Nursing 10 Final Exam Questions

An older adult who was diagnosed with atrial fibrillation asks a nurse, "I feel fine. I have no symptoms at all with this heart problem, yet I am now on a blood thinner medication, which I understand can by very dangerous. Is this really necessary?" The nurse formulates a response based on the understanding that: atrial fibrillation, while initially asymptomatic, will progress and become symptomatic. the risk of stroke is very high for a person with atrial fibrillation. untreated atrial fibrillation will likely cause a heart attack. atrial fibrillation can cause coronary heart disease.

the risk of stroke is very high for a person with atrial fibrillation.

A nurse is conducting quantitative research to examine the effects of following nursing protocols in the emergency department (ED) on patient outcomes. This is also known as what type of research? A. Descriptive B. Correlational C. Quasi-experimental D. Experimental

C. Quasi- experimental research done in clinical setting to examine the effects of nursing intervention on patient outcomes

A nurse manager schedules a clinic for the staff to address common nursing interventions used in the facility and to explore how they can be performed more efficiently and effectively. The nurse manager's actions to change clinical practice are an example of a situation described by which nursing theory? A. Prescriptive theory B. Descriptive theory C. Developmental theory D. General systems theory

A. Prescriptive theory address nursing interventions and designed to control, promote, and change clinical nursing practice

A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instruction? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am ay my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."

B

A nurse manager who is attempting to institute the SBAR process to communicate with health care providers and transfer patient information to other nurses is meeting staff resistance to the change. Which action would be most effective in approaching this resistance? A. Containing the anxiety in a small group and moving forward with the initiative B. Explaining the change and listing the advantages to the person and the organization C. Reprimanding those who oppose the new initiative and praising those who willingly accept the change D. Introducing the change quickly and involving the staff in the implementation of the change

B

An older adult who has a balance disorder and has sustained repeated falls is recommended to start an exercise program. Which of the following exercises would be most beneficial in improving balance in this individual? (Select all that apply.) Yoga Tai Chi Swimming Pilates Weight lifting

Yoga Tai Chi

A nurse is acquainting a group of newly licensed nurses with the roles of various members of the health care team they will encounter o a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (type all that apply) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

a b c e

Symptoms of HIV are often under-recognized in older adults because: there is a very low incidence of HIV in older adults. many of the classic symptoms are also common to other conditions common in older adults. presenting symptoms are markedly different from those in younger adults. AIDS progresses much slower in older adults so symptoms are not recognized easily.

many of the classic symptoms are also common to other conditions common in older adults.

Symptoms of HIV are often under-recognized in older adults because: there is a very low incidence of HIV in older adults. many of the classic symptoms are also common to other conditions common in older adults. presenting symptoms are markedly different from those in younger adults. AIDS progresses much slower in older adults so symptoms are not recognized easily.

many of the classic symptoms are also common to other conditions common in older adults.

An older adult says to the nurse, "I don't know why I can't handle booze like I used to when I was younger." The nurse's response is based on the knowledge that: older adults develop higher blood alcohol levels due to age-related changes in the neurological system. older adults develop higher blood alcohol levels due to age-related changes that alter absorption and distribution of alcohol. older adults develop higher blood alcohol levels due to slowed reaction times. older adults develop higher blood alcohol levels due to cognitive changes.

older adults develop higher blood alcohol levels due to age-related changes that alter absorption and distribution of alcohol.

An older widow who is a newly admitted resident of a long-term care facility develops a romantic relationship with a male resident. When the resident's daughter demands that the staff "put a stop to this sexual behavior right now," the nurse's response is based on the understanding that: such activity in a long-term care facility is inappropriate. older adults need to express love and intimacy. sexual desire is usually absent in older adults. sexual activity can be dangerous for older adults with chronic illnesses.

older adults need to express love and intimacy.

An 88-year-old woman is admitted to the hospital with a diagnosis of pneumonia. She has a history of hypertension and congestive heart failure and is on a total of five different medications for these chronic conditions. The nurse caring for the woman develops a care plan that includes the diagnosis Risk for Falls. A priority nursing intervention for this client is to: perform a fall assessment. keep all of the side rails up on the client's bed at nighttime. place the client on bed rest so that she does not fall. assess the client's dietary intake for calcium adequacy.

perform a fall assessment.

While the older African American is at the highest risk for developing dementia, the nurse demonstrates an understanding of this disease process's risk factors when assessing this population's: weight and elimination patterns. heart rate and capillary refill status. genetic makeup. muscle strength and reflex times.

genetic makeup

Which is the most likely reason that type 2 diabetes mellitus is often difficult to diagnose in older adults? Presenting symptoms occur very quickly. The disease rarely occurs in older adults The classic symptoms may not be present in older adults. There are no recognizable symptoms; it is a "silent killer."

The classic symptoms may not be present in older adults.

Which question has priority when assessing a client for risk factors related to the use of sildenafil (Viagra)? "How old are you?" "Are you currently being treated for hypertension?" "Do you have a history of respiratory infections?" "Have you ever been told you have prostate problems?"

"Are you currently being treated for hypertension?"

How should the nurse reply when an older adult asks, "How much alcohol is good for you?" "Alcohol isn't good for you so avoid it as a general rule." "Experts in the field recommend only one regular sized drink a day." "It's been said that red wine has health benefits, but that doesn't mean drink a whole bottle." "If you are only drinking on special occasions, limit yourself to two drinks."

"Experts in the field recommend only one regular sized drink a day."

An older man who recently had a myocardial infarction is being discharged home from the hospital. He tells a nurse, "I am really worried about having sex with my wife. I am afraid that I am going to have another heart attack." The best response by the nurse includes which of the following? (Select all that apply.) "If you are able to engage in mild to moderate physical activity without symptoms, you can resume sexual activity." "You really should not engage in sexual activity until 3 months have passed post heart attack." "It is best if you avoid eating a large meal for several hours before you have sexual relations." "If you have chest pain while having sex, stop and rest, and take your nitroglycerin." "You might want to consider some alternate positions that avoid strain."

"If you are able to engage in mild to moderate physical activity without symptoms, you can resume sexual activity." "It is best if you avoid eating a large meal for several hours before you have sexual relations." "If you have chest pain while having sex, stop and rest, and take your nitroglycerin." "You might want to consider some alternate positions that avoid strain."

A nurse is caring for an older hospitalized patient who recently suffered a myocardial infarction (MI). The patient asks the nurse, "I didn't even know that I had a heart attack. I did not have crushing chest pain like you see on television. Why didn't I?" The best response by the nurse is: "Older patients do not feel pain in the same way that younger patients do." "Oh, that is just television. Hardly anyone has crushing chest pain when he has a heart attack." "Older people often do not have the typical signs and symptoms when they have a heart attack." "Older people never have chest pain when they have a heart attack."

"Older people often do not have the typical signs and symptoms when they have a heart attack."

An older patient asks a nurse, "I really have trouble sleeping and my doctor does not want to prescribe a sleeping pill for me. He says they are not good for older people. I really don't understand his response. Can you help me?" The best response by the nurse is: "Sleeping medications have many adverse effects in older people and only have minimal effects in improving sleep." "Prescription sleeping medications have many adverse effects in older people. Why don't you try using an over-the-counter medication?" "Sleeping medications do not provide any improvement in sleep for older people." "Sleep problems are common in older people. There really is nothing that you can do to help with that."

"Sleeping medications have many adverse effects in older people and only have minimal effects in improving sleep."

A nurse is working with an older individual who has recently started an exercise program. The individual tells the nurse, "This exercise thing is really hard, and I absolutely hate walking on a treadmill going nowhere. I think I am going to call it quits." Which of the following responses by the nurse will be most effective in encouraging the individual to remain in the program? "If you stop exercising, you will reverse all the good effects that the exercise accomplished." "I will have to report that to your physician." "What types of exercise do you enjoy doing?" "Most older people hate exercising, but they do it anyways."

"What types of exercise do you enjoy doing?"

An older adult's diagnosis of sleep apnea is supported by nursing assessment and history data that include: (Select all that apply.) followed a vegetarian diet for last 28 years. male gender. a smoking history of 1 pack a day for 45 years. 30 pounds over ideal weight. history of Crohn's disease.

male gender. a smoking history of 1 pack a day for 45 years. 30 pounds over ideal weight.

