the healthcare provider should the nurse​ expect? (Select all that​ apply.) A. Anxiolytic B. Antipsychotic C. Antispasmodic D. Antidepressant E. Antihypertensive

A. Anxiolytic B. Antipsychotic D. Antidepressant ​Rationale: There are variations in pharmacologic treatment of personality disorders that depend on the nature and symptoms of the disorder and the presence of comorbid conditions. Some of the possible medications include​ antidepressants, anxiolytics​ (antianxiety medications), and antipsychotics. Antispasmodics are used to treat muscle spasms. Antihypertensives are generally prescribed for high blood pressure.

The nurse assessing a client suspects a right pneumothorax. Which finding supports the​ nurse's suspicion? A. Asymmetry of the chest expansion B. Right tracheal shift C. Decreased expansion on the left side of the chest D. O2 saturation of​ 94%

A. Asymmetry of the chest expansion ​Rationale: A right pneumothorax would cause asymmetry of the chest expansion and decreased expansion on the right side. Tracheal deviation would occur with a tension pneumothorax to the opposite side. An O2 saturation of​ 94% does not suggest a pneumothorax.

The nurse is participating in a community health clinic. Which client should the nurse identify as being at risk for compromised​ oxygenation? (Select all that​ apply.) A. A​ 46-year-old woman with a history of anxiety attacks B. A​ 64-year-old woman with osteoporosis and limited mobility C. A​ 70-year-old woman who eats a​ well-balanced diet and exercises daily D. A​ 56-year-old man who has been working at a textile factory E. A​ 28-year-old man who smokes with a 10 pack per year history

A. A​ 46-year-old woman with a history of anxiety attacks B. A​ 64-year-old woman with osteoporosis and limited mobility D. A​ 56-year-old man who has been working at a textile factory E. A​ 28-year-old man who smokes with a 10 pack per year history Rationale: Clients with occupations that cause them to inhale chemicals and dust are at increased risk for developing lung disease. Individuals who live a sedentary lifestyle have diminished alveolar​ expansion, placing them at risk for altered respiratory function.​ Additionally, musculoskeletal impairment such as kyphosis​ (which may result from​ osteoporosis) diminishes lung capacity. Clients who smoke are at risk for pulmonary and cardiac disease. High levels of anxiety can cause bronchospasms and the onset of bronchial asthma. Some clients hyperventilate in response to stress. The​ client's arterial oxygen levels​ rise, and the arterial carbon dioxide levels decline. Intake of a diet high in fat predisposes clients to cardiovascular disease.

The nurse cares for a client who has issues with​ self-concept. Which component of​ self-concept should the nurse assess in the​ client? (Select all that​ apply.) A. Body image B. ​Self-awareness C. Personal identity D. Role performance E. Global​ self-esteem

A. Body image C. Personal identity D. Role performance Rationale: The three components that form​ self-concept are personal​ identity, body​ image, and role performance. Global​ self-esteem, also called the global evaluative dimension of the​ self, is how one likes oneself as a whole. This is a part of​ self-esteem, not​ self-concept. Self-awareness describes the extent to which an individual is aware of her​ traits, feelings, and behaviors. This is not an aspect of​ self-concept.

The mother of a​ 13-day-old newborn calls the nurse in the clinic and reports that the newborn has an axillary temperature of​ 101.8°F. Which intervention should the nurse suggest to the​ mother? A. Bring the newborn to the emergency department for evaluation. B. Administer acetaminophen and call back if the fever does not go away. C. Put the newborn in warm clothing while the fever is present. D. Take the temperature again orally after giving the newborn a cold bath.

A. Bring the newborn to the emergency department for evaluation. ​Rationale: Any newborn younger than 4 weeks old with a fever should be admitted to the hospital for further evaluation and testing. It is not appropriate for the nurse to suggest just giving the baby a cool bath or administering acetaminophen or ibuprofen.

The nurse is discussing the use of electronic health records​ (EHRs) when providing client discharge teaching. Which information should the nurse​ include? (Select all that​ apply.) A. Client teaching materials are more accurate due to standardization. B. The nurse may choose not to personally review standardized teaching materials with the client. C. Standardized teaching materials should not contain web links. D. Many EHR systems offer educational information in various languages. E. Before using standardized teaching​ materials, the nurse should assess the​ client's ability to read.

A. Client teaching materials are more accurate due to standardization. D. Many EHR systems offer educational information in various languages. E. Before using standardized teaching​ materials, the nurse should assess the​ client's ability to read. ​Rationale: Standardization of the EHR allows clients in any healthcare setting to receive the same educational material. When the educational material is current and evidenced​ based, client teaching is more accurate and meaningful. Some material may provide links to websites for additional information. Many EHR systems offer educational information in different​ languages, as well. When using standardized teaching​ material, nursing responsibilities still include reviewing the information in person with the client or family member and assessing the client or family​ member's ability to read and understand the information.

The nurse is using the electronic health record​ (EHR) to document client information. Which information is communicated to the healthcare provider through the​ EHR? (Select all that​ apply.) A. Client vital signs B. Acute changes in the​ client's condition C. Assessment notes on the​ client's condition D. Client responses to nursing interventions E. Medications administered to the client

A. Client vital signs C. Assessment notes on the​ client's condition D. Client responses to nursing interventions E. Medications administered to the client ​Rationale: Most EHRs allow nurses to input a wide range of data without leaving the​ client, including vital​ signs, medication administration​ records, assessment​ notes, and responses to nursing interventions. The EHR is not a substitute for​ in-person and other means of verbal communication with​ peers, fellow health​ professionals, and especially the client. Acute changes in the​ client's condition still require a phone call to the healthcare professional.

In a professional development​ seminar, the educator shares barriers that they may encounter as they try to implement​ evidence-based practice​ (EBP) into their care. Which statement most accurately describes these potential​ barriers? (Select all that​ apply.) A. Client workload demands B. Nursing misperceptions about EBP C. Providing accountability for nursing care D. Ensuring credibility of the nursing profession E. Lack of access to continuing education programs

A. Client workload demands B. Nursing misperceptions about EBP E. Lack of access to continuing education programs ​Rationale: Potential barriers to implementation of​ evidence-based practice​ (EBP) include lack of access to continuing education​ programs, nursing misperceptions about​ EBP, and client workload demands. Benefits of EBP include providing accountability for nursing care and ensuring credibility of the nursing profession.

The nurse is preparing information at a community health fair about safety during hot weather. Which information should the nurse​ include? (Select all that​ apply.) A. Drink extra fluids when exercising or working out of doors. B. Limit the intake of alcohol to the end of the day. C. Drink fluids throughout the day. D. Spend time outdoors during the hours of 10 a.m. and 2 p.m. E. Wear a hat.

A. Drink extra fluids when exercising or working out of doors. C. Drink fluids throughout the day. E. Wear a hat. Rationale: Actions to ensure thermoregulation during hot weather include wearing a​ hat, drinking an adequate amount of​ fluids, and drinking extra fluids when exercising. Alcohol is not recommended for use during hot weather. The sun is hottest between the hours of 10 a.m. and 2​ p.m.; being outside during those hours may promote​ heat-related illnesses.

The nurse is evaluating the treatment plan for a client with anorexia nervosa. Which behavior by the client demonstrates that the treatment plan was​ successful? (Select all that​ apply.) A. Eats meals with the family. B. Skin on arms and legs is dry and pale. C. Gained 2 pounds in the past two weeks. D. Lacks concentration when answering questions. E. Has an albumin blood level within normal limits.

A. Eats meals with the family. C. Gained 2 pounds in the past two weeks. E. Has an albumin blood level within normal limits. Rationale: Eating disorders require​ long-term therapy, which involves the client and family. The client eating with the family can be seen as a positive assessment finding. The normal albumin level for an adult is 3.5dash5.0 ​g/dL. This is a positive assessment finding. The client is expected to have a healthy and progressive weight gain. A weight gain of 2 pounds is a positive indicator. In clients with​ malnutrition, the skin is​ dry, pale, and may be jaundiced. Symptoms of anorexia nervosa include poor​ concentration, irritability,​ apathy, and depression due to electrolyte imbalance and malnutrition.

The nurse is caring for a client with a chest tube. Which intervention should the nurse​ implement? (Select all that​ apply.) A. Ensure oxygen is available. B. Report hyperresonance with percussion. C. Monitor for air leaks. D. Assess for pain. E. Prescribe pain medications as needed.

A. Ensure oxygen is available. C. Monitor for air leaks. D. Assess for pain. ​Rationale: When caring for a client with a chest​ tube, the nurse would ensure that oxygen is​ available, monitor tubing for air​ leaks, and assess for pain. The nurse would not report hyperresonance with percussion but would report​ tympany, or a hollow sound. It is outside the scope of nursing practice to prescribe pain medications.

The nurse is preparing to perform a nursing assessment on a client diagnosed with a personality disorder. Which action by the nurse should ensure an effective​ assessment? A. Establishing a therapeutic environment B. Asking questions related to family​ members' mental health C. Establishing an authoritative environment D. Asking​ detailed, personal questions

A. Establishing a therapeutic environment Rationale: Prior to​ assessment, the nurse must establish a therapeutic environment by creating trust and communication. The nurse should avoid asking personal questions. The environment should be therapeutic and establish mutual trust. It should not be authoritative. The nurse will not specifically ask questions related to family​ members' mental health because this assessment is focused on the client.

