Nursing Judgement Final
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy? A) A client exhibiting exotic behavior B) A client admitted 12 hr ago for acute mania C) A client who is experiencing alcohol intoxication D) A client who has been taking amitriptyline for 3 months for depression
A client who has been taking amitriptyline for 3 months for depression. Explanation: Psychotherapy groups provide clients with the opportunity to enhance their personal relationships, increase self-awareness, and try new behaviors in a safe social setting. Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be experiencing improvement in depressive manifestations and be ready to interact in a group setting.
A nurse is providing teaching to a group of adult athletes about preventing the effects of dehydration on the body. Which of the following manifestations should the nurse include in the teaching? A) Impaired motor control B) Drop in body temperature during exercise C) Increase in appetite. D) Decreased resting heart rate
A) Impaired motor control Explanation: Impaired motor control is a clinical manifestation of dehydration.
A nurse is discussing culturally competent care at a nursing staff in-service. Which of the following information should the nurse include when discussing clients' cultures? A) Nurses should focus on clients' cultures, rather than their ethnicity, when providing care. B) Nonverbal communication is important in few cultures. C) Culture plays no role in determining when a client will seek medical care. D) Nurses should expect clients to adapt to the care provided regardless of culture.
A) Nurses should focus on clients' cultures, rather than their ethnicity, when providing care. Nurses should assess clients and make decisions regarding care based on culture, rather than based on ethnicity or race.
A nurse is discussing ageism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concept?
Ageism refers to the stereotype that older adults are not able to understand new information. Explanation: Risk factors for cardiovascular disease include BP elevation, obesity, smoking, and a sedentary lifestyle.
A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI? A) A client with a weight of 128 lb and height of 70 inches B) A client with a weight of 150 lb and height of 68 inches C) A client with a weight of 200 lb and height of 72 inches D) A client with a weight of 133 lb and a height of 60 inches
B) A client with a weight of 150 lb and height of 68 inches Explanation: The formula for calculating BMI is weight in kilograms divided by the height in meters squared. The formula to convert pounds to kilograms is to divide the weight in pounds by 2.2 kilograms. The formula for converting inches to meters is to multiply the total inches times 0.0254 meters. 150 pounds divided by 2.2 equals 68.18 kilograms. 68 inches multiplied times 0.0254 inches equals 1.7272 meters. 1.7272 meters (squared) is 2.983 meters. 68.18 kilograms divided by 2.983 meters equals a BMI of 22.85. A BMI of 18.5-24.9 is considered a healthy weight.
A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is the roast beef dinner with nonfat milk. Which of the following actions should the nurse take? A) Allow the AP to deliver the food tray to the client. B) Call the dietary department and ask for a kosher tray. C) Replace the nonfat milk with apple juice. D) Explain to the client that he needs the protein in the milk and the beef.
B) Call the dietary department and ask for a kosher tray. Explanation: This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who practice the Orthodox Jewish faith do not eat meat and dairy together.
A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his BMI is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders? A) Testicular cancer B) Cardiovascular disease C) Depression D) Thyroid disease
B) Cardiovascular disease Explanation: Risk factors for cardiovascular disease include BP elevation, obesity, smoking, and a sedentary lifestyle.
A nurse is about to explain a therapeutic procedure to a client who doesn't speak the same language as the nurse. Which of the following actions should the nurse take? A) Ask a family member to translate. B) Have a medical interpreter present during the teaching. C) Tell the client that he will receive written information in his language after the procedure. D) Use nonverbal gestures to assure the client that the procedure is safe and will help him.
B) Have a medical interpreter present during the teaching. Explanation: Federal law requires specific procedures for accommodating language barriers. The nurse should use a medical interpreter to give the client instructions he can understand.
A nurse is completing the admission of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborns chest circumference? A) Sternal notch B) Nipple Line C) Xiphoid process D) Fifth intercostal space
B) Nipple Line Explanation: The nurse should measure the newborn's chest circumference at the nipple line.
A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? A) "I journal when I find it difficult to talk." B) "I pray when I begin to breathe fast." C) "I fix myself a pot of coffee when I get anxious." D) "I exercise when my neck is tense."
C) "I fix myself a pot of coffee when I get anxious." Explanation: Clients who are experiencing stress or anxiety should eliminate or decrease the intake of caffeine.
A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A) "I should wait to empty my client's drainable colostomy until it is three-fourths full." B) "I should delegate providing closed irrigation to the assistive personnel (AP)." C) "I should encourage clients to receive an annual flu immunization." D) "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care."
C) "I should encourage clients to receive an annual flu immunization." Explanation: Cost containment is the delivery of effective and efficient care. Cost is maintained without loss of quality. The nurse should encourage clients to receive an annual flu immunization to prevent the need for treatment and hospitalization necessary with influenza.
A nurse is providing teaching about nutrition to a group of clients. The nurse should include that which of the following foods contains the highest level of thiamine per serving? A) 1 hard-boiled egg B) 1 cup dried pears C) 1 cup whole grain wheat flour D) 1 cup brussel sprouts
C) 1 cup whole grain wheat flour Explanation: Whole or enriched grains contain 0.981 mg thiamine, which is the highest level of thiamine.
A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN) Which of the following lab values indicates the treatment is effective? A) Hct 43% B) WBC 8,000/uL C) Albumin 4.2 g/dL D) Calcium 9.4 mg/dL
C) Albumin 4.2 g/dL Explanation: Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein.
A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? A) Serve foods that have a hot/cold balance. B) Serve milk products separately from meals. C) Request a meal tray without pork. D) Remove tea and coffee from meal trays.
C) Request a meal tray without pork. Explanation: Clients who practice Islam do not eat pork. Clients who practice the Hindu, Seventh-Day Adventist, Mormon, and Jewish faiths abstain from pork as well.
A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray? A) Cranberry juice B) Flavored gelatin C) Skim milk D) Chicken broth
C) Skim milk Explanation: Full liquids include milk and milk products, so the client may now ask for skim milk.
A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy? A) 56-year-old who had a colonoscopy 6 years ago B) 34-year-old who reports a new onset of constipation C) 32-year-old who has a sister who died of colon cancer D) 51-year-old who is being seen for an annual physical examination
D) 51-year-old who is being seen for an annual physical examination Explanation: Colorectal cancer (CRC) is not common prior to the age of 40 years. When an adult turns 40, the provider should begin screening the client for risk factors of CRC (e.g., family history, inflammatory bowel disease, tobacco and alcohol use, high-fat and low-fiber diet, diet high in animal fats and red meat, sedentary lifestyle). The provider also may begin fecal occult blood testing depending on the client's risk. Screening colonoscopies are recommended starting at age 50 for those clients considered to be at normal risk with no family history and repeated every 10 years. It may begin earlier and performed more often for clients at high risk.