NCLEX A nurse at a clinic is collecting data about pain from a client who reports sever abdominal pain. The nurse asks the client whether he has nausea or has been vomiting. which of the following pain characteristics is the nurse attempting to determine A. presence of associated manifestations B. location of pain C. pain quality D. aggravating and relieving factors

A

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply) A. Practice muscle relaxation techniques B. Exercise each morning C. Take an afternoon nap D. Alter the sleep environment for comfort E. Limit fluid intake at least 2 hr before bedtime

A B D E

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply) A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you sleep?" E. "Tell me about any personal stress you are experiencing."

A C D E

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply) A. REM sleep provides cognitive restoration B. REM sleep lasts about 90 mins C. It is difficult to awaken a person in REM sleep D. Sleepwalking occurs during REM sleep E. Vivid dreams are common during REM sleep

A C E

A nurse is using time management techniques when planning activities for patients. Which nursing action reflects effective time management? A. The nurse asks patients to prioritize what they want to accomplish each day B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse "front loads" the schedule with "must do" priorities D. The nurse avoids helping other nurses if scheduling does not permit it

A by asking the patient to prioritize what they want to accomplish each day, the nurse is demonstrating an effective time management technique.

An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A. "I'm sorry, but I can't talk with you; you will have to contact my attorney." B. "I will answer your questions so you'll understand how the situation occurred. C. "I hope I won't be blamed for the death because it was so busy that day." D. "First tell me why you are doing this to me. This could ruin my career!"

A the nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer

A nurse is using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model PET as a clinical decision-making tool when delivering care to patients. Which steps reflect the intended use of this tool? Select all that apply. A. A nurse recruits an interprofessional team to develop and refine an EBP question. B. A nurse draws from personal experiences of being a patient to establish a therapeutic relationship with a patient. C. A nurse searches the Internet to find the latest treatments for type 2 diabetes. D. A nurse uses spiritual training to draw strength when counseling a patient who is in hospice for an inoperable brain tumor. E. A nurse questions the protocol for assessing postoperative patients in the ICU. F. A nursing student studies anatomy and physiology of the body systems to understand the disease states of assigned patients.

A C E The JHNEBP model is a powerful problem-solving approach to clinical decision making, and is accompanied by user-friendly tools to guide individual or group use

Newly hired nurses in a busy suburban hospital are required to read the state nurse practice act as part of their training. Which topics are covered by this act? Select all that apply. a. Violations that may result in disciplinary action b. Clinical procedures c. Medication administration d. Scope of practice e. Delegation policies f. Medicare reimbursement

A D. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act

An older adult is diagnosed with Alzheimer's disease. The nurse knows that this diagnosis is made on the presence of which of the following? (Select all that apply.) A decline from a previous level of functioning Fluctuation of symptoms over the course of a 24-hour period An insidious onset A gradual decline in cognitive abilities The cognitive changes worsen in the evening hours

A decline from a previous level of functioning An insidious onset

2. A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? a. "We're at the age when we should consider ceasing sexual activity." b. "We need more time for sexual stimulation than we used to." c. "If we are unable to have sex we can still have an intimate relationship." d. "If we change our position we can still have sex and be more comfortable."

A. "We're at the age when we should consider ceasing sexual activity." Explain: age does not limit sex life

A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan or referrals to another facility. Which patients would most likely be a candidate for these services? select all that apply. A) an older adult who is diagnosed with dementia in the hospital B) a 45-year-old who is diagnosed with Parkinson's disease C) a 35-year-old women who is receiving chemotherapy for breast cancer D) a 16-year-old boy who is being discharged with a cast on his leg E) a new mother who delivered a healthy infant via a cesarean birth F) a 59-year-old man who is diagnosed with end-stage bladder cancer

A) an older adult who is diagnosed with dementia in the hospital B) a 45-year-old who is diagnosed with Parkinson's disease F) a 59-year-old man who is diagnosed with end-stage bladder cancer explain: the patients who are most likely to need a formal discharge plan o referral to another facility are those who are emotionally or mentally unstable, those who recently diagnosed chronic disease and those who have terminal illness.

a patient is being transferred from the ICU to a regular hospital room. what must the ICU nurse be prepared to do as part of this transfer? A) provide a verbal report to the nurse on the new unit B) provide a detailed written report to the unit secretary C) delegate the responsibility for providing information D) make a copy of the patient's medical record

A) provide a verbal report to the nurse on the new unit

To promote sleep in a patient, a nurse suggests what intervention? a. Follow the usual bedtime routine if possible. b.Drink two or three glasses of water at bedtime. c.Have a large snack at bedtime. d.Take a sedative-hypnotic every night at bedtime.

A. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? A. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." B. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" C. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." D. "I agree! It's impossible to be ethical when working in a practice setting like this!"

A. the ability to be ethical, to make decision, and to act in an ethically justified manner begins in childhood and develops gradually.

A nurse mentor is teaching a new nurse about the underlying beliefs of CHAs versus allopathic therapies. Which statements by the new nurse indicate that teaching was effective? Select all that apply. "CHA proponents believe the mind, body, and spirit are integrated and together influence health and illness." "CHA proponents believe that health is a balance of body systems: mental, social, and spiritual, as well as physical." "Allopathy proponents believe that the main cause of illness is an imbalance or disharmony in the body systems." "Curing according to CHA proponents seeks to destroy the invading organism or repair the affected part." "The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing." "According to CHA proponents, health is the absence of disease."

A. "CHA proponents believe the mind, body, and spirit are integrated and together influence health and illness." B. "CHA proponents believe that health is a balance of body systems: mental, social, and spiritual, as well as physical." E. "The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing."

A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? a. "HPV causes genital warts and cervical and other genital cancers." b. "HPV causes a single painless genital lesion and can lead to sterility." c. "50% of women between the ages of 14 and 19 are infected with HPV" d. "The HPV vaccination is only recommended for the female population."

A. "HPV causes genital warts and cervical and other genital cancers."

A nurse manager who works in a hospital setting is researching the use of energy healing to use as an integrative care practice. Which patient would be the best candidate for this type of CHA? A patient who is anxious about residual pain from cervical spinal surgery A patient who is experiencing abdominal discomfort A patient who has chronic pain from diabetes A patient who has frequent cluster headaches

A. A patient who is anxious about residual pain from cervical spinal surgery explain: energy healing is focused on the pain that lingers after an injury heals, as well as pain complicated by trauma, anxiety, or depression

A nurse cares for patients in a chiropractic office. What patient education might this nurse perform? Select all that apply. Applying heat or ice to an extremity Explaining the use of electrical stimulation Teaching a patient relaxation techniques Teaching a patient about a prescription Explaining an invasive procedure to a patient Teaching about dietary supplements

A. Applying heat or ice to an extremity B. Explaining the use of electrical stimulation C. Teaching a patient relaxation techniques F. Teaching about dietary supplements

A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A. Complete a fall-risk assessment. B. Educate the client and family on fall risks. C. Complete a physical assessment. D. Survey the client's belongings.

A. CORRECT: The greatest risk to this client is injury due to a fall. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures.

A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend? a. Diaphragm b. Oral contraceptive pills c. Depo-Provera d. Evra patch

A. Diaphragm The diaphragm is the only barrier method of contraception listed; all the other methods are hormonal.

8. A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority? a. Getting the patient into a safe environment and mobilizing support for her. b. Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped. c. Convincing the student to be assessed for pregnancy, STIs, or other complications. d. Convincing the student to tell her parents so that she can receive their support.

A. Getting the patient into a safe environment and mobilizing support for her. While the remaining options may be indicated, the first priority is to ensure the safety of the woman and to get her the support she needs at this moment.

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. instruct the patient to avoid sudden position changes that may cause dizziness b. recommend that the patient restrict fluid until after exercising is finished c. instruct patient to push a little further beyond fatigue each section d. instruct the patient to avoid exercising is very cold or very hot temperatures e. encourage the patient to modify exercise if weak or ill f. recommend that the patient consume a high carb, low protein diet

A. Instruct the patient to avoid sudden position changes that may cause dizziness D. Instruct the patient to avoid exercising ing in very cold or very hot temperature Explain: exercising for a patient with COPD include avoiding sudden change in position that can cause dizziness, and avoid extreme temperature. Patient should also have good hydration, and no push their body to the point of exhaustion.