The nurse discusses Erik​ Erikson's theory of psychosocial development with colleagues. Which should the nurse recognize as an overriding theme in​ Erikson's theory?​ (Select all that​ apply.) A. Establishing trust in others B. Developing a sense of identity in society C. Viewing life experiences as isolated events D. Helping the next generation prepare for the future E. Identifying relationships that connect actions to self

A. Establishing trust in others B. Developing a sense of identity in society D. Helping the next generation prepare for the future ​Rationale: Establishing trust in​ others, developing a sense of identity in​ society, and helping the next generation prepare for the future are the main themes in​ Erikson's theory. Viewing life experiences as isolated events and identifying relationships that connect actions to self are part of developing​ self-awareness.

The nurse observes a mother stroking her​ child's arms and legs with a​ cool, damp washcloth. Which method of heat transfer is the mother using to reduce the​ fever? A. Evaporation B. Conduction C. Metabolism D. Radiation

A. Evaporation Rationale: Heat can be transferred between places or objects. Evaporation is the conversion of water to​ vapor, which is what occurs when the mother applies cool water to the​ child's limbs. Radiation is the release of heat through no physical contact. Conduction is the release of heat through physical contact. Metabolism is not a method of heat transfer.

On a​ hot, humid​ day, a client presents with a body temperature of​ 40.9°C (105.6°F), dry and flush​ skin, vomiting, low blood​ pressure, and muscle cramps. Which type of injury should the nurse suspect based on the​ manifestations? A. Heat stroke B. Normothermia C. Hypothermia D. Malignant hyperthermia

A. Heat stroke ​Rationale: The nurse should suspect heat​ stroke, which can occur during hot weather and high humidity and results in dysfunction of the​ brain's thermoregulation center. Signs and symptoms of​ heat-related injuries include​ paleness, dizziness, nausea and​ vomiting, fatigue, low blood​ pressure, muscle​ cramps, and fainting. Late signs include​ irritability, confusion,​ stupor, and coma. Hypothermia is a core body temperature below​ 35°C (95°F), and is classified as​ mild, 32-​35°C ​(89.6-95°F); ​moderate, 28-​32°C ​(82.4-​89.6°F), or​ severe, below​ 28°C (less than​ 82.4°F). The usual range of core body temperature is called normothermia. The normal range for adults is between​ 36°C and​ 38.5°C (96.8°F and​ 101.3°F). Malignant hyperthermia is a potentially​ fatal, inherited disorder that results from the​ body's reaction to volatile inhalation of anesthetic gases and​ succinylcholine, a depolarizing neuromuscular blocker.

The nurse is teaching a class about the Office of the National Coordinator for Health Information Technology and meaningful use objectives. Which item should be​ included? (Select all that​ apply.) A. Improving care coordination to improve client outcomes B. Controlling and monitoring​ clients' healthcare choices C. Ensuring the security and privacy of protected medical information D. Engaging clients and their families in the​ client's care E. Reducing health disparities by improving safety and quality of care

A. Improving care coordination to improve client outcomes C. Ensuring the security and privacy of protected medical information D. Engaging clients and their families in the​ client's care E. Reducing health disparities by improving safety and quality of care ​Rationale: The Office of the National Coordinator for Health Information Technology​ (ONC) monitors the achievement of meaningful use​ objectives, which are reported back to the Centers for Medicare and Medicaid Services​ (CMS) in order to authorize financial reimbursement. Meaningful use objectives include improving care​ coordination, reducing health disparities among U.S. citizens by improving the safety and quality of​ care, ensuring the security and privacy of protected medical​ information, and engaging clients and their families in the​ client's care. Meaningful use objectives do not include controlling and monitoring​ clients' healthcare choices.

The nurse performs a nursing assessment of a client with a suspected alteration of self. Which nursing action should the nurse include in the​ assessment? (Select all that​ apply.) A. Interview the client. B. Establish a safe environment. C. Assess the​ client's role mastery. D. Establish a therapeutic relationship. E. Assess the​ client's personal identity.

A. Interview the client. B. Establish a safe environment. D. Establish a therapeutic relationship. Rationale: When performing an assessment of a client with a suspected alteration of​ self, the nurse should establish and maintain a safe​ environment, establish a therapeutic​ relationship, interview the​ client, and avoid asking personal questions that will not substantially add to the assessment data. Assessing the​ client's role mastery and personal identity are not important aspects of nursing assessments of clients with alterations of self.

The nurse is planning a webinar about the benefits of using uniform language in the electronic health record. Which information should the nurse​ include? (Select all that​ apply.) A. It helps healthcare organizations validate the benefits and costs of nursing care. B. It reduces the emphasis on the need for critical thinking when providing client care. C. For healthcare​ organizations, it facilitates the measurement of nursing​ care's impact on the client. D. It enhances the individual​ nurse's decision making at the point of care. E. It decreases nurse​ educators' ability to teach vital concepts related to the nursing process.

A. It helps healthcare organizations validate the benefits and costs of nursing care. C. For healthcare​ organizations, it facilitates the measurement of nursing​ care's impact on the client. D. It enhances the individual​ nurse's decision making at the point of care. Rationale: Using uniform language in the electronic health record​ (EHR) enhances nurse​ educators' ability to tailor curricula to teach vital concepts related to the nursing process. Uniform language also allows healthcare organizations to more effectively measure nursing care and its impact on the​ client, as well as to validate the benefits and actual costs of nursing care to administrators. Additional benefits of using uniform language include facilitating decision making and critical thinking at the point of care.

The nurse is performing a psychosocial assessment of a client. The nurse should assess for which specific behavioral​ element? (Select all that​ apply.) A. Nonverbal cues B. Verbal expression of emotion C. Current roles and role conflicts D. Ability to follow a conversation E. Spiritual affiliations and practices

A. Nonverbal cues B. Verbal expression of emotion D. Ability to follow a conversation Rationale: Many elements of a psychosocial assessment involve asking the client questions and recording answers.​ However, some elements of the psychosocial assessment are solely based on the observations the nurse makes about the​ client's behaviors.​ Specifically, these elements are in the dimension of communication skills and​ behaviors, which includes observations of the​ client's emotional tone and ability to follow conversation as well as their verbal expression of emotion and verbal and nonverbal cues. The​ client's current roles and role conflicts refer to the​ client's self-concept and are not behavioral elements. The​ client's spiritual affiliations and practices refer to the​ client's psychosocial, not behavioral health.

The nurse is performing a respiratory assessment on a young adult. Which finding is considered an alteration of​ oxygenation? (Select all that​ apply.) A. Orthopnea B. Dyspnea C. Tachypnea D. Eupnea E. Retractions

A. Orthopnea B. Dyspnea C. Tachypnea E. Retractions ​Rationale: Alterations of oxygenation are manifested by​ dyspnea, orthopnea,​ tachypnea, and retractions.​ Eupnea, or normal​ breathing, is not a finding that indicates an alteration in oxygenation.

A client asks the nurse how to obtain the​ client's lab results and history of visits. Which informatics application should the nurse​ recommend? A. Patient portal B. Insurance billing summary C. Clinical decision support D. Telehealth

A. Patient portal Rationale: A patient portal allows clients to access parts of the electronic health​ record, schedule​ appointments, and communicate with providers. Telehealth describes the assessment and care being provided remotely through the use of technology. Clinical decision support is the use of data to trigger alerts and recommendations for treatment options. An insurance billing summary is not a useful tool in this situation.

The nurse is preparing to present the benefits of​ evidence-based practice​ (EBP) as it relates to nursing to colleagues. Which benefit should the nurse​ include? (Select all that​ apply.) A. Receiving the best clientoutcomes B. Increasing the accuracy of charting C. Contributing to the knowledge of nursing D. Increasing teamwork in healthcare facilities E. Assisting in the delivery of​ high-quality nursing care

A. Receiving the best clientoutcomes C. Contributing to the knowledge of nursing E. Assisting in the delivery of​ high-quality nursing care Rationale: Some basic activities can provide a foundation for implementing EBP. These strategies can spark the necessary stimulus to engage in behaviors that encourage best practice. Participating in EBP contributes to the knowledge of nursing and client care in​ today's healthcare systems and delivery of​ high-quality nursing care for best outcomes. Utilizing EBP​ doesn't increase the accuracy of​ charting, as that is all dependent on the nurse and the knowledge of what they add to the record. EBP governs nursing​ practice, but teamwork is something that needs to be encouraged by management in each individual healthcare facility.

The nurse is listing consequences of malignant hyperthermia. Which consequence should be​ included? (Select all that​ apply.) A. Renal failure B. Disseminated intravascular coagulation C. Pulmonary edema D. Gastroenteritis E. Cardiac dysrhythmias

A. Renal failure B. Disseminated intravascular coagulation C. Pulmonary edema E. Cardiac dysrhythmias Rationale: Malignant hyperthermia is an inherited disorder that affects temperature regulation. With this​ condition, an individual experiences a serious reaction to inhaled anesthetic gases and depolarizing neuromuscular blockers. If not​ treated, the individual will develop renal​ failure, pulmonary​ edema, cardiac​ dysrhythmias, and disseminated intravascular coagulation. Malignant hypothermia does not cause gastroenteritis.

The nurse is at a party when a guest faints due to suspected hyperthermia. What should the nurse do first​? A. Send someone to call 911 and stay with the guest. B. Remove clothing and lightly mist the guest with cool water. C. Run inside and call 911. D. Help the guest get​ inside, and call 911.

A. Send someone to call 911 and stay with the guest. ​Rationale: It is important for the nurse to stay with the client until help arrives. The nurse should send another guest to call for help. The nurse should remove as much clothing as​ possible, lightly mist the client with​ water, and move them into an​ air-conditioned or​ cool, shaded area while waiting for the ambulance.

The nurse is discussing how quality metrics are used to meet and document the requirements of regulatory agencies for reimbursement and accreditation. Which component should the nurse​ include? (Select all that​ apply.) A. Stroke center certification B. Client demographic documentation C. Insurance reimbursement D. Employee background checks E. Trauma center certification

A. Stroke center certification C. Insurance reimbursement E. Trauma center certification ​Rationale: The availability of quality metrics simplifies the process of meeting and documenting the requirements set forth by regulatory agencies that govern healthcare​ organizations' eligibility for reimbursement and accreditation in numerous areas. Those areas include certification as a trauma center or stroke center and reimbursement by insurance plans that require adherence to policies issued by The Joint Commission and the Centers for Medicaid and Medicare Services. Quality metrics do not apply to documenting client demographics or conducting employee background checks.

The nurse is planning care for a client with weight loss related to respiratory alterations. Which intervention should the nurse​ include? (Select all that​ apply.) A. Supply nutritional supplements during the day. B. Consult with a dietitian. C. Choose foods the client enjoys. D. Encourage the client to eat three full meals every day. E. Select foods to meet caloric requirements.

A. Supply nutritional supplements during the day. B. Consult with a dietitian. C. Choose foods the client enjoys. E. Select foods to meet caloric requirements. Rationale: Individuals with respiratory alterations often need an increased calorie intake but lack the endurance to consume adequate nutrition. Increased calories are necessary because the client is burning more calories due to the increased work of breathing. A nutritionist is able to assist the individual to select foods and supplements the client enjoys to meet daily caloric and nutritional needs. A nutritionist can guide the individual in developing menus consisting of​ frequent, small, nutritious meals.

The nurse is providing teaching for a client who is taking a nonsteroidal​ anti-inflammatory drug​ (NSAID). What are common side effects that the nurse should include in the​ teaching? (Select all that​ apply.) A. Ulcer formation B. Blood coagulation C. Bleeding D. Upset stomach E. Ringing in the ears

A. Ulcer formation C. Bleeding D. Upset stomach Rationale: Common side effects for NSAIDs are​ bleeding, stomach​ upset, and ulcer formation. NSAIDS do not cause blood coagulation. Ringing in the ears is an adverse reaction to acetylsalicylic acid.

The nurse is describing applications of telehealth. Which activity should the nurse​ include? (Select all that​ apply.) A. Using dual webcams to visually assess the​ client's condition B. Allowing clients to consult with healthcare providers regardless of location C. Managing acute and chronic conditions of the client D. Having the client meet with a virtual health coach E. Watching clients perform a return demonstration of skills

A. Using dual webcams to visually assess the​ client's condition C. Managing acute and chronic conditions of the client D. Having the client meet with a virtual health coach E. Watching clients perform a return demonstration of skills ​Rationale: Applications of telehealth include allowing the client to meet with a virtual health​ coach, managing acute and chronic​ conditions, using dual webcams to visually assess the​ client's condition, and watching clients perform a return demonstration of skills. Not all states issue telemedicine licenses that permit healthcare providers to practice telehealth across state lines. As​ such, not every healthcare provider can consult with​ out-of-state clients via telehealth.

The nurse prepares to interview a client with suspected alterations of self. Which component should the nurse include in the​ assessment? (Select all that​ apply.) A. ​Self-esteem B. ​Self-concept C. ​Self-awareness D. Global ideal self E. Specific​ self-image

A. ​Self-esteem B. ​Self-concept C. ​Self-awareness Rationale: In performing an assessment of a client with a suspected alteration of​ self, the nurse must interview the client regarding components related to​ self-concept, self-esteem, and​ self-awareness. Specific​ self-image and global ideal self are not aspects in all nursing interviews of clients with suspected alterations of self.

Which response is an example of a background​ question? (Select all that​ apply.) A. Why​ isn't long-acting insulin administered via the IV​ route? B. What is the pathophysiology of left ventricular heart​ failure? C. How does acupuncture compare with pain medication for treating chronic knee​ pain? D. How does incentive spirometry help prevent collapse of the small airways in the​ lungs? E. -What is the link between healthcare​ providers' stethoscopes and​ healthcare-acquired infections?

A. Why​ isn't long-acting insulin administered via the IV​ route? B. What is the pathophysiology of left ventricular heart​ failure? D. How does incentive spirometry help prevent collapse of the small airways in the​ lungs? Rationale: Background questions are knowledgebased and seek more information about a​ topic, such as medications or diseases. Answers to background questions can be found in​ textbooks, drug​ guides, medical​ dictionaries, and other education resources. Foreground questions are practice based​ and, compared with background​ questions, they are narrower in scope. Foreground questions focus on a specific clinical issue and their answers identify useful information about direct client care that may guide the formulation of nursing interventions that improve client outcomes.

The nurse conducting a research study needs to determine if an individual qualifies to be a participant. Which criteria must be met for​ inclusion? (Select all that​ apply.) A. he individual meets all the inclusion criteria. B. The individual has been given informed consent. C. The individual receives payment for participation. D. The individual must waive the right to anonymity. E. The individual is informed of all aspects of the study.

A. he individual meets all the inclusion criteria. B. The individual has been given informed consent. E. The individual is informed of all aspects of the study. ​Rationale: Research participants are defined as volunteers for a specific study project who meet all the inclusion​ criteria, have been informed of all aspects of the​ study, and have given informed consent. Adherence to the ethical principle of justice requires protection of the research​ participant's anonymity. Payment is not a mandatory condition of participation in research.

The nurse provided teaching to the parent of a newborn about thermoregulation. Which statement by the parent indicates that learning has​ occurred? A. ​"I should put a hat on my baby to prevent heat loss through the​ head." B. ​"I should report a temperature greater than 102degreesF to the​ doctor." C. ​"I should avoid bathing the baby for at least 6​ weeks." D. ​"I should use an oral thermometer whenever I take the​ baby's temperature."

A. ​"I should put a hat on my baby to prevent heat loss through the​ head." ​Rationale: Young infants are at higher risk for heat loss through their​ heads, so it is important for them to wear hats. It is not necessary to avoid bathing the baby. Any fever in a newborn should be reported to the healthcare​ provider, not just a temperature greater than​ 102°F. An oral thermometer is not appropriate for a newborn infant because the baby is not able to keep the thermometer in place and it could possibly cause injury to the​ baby's mouth.

The nurse provided teaching to the parents of a​ 7-year-old child about antipyretics. Which statement by the parent indicates that learning has​ occurred? A. ​"I will not give aspirin or any other medication with aspirin in it to my​ child." B. ​"I will give my child ibuprofen on an empty​ stomach." C. ​"I will only use acetaminophen to reduce swelling from now​ on." D. ​"I will call the healthcare provider before giving acetaminophen to my​ child."

A. ​"I will not give aspirin or any other medication with aspirin in it to my​ child." ​Rationale: Acetylsalicylic acid​ (ASA), or​ aspirin, is contraindicated in children under the age of 18 due to the risk of Reye syndrome. This is especially important in children with a suspected viral​ infection, such as the flu or varicella. Ibuprofen is given with food or a full glass of water to decrease gastric irritation. Acetaminophen is used for pain or​ fever, not inflammation. Acetaminophen may be given to a​ 7-year-old without an order from the healthcare provider.

Which statement by the nurse describes the ideal use of clinical decision support systems in the electronic health​ record? A. ​"It should facilitate the use of nursing research in client​ care." B. ​"It should eliminate certain steps from the nursing research​ process." C. ​"It should have no impact on the quality of client​ care." D. ​"It should reduce the need for critical thinking in​ nursing."

A. ​"It should facilitate the use of nursing research in client​ care." Rationale: A clinical decision support system is a type of artificial intelligence that analyzes data and provides information about​ evidence-based practices. The use of electronic health records​ (EHRs) that contain clinical decision support systems should promote best practices through incorporating nursing​ research, as well as by making it easier to use current nursing research at the point of care. Although there is no substitute for sound nursing​ judgment, clinical decision support systems may improve client safety and quality of care. Even with advanced technology and information​ access, the steps of the nursing research process should remain the same.

The nurse performs the admission assessment of a child who is severely underweight. The​ child's mother states that the child has lost much weight in the last month and refuses to eat at meals. Which disorder should the nurse suspect that the child is​ experiencing? A. ​Avoidant/restrictive food intake disorder B. Rumination disorder C. ​Prader-Willi syndrome D. Pica

A. ​Avoidant/restrictive food intake disorder Rationale: Avoidant/restrictive food intake disorder is characterized by a disturbance in eating patterns in which the client fails to meet nutritional needs. In​ pica, individuals consume nonnutritive and nonfood substances. Rumination disorder describes the repeated regurgitation of food outside the presence of a medical condition.​ Prader-Willi syndrome is a genetic disorder that features mental​ retardation, poor muscle​ tone, and an incessant desire to eat.

The nurse teaches a client to engage in a personal exploration and evaluation of​ thoughts, emotions, and values. Which component of​ self-concept is the nurse​ teaching? A. ​Self-awareness B. Role performance C. Personal identity D. ​Self-esteem

A. ​Self-awareness ​Rationale: The process of exploring and evaluating​ thoughts, emotions, and values is introspection. Introspection is a necessary process to develop​ self-awareness. Personal identity is evaluated from the standpoint of ideal​ self, real​ self, and public self.​ Self-esteem is the​ individual's opinion of himself and is the degree to which the individual approves of or likes himself. Role performance is how well the individual exhibits the behaviors expected to fulfill a role.

Which oxygen delivery method should the nurse know may be set to deliver an exact FiO2 of​ 45%? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Venturi mask

D. Venturi mask ​Rationale: Venturi masks are set with a specific oxygen flow rate and specific jet adapter device. Flow rates of 24dash​50% may be set with the Venturi mask. The other oxygen delivery methods cannot deliver a specific flow rate.

The nurse is planning to assess a​ 4-year-old child to help determine the cause of the​ child's fever. Which body system is a priority to​ assess? (Select all that​ apply.) A. Neurologic B. Respiratory C. Urinary D. Musculoskeletal E. Gastrointestinal

B. Respiratory C. Urinary E. Gastrointestinal ​Rationale: Infections of the​ urinary, respiratory, and gastrointestinal systems are the most common reason for a fever in this age range. The neurologic and musculoskeletal systems are not common systems for infections in children.

While assessing a​ client, the nurse notes that the client has areas of decay on several teeth and her weight is less than​ 85% of normal. The​ client's mother privately tells the nurse her daughter is vomiting after meals and not eating very much during the day. Which alteration of self does the nurse suspect the client to be​ experiencing? A. Pica B. Anorexia nervosa C. Rumination disorder D. ​Binge-eating disorder

B. Anorexia nervosa ​Rationale: The nurse should consider that the client is experiencing anorexia​ nervosa, a condition marked by obsession about food and​ weight; while the hallmark symptom of anorexia is food​ restriction, some clients will vomit to avoid weight gain. Anorexia nervosa is characterized by a weight less than​ 85% of normal. Pica is a condition characterized by the consumption of​ nonnutritive, nonfood​ substances, and is a result of a nutritional deficiency. Rumination disorder is characterized by the repeated regurgitation of food outside the presence of a medical condition. The client likely does not have a​ binge-eating disorder, which is characterized by​ obesity, recurrent episodes of consuming large amounts of food within a short​ time, with feelings of loss of​ control, guilt, and shame.

A client asks the nurse about the purpose of incentive spirometry. Which information should the nurse include in the​ explanation? A. Decreases oxygen demand B. Clears mucus secretions C. Prevents lung collapse D. Increases lung volume

B. Clears mucus secretions ​Rationale: Incentive spirometry is a breathing exercise using an incentive spirometer that helps clients breathe deeply to expand the lungs. This process can help clients clear mucus secretions and increase the amount of oxygen delivered to the bronchi and alveoli. Incentive spirometry does not decrease oxygen demand or increase lung volume. It may prevent collapse of the​ alveoli, but not the lungs.

The nurse is assessing a client who fell into a cold lake. Which assessment finding indicates that the​ client's body is attempting to regulate its​ temperature? (Select all that​ apply.) A. Thirst B. Cold hands C. Shivering D. Sleepiness E. Sweating

B. Cold hands C. Shivering Rationale: When the skin is​ chilled, the body attempts to regulate temperature by vasoconstriction of blood vessels. This could be why the​ client's hands are cold. The body also shivers to increase heat production. The body does not regulate temperature through​ sleep, thirst, or by sweating.

Which term should the nurse use to describe the computerized medical​ record? (Select all that​ apply.) A. Clinical information system B. Computerized patient record C. Electronic health records system D. Clinical decision support system E. Administrative information system

B. Computerized patient record C. Electronic health records system ​Rationale: Other terms commonly used to describe the computerized medical record​ (CMR) include electronic health records system​ (EHRS), electronic medical record​ (EMR), electronic health record​ (EHR), computerized patient record​ (CPR), patient medical records software​ (PMRS), and personal health record​ (PHR). Clinical decision support systems are a type of artificial intelligence that analyze data and provide information about​ evidenced-based practices. A clinical information system allows multiple disciplines to simultaneously access the​ client's chart and record data that can be viewed and analyzed by multiple healthcare providers in real time. An administrative information system provides support and management for the business aspects of health care.

A​ 2-year-old child with cerebral palsy may benefit from the model known as a medical home.Which goal from Healthy People 2020 does the nurse identify for the​ client? A. Limiting who lives in the home B. Coordinating their healthcare services C. Paying for their medication D. Paying the mortgage for the home

B. Coordinating their healthcare services ​Rationale: Healthy People 2020 objectives include reducing child mortality rates as well as decreasing the incidence of transmission of preventable diseases among children. Increasing access to a medical home-which is a model of care that promotes​ physician-led, client-centered, coordinated health services-for children with special needs is also an objective. The services do not provide financial backing nor do they limit who lives in the home.

The nurse is caring for a client with an alteration in oxygenation. Which independent action should the nurse​ perform? (Select all that​ apply.) A. Prescribe oxygen therapy. B. Place the client in high Fowler position. C. Suction the upper airway. D. Order a diet high in iron. E. Teach about smoking cessation.

B. Place the client in high Fowler position. C. Suction the upper airway. E. Teach about smoking cessation. ​Rationale: Independent interventions are those the nurse can implement without an order or prescription. Teaching about smoking​ cessation, placing a client in high Fowler​ position, and suctioning the upper airway are all interventions the nurse can perform independently. Ordering a diet high in iron and prescribing oxygen therapy are outside the scope of nursing practice.

The nurse is preparing an​ in-service about the benefits and recommended uses of the electronic health record. Which topic should the nurse​ include? (Select all that​ apply.) A. Notifying healthcare providers about acute changes in​ clients' conditions B. Documenting client responses to nursing interventions C. Delivering sensitive test results to clients using online systems D. Reducing time spent away from the​ client's bedside E. Inputting data related to administering client medications

B. Documenting client responses to nursing interventions D. Reducing time spent away from the​ client's bedside E. Inputting data related to administering client medications ​Rationale: Most electronic health records​ (EHRs) allow nurses to input a wide range of data without leaving the​ client, including vital​ signs, medication administration​ records, assessment​ notes, and responses to nursing interventions. Acute changes in the​ client's condition still require a phone call to the healthcare provider. Sensitive test​ results, such as pathology​ reports, should still be delivered in person by the healthcare provider and not discovered by the client online.

The nurse is doing a case study on a client with​ long-term cardiovascular disease.Which would be the best way to target health promotion for treatment as it relates to​ evidence-based practice? A. Looking at the hospital data B. Genomic standpoint C. Examining cultural views D. Following federal regulation

B. Genomic standpoint Rationale: Targeting health promotion from a genomic standpoint allows for more accurate risk​ prediction, diagnosis, and treatment of a variety of health​ alterations, such as heart​ disease, stroke,​ cancer, diabetes, and Alzheimer disease​ (HHS, 2016e). Goals associated with the promotion of global health include protecting the health of the national population as well as limiting the international transmission of infectious diseases during travel.​ Evidence-based resources related to global health and genomics are emerging.

A school nurse is recommending a​ school-wide initiative to reduce the risk of​ heat-related injuries in athletes. Which recommendation should the nurse​ include? A. Cancel athletic games when the temperature is above 80 degrees F. B. Increase access to​ fresh, cold water. C. Encourage the school to move athletic activities indoors. D. Reduce athletic activities at the school.

B. Increase access to​ fresh, cold water Rationale: Increasing access to fresh cold water and encouraging frequent water breaks can decrease the risk of hyperthermia. It is highly unlikely that the school will reduce athletic​ activities, and it may not be possible to cancel games when the temperature is above​ 80°F. The school may not have the facilities to host indoor​ athletics, and it​ doesn't address the needs of athletes when they play at other locations.

Which​ evidence-based resource would be appropriate for the nurse to integrate into the care of a pregnant​ client? A. Consequences of illegal drug use from the local police department B. Information on breastfeeding from Healthy People 2020 C. Safety instructions from a car seat manufacturer D. Teaching pamphlets on circumcision

B. Information on breastfeeding from Healthy People 2020 ​Rationale: Evidence-based resources use current best evidence in making decisions about the care of individual patients. Healthy People 2020 provides​ science-based benchmarks to track and monitor progress towards health to motivate individuals. While there are multiple opportunities for educational​ topics, only those based in the science can be considered​ evidence-based. Healthy People 2020 strives to identify nationwide health improvement priorities. As​ such, breastfeeding information from this source would be considered​ evidence-based, while other teaching pamphlets or information from local agencies or manufacturers may not.

The nurse assessing a newborn suspects respiratory distress. Which finding supports the​ suspicion? A. Acrocyanosis at birth B. Intercostal retractions C. Respiratory rate of 44 D. Abdominal breathing

B. Intercostal retractions ​Rationale: Retraction of the intercostals occurs with respiratory distress. A respiratory rate of​ 44, abdominal​ breathing, and acrocyanosis are normal findings for​ neonates/newborns.

The nurse explains the role of family in the development of healthy​ self-esteem to a group of parents. Which action should the nurse explain may contribute to lowered​ self-esteem in​ children? (Select all that​ apply.) A. Loss of a pet B. Interfamilial violence C. Authoritative parenting D. Overprotective parenting E. Movement to a new neighborhood

B. Interfamilial violence C. Authoritative parenting D. Overprotective parenting ​Rationale: Family dynamics that can contribute to lowered​ self-esteem include an overprotective or authoritative parenting style or interfamilial violence. Loss of a close family​ member, not a​ pet, may also contribute. Movement to a new neighborhood is not known to lower​ self-esteem.

Which question is most appropriate for the nurse to consider when evaluating the impact of​ evidence-based practice​ (EBP) on client​ outcomes? (Select all that​ apply.) A. Is the new practice beneficial to the​ nurse? B. Is the new practice being implemented​ correctly? C. Does the change in practice yield the intended​ results? D. Is the practice in accordance with the​ state's nurse practice​ act? E. Does the practice adhere to the American Nurses Association​ (ANA) standards of nursing​ care?

B. Is the new practice being implemented​ correctly? C. Does the change in practice yield the intended​ results? Rationale: Evaluation seeks to answer questions​ including, "Is the new practice being implemented​ correctly?" and​ "Does the change in practice yield the intended​ results?" Nurses are legally bound to practice in accordance with their​ state's nurse practice act and to provide care that adheres to the ANA standards of nursing​ care; these concerns must be addressed before implementing care. The practice is intended to be beneficial to the client.

Which factor should the nurse exclude as a benefit of electronic medical​ records? A. Recognizing the need for vaccines B. Notifying clients of upcoming appointments C. Tracking client data over time D. Identifying the need for mammograms

B. Notifying clients of upcoming appointments ​Rationale: Tracking client data over​ time, identifying the need for​ vaccines, and identifying the need for mammograms are all benefits of electronic medical records. Notifying clients of upcoming appointments is not a benefit of electronic medical records.

The nurse is listing what clients may perform through patient portals. Which component should the nurse​ include? (Select all that​ apply.) A. Making changes to the electronic health record B. Sending messages to a provider C. Scheduling appointments D. Requesting an official copy of their records E. Reviewing lab results

B. Sending messages to a provider C. Scheduling appointments E. Reviewing lab results ​Rationale: A patient portal allows clients to see parts of the medical record and to schedule appointments. Many also have the ability to send messages and requests to the care team. Clients are not able to make changes to their medical records through a patient portal.​ Also, requesting an official copy of records is not a function of the patient portal.

A client is prescribed an oral steroid drug to improve breathing. Which instruction should the nurse provide to the​ client? A. ​"Stop the medication when your symptoms​ subside." B. ​"Be sure to follow the​ step-wise reduction of the​ medication." C. ​"You will probably be taking this medication​ long-term." D. ​"If you feel side​ effects, cut the dosage in​ half."

B. ​"Be sure to follow the​ step-wise reduction of the​ medication." ​Rationale: Exogenous steroid administration can cause suppression of natural corticosteroid production by the adrenal glands. The degree of adrenal suppression that occurs is dependent on the length of medication therapy. Because of​ this, discontinuation of corticosteroid medications requires a​ progressive, step-wise reduction​ (tapering) of the medication. Abrupt discontinuation can cause adrenal​ crisis, which is characterized by manifestations associated with insufficient glucocorticoid​ production, such as profound​ hypotension, tachycardia, and cardiovascular collapse. Because oral steroids have a number of side​ effects, they are usually administered for a short period of time. The client should not be told to decrease the​ dosage, but to call the healthcare provider if side effects occur.

Which statement best reflects the​ nurse's correct understanding of principles related to​ evidence-based practice​ (EBP)? (Select all that​ apply.) A. ​"Client choices do not affect​ evidence-based practice." B. ​"Client-centered care is an outcome of​ evidence-based practice." C. ​"The nurse's level of expertise influences​ evidence-based practice." D. ​"Evidence-based practice promotes individualization of client​ care." E. ​"Evidence-based practice requires application of all research evidence about a given​ topic."

B. ​"Client-centered care is an outcome of​ evidence-based practice." C. ​"The nurse's level of expertise influences​ evidence-based practice." D. ​"Evidence-based practice promotes individualization of client​ care." ​Rationale: Evidence-based practice​ (EBP) combines the best evidence from the most current research​ available, the​ nurse's clinical​ expertise, and the​ client's preferences, including​ needs, values, and choices. EBP promotes individualization of client care and provides best practice for​ client-centered care.

The nurse researcher is explaining​ evidence-based practice​ (EBP) to a group of nurses. Which statement is appropriate to include in the​ explanation? (Select all that​ apply.) A. ​"EBP promotes generalization of client​ care." B. ​"EBP incorporates the​ nurse's clinical​ expertise." C. ​"EBP considers the​ client's needs,​ values, and​ choices." D. ​"EBP tests hypotheses about​ health-related conditions." E. ​"EBP is reflective of the best evidence from current​ research."

B. ​"EBP incorporates the​ nurse's clinical​ expertise." C. ​"EBP considers the​ client's needs,​ values, and​ choices." D. ​"EBP tests hypotheses about​ health-related conditions." Rationale: Evidence-based practice​ (EBP) combines the best evidence from the most current research​ available, the​ nurse's clinical​ expertise, and the​ client's preferences, including​ needs, values, and choices. EBP promotes individualization of client care. Nursing research tests hypotheses about​ health-related conditions and nursing care.

The nurse is delivering a presentation about​ evidence-based practice​ (EBP). Which statement best reflects the​ nurse's correct understanding of​ EBP? A. ​"EBP is the gathering of objective facts and information to advance knowledge about a specific​ topic." B. ​"EBP involves combining quality​ research, clinical​ expertise, and client preferences to achieve the best client​ outcomes." C. ​"EBP uses a systematic and strict scientific process to test hypotheses about​ health-related conditions and nursing​ care." D. ​"EBP incorporates clinical​ knowledge, expert​ opinion, or information resulting from​ research."

B. ​"EBP involves combining quality​ research, clinical​ expertise, and client preferences to achieve the best client​ outcomes." ​Rationale: Evidence-based practice​ (EBP) seeks to achieve optimal client outcomes by combining the best evidence from the most current research​ available, the​ nurse's clinical​ expertise, and the​ client's preferences, including​ needs, values, and choices. Research involves gathering objective facts and information to advance knowledge about a specific topic. Nursing research is a systematic and strict scientific process that tests hypotheses about​ health-related conditions and nursing care. Evidence can be defined as clinical​ knowledge, expert​ opinion, or information resulting from research.

The nurse provided teaching to an older adult client about fevers. Which client statement indicates that the teaching was​ effective? A. ​"Cancer is the top source of fever in older​ adults." B. ​"I may not have a fever when I get sick or have an​ infection." C. ​"I am less sensitive to environmental temperatures than when I was​ younger." D. ​"The rectal route is the best way to have my temperature​ taken."

B. ​"I may not have a fever when I get sick or have an​ infection." Rationale: Older adults do not exhibit the​ sign/symptom of fever with​ infection, as do younger persons.​ However, the top source of fever is still infection or an inflammatory​ process, not cancer. Rectal route for taking a temperature is not the best route due to discomfort and increased prevalence of hemorrhoids. Older adults are more sensitive to extreme environmental temperature changes due to decreased thermoregulatory controls.

Which statement best describes validity of research​ evidence? A. It is the​ study's ability to produce consistent results with each use. B. It is used to determine the strengths and weaknesses of a study and its resulting evidence. C. It is the degree to which the study measured what it intended to measure. D. It is reflective of the​ study's application to clinical practice.

C. It is the degree to which the study measured what it intended to measure. Rationale: Validity is the degree to which the study measured what it intended to measure. Reliability is the​ study's ability to produce consistent results with each use. Usefulness is reflective of the​ study's application to clinical practice. Critical appraisal is used to identify strengths and weaknesses of a study and its resulting evidence.

The nurse is describing geographic information system​ (GIS) technology. Which statement should the nurse exclude​? A. ​"It is useful in the plotting of lifestyle​ choices." B. ​"It is limited to use strictly within​ healthcare." C. ​"It is dependent on global positioning​ systems." D. ​"It is useful in analyzing​ location-based data."

B. ​"It is limited to use strictly within​ healthcare." ​Rationale: Geographic information system​ (GIS) technology has been used both inside and outside of healthcare. To capture geographical​ data, GIS relies on satellite imaging and global positioning systems​ (GPSs). Applications of GIS may include analyzing​ population- or​ location-based data, such as disease​ transmission, obesity​ rates, cancer​ rates, trends in​ diseases, and environmental data. GIS can also be used to plot and analyze lifestyle​ choices, such as improper​ nutrition, tobacco​ use, and physical activity rates.

A nurse is discussing the effects of using uniform language in the electronic health record​ (EHR). Which statement should the nurse​ include? A. ​"Documentation is more challenging when computerized systems incorporate uniform​ language." B. ​"Retrieval of​ evidence-based information about client care is easier when using a uniform​ language." C. ​"Most computerized systems use uniform language to integrate nursing terminologies into the​ EHR." D. ​"The use of uniform language will increase the number of steps in the nursing research​ process."

B. ​"Retrieval of​ evidence-based information about client care is easier when using a uniform​ language." ​Rationale: Most computerized systems do not provide a way to integrate nursing terminologies directly into the​ EHR, which is reflective of a barrier to the use of uniform language in research environments. The use of uniform language combined with the ability to query EHRs should make nursing research easier.​ However, the steps of the nursing research process should remain the same. For the nurse​ researcher, using uniform language increases the ease of documentation and retrieval of​ evidence-based information about client care.

The nurse is caring for a young client at an outpatient pediatric office. The​ client's father is concerned that his daughter is developing an eating disorder and inquires if there is any laboratory test to diagnose this. How should the nurse​ respond? A. ​"We can run a complete blood count test to see if she has an eating​ disorder." B. ​"Unfortunately, there are no laboratory tests to diagnose eating​ disorders." C. ​"A urinalysis test can tell us if your daughter is developing an eating​ disorder." D. ​"A liver-function test can determine whether your daughter has an eating​ disorder."

B. ​"Unfortunately, there are no laboratory tests to diagnose eating​ disorders." ​Rationale: There are no specific laboratory diagnostic tests for confirming a diagnosis for alterations of​ self, such as eating disorders or personality disorders. A complete blood count​ (CBC) does not diagnose eating disorders.​ Rather, this test may diagnose anemia associated with an eating disorder. A urinalysis does not diagnose eating disorders.​ Rather, this test may be used in a client with a suspected eating disorder to rule out a physical problem. A​ liver-function test does not diagnose eating disorders.​ Rather, this test may be used in a client with a suspected eating disorder to rule out a physical problem.

The nurse is planning care for a client who is receiving oxygen. Which intervention should the nurse​ include? A. Assess the client for anxiety. B. Suction upper airways each shift. C. Ensure the client is comfortable with the manner of administration. D. Increase the oxygen flow if the client requests.

C. Ensure the client is comfortable with the manner of administration. ​Rationale: The nurse ensures that the client is comfortable with the manner in which the oxygen is being administered. There are several​ choices, and the client should be consulted in terms of which method is most comfortable. The nurse should not increase the flow of oxygen at the​ client's request, because the healthcare provider prescribes the flow. Clients who are prescribed oxygen are at risk for​ depression, not anxiety. Suctioning the upper airway should only be done as​ required, if at all.

The nurse is designing a nursing clinical research study. Which research question is most appropriate for this type of​ study?(Select all that​ apply.) A. What factors influence an​ individual's choice to enroll in online nursing​ education? B. How do communication styles influence the​ nurse's perception of nurse​ educators? C. How do environmental noise levels affect the​ client's pain perception​ postanesthesia? D. Is there a relationship between acupressure and incidence of nausea in clients who are receiving chemotherapy​ medications? E. What is the relationship between the duration of​ nurse-client interaction and the​ client's level of satisfaction with nursing​ care?

C. How do environmental noise levels affect the​ client's pain perception​ postanesthesia? D. Is there a relationship between acupressure and incidence of nausea in clients who are receiving chemotherapy​ medications? E. What is the relationship between the duration of​ nurse-client interaction and the​ client's level of satisfaction with nursing​ care? Rationale: Nursing research is a systematic and strict scientific process that tests hypotheses about​ health-related conditions and nursing​ care; as an extension of nursing​ research, nursing clinical research seeks answers that will ultimately improve client care.

Which factor that inhibits​ evidence-based practice would be considered an external​ factor? A. Thoughts that the process​ doesn't work B. Resistance to change C. Lack of support by management D. Personal aversion to the idea

C. Lack of support by management ​Rationale: Nurses need to assess the obstacles that inhibit them from using EBP more frequently. These may include internal​ factors, such as beliefs or​ misconceptions, or external​ factors, such as lack of management support. Resistance to​ change, a personal aversion to the​ idea, and a thought that the process​ doesn't work are all examples of internal factors.

The nurse conducts a support group for families of clients diagnosed with personality disorders. Which risk factor should the nurse include in the​ teaching? (Select all that​ apply.) A. Older age B. Male sex C. Loss of a spouse D. History of sexual abuse E. History of childhood trauma

C. Loss of a spouse D. History of sexual abuse E. History of childhood trauma ​Rationale: Risk factors for the development of personality disorders​ include: history of sexual abuse or childhood trauma and loss of a significant support​ person, such as a spouse. Sex is a factor in the development of eating​ disorders, with girls being twice as likely to develop an eating disorder as boys.​ Typically, the onset of personality disorders is adolescence or early adulthood.

The nurse is discussing useful functions of the electronic health record for case managers. Which function should the nurse​ include? A. Notification of change in medication B. Recommendation for isolation C. Notification that a client met criteria for discharge D. Update of a prescription drug formulary

C. Notification that a client met criteria for discharge ​Rationale: A case manager coordinates a​ client's total​ care, and being able to determine that a client has met criteria for discharge is a notification to a case manager that the discharge plan that began at admission is to be implemented. A recommendation for isolation and notification of a change in medication would be most helpful to the direct client care team. An update of a prescription drug formulary is useful for a case​ manager, but the discharge criteria notification is far more beneficial.

A client has crackles and reports increasing shortness of breath. Which action should the nurse take first​? A. Assess the respiratory rate. B. Apply oxygen to the client. C. Place the client in high Fowler position. D. Administer a bronchodilator.

C. Place the client in high Fowler position. ​Rationale: Positioning affects​ oxygenation, and the high Fowler position may benefit individuals experiencing alterations in oxygenation by moving fluid to the bases and allowing for increased lung expansion. A bronchodilator is used when bronchoconstriction is a concern for oxygenation. Oxygen may be​ used, but position change will have a more immediate impact. Assessment of the respiratory rate may be​ done, but after the position is changed.

The nurse is assessing an​ 8-year-old client. Which anatomical difference should the nurse expect to find compared to an​ adult? (Select all that​ apply.) A. Larynx and glottis lower in the neck B. Atrophy of the tonsils C. Smaller nasopharynx D. Small mouth with large tongue E. Soft tracheal cartilage

C. Smaller nasopharynx D. Small mouth with large tongue E. Soft tracheal cartilage Rationale: Normal findings for the pediatric client from infancy until the age of 12 include a smaller​ nasopharynx, a small mouth with a large​ tongue, and soft tracheal cartilage. The nurse would expect to find enlarged​ tonsils; atrophy does not occur until after 12 years of age. The nurse would expect the larynx and the glottis to be higher in the​ neck, not lower.

The nurse wants to ensure that a safe level of narcotic medications is being prescribed for a client who may have an issue with addiction. Which informatics application should the nurse​ use? A. The​ client's health history and records B. Telemedicine C. Statewide prescription database D. Clinical decision support

C. Statewide prescription database ​Rationale: A statewide database that tracks prescription narcotics can help ensure that clients are not given unsafe amounts of pain medications. This process can also identify specific providers who may be issuing prescriptions for narcotics in an irresponsible manner. Telemedicine is the remote access of healthcare services through technology. Clinical decision support describes the use of data from an electronic health record​ (EHR) to identify best practices. A review of medical records is always​ advisable, but this is not an application of informatics.

A client diagnosed with bronchitis asks the nurse about the function of the bronchi. Which should the nurse include in the​ response? A. Contain the​ heart, trachea,​ esophagus, and the great vessels B. Capture and help sweep the debris toward the mouth for removal when coughing C. Warm and moisten air as it moves through the respiratory tract to the alveoli D. Help to keep the lungs inflated

C. Warm and moisten air as it moves through the respiratory tract to the alveoli Rationale: The function of the bronchi is to warm and moisten the air as it moves through the respiratory tract to the alveoli in the lungs. The mediastinum contains the​ heart, trachea,​ esophagus, a portion of the right and left main​ bronchi, and the great vessels. Cilia within the trachea capture debris and help to sweep the debris toward the mouth for removal when coughing. Surface​ tension, created by fluid and negative​ pressure, keeps the lungs inflated.

