Practice questions for exam 2

During the orientation phase of the helping relationship, the nurse might do which of the following? 1.Discuss the cards and flowers in the room 2.Work together with the client to establish goals 3.Review the client's history to identify possible health concerns 4.Use therapeutic communication to manage the client's confusion

1.Discuss the cards and flowers in the room

The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? 1. Providing information 2. Clarifying 3. Focusing 4. Paraphrasing

2. Clarifying

Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? 1. Provide her the opportunity to practice drawing up insulin 2. Coach her to give herself positive messages about her ability to do this 3. Bring her written material that clearly describes the steps of insulin administration 4. Use therapeutic communication to help her express her feeling about giving herself an injection

2. Coach her to give herself positive messages about her ability to do this

A nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1.Call for help. 2.Extinguish the fire. 3.Activate the fire alarm. 4.Confine the fire by closing the room door

3.Activate the fire alarm.

If the nurse is working with a client who has expressive aphasia, it would be most helpful for the nurse to: 1.Ask open-ended questions 2.Speak loudly and use simple sentences 3.Allow extra time for the client to respond 4.Encourage a family member to answer for the client

3.Allow extra time for the client to respond

A nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report? 1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found lying on the floor. 4.The client became restless and tried to get out of bed.

3.The client was found lying on the floor.

You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? 1. Summarize what you have talked about in the previous sessions 2. Review his medical record and talk to other nurses about how he is reacting 3. Explore his feelings about losing his leg 4. Talk with him about his favorite hobbies

4. Talk with him about his favorite hobbies

The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse's states, "This is not normal behavior". The nurse documents this is which of the following: a) inference b) Subjective data c) Objective data d) Secondary subjective

C) Objective data

What is the leading cause of unintentional death for the entire U.S. population? 1) Motor vehicle accidents 2) Poisoning 3) Choking 4) Falls

1) Motor vehicle accidents Rationale: The leading causes of unintentional death for the total population, in this order, are automobile accidents, poisoning, falls, and drowning.

A nurse is working with a nursing assistive personnel (NAP) on a bust oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine sample from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.) 1. A nurse explain to the NAP the approach to use in getting the patient up and why the patient has activity limitations. 2. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead. 3. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. 4. The nurse is in Patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room. 5. The nurse offers to support the NAP when needed but allows her to complete patient care tasks without constant oversight.

1. A nurse explain to the NAP the approach to use in getting the patient up and why the patient has activity limitations. 3. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. 4. The nurse is in Patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room.

"We've talked a lot about your medications, but let's look more closely at the trouble you're having in taking them on time." The nurse is using the therapeutic technique: 1.Focusing 2.Clarifying 3.Paraphrasing 4.Providing information

1. Focusing

A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8 hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of: 1. Planning 2. Evaluation 3. Intervention 4. Diagnosis

2. Evaluation

As a nursing student, you give yourself positive messages regarding your ability to do well on a test. This is an example of what level of communication? 1. Public 2. Intrapersonal 3. Interpersonal 4. Transpersonal

2. Intrapersonal

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) 1. Turning on the television to her favorite show 2. Pulling the curtain to provide privacy 3. Offering to discuss information about her condition 4. Asking her why she is crying 5. Sitting quietly by her bed and hold her hand

2. Pulling the curtain to provide privacy 3. Offering to discuss information about her condition 5. Sitting quietly by her bed and hold her hand

A nurse is caring for an older-adult couple in a community-based assisted living facility. During the family assessment he notes that the couple has many expired medications and multiple medications for their respective chronic illnesses. They note that they go to two different health care providers. The nurse begins to work with the couple to determine what they know about their medications and helps them decide on one care provider rather than two. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork 4. Informatics

2. Safety

Which of the following nurse statements would be nontherapeutic and tend to block communication? (Choose all that apply.) 1."You look sad today." 2."Why are you so nervous?" 3."If I were you, I'd have the surgery." 4."I'm sure the test will come out fine." 5."Tell me what it's like to live with dizziness."