A charge nurse meets with staff to outline a plan to provide transcultural nursing care for patients in their health care facility. Which theorist promoted this type of caring as the central theme of nursing care, knowledge, and practice? A. Madeline Leininger B. Jean Watson C. Dorothy E. Johnson D. Betty Newman

A. Madeline Leininger

A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? Select all that apply A. Making accurate assessments B. Researching new treatments for chronic diseases C. Communicating effectively D. Delegating tasks appropriately E. Performing clinical skills effectively F. Making independent decisions

A. Making accurate assessments C. Communicating effectively E. Performing clinical skills effectively F. Making independent decisions

A student nurse interacting with patients on a cardiac unit recognizes the four concepts in nursing theory that determine nursing practice. Of these four, which is most important? A. Person B. Environment C. Health D. Nursing

A. Person The most important of the four concept is the person, which the the focus of care for nursing

A nurse is providing range of motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. a. stop performing the exercises b. decrease the number of repetitions performed c. reevaluate the nursing care plan d. move to the patient's other side to perform exercises e. encourage the patient to finish exercises and then rest f. assess the patient for other symptoms

A. Stop performing the exercise C. Reevaluate the nursing care plan F. Asses the patient for other symptoms

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. support weight on stronger leg and cane and advance weaker foot forward b. hold the cane in the same hand of the leg with the most severe deficit c. stand with as much weight distributed on the cane as possible d. do not use the cane to rise from a sitting position, as this is unsafe

A. Support weight on stronger leg and cane and advance weaker foot forward

A nurse is caring for a patient who has crippling rheumatoid arthritis. Which nursing intervention best represents the use of integrative care? A. The nurse administers naproxen and uses guided imagery to take the patient's mind off the pain. B. The nurse prepares the patient's health care provider-approved herbal tea and uses meditation to relax the patient prior to bed. C. The nurse administers naproxen and performs prescribed range-of-motion exercises. D. The nurse arranges for acupuncture for the patient and designs a menu high in omega-3 fatty acids.

A. The nurse administers naproxen and uses guided imagery to take the patient's mind off the pain.

A nurse is assessing an older patient with new onset confusion. The nurse understands that in order to have a diagnosis of delirium, the patient must exhibit which of the following? (Select all that apply.) Acute onset of symptoms or fluctuating course Inattention Disorganized thinking Altered level of consciousness Flat affect

Acute onset of symptoms or fluctuating course Inattention Disorganized thinking Altered level of consciousness

A nurse is caring for an older adult with Parkinson's disease. The patient is receiving the medication levodopa-carbidopa. The nurse understands that in order to maximize effectiveness, the administration schedule for this medication should adhere to which of the following? Administer with meals only Administer first thing in the morning only Administer on an empty stomach, 30-60 minutes before or 45-60 minutes after a meal Administer with a full 8 oz of water and have the patient sit upright for 30 minutes after

Administer on an empty stomach, 30-60 minutes before or 45-60 minutes after a meal

An older adult client has been voluntarily admitted for treatment of alcohol dependency. In implementing care, the nurse plans which intervention based upon knowledge about alcohol and aging? Assessing the client for both depression and anxiety Discussing the poor prognosis of this disorder with the client Explaining the need for proper nutrition to minimize the effects of alcoholism Identifying the effects of chronic alcoholism on the human body

Assessing the client for both depression and anxiety

Which intervention best addresses the principle that is the basis for communicating with a client experiencing postsurgical delirium? Reminding the client that delirium is generally acute and reversible Assuming that the client's statements are an attempt to express needs Allowing the client sufficient time to formulate an answer to questions Using nonverbal communication techniques to communicate with the client

Assuming that the client's statements are an attempt to express needs

A new nurse manager at a small hospital is interested in achieving Magnet status. Which action would help the hospital to achieve this goal? A. Centralizing the decision-making process B. Promoting self-governance at the unit level C. Deterring professional autonomy to promote teamwork D. Promoting evidence-based practice over innovative nursing practice

B Magnet hospitals use a decentralized decision-making process, self-governance at the unit level, and respect for and acknowledgment of professional autonomy.

Which statement or question MOST exemplifies the role of the nurse in establishing a discharge plan for a patient who has had a major abdominal surgery? A) "I'll bet you will be so glad to be home in your own bed." B) "What are your expectations for recovery from your surgery?" C) "be sure to take your pain meds and change your dressing." D) "you will be just fine! please stop worrying."

B) "What are your expectations for recovery from your surgery?" explain: continuity of care, making sure the patient and family needs are consistently met as the patient moves from a care setting to home

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A.A patient decides to quit smoking following a diagnosis of lung cancer. B. A patient shows off a new outfit that she is wearing after losing 20 pounds. C. A patient chooses to work fewer hours following a stress-related myocardial infarction. D. A patient incorporates a new low-cholesterol diet into his daily routine. E. A patient joins a gym and schedules classes throughout the year. F. A patient proudly displays his certificate for completing a marathon.

B, F prizing something one values involves pride, happiness, and public affirmation, such as losing weight, or running a marathon.

5. The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern? a. "Children should be taught not to masturbate because most people believe self-stimulation is wrong." b. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty." c. "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." d. "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

B. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty."

At a follow-up visit, a patient recovering from a myocardial infarction tells the nurse: "I feel like my life is out of control ever since I had the heart attack. I would like to sign up for yoga, but I don't think I'm strong enough to hold poses for long." What would be the nurse's best response? "Right now you should concentrate on relaxing and taking your blood pressure medicine regularly, instead of worrying about doing yoga." "There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into." "Ashtanga yoga is a gentle paced yoga that would help with your breathing and blood pressure." "Yoga is contraindicated for patients who have had a heart attack."

B. "There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into."

A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of a hospitalized patient. During the patient interview, the nurses documents the following patient data: "patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on the data, Which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6

B. 4 Explain: one point is awarded for the following activities: bathing, dressing, toileting, transferring, continence, and feeding

A nurse caring for patients in a pediatricians office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? a. a 4 month old infant who is unable to roll over b. a 6 month old infant who is unable to hold his head up himself c. an 11 month old infant who cannot walk unassisted d. an 18 month old toddler who cannot jump

B. 6 month old infant who is unable to hold his head up Explain: by 5 months infants usually should be able to achieve head control

A nurse working in a long-term care facility incorporates aromatherapy into her practice. For which patient would this nurse use the herb ginger? A patient who has insomnia A patient who has nausea A patient who has dementia A patient who has migraine headaches

B. A patient who has nausea

A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer medications as prescribed." D. "I will be prepared to insert an airway."

B. CORRECT: During a seizure, the client should not be left alone. The nurse remains with the client and calls for assistance using the call light.

A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP)

B. CORRECT: A client who is postoperative following thoracic surgery requires professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care.

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

B. CORRECT: The right supervision and evaluation is one of the five rights of delegation. They also include the right task and the right person. C. CORRECT: Right direction and communication is one of the five rights of delegation. They also include the right task and the right person. E. CORRECT: The right circumstances is one of the five rights of delegation. They also include the right task and the right person.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning.

B. CORRECT: To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. CORRECT: To complete this assignment safely, the AP should make sure the client uses a front-wheeled walker. D. CORRECT: To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication

A nurse is caring for a patient who is on bedrest following a spinal injury. In which position would the nurse place the patient's feet to prevent foot drop? a. supination b. dorsiflexion c. hyperextension d. abduction

B. Dorsiflexion

A nurse studies the culture of Native Alaskans to determine how their diet affects their overall state of health. Which method of qualitative research is the nurse using? A. Historical B. Ethnography C. Grounded theory D. Phenomenology

B. Ethnography examine culture of interests in nursing.

A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? Select all that apply A. Performing an admission health assessment B. Evaluating the nursing plan for effectiveness of care C. Participating in the transfer of the patient to the postoperative care unit D. Making referrals to appropriate agencies E. Maintaining records of patient satisfaction with services F. Assessing the strengths and limitations of the patient and family

B. Evaluating the nursing plan for effectiveness of care D. Making referrals to appropriate agencies F. Assessing the strengths and limitations of the patient and family

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? a. use the axillae to bear the body weight b. keep elbows close to the sides of the body c. When rising, extend the uninjured leg to prevent weight bearing d. properly documenting the patient lift

B. Keeps elbows close to the sides of the body

A nurse is providing health checkups for patients in a clinic located in a predominately LGBT community. Which health disparities should the nurse keep in mind related to this population? Select all that apply. A. LGBT youth are four times more likely to attempt suicide. B. LGBT youth are more likely to be homeless. C. Lesbians are less likely to get preventive services for cancer. D. Lesbians and bisexual females are more likely to be underweight. E. Transgender people have a high prevalence of HIV and sexually transmitted infections. F. LGBT populations have the lowest rates of tobacco, alcohol, and other drug use in the country.

B. LGBT youth are more likely to be homeless. C. Lesbians are less likely to get preventive services for cancer. E. Transgender people have a high prevalence of HIV and sexually transmitted infections. Explain: answer A is incorrect because LGBT youth are 2 to 3 times more likely to attempt suicide, not 4

A nurse works for a health care provider who practices the naturopathic system of medicine. What is the focus of nursing actions based on this type of medical practice? Select all that apply. Treating the symptoms of the disease Providing patient education Focusing on treating individual body systems Making appropriate interventions to prevent illness Believing in the healing power of nature Encouraging patients to take responsibility for their own health

B. Providing patient education D. Making appropriate interventions to prevent illness E. Believing in the healing power of nature F. Encouraging patients to take responsibility for their own health

A nurse is using general systems theory to describe the role of nursing to provide health promotion and patient teaching. Which statements reflect key points of this theory? Select all that apply. A. A system is a set of individual elements that rarely interact with each other. B. The whole system is always greater than the sum of its parts. C. Boundaries separate systems from each other and their environments. D. A change in one subsystem will not affect other subsystems. E. To survive, open systems maintain balance through feedback. F. A closed system allows input from or output to the environment.

B. The whole system is always greater than the sum of its parts. C. Boundaries separate systems from each other and their environments. E. To survive, open systems maintain balance through feedback.

A nurse is caring for a patient in a long term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. improved renal blood supply to the kidneys b. urinary stasis c. decreased urinary calcium d. acidic urine formation

B. Urinary stasis Explain: in a lay down position patient's body lack the pull of gravity that allow urine to be pee out, as a result the urine remains in the bladder or ureter causing urinary stasis (urine stuck in place)

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. a. do full body push ups in bed six to eight times daily b. breathe in and out smoothly during quadricep drills c. place the bed in the lowest position or use a footstool for dangling d. dangle on the side of the bed for 30 or 60 minutes e. allow the nurse to bathe the patient completely to prevent fatigue f. perform quadriceps 2-3 times per hour, 4-6 times per day.

B. breathe in and out smoothly during quadricep drills C. place the bed in the lowest position or use a footstool for dangling F. perform quadriceps 2-3 times per hour, 4-6 times per day.

A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for a sleeping medication

C

a nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. which of the following statements indicates that the client knows how to use the device A. ill wait to use the device until its absolutely necessary B. ill be careful about pushing the button too much so i dont get an overdose C. i should tell the nurse if the pain doesn't stop while i am using this device D. i will ask my adult child to push the dose button when i am sleeping

C

a nurse is collecting data from a client who is reporting pain despite taking analgesia, which of the following actions should the nurse take to determine the intensity of the clients pain A. ask the client what precipitates the pain B. question the client about the pain location C. offer the client a pain scale to measure pain D. use open-ended questions to identify clients pain sensations

C

10. A nurse is assessing a 27-year-old female patient who visits her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? a. Human papillomavirus (HPV) b. Syphilis c. Trichomoniasis d. Herpes simplex virus

C Trichomoniasis causes a foul-smelling vaginal discharge that is thin, foamy, and green in color, and also causes itching of the vulva and vagina, burning on urination, and dyspareunia. HPV causes a profuse watery vaginal discharge, dyspareunia, intense pruritus, and vulvar irritation. Syphilis causes a single painless genital lesion 10 days to 3 months after exposure and generalized skin rash, enlarged lymph nodes, and fever that may appear 2 to 4 weeks after appearance of primary lesion and may last for several years. Herpes presents as single or multiple painful vesicles that rupture and form ulcer-like lesions, which form scabs as they heal.

A home health care nurse is scheduled to visit a 38-year-old woman who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? select all that apply A) collect information about the patient's diagnosis, surgery, & treatments B) call the patient to make initial contact and schedule a visit C) develop rapport with the patient and her family D) assess the patient to identify her needs E) assess the physical environment of the home F) evaluate safety issues including the neighborhood in which she lives

C) develop rapport with the patient and her family D) assess the patient to identify her needs E) assess the physical environment of the home

A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. what is the primary role of the nurse during the admission process? A) to assist with screening tests B) to provide patient teaching C) to assess what has been done and what still needs to be done D) to assist with hernia repair

C) to assess what has been done and what still needs to be done

A nurse is ambulating a patient for the fist time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these actions in order in which the nurse should perform them to protect the patient: a. grasp the gait belt b. stay with the patient and call for help c. place feet wide apart with one foot in front d. gently slide patient down to the floor, protecting her head e. pull the weight of the patient backward towards your body f. rock your pelvis out on the side of the patient

C, F, A, E, D, B

An 18-year-old female presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate? a. "Vaginal intercourse is most commonly performed in the missionary position." b. "The side by side position achieves better clitoral stimulation than the missionary position." c. "Achieving simultaneous orgasms is the goal of vaginal intercourse." d. "The period after coitus is just as significant as the events leading up to it."

C. "Achieving simultaneous orgasms is the goal of vaginal intercourse." Simultaneous orgasms, or both people attaining orgasm at the same moment, are difficult to achieve, and a preoccupation with attaining simultaneous orgasms might disrupt the ultimate intimacy and satisfaction possible during coitus. The most common position in Western cultures is the "missionary position," in which the woman lies horizontally underneath the man. Clitoral stimulation is difficult to achieve in the missionary position. Lying side by side, female on top, and rear entry are some examples of coital positions that enable clitoral stimulation. The period after coitus is just as significant as the events leading up to it.

A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in low position with full side rails up. C. Ensure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

C. CORRECT: Ensuring that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear may keep the client from slipping. E. CORRECT: A fall-risk assessment serves as the basis for an individualized plan of care

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler

C. CORRECT: Providing nasopharyngeal suctioning is within the scope of practice of the PN.

A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A. Extinguish the fire. B. Pull the fire alarm. C. Evacuate the clients. D. Close all open doors on the unit.

C. CORRECT: Rescue is the first action in the fire response. Protecting and evacuating clients in close proximity to the fire is the priority action.

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Updating the plan of care for a client who is postoperative B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure injury

C. CORRECT: The application of a condom catheter is a noninvasive, routine procedure that can be delegated to an AP

When conducting quantitative research, the researcher collects information to support a hypothesis. This information would be identified as: A. The subject B. Variables C. Data D. The instrument

C. Data the information the researcher collects from the subjects

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into what position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. lateral position c. fowler's position d. Sims' position

C. Fowler's position

A nurse is providing a lecture on CHAs to a group of patients in a rehabilitation facility. Which teaching point should the nurse include? CHAs are safe interventions used to supplement traditional care. Many patients use CHA as outpatients but do not wish to continue as inpatients. Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients. Most complementary and alternative therapies are relatively new and their efficacy has not been established.

C. Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients.

A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia. D. Dizziness or light-headedness when changing positions is a common adverse effect of opioid analgesia. E. Nausea and vomiting are common adverse effects of opioid analgesia.

A nurse is guiding a patient in the practice of meditation. Which teaching point is most useful in helping the patient to achieve a state of calmness, physical relaxation, and psychological balance? Teach the patient to always lie down in a comfortable position during meditation. Teach the patient to focus on multiple problems that the patient feels demand attention. Teach the patient to let distractions come and go naturally without judging them. Teach the patient to suppress distracting or wandering thoughts to maintain focus.