The nurse is describing the function of a Global Location Number​ (GLN) as it relates to standardization. Which statement is​ accurate? A. ​"A GLN replaces the custom item numbers of the healthcare​ institution's products." B. ​"A GLN increases the ease of locating supplies in the healthcare​ institution's storage​ facility." C. ​"A GLN makes it easier for the healthcare institution to be​ located." D. ​"A GLN helps identify the room assignments of clients admitted to the healthcare​ facility."

C. ​"A GLN makes it easier for the healthcare institution to be​ located." Rationale: The materials management and supply chain community sought standardization through measures including issuing each facility a GLN instead of an account​ number, which improves the ease of locating healthcare institutions. Standardization strategies also included assigning each product used in a healthcare facility a Global Trade Item Number​ (GTIN) as opposed to a custom item number.

The nurse is discussing some barriers that they have encountered with a journal club related to the topic. Which statement by the nurse describes potential​ barriers? (Select all that​ apply.) A. I am an​ administrator." B. ​"I work in a nursing​ home." C. ​"I don't have time to do those​ trainings." D. ​"I have been in nursing 20​ years; I do not need more​ training." E. ​"The hospital I work at stopped professional development based on​ funds."

C. ​"I don't have time to do those​ trainings." D. ​"I have been in nursing 20​ years; I do not need more​ training." E. ​"The hospital I work at stopped professional development based on​ funds." ​Rationale: When a healthcare facility makes​ cuts, it has been seen that educational programs and trainings go by the wayside. The other barrier would be not making time for the staff to attend trainings that are offered. The​ overconfident, stuck-in-their-ways nurse is a difficult person to educate on change and an alternate way of thinking. Being an administrator or working in a nursing home is not a barrier to promoting​ evidence-based practice in a healthcare facility.

A client confesses to secretly eating large amounts of food and then feeling guilty about it afterward. Which response by the nurse is​ appropriate? A. ​"Do you regularly eat nonfood items and regurgitate​ them?" B. ​"You might have​ Prader-Willi syndrome, which is a chromosomal​ disorder." C. ​"It sounds as though you may be suffering from​ binge-eating disorder." D. ​"Have you noticed any insomnia or weight loss associated with your​ behavior?"

C. ​"It sounds as though you may be suffering from​ binge-eating disorder." ​Rationale: Binge-eating disorder​ (BED) is characterized by recurrent episodes of consuming large amounts of food within a short​ time, with feelings of loss of​ control, guilt, and shame.​ Prader-Willi syndrome is characterized by mental​ retardation, poor muscle​ tone, and an incessant desire to eat. Nocturnal​ sleep-related eating disorder​ (NSRED) is characterized by​ insomnia, followed by an episode of sleepwalking or​ semiconsciousness, during which the individual consumes unusual foods or nonfood items. It is not associated with binge eating. Regurgitation is a characteristic of a rumination disorder and is not associated with binge eating.

The government affects the process of transitioning to the use of electronic medical records​ (EMRs). Which statement by the nurse describes this​ process? A. ​"The Office of the National Coordinator for Health Information Technology is the sole agency overseeing transitioning to​ EMRs." B. ​"The Office of the National Coordinator for Health Information Technology authorizes financial​ reimbursement." C. ​"The Centers for Medicare and Medicaid Services monitors the transition of EMRs at the federal​ level." D. ​"The Centers for Medicare and Medicaid Services monitors achievement of meaningful use​ objectives."

C. ​"The Centers for Medicare and Medicaid Services monitors the transition of EMRs at the federal​ level." ​Rationale: On a federal​ level, the Centers for Medicare and Medicaid Services​ (CMS) and the Office of the National Coordinator for Health Information Technology​ (ONC) oversee the process of transitioning to the use of EMRs. The ONC monitors the achievement of meaningful use​ objectives, which are reported to the CMS to authorize financial reimbursement.

The nurse is critically appraising a research study. Which statement is reflective of an appraisal of the​ study's reliability? A. ​"The study's results are applicable to clinical​ practice." B. ​"Although the study was supposed to measure the​ client's wound​ healing, it really measured the​ client's satisfaction with​ care." C. ​"The original study was repeated three​ times, but it did not produce consistent​ results." D.​"The study's results are not applicable to clinical​ practice."

C. ​"The original study was repeated three​ times, but it did not produce consistent​ results." ​Rationale: Reliability is the​ study's ability to produce consistent results with each use. Validity is the degree to which the study measured what it intended to measure. Usefulness is reflective of the​ study's application to clinical practice.

The nurse taught a class about the role of the pleural membranes. Which statement by a participant indicates that learning​ occurred? A. ​"The pleural membranes contain the​ heart." B. ​"The pleural membranes permit gas​ exchange." C. ​"The pleural membranes help to keep the lungs​ inflated." D. ​"The pleural membranes warm and moisten​ air."

C. ​"The pleural membranes help to keep the lungs​ inflated." ​Rationale: The pleural membranes help keep the lungs​ inflated; this statement indicates appropriate understanding of the content. The mediastinum contains the heart. The alveoli permit gas exchange. The bronchi warm and moisten air.

The charge nurse is providing an educational seminar for a group of nurses. Which factor should the nurse expect to be discussed as an​ evidence-based practice topic for older adults that correlates with Healthy People 2020​? A. Transmission of infectious disease during travel B. Obesity prevention C. ​Fall-related injuries D. Screening protocols for sickle cell

C. ​Fall-related injuries ​Rationale: For older​ adults, Healthy People 2020 objectives address topics including increasing the number of individuals who are up to date on basic preventive care and decreasing the incidence of health alterations such as pressure ulcers and fall related injuries. For the general care of​ adults, goals associated with the promotion of global health include protecting the health of the national population as well as limiting the international transmission of infectious diseases during travel.​ Evidence-based resources related to newborns and infants address topics such as screening protocols for phenylketonuria and sickle cell disease.

The nurse is working with an interprofessional team to care for a client with a personality disorder. The team has collaboratively decided on therapies that might benefit the client. Which specific type of therapy should the nurse anticipate might be used to treat the​ client's condition?​ (Select all that​ apply.) A. Expressive therapy B. Collaborative therapy C. ​Schema-focused therapy D. Cognitivedashbehavioral therapy E. Dialectical behavioral therapy

C. ​Schema-focused therapy D. Cognitivedashbehavioral therapy E. Dialectical behavioral therapy ​Rationale: The main treatment for personality disorders is counseling and therapy. Cognitive-behavioral therapy​ (CBT) is most often used. Other forms of therapies include dialectical behavioral therapy​ (DBT) and​ schema-focused therapy​ (SFT). Expressive and collaborative therapies are not commonly used in the treatment of a client with a personality disorder.

The nurse conducts a support group for families of clients diagnosed with personality disorders and discusses the components of self that can cause the development of personality disorders. Which component should the nurse​ include? (Select all that​ apply.) A. Real self B. Public self C. ​Self-esteem D. ​Self-concept E. ​Self-awareness

C. ​Self-esteem D. ​Self-concept E. ​Self-awareness ​Rationale: Alterations in one or more of the components of self​ (self-concept, self-esteem, and​ self-awareness) may cause the development of personality disorders. Public and real self are aspects of personal identity and do not contribute to the development of personality disorders.

Which is a noninvasive method that the nurse uses to assess a​ client's temperature?​ (Select all that​ apply.) A. Oral B. Tympanic membrane C. Rectal D. Axillary E. Temporal artery

D. Axillary E. Temporal artery ​Rationale: The two methods of measuring temperature that are safe and noninvasive are the axillary method and temporal artery. The client could bite down during the oral approach and damage sensitive oral mucosa. The rectal method is invasive and could damage sensitive tissue. Although generally​ safe, the tympanic temperature measurement is an invasive procedure.

Evidence-based practice​ (EBP) is very prescriptive across the lifespan. Which client would be the focus for decreasing the incidence of pressure ulcers as presented in Healthy People 2020​? A. A​ 35-year-old who is in a rehab facility following neck fusion surgery B. A​ 16-year-old who is hospitalized after knee surgery C. A​ 12-year-old whosleeps​ 10?12 hours a day D. A​ 65-year-old client who is bedridden in a nursing home

D. A​ 65-year-old client who is bedridden in a nursing home Rationale: For older​ adults, Healthy People 2020 objectives address topics including increasing the number of individuals who are up to date on basic preventive care and decreasing the incidence of health alterations such as pressure ulcers and fall related injuries. The older adult who is bedridden would be the focus of pressure ulcer prevention due to thinner skin and no mobility. Lying in the bed put pressure on the bony prominences.

The nurse cares for a client who has undergone an amputation of the right leg. The nurse is concerned the client might experience issues with​ self-concept. Which component of​ self-concept should the nurse assess in the​ client? A. Role performance B. ​Self-esteem C. Personal identity D. Body image

D. Body image ​Rationale: Body image is the mental picture a person has of the physical self. This is changed by the amputation of a leg because the body is no longer ideal. Personal identity includes the components of ideal​ self, real​ self, and public self. Role performance is associated with behaviors necessary to fulfill a role.​ Self-esteem is the​ individual's opinion of self and how much the individual values self.