2."Why are you so nervous?" 3."If I were you, I'd have the surgery." 4."I'm sure the test will come out fine."

"I'm not sure I understand what you mean by 'sicker than usual.' What is different now?" The nurse is using the therapeutic technique: 1.Focusing 2.Clarifying 3.Paraphrasing 4.Providing information

2.Clarifying

A client newly diagnosed with cervical cancer is going home. The client is avoiding discussion of her illness and postoperative orders. In teaching the client about discharge instructions, the nurse: 1.Teaches the client's spouse 2.Provides only the information the client needs to go home 3.Focuses on knowledge the client will need in a few weeks 4.Convinces the client that learning about her health is necessary

2.Provides only the information the client needs to go home

Clients frequently request copies of their medical records. The nurse understands: 1.Only the families may read the records 2.They have the right to read those records 3.They are not allowed to read those records 4.Only the health care workers have access to the records

2.They have the right to read those records

A 67-year old patient will be discharged from the hospital in the morning. The health care provider has ordered three new medications for her. Place the following steps of the nursing process in the correct order: 1. The nurse returns to the patient's room and asks her to describe the medications she will be taking at home. 2. The nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit. 3. The nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her medications. 4. The nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her. 5. The nurse considers what she learns from the patient and identifies the patient's nursing diagnosis.

3, 5, 2, 4, 1

The nurse demonstrates active listening by: 1.Agreeing with the client 2.Repeating everything the client says to clarify 3.Assuming a relaxed posture and leaning toward the client 4.Smiling and nodding continuously throughout the interview

3. Assuming a relaxed posture and leaning toward the client

When an individual internalizes the beliefs, behavior, and values of role models into a personal, unique expression of self, the nurse would document this as: 1.Inhibition 2.Substitution 3.Identification 4.Reinforcement-extinction

3. Identification

A nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1.A client scheduled for a chest x-ray 2.A client requiring daily dressing changes 3.A postoperative client preparing for discharge 4.A client receiving nasal oxygen who had difficulty breathing during the previous shift

4. A client receiving nasal oxygen who had difficulty breathing during the previous shift

The type of care management approach that coordinates and links health care services to clients and their families while streamlining costs and maintaining quality is: 1.Primary nursing 2.Total patient care 3.Functional nursing 4.Case management

4.Case management

Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurate in the way it is written? 1.Client up, out of bed, walked down hallway with assistance, tolerated well. 2.Client up, out of bed, walked 50 feet and back down hallway, tolerated well. 3.Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse. 4.Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise.

4.Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise.

A nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by: 1.Documenting a late entry into the client's record 2.Trying to erase the error for space to write in the correct data 3.Using whiteout to delete the error to write in the correct data 4.Drawing one line through the error, initialing and dating the line, and then documenting the correct information

4.Drawing one line through the error, initialing and dating the line, and then documenting the correct information

A nurse is giving a report to a nursing assistant who will be caring for a client who has hand restraints (safety devices). The nurse instructs the nursing assistant to check the skin integrity of the restrained hands: 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 30 minutes

4.Every 30 minutes

As the nurse, you need to complete all of the following. Which task do you complete first? 1.Cough and deep breathe the client who had surgery yesterday. 2.Make a referral to the home care nurse for a client who is being discharged in 2 days. 3.Do the teaching on wound care for a client with a wound drain who is being discharged later today. 4.Notify the health care provider of the decreased level of consciousness in the client who had a stroke yesterday.

4.Notify the health care provider of the decreased level of consciousness in the client who had a stroke yesterday.

A client needs to learn to use a walker. Acquisition of this skill will require learning in the: 1.Affective domain 2.Cognitive domain 3.Attentional domain 4.Psychomotor domain

4.Psychomotor domain

The statement that best explains the role of collaboration with others for the client's plan of care is which of the following? 1.The professional nurse consults the physician for direction in establishing goals for clients. 2.The professional nurse depends on the latest literature to complete an excellent plan of care for clients. 3.The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. 4.The professional nurse collaborates with colleagues and the client's family to provide combined expertise in planning care.