C. Teach the patient to let distractions come and go naturally without judging them.

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a MVA. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. have the patient extend his arms outward and cross his legs on top of a pillow b. stand at the side of the bed at which the patient will be turned while another nurse gently pushes the patient from the other side c. have the patient cross his arms on his chest and place a pillow between his knees d. place a cervical collar on the patient's neck and gently roll him to the other side of the bed

C. have the patient cross his arms on his chest and place a pillow between his knees

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and the patient tells the nurse that she feels faint. What is the appropriate nursing action? a. wait a few minutes and then continue to move to the chair b. call for assistance and continue the move with the help of another nurse c. lower the patient back to the side of the bed and pivot her back into bed d. have the patient sit down on the bed and dangle her feet before moving

C. lower the patient back to the side of the bed and pivot her back into bed

Which assessment finding is a contributor to an older client's risk for falls? (Select all that apply.) Client is awaiting cataract surgery on right eye. Client's type 2 diabetes is poorly controlled with diet and exercise alone. Client reports a fall in the last year. Client has a history of contact dermatitis and psoriasis. Client attends Tai Chi classes at the senior center.

Client is awaiting cataract surgery on right eye. Client's type 2 diabetes is poorly controlled with diet and exercise alone. Client reports a fall in the last year.

The role of a nurse caring for an older patient who is in the stable phase of a chronic illness may include which of the following? (Select all that apply.) Coordinating care with members of the interdisciplinary team Administering medications to the patient Providing assistance with bathing and dressing Ensuring that the patient's immunizations are up to date Providing emergency care

Coordinating care with members of the interdisciplinary team Administering medications to the patient Providing assistance with bathing and dressing

A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. B. The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community. C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery. D. The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

D

a nurse is discussing the care of a group of clients with a newly licensed nurse, which of the following clients should the newly licensed nurse identify as experiencing chronic pain A. client who has a broke femur and reports hip pain B. client who has incisional pain 72hr following pacemaker insertion C. client who has food poisoning and reports abdominal cramping D. client who has episodic back pain following a fall 2 years ago

D

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? A. The nurse is not responsible, because the nurse was following the doctor's orders. B. Only the nurse is responsible, because the nurse actually administered the medication. C. Only the health care provider is responsible, because the health care provider actually ordered the drug. D. Both the nurse and the health care provider are responsible for their respective actions.

D nurse are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. Both nurse and healthy care provider are responsible

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape B. Obtain a class C fire extinguisher to extinguish the fire C. Remove all electrical equipment from the client's room D. Place a wet towels along the base of the door to the client's room

D . Place the wet towels along the base of the door to the client's room to contain the fire and the smoke in the room

A nurse is counseling an older women who has been hospitalized for dehydration secondary to a UTI. the patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility o the nurse in this situation? A) to inform the patient that only the primary health care provider can authorize discharge from a hospital B) to collect the patient's belongings & prepare the paperwork for the patient's discharge C) to request a psychiatric consult for the patient and inform her PCP of the results D) To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form

D) To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form

a hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. which activity could the nurse delegate to licensed assistive personnel? A) collecting into for a health history B) performing a physical activity C) contacting the health care provider for medical orders D) preparing the bed and collecting needed supplies

D) preparing the bed and collecting needed supplies

A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? A) the bed linens are folded back B) a hospital gown is on the bed C) equipment for taking vital signs is in the room D) the bed is in the highest position

D) the bed is in the highest position

9. A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? a. "Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." b. "The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus." c. "Abstinence may be an effective method of contraception and may be used as a periodic or continuous strategy." d. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

D. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections." Explain: Withdrawal offers no protection against sexually transmitted infections.

A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station? A. A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B. A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C. A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle D. A 79-year-old client who is postoperative following a below-the-knee amputation

D. CORRECT: This client should be assigned to a room near the nurses' station due to risk factors that include client's age, mobility, and balance issues related to the surgery, and potential side effects, such as drowsiness, as a result of analgesic medication.

A nurse is formulating a clinical question in PICOT format. What does the letter P represent? A. Comparison to another similar protocol B. Clearly defined, focused literature review of procedures C. Specific identification of the purpose of the study D. Explicit descriptions of the population of interest

D. Explicit descriptions of the population of interest The P in the PICOT format represents an explicit description of the patient population of interest. I represents the intervention, C = comparison, O= outcome, T= time

A nurse is caring for a postoperative patient who is experiencing pain. Which CHA might the nurse use to ensure active participation by the patient to achieve effective pre- or postoperative pain control? A. Acupuncture B. TT C. Botanical supplements D. Guided imagery

D. Guided imagery

A patient who injured their spine in a motorcycle accident is receiving rehabilitation services in a short term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in what position? a. side-lying b. fowler's c. sims' d. prone

D. Prone

A student nurse asks an experienced nurse why it is necessary to change the patient's bed every day. The nurse answers: "I guess we have just always done it that way." This answer is an example of what type of knowledge? A. Instinctive knowledge B. Scientific knowledge C. Authoritative knowledge D. Traditional knowledge

D. Traditional knowledge is the part of nursing practice passed down from generation to generation, often without research data to support it.

Which precaution would be beneficial in minimizing an older adult's risk of being a victim of fraud? (Select all that apply.) Do not allow uninvited salespersons into your home. Never provide personal information to telephone sales solicitors. Rely on the advice of people who only friends have recommended Contact the local Medicare or Medicaid service office for information when needed. Keep your bank account and credit card numbers with you at all times.

Do not allow uninvited salespersons into your home. Never provide personal information to telephone sales solicitors. Contact the local Medicare or Medicaid service office for information when needed.

A nurse is educating a group of older adults on the benefits of an exercise program. The nurse includes education on when not to exercise. Which of the following should the nurse include in the education? (Select all that apply.) Do not exercise if your resting heart rate is over 80. Do not exercise if your blood pressure is greater than 200 systolic and 100 diastolic. It is important to wait 30 minutes after a big meal before engaging in vigorous exercise. Do not exercise if a joint that you are using to exercise is red, warm, and painful. Do not exercise if you have a fever and muscle aches.

Do not exercise if your blood pressure is greater than 200 systolic and 100 diastolic. Do not exercise if a joint that you are using to exercise is red, warm, and painful. Do not exercise if you have a fever and muscle aches.

What information should be included in an informational program to be presented on burn prevention to a senior citizens group? (Select all that apply.) Do not smoke in bed or when sleepy. Wear well-fitted clothing when cooking or when grilling outdoors. Establish a meeting place for all family members outside of the home in case of a fire. Establish a plan for exiting each room of your home in the case of a fire. Have a fire extinguisher readily available in the kitchen.

Do not smoke in bed or when sleepy. Wear well-fitted clothing when cooking or when grilling outdoors. Have a fire extinguisher readily available in the kitchen.

An older adult with suspected Parkinson's disease has a "challenge test" performed in order to confirm the diagnosis. The nurse understands that a "challenge test" will demonstrate which of the following? Immediate reversal of all symptoms of Parkinson's disease after administration of levodopa Dramatic improvement of symptoms of Parkinson's disease after administration of levodopa Dramatic improvement in gait only after administration of levodopa Dramatic improvement in tremor only after administration of levodopa

Dramatic improvement of symptoms of Parkinson's disease after administration of levodopa

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A. Autonomy B. Beneficence C. Justice D. Fidelity E. Nonmaleficence

E. Non-maleficence is defined as the obligation to prevent harm

Which intervention has priority before touching a client's consent zone? Draping the area to minimize exposure Having another nurse present Explaining why the area will be touched while asking permission Assuring the client that the touch is absolutely necessary

Explaining why the area will be touched while asking permission

A nurse at a senior center promotes activity by leading a yoga class. Which of the following is a benefit of such exercise? Facilitates range of motion. Strengthens the heart muscle. Decreases serum triglycerides. Prevents sarcopenia.

Facilitates range of motion.

An older adult tells a nurse that he is experiencing difficulty falling asleep, he routinely gets into bed at 8:30 PM and watches his favorite television shows until 11:00 PM, and often lies awake for hours after. Which of the following suggestions are appropriate for the nurse to give to this patient? (Select all that apply.) Go to bed only when sleepy. If unable to sleep within a reasonable time (15-20 minutes), get out of bed and pursue relaxing activities. Engage in moderate exercise to induce fatigue. Do not watch television or work in bed. If unable to sleep, engage in enjoyable activities on the computer.

Go to bed only when sleepy. If unable to sleep within a reasonable time (15-20 minutes), get out of bed and pursue relaxing activities. Do not watch television or work in bed.

A nurse is planning health education on chronic illnesses for a group of seniors in the community. When deciding upon which illnesses to focus upon, the nurse knows that which of the following are the most common diseases in the United States? (Select all that apply.) Heart disease Cancer Asthma Osteoarthritis Diabetes

Heart disease Cancer Osteoarthritis Diabetes

The nurse is recommending that a client diagnosed with moderate stage Alzheimer's disease attend a support group when he becomes defensive about not driving his automobile and the effects it will have on "being stuck at home." Which is the priority outcome expected for this client when attending the group sessions? Facilitates socialization thus minimizing the effects of social isolation. Helps with minimizing the loss as a factor in causing depression. Provides caregivers with respite while assuring the client is well attended to. Allows for the opportunity for a mental health professional to assess the client.

Helps with minimizing the loss as a factor in causing depression.

A group of older women in an assisted living facility are talking about one of the residents who fell and fractured her hip. The women ask a nurse the following: "It seems like so many of us fall and break our hips, and then it is downhill from there. Is this really true?" In formulating a response, the nurse considers which of the following? (Select all that apply.) Hip fractures are a leading cause of hospitalization for older people. The major cause of hip fractures is falls. Women have significantly higher mortality rates from hip fractures than do men. Nearly all older patients who sustain a hip fracture will regain prefracture mobility status within 1 year. Hip fractures are associated with very high morbidity and mortality.

Hip fractures are a leading cause of hospitalization for older people. The major cause of hip fractures is falls. Hip fractures are associated with very high morbidity and mortality.

An older client admitted to the hospital after having sustained a fall at home is diagnosed with a right hip fracture and experienced a surgical reduction of the fracture. At 2:30 AM, she awakens from sleep insisting that her daughter is in the other room and wants to see her. Attempts to reorient her to the surroundings are unsuccessful. In reviewing the client's record, what data would be considered a primary risk factor for the delirium? History of dementia Death of the client's husband last month The client's age History of cardiac disease

History of dementia

The daughter of an older patient says to a nurse, "I am so concerned that my dad is still driving. He is dangerous! He has had a couple of accidents and I am worried that he is going to kill himself or, worse, somebody else. What can I do?" The nurse recommends which of the following involved type action strategies for driving cessation? (Select all that apply.) Report the person to the division of motor vehicles for license suspension. Hold a family meeting with the person to discuss the situation and come to a mutual agreement of the problem. Arrange for alternate transportation for the person. Confiscate the keys to the car. Ask the patient's physician to write a prescription for the person to stop driving.

Hold a family meeting with the person to discuss the situation and come to a mutual agreement of the problem. Arrange for alternate transportation for the person.

Which statement regarding touch and touch zones is most accurate? People between the ages 66 and 100 are the most often touched. Newly graduated nurses tend to touch clients less often than do nursing students. When performing pericare, the nurse is working within the zone of intimacy. Illness, confinement, and dependency are stresses on the intimate zone of touch.

Illness, confinement, and dependency are stresses on the intimate zone of touch.

Which attempt by the family to prevent an older, frail adult from falling causes the home health nurse concern? Keeping several low wattage night-lights on in the evening Installing wooden railings on the stairway to the bathroom Keeping the side rails up on the client's bed at night Encouraging the client to use a cane when ambulating

Keeping the side rails up on the client's bed at night

A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the patient eliminate which of the following? (Select all that apply.) Night-lights Railings on the stairway Loose carpeting on the floors The use of a cane Excess clutter

Loose carpeting on the floors Excess clutter

A nurse is caring for a frail older adult in a long-term care facility and is concerned about preventing hypothermia. Which of the following interventions should the nurse implement? (Select all that apply.) Make sure that the temperature in the resident's room is at least 68° F. Cover residents well when in bed and while bathing. Provide a head covering for the resident. Maintain resident in bed covered with heavy blankets at all times. Provide hot, high-protein meals and bedtime snacks.

Make sure that the temperature in the resident's room is at least 68° F. Cover residents well when in bed and while bathing. Provide a head covering for the resident. Provide hot, high-protein meals and bedtime snacks.

A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse? Immediately contact the medical provider. Obtain a second set of measurements at a different time. Measure the blood pressure in sitting and standing positions. Document the findings in the medical record; elevated blood pressures are normal in older adults.

Obtain a second set of measurements at a different time.

A nurse in a long-term care facility notes that an older resident with dementia awakens frequently at night and is restless and agitated. Which of the following interventions will be most effective to help manage this resident's sleep problems? Passive music therapy at bedtime Limiting fluid intake for the resident Educating the resident on the association between dementia and insomnia Administering a mild sedative hypnotic at bedtime

Passive music therapy at bedtime

The partner of a client comments, "Our sex life will certainly suffer now that he's had a heart attack." Which statement is the basis for the nurse's response? The client should no longer have sexual relations because of the demand on his heart. The energy expenditure during sex is equivalent to briskly climbing six flights of stairs. People with heart disease may reduce their sexual activity out of fear of their condition. The couple will benefit from attending a cardiac support group.

People with heart disease may reduce their sexual activity out of fear of their condition.

A client is newly diagnosed with type 2 diabetes mellitus. Which diagnostic test will best evaluate the management plan prescribed for this client? A yearly funduscopic examination by an ophthalmologist Regular foot examinations by a podiatrist Quarterly hemoglobin A1C Biannual cholesterol testing

Quarterly hemoglobin A1C

What intervention should a nurse implement when an older male diagnosed with dementia is observed masturbating in the unit's dayroom? Remove the resident from the dayroom and complete an assessment of his behavior. Cover the resident's lap with a blanket and leave him in the dayroom. Counsel the resident by telling him that his behavior is inappropriate. Distract the resident so that he will stop the behavior.

Remove the resident from the dayroom and complete an assessment of his behavior.

What intervention should a nurse implement when an older male diagnosed with dementia is observed masturbating in the unit's dayroom? Remove the resident from the dayroom and complete an assessment of his behavior. Cover the resident's lap with a blanket and leave him in the dayroom. Counsel the resident by telling him that his behavior is inappropriate. Distract the resident so that he will stop the behavior.

Remove the resident from the dayroom and complete an assessment of his behavior.

The nurse is caring for an older client who experienced a hip replacement surgery 10 hours ago. Which intervention will help minimize this client's risk of developing delirium? Requesting that staff offer fluids each time they interact with the client Medicating the client to best facilitate restorative sleep Encouraging the client to remain still and thus minimize pain Suggesting that visitors are limited to family members only

Requesting that staff offer fluids each time they interact with the client

A nurse cares for an older adult who is described as being "frail." The nurse understands that in order to be characterized as frail an individual must possess which of the following characteristics? (Select all that apply.) Slow walking speed Low activity level Self-reported exhaustion Taking at least five prescribed medications A diagnosis of at least two chronic conditions

Slow walking speed Low activity level Self-reported exhaustion

A nurse is teaching a group of older adults about healthy aging. The nurse discusses global lifestyle risk factors for chronic disease. The nurse includes which of the following in the education? (Select all that apply.) Smoking cessation and avoidance of tobacco Maintenance of high levels of physical activity Importance of eating a balanced diet Development of advance directives Maintenance of blood pressure readings at a level of 120/80 or lower

Smoking cessation and avoidance of tobacco Maintenance of high levels of physical activity Importance of eating a balanced diet

A nurse is discussing the importance of exercise with a 78-year-old female who states: "I know I should be exercising, but I have arthritis in my knees and it is painful. Can you recommend a type of exercise that would be beneficial and cause me less pain?" Which of the following exercises should the nurse recommend? Tennis Swimming Dancing Use of a treadmill and elliptical machine in the gym

Swimming

Which intervention to manage a wandering client in a long-term care facility should be implemented? (Select all that apply.) Walk with the person, allowing them control within the bounds of safety. Redirect the person back toward the facility. Call the person by his or her formal name. Using physical restraints to prevent wandering to maintain safety. Make direct eye contact with the person.

Walk with the person, allowing them control within the bounds of safety. Redirect the person back toward the facility. Call the person by his or her formal name. Make direct eye contact with the person.