Which manifestation should the nurse recognize as a sign of chronic respiratory disease in a​ client? A. Inspiration to expiration​ (I:E) ratio of​ 1:2 B. Sudden shortness of breath C. Crackles noted in bilateral lungs D. Clubbing of the nails

D. Clubbing of the nails Rationale: Clubbing of the nails can occur with chronic cardiovascular or respiratory disease. An​ I:E ratio​ (duration of inspiration to expiration​ ratio) of​ 1:2 is normal. Sudden shortness of breath and crackles can occur in acute respiratory disorders.

A client asks the nurse how long the chest tube will remain in place. Which response by the nurse is best​? A. 5 days B. 2 days C. 1 week D. Until the lung has​ re-expanded

D. Until the lung has​ re-expanded ​Rationale: A chest tube​ (also called a chest drain or thoracic​ catheter) is used to treat conditions in which air or fluid enters the pleural​ cavity, causing lung collapse. Inserted under emergency conditions and treated as a surgical​ procedure, a chest tube will typically remain in place for 2-5 days until the​ client's x-rays indicate that all fluid or air from the pleural cavity has been removed.

A nurse researcheris designing a study intended to explore how certification exam preparation courses affect nursing​ students' success rates in passing the exam. Which element best reflects the​ nurse's use of a randomized control trial​ (RCT) design? A. Compare graduate nurses who successfully passed the certification exam with graduate nurses who did not pass the exam in order to determine whether or not completing a certification exam preparation course was a variable that contributed to test performance. B. Examine a group of studies on graduate nurses who completed certification exam preparation courses and then combine and analyze the results as if they were from one large study. C. Interview five graduate nurses who completed a certification exam preparation course and detail their experiences with the course and then identify the number of graduate nurses who successfully completed the certification exam. D. Compare the exam performance of a control group of graduate nurses who did not complete any certification exam preparation course with a group of graduate nurses who completed a specific certification exam preparation course prior to taking the exam.

D. Compare the exam performance of a control group of graduate nurses who did not complete any certification exam preparation course with a group of graduate nurses who completed a specific certification exam preparation course prior to taking the exam. Rationale: Randomized control trials​ (RCTs) are designed to illustrate a​ cause-and-effect relationship by using a control group and an experimental group. An RCT is best illustrated by comparing the exam performance of a control group of graduate nurses who did not complete any certification exam preparation course with a group of graduate nurses who completed a specific certification exam preparation course prior to taking the exam. A​ meta-analysis examines a group of studies on a given topic and combines and analyzes the results as if they were from one large​ study; this design is best reflected by examining a group of studies on graduate nurses who completed certification exam preparation courses and then combining and analyzing the results as if they were from one large study. A case study is specific to one​ individual, issue, or​ event; this design is best reflected by interviewing five graduate nurses who completed a certification exam preparation course and detailing their experiences with the​ course, as well as identifying the number of graduate nurses who successfully complete the certification exam.​ Case-control studies compare individuals with and without a specific condition to identify predictive​ variables; this design is best reflected by comparing graduate nurses who successfully passed the certification exam with graduate nurses who did not pass the exam to determine whether or not completing a certification exam preparation course contributed to the success rates.

The nurse is preparing a presentation to parents about vehicle safety and​ heat-related injuries. Which important teaching point should be​ included? A. Store car keys in a visible place and within the​ children's reach in case of an emergency. B. Leave a child alone in the car only if the outside temperature is below 80 degrees F. C. Stay with a child in the car for up to 10 minutes with the windows cracked open. D. Keep important articles in the backseat to ensure checking the area before leaving the vehicle.

D. Keep important articles in the backseat to ensure checking the area before leaving the vehicle. ​Rationale: Estimates indicate that numerous children die from vehicle​ hyperthermia, or sustain heat​ exhaustion, heat​ stroke, and thermal burn after being left in vehicles on warm days. One way of ensuring that such incidents do not happen is to teach caregivers to place something​ important, such as their wallet or cell​ phone, in the backseat of the car. This will ensure that they check the backseat before leaving the vehicle. Advise them to always look before they​ lock, when not in use. According to reports and​ findings, leaving a child in a car with a cracked window for even a short amount of​ time, holds the potential for lethal consequences. Children should never be left unattended or around vehicles. Though it is a good practice to keep car keys in a visible​ place, ensure that they are out of reach of children.

Which method is the most acurate for measuring a​ client's respiratory​ rate? A. Measure the respiratory rate for 15 seconds and multiply by 4. B. Measure the respiratory rate for 6 seconds and multiply by 10. C. Measure the respiratory rate for 30 seconds and multiply by 2. D. Measure the respiratory rate for 1 minute.

D. Measure the respiratory rate for 1 minute. Rationale: The correct method is to count the respiratory rate for one full​ minute, counting one inspiration and one expiration as one breath. While the other methods may yield a​ 1-minute answer, they do not take into account changes in the pattern over a minute.

The nurse researcher is encouraging a nurse to incorporate​ evidence-based practice​ (EBP) into client care. Which action should the researcher encourage the nurse to​ do? A. Speaking with the hospitalist B. Looking at past data C. Reviewing a​ client's record D. Participating in a research project

D. Participating in a research project ​Rationale: It would be beneficial for the graduate nurse to participate in a research project to be a part of an EBP​ process, so they could see firsthand how the process works in action. Reviewing a​ client's chart may be a way to look at what treatment was​ performed, but it would not reveal if it was evidence based. Looking at past data will not provide a look at​ evidence-based practice. A hospitalist may be able to share their opinion of​ evidence-based practice, but that does not expose the nurse to the process.

The nurse is preparing to use the tympanic membrane to measure the temperature of a​ 4-year-old child. Which approach should the nurse take when completing this​ measurement? A. Pull the earlobe back and down. B. Pull the pinna back and down. C. Pull the earlobe back and up. D. Pull the pinna back and up.

D. Pull the pinna back and up. Rationale: The pinna is pulled straight back and upward when taking temperature in children over 3 years of age. To measure temperature using the tympanic membrane in an​ infant, the pinna is pulled straight back and slightly downward. The earlobe is not manipulated to measure temperature using the tympanic membrane.

The nurse preceptor is monitoring the actions of a new graduate nurse caring for a client with a tracheostomy. Which action by the new graduate requires ​follow-up from the​ preceptor? A. Assessing for irritation around the stoma B. Assessing oxygen saturation C. Suctioning the​ tracheostomy, then the mouth D. Suctioning secretions with a clean technique

D. Suctioning secretions with a clean technique ​Rationale: Sterile​ suctioning, not​ clean, is necessary to remove these secretions from the trachea and bronchi to maintain a patent airway. It is correct to assess oxygen​ saturation, irritation, and suction the tracheostomy first.

Which type of body temperature changes in response to the​ environment? A. Core B. Metabolic C. Physiologic D. Surface

D. Surface ​Rationale: Surface temperature changes in response to the environment. Core temperature remains constant and stays within a specific range. Metabolic and physiologic are not types of body temperature.

The nurse is discussing a method of measuring nursing care and its impact on the​ client, as well as validating the benefits and actual costs of nursing care. Which is the nurse​ discussing? A. Clinical decision support systems B. ​Evidence-based practice C. Nursing research D. Uniform language

D. Uniform language ​Rationale: Benefits of using uniform language include a better capability to measure nursing care and its impact on the client and to validate the benefits and actual costs of nursing care to administrators. Uniform language also allows easier retrieval of​ evidence-based information. Clinical decision support systems are tools designed to supplement​ decision-making processes during and after client care. Point of care refers to the​ nurse's ability to perform client interventions or testing using portable devices near the client.​ Evidence-based practice is reflective of research.

Which statement should the nurse use to explain​ point-of-care services? A. ​"Point of care may increase the wait time for receipt of certain laboratory test​ results." B. ​"Use of computerized medical records is a barrier to point of​ care." C. ​"Increased efficiency is an unexpected outcome when using point of​ care." D. ​"An intervention occurring near the client using a handheld device is called point of​ care."

D. ​"An intervention occurring near the client using a handheld device is called point of​ care." Rationale: Point of care refers to interventions or tests that involve the use of​ portable, transportable, or handheld devices near the client. This model eliminates the need to wait for certain laboratory test results. The electronic health record also allows for charting at the point of​ care, which, in​ turn, results in increased efficiency.

An older adult client asks the​ nurse, "Why is my body temperature only​ 99°F if I have this serious​ infection?" Which is the​ nurse's best​ response? A. ​"The true temperature will not register because you are a mouth​ breather." B. ​"Your body temperature fluctuates​ significantly, so a true temperature is difficult to​ obtain." C. ​"I will to take your temperature​ rectally, since it is the only reliable route in somebody your​ age." D. ​"Body temperature in an older adult is not a reliable indicator of the seriousness of an​ illness."

D. ​"Body temperature in an older adult is not a reliable indicator of the seriousness of an​ illness Rationale: Body temperature may not be a valid indication of serious illness in an older adult. The older adult may have an infection and exhibit only a slight temperature elevation. Other​ symptoms, such as confusion and​ restlessness, may be present. These require​ follow-up to determine whether an underlying disease process is present. There is no evidence to support that the client is a mouth breather. Rectal temperatures in older adult clients may be contraindicated if hemorrhoids are present. Body temperature in an older adult does not fluctuate significantly.