4.The professional nurse collaborates with colleagues and the client's family to provide combined expertise in planning care.

The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: 1) Are comprehensive charting forms that integrate assessments and nursing actions 2) Contain only graphic information, such as I&O, vital signs, and medication administration 3) Are used to record routine aspects of care; they do not contain assessment data 4) Contain vital data collected upon admission, which can be compared with newly collected data

Answer: 1) Are comprehensive charting forms that integrate assessments and nursing actions Rationale: Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information.

Which pain management task can the nurse safely delegate to nursing assistive personnel? 1) Asking about pain during vital signs 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications

Answer: 1) Asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse.

A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship? The patient will be able to: 1) Describe how to operate the bed and call for the nurse. 2) Discuss communication patterns and roles within the family. 3) Openly express his concerns about the hospitalization. 4) State expectations related to discharge.

Answer: 1) Describe how to operate the bed and call for the nurse. Rationale: This is the orientation phase of the relationship. The orientation phase begins when the nurse introduces herself to the patient and begins to gather data. In this phase, the nurse and patient are getting to know each other. As part of the orientation phase, the nurse will orient the patient to the hospital room and routines. In the preinteraction phase, the nurse gathers information about the patient before she meets him. Discussion of personal information, particularly if sensitive or complex, is suitable for the working phase of the nurse-patient interaction. The patient expressing feelings and concerns also occurs during the working phase. During the working phase, care is communicated, thoughts and feelings are expressed, and honest verbal and nonverbal communication occurs. Stating expectations related to discharge is most appropriate for the termination phase—the conclusion of the relationship.

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: 1) Identify personal biases that may affect his thinking and actions 2) Identify the most effective interventions for a patient 3) Communicate more efficiently with colleagues, patients, and families 4) Learn and remember new procedures and techniques

Answer: 1) Identify personal biases that may affect his thinking and actions Rationale: The most basic reason is that self-knowledge directly affects the nurse's thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affects all the other nursing actions, it is the most basic reason.

Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply. 1) Orthostatic hypotension 2) Appendectomy 3) Dizziness 4) Hyperthyroidism

Answer: 1) Orthostatic hypotension 3) Dizziness Rationale: Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling.

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: 1) Separates the health record according to discipline 2) Organizes documentation around the patient's problems 3) Highlights the patient's concerns, problems, and strengths 4) Is designed to streamline documentation

Answer: 1) Separates the health record according to discipline Rationale: In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient's problems. Focus® charting highlights the patient's concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation.

The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: 1) Pulse deficit 2) Blood pressure 3) Apical pulse 4) Pulse pressure

Answer: 2) Blood pressure Rationale: If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures.

Which situation requires intrapersonal communication? 1) Staff meetings 2) Positive self-talk 3) Shift report 4) Wound care committee meeting

Answer: 2) Positive self-talk Rationale: The nurse engaging in positive self-talk is using intrapersonal communication—conscious internal dialogue. Staff meetings, shift report, and a committee meeting are all examples of group or interpersonal communication.

The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following? 1) Team nursing 2) Case method nursing 3) Functional nursing 4) Primary nursing

Answer: 3) Functional nursing Rationale: With team nursing, an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. In case method nursing, one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. This medical surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. When the primary nursing model is utilized, one nurse manages care for a group of patients 24 hours a day, even though others provide care during part of the day.

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply): 1) A body systems model 2) A head-to-toe framework 3) Maslow's hierarchy of needs 4) Gordon's functional health patterns

Answer: 3) Maslow's hierarchy of needs 4) Gordon's functional health patterns Rationale: Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and head-to-toe are not nursing models, and they are not holistic; they focus on identifying physiological needs or disease. Maslow's hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon's functional health patterns are a nursing model.

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO

Answer: 3) NKA Rationale: The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth.