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (type all that apply) A. A client who has terminal cancer requests hospice care in her home. B. A client asks about community resources available for older adults. C. A client states that she wants her child baptized before surgery. D. A client requests an electric wheelchair for use after discharge. E. A client states that he does not understand how to use a nebulizer.

a b d

A nurse who is newly hired to manage a busy pediatric office is encouraged to use a transactional leadership style when dealing with subordinates. Which activities best exemplify the use of this type of leadership? Select all that apply. a. The manager institutes a reward program for employees who meet goals and work deadlines. b. The manager encourages the other nurses to participate in health care reform by joining nursing organizations. c. The manager promotes compliance by reminding subordinates that they have a good salary and working conditions. d. The manager makes sure all the employees are kept abreast of new developments in pediatric nursing. e. The manager works with subordinates to accomplish all the nursing tasks and goals for the day. f. The manager allows the other nurses to set their own schedules and perform nursing care as they see fit.

a c transactional leadership is based on task-and-reward orientation.

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the inter professional care team can assist the client in understanding the medication's effects? (type all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

a c d

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A. Advocacy is the protection and support of another's rights. B. Patient advocacy is primarily performed by nurses. C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. D. Nurse advocates make good health care decisions for patients and residents. E. Nurse advocates do whatever patients and residents want. F. Effective advocacy may entail becoming politically active.

a c f Advocacy is the protection and support of another's right. Among the patients with special advocacy needs are the very young and the older adult, those who are seriously ill, and those with disabilities. Effective advocacy may entail politically active. Patient advocacy is the responsibility of every member of the professional caregiving team, not just nurses.

A nurse is a servant leader working in an economically depressed community to set up a free mobile health clinic for the residents. Which actions by the leader BEST exemplify a key practice of servant leaders? Select all that apply a. The nurse motivates coworkers to solicit funding to set up the clinic. b. The nurse sets only realistic goals that are present oriented and easily achieved. c. The nurse forms an autocratic governing body to keep the project on track. d. The nurse spends time with supporters to help them grow in their roles. e. The nurse first ensures that other's lowest priority needs are served. f. The nurse prizes leadership because of the need to serve others.

a d f Development and investment for current needs and motivate others to follow and engage to provide ongoing opportunities for collaboration, sharing, reflection, encouragement , and celebration for hard works. The servant leader allows others to have a voice, to exercise control, and to practice leading themselves. Always makes sure other's priority needs are served.

6. A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. a. A patient who has uncontrolled hypothyroidism. b. A patient with coronary artery disease. c. A patient who has GERD. d. A patient who is HIV positive. e. A patient who is taking corticosteroids for arthritis. f. A patient with a urinary tract infection.

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

14. Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply. a. A patient who is breast-feeding b. A patient who is diagnosed with anorexia c. A patient who chooses to abstain from sexual intercourse d. A patient who has pelvic inflammatory disease e. A patient who is obsessed with exercising f. A patient who has a spinal cord injury

a, b, d, e Causes of menstrual cycle irregularities include pregnancy or breastfeeding, eating disorders, extreme weight loss, excessive exercising, and pelvic inflammatory disease, as well as many other causes.

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. Arrange for assessment for depression and treatment. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage patient to engage in some type of physical activity. f.Assess medication for side effects of sleep pattern disturbances.

a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply. a. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." b. "I should wean my infant by 4 months and encourage him to use a sippy cup." c. "I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body." d. "I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears." e. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." f. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

a, b, e, f. Self-manipulation of genitals is normal behavior—parents should avoid denoting this as "bad." Parents should avoid early weaning of infants to prevent oral deprivation. Parents should explain contraception and STIs to their adolescent children. Parents should share their beliefs and moral system with their children. Parents should also give their children the desired information about sexuality in a clear, factual form and give them information about body changes before they experience them to alleviate fears.

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

3. A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply. a. A 72-year-old male with a history of diabetes b. A 78-year-old male who has a new partner c. A 75-year-old male who has Parkinson disease d. An 80-year-old male who is an alcoholic e. An 85-year-old male who takes antihypertensive medication f. A 76-year-old male who smokes tobacco

a, d, e Explain: risk factors for erectile dysfunction include history of diabetes, spinal cord trauma, cardiovascular disease, surgical procedure, alcoholism, and use of antihypertensives, antidepressant, or illicit drugs

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A. The nurse helps the patient prepare a durable power of attorney document. B. The nurse gives the patient undivided attention when listening to concerns. C. The nurse keeps a promise to provide a counselor for the patient. D. The nurse competently administers pain medication to the patient.

a. The principles of autonomy obligates nurse to provide the information and support patients and their surrogates need to make decisions that advance their interests

15. A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? a.Increase physical activities during the day. b. Encourage short periods of napping during the day. c.Increase fluids during the evening. d.Dispense diuretics during the afternoon hours.

a. Increase physical activities during the day. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

2. A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? a. No action is necessary as this is a normal finding during sleep b. Call the primary care provider to report possible neurologic deficit. c. Lower the temperature in the patient's room. d. Awaken the patient as this is an indication of night terrors.

a. No action is necessary as this is a normal finding during sleep Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.

An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? A. The assessment of a patient who has just arrived on the unit B. Teaching a patient with newly diagnosed diabetes about foot care C. Documentation of a patient's I & O on the flow chart D. Helping a patient who has recently undergone surgery out of bed for the first time

c

A client who reported "a problem sleeping" shows an understanding of good sleep hygiene by: doing 10 pushups before bed to encourage a "pleasant tiredness." seldom eating a bedtime snack. engaging in computer games as a pre-bed activity. avoiding daytime napping.

avoiding daytime napping.

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honestly

b

Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A. Assault B. Battery C. Invasion of privacy D. False imprisonment

b Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Everyone is granted freedom from bodily contact by another person unless consent is granted.

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A. Ethical uncertainty B. Ethical distress C. Ethical dilemma D. Ethical residue

b Ethical distress result from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job)

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their acts of negligence resulting in patient injury. B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

b student nurse are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury.

A charge nurse in a busy hospital manages a skilled nursing unit using an autocratic style of leadership. Which leadership tasks BEST represent this style of leadership? Select all that apply. a. The charge nurse polls the other nurses for input on nursing protocols. b. The charge nurse dictates break schedules for the other nurses. c. The charge nurse schedules a mandatory in-service training on new equipment. d. The charge nurse allows the other nurses to divide up nursing tasks. e. The charge nurse delegates nursing responsibilities to the staff. f. The charge nurse encourages the nurses to work independently.

b c e autocratic leadership involves the leader assuming control over the decision and activities of the group, such as dictating schedules and work responsibilities, and scheduling mandatory in-service training.

A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. A. An incident report is used as disciplinary action against staff members. B. An incident report is used as a means of identifying risks. C. An incident report is used for quality control. D. The facility manager completes the incident report. E. An incident report makes facts available in case litigation occurs. F. Filing of an incident report should be documented in the patient record.

b c e incidence reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a mean of identifying risks and are filled out by the nurse responsible for the injuries party. An incident report makes facts available in case litigation occurs in some states, incident reports may be used in courts as evidence.

7. A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. A patient who is taking iron supplements for anemia. b. A patient with Parkinson's disease who is taking dopamine. c. An older adult taking diuretics for congestive heart failure. d. A patient who is taking antibiotics for an ear infection. e. A patient who is prescribed antidepressants. f. A patient who is taking low-dose aspirin prophylactically

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those bringing the charges against the nurse? A. Appellates B. Defendants C. Plaintiffs D. Attorneys

c The person or government bringing suit against another is called the plaintiff

A nurse manager is attempting to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: a. The nurse devises a plan to switch to EHR. b. The nurse records the time spent on written records versus EHR. c. The nurse attains approval from management for new computers. d. The nurse analyzes all options for converting to EHR. e. The nurse installs new computers and provides an in-service for the staff. f. The nurse explores possible barriers to changing to EHR. g. The nurse follows up with the staff to check compliance with the new system. h. The nurse evaluates the effects of changing to EHR.

b, f, d, c, a, e, h, g planned change: 1. Symptoms / data collection 2. Identify problem 3. Find different solution 4. Select solution 5. Plan for change 6. Implement change 7. Evaluate change 8. Stabilize change

9. A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. Circadian rhythm sleep-wake disorder b. Narcolepsy c. Enuresis d. Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? a. "I can expect my newborn to sleep an average of 16 to 24 hours a day." b. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." c. "I will place my infant on his back to sleep." d. "I will not place pillows or blankets in the crib to prevent suffocation."

b. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.

14. A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? a. Keep the room light dimmed during the day. b. Keep the room cool. c. Keep the door of the room open. d. Offer a sleep aid medication to patients on a regular basis

b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A. Carefully assessing the patient care environment B. Using two nurses to lift a patient who cannot assist C. Wearing a back belt to perform routine duties D. Properly documenting the patient lift

b. Using two nurses to lift a patient who cannot assist

A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply. A. People are born with values. B. Values act as standards to guide behavior. C. Values are ranked on a continuum of importance. D. Values influence beliefs about health and illness. E. Value systems are not related to personal codes of conduct. F. Nurses should not let their values influence patient care.

b. Value act as standards to guide behaviors c. Values are ranked on a continuum of importance d. Values influence believes about health and illness

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D. Board approval

c certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area

13. A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? a. The use of a central nervous system stimulant b. Continuous positive airway pressure machine (CPAP) c. Chronotherapy d. The application of heat or cold therapy to promote sleep

c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.

8. A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? a. Preparing the family for a diagnosis of insomnia and related treatments. b.Preparing the family for a diagnosis of narcolepsy and related treatments. c. Anticipating the scheduling of polysomnography to confirm OSA. d. No action would be taken, as this is a normal finding for hospitalized children.

c. Obstructive sleep apnea- OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.

5. A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. d. Exercising right before bedtime can hinder sleep

c. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

3. A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. He is aware of his surroundings at this point. b. He is in delta sleep at this time. c.It would be most difficult to awaken him at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f.The muscles are relaxed in this stage.

c. It would be most difficult to awaken him at this time. e. This stage constitutes around 20% to 25% of total sleep. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

A 38-year-old patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. The nurse documents this data as: a. Masochism b. Pedophilia c. Voyeurism d. Sadism

c. Voyeurism Explain: the achievement of sexual arousal by looking at the body of someone other than a person's own sexual partner

A major difference in the diagnosis of chronic disease between younger adults and older adults is that: chronic disease is often diagnosed earlier in younger adults and measures can be implemented to prevent later problems. chronic disease is often diagnosed earlier in older adults since they are more likely to seek medical care. chronic disease is usually not identified in older adults because of the many age-related changes. chronic illness is uncommon in younger adults.

chronic disease is often diagnosed earlier in younger adults and measures can be implemented to prevent later problems.

An older person has sudden onset of a severe headache, left-sided facial drooping, and left arm numbness. The person's daughter calls 911 and the person is transported to the emergency department. The first diagnostic test that will likely be performed is a(n): electrocardiogram (ECG) to assess for atrial fibrillation. computed tomography (CT) scan to differentiate hemorrhagic from ischemic stroke. international normalized ratio to determine level of anticoagulation. lumbar puncture to assess for infection.

computed tomography (CT) scan to differentiate hemorrhagic from ischemic stroke.

An older adult has recently experienced a number of stressful life events. The client comes to the ambulatory clinic and tells the nurse that, "On top of all I've had to endure, now I've got this flu!" In rendering care for this client, the nurse recognizes that: the client is exhibiting attention-seeking behaviors to substitute for poor coping skills. crisis and stressful situations may produce emotions that erode the health of the older people. the client is exhibiting learned helplessness as a result of the recent stressors. a period of crisis will ultimately lead to a lower level of physical and mental functioning.

crisis and stressful situations may produce emotions that erode the health of the older people.

A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist

d

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the inter professional care team? A. Social worker B. Certified nursing assistant C. Registered dietician D. Occupational therapist

d

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity

d

A nurse is asked to act as a mentor to a new nurse. Which nursing action is related to this process? A. The nurse mentor accepts payment to introduce the new nurse to his or her responsibilities B. The nurse mentor hires the new nurse and assigns duties related to the position C. The nurse mentor makes it possible for the new nurse to participate in professional organizations D. The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

d

A nurse manager of a busy cardiac unit observes disagreements between the RNs and the LPNs related to schedules and nursing responsibilities. At a staff meeting, the manager compliments all the nurses on a job well done and points out that expected goals and outcomes for the month have been met. The nurse concludes the meeting without addressing the disagreements between the two groups of nurses. Which conflict resolution strategy is being employed by this manager? A. Collaborating B. Competing C. Compromising D. Smoothing

d the manager resolves conflict by complimenting the parties involved and focusing on agreement rather than disagreement

4. A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d.Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? A. Public law B. Private law C. Civil law D. Criminal law

d. Criminal law concerns state and federal criminal statues, which define criminal actions as murders, manslaughter, criminal negligence, theft, and illegal possession of drugs

Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? a. "Do you currently have a new partner?" b. "Have you been diagnosed with a neurologic disorder?" c. "Do you take anti-hypertensive medication?" d. "Do you use antihistamines?"

d. "Do you use antihistamines?" Antihistamine is a factors that contributes to dyspareunia ( difficulty urinating)

A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning? a. "Each person is born with a certain amount of sexual drive, which can be depleted in later years." b. "If you want to be a great athlete, sexual abstinence is necessary when you are training." c. "If you have a nocturnal emission (wet dream) it is an indicator of a sexual disorder." d. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

d. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man." Physiologic studies indicate that, in some respects, the woman's sex drive is not only as strong but may be even stronger than that of the man. The more consistently sexually active a person is, the longer the activity continues into the later years of life. Physiologically, the achievement of orgasm is rarely more demanding than most activities encountered in daily life; there is no scientific evidence that sex "weakens" a person. Erotic dreams that culminate in orgasms are normal common physiologic phenomena in at least 85% of men.

A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? A. Modeling B. Moralizing C. Laissez-faire D. Rewarding and punishing

d. Rewarding and punishing

A nurse is educating an older adult with diabetes on glucose self-monitoring. When developing the teaching plan, the nurse includes which of the following goals in the teaching plan? The patient will: (Select all that apply.) demonstrate the technique for obtaining a blood sample. verbalize actions to take when results indicate an error on the machine. state the correct timing of blood glucose monitoring. state the signs and symptoms of both hyperglycemia and hypoglycemia. demonstrate technique for storing and transporting insulin correctly.

demonstrate the technique for obtaining a blood sample. verbalize actions to take when results indicate an error on the machine. state the correct timing of blood glucose monitoring.

A nurse is caring for an older adult who has hyperthyroidism. The nurse knows that the following manifestations are more likely in the older adult: (Select all that apply.) depression. weight loss. heat intolerance. dyspnea. tremor.

depression, weight loss, dyspnea

The greatest risk for injury for a client with progressed Parkinson's disease is: falls. suicide. bleeding ulcers. respiratory arrest.

falls

A nurse in a long-term care facility notes that there has been an increase in falls on one unit and that many of the falls are occurring immediately following mealtime. The nurse recommends that the nursing home conduct a trial of six smaller meals instead of the three traditional meals. The nurse makes this recommendation on the understanding that: postural changes in blood pressure are common in older adults and frequently occur around mealtimes. postprandial hypotension occurs after ingestion of a carbohydrate meal and may be related to the release of a vasodilatory peptide. residents of long-term care facilities are often on many different medications, which are given at mealtimes. it is common practice to take long-term care residents to the bathroom immediately following meals.

postprandial hypotension occurs after ingestion of a carbohydrate meal and may be related to the release of a vasodilatory peptide.

An older patient asks a nurse: "I went to my diabetes doctor and everything was stable. The nurse practitioner spent the entire time teaching me about decreasing my risks of heart disease. It seemed odd that she did not focus on teaching me how to better control my diabetes. Do you know why?" The nurse formulates a response based on the understanding that: (Select all that apply.) promoting cardiovascular health has the potential to minimize the complications of DM. there is little evidence that demonstrates that the course of DM can be altered in an older adult. the benefits of better control of blood pressure and lipid levels are seen much quicker than the benefits of better glycemic control. older adults are less receptive to teaching about diabetes than they are to teaching about cardiovascular disease. diabetes is not a common chronic condition in older adults.

promoting cardiovascular health has the potential to minimize the complications of DM. the benefits of better control of blood pressure and lipid levels are seen much quicker than the benefits of better glycemic control.

A nurse is auscultating an older patient's heart and notes a systolic murmur (heard between the S1 and S2 heart sounds. The first action by the nurse is to: question the patient about the presence of the murmur. note it in the chart as this is always a normal finding for an older adult. contact the medical provider as this is an abnormal finding. immediately implement emergency interventions.

question the patient about the presence of the murmur.

In order to focus on the older population with the greatest risk for suicide, the nurse would conduct a depression screening that targets: African American men. white men. white women. African American women.

white men.