What should parents do to promote child safety in the home? 1) Attach the baby's pacifier to a ribbon so that it does not fall on the floor. 2) Give a 2-year-old whole grapes instead of popcorn for a snack. 3) Store firearms unloaded and out of sight in a location too high for the child to reach. 4) Install window guards; never leave a window wide open.

Answer: 4) Install window guards; never leave a window wide open. Rationale: To prevent falls, install window guards and never leave a window wide open. A ribbon can become entangled around a small child's neck, causing asphyxiation. Young children can easily choke on a grape. Firearms should be unloaded, but stored in a locked cabinet. Children are curious and like to explore and climb. It would not be too difficult for a child to find a firearm stored, for example, on a high closet shelf.

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes.

Answer: 4) Make a late entry as an addition to the narrative notes. Rationale: If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed.

A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? 1) Apply a vest restraint. 2) Move the patient to a quieter room. 3) Ask another nurse to care for the patient. 4) Provide comfort measures.

Answer: 4) Provide comfort measures. Rationale: Patients sometimes become agitated because they are uncomfortable or in pain. Providing comfort measures may decrease agitation. If the patient continues to be agitated, the nurse should encourage a family member or friend to sit with the patient. Applying a physical restraint should be kept as a last resort for use only when less restrictive measures fail. The patient should be placed in a room near the nurses' station so he can be checked frequently if there is no one available to provide one-on-one supervision. A quieter room would probably not help.

A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity?

Answer: Dehydration Rationale: Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit, causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional status.

A client is hospitialized with numerous acute health problems. According to Maslow's Basic needs model, which nursing diagnosis would take the highest priority: a) Risk for injury related to unsteady gait b) Altered nutrition, less than body requirements related to inability to absorb nutrients c) Self-care deficit related to weakness and debilitation d) Powerlessness related to chronic disease state

B) Altered nutrition, less than body requirements related to inability to absorb nutrients

When performing a physical assessment, the technique the nurse will always use first is: A) palpation. B) inspection. C) percussion. D) auscultation.

B) inspection. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.

The nurse completes the standard orders on a client's first day postoperatively. The instrument that is used to coordinate the client's care is: A) A Medicare plan B) A discharge plan C) A critical pathway D) Standard nursing care

C. A critical pathway is a multidisciplinary treatment plan with interventions prescribed within a structured framework. A discharge plan includes an assessment and anticipation of the client's needs. Medicare is a federal health insurance plan for those 65 years of age and older. Standard nursing care is the minimum care to be given to a client.

The multidisciplinary care model used to move clients efficiently from admission to discharge is known as: A) Team nursing B) Nursing process C) Case management D) Interdisciplinary care

C. Case management is a model of organizing care in which the case manager monitors, directs, and advises the nursing care personnel on specific care issues and the progress of a client. In team nursing, care might be provided by groups composed of registered nurses, licensed practical nurses, and possibly assistive personnel. Nursing process is used to plan the nursing care for a client. Interdisciplinary care is care provided by a team whose members come from a variety of disciplines.

Which task is it not appropriate for a professional nurse to delegate to assistive personnel? A) Ambulate a client B) Complete a bed bath C) Obtain a sterile urine specimen D) Complete the intake and output (I&O) record

C. Obtaining a sterile specimen requires insertion of a catheter, a procedure that must be performed by a licensed nurse. Therefore, this would not be an appropriate task to delegate to an assistive person. Assistive personnel would be able to ambulate a client, give a bed bath, and add to the I&O record.

Maslow's hierarchy of needs is useful to nurses, who must continually prioritize a client's nursing care needs. The most basic or first-level needs include: A) Self-actualization B) Love and belonging C) Air, water, and food D) Esteem and self-esteem

C. The first level of Maslow's hierarchy of needs includes the need for air, food, and water—basic elements of survival. Love and belonging are on the second level, esteem and self-esteem are on the fourth level, and self-actualization is the final level

During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? A) Reflection B) Facilitation C) Direct question D) Open-ended question

D) Open-ended question Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic