Professional Nursing- Exam 1

A nurse is providing anticipatory guidance to the parents of a 2 1/2-year-old girl. To foster the development of autonomy, which instruction would the nurse include? "Be sure to reprimand her for seeking out new things." "Encourage the child to dress herself." "Allow the child to explore the why about things." "Encourage her to do things that are beyond her skill level."

"Encourage the child to dress herself." As motor and language skills develop, the toddler (ages 1 to 3 years) learns from the environment and gains independence through encouragement from caregivers to feed, dress, and toilet self. If the caregivers are overprotective or have expectations that are too high, shame and doubt, as well as feelings of inadequacy, may develop in the child. Confidence gained as a toddler allows the preschooler (ages 4 to 6 years) to take the initiative in learning so that the child actively seeks out new experiences and explores the how and why of activities. If the child experiences restrictions or reprimands for seeking new experiences and learning, guilt results, and the child hesitates to attempt more challenging skills in motor or language development.

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse? "Please read my name tag." "Close your eyes and tell me when you feel something." "Have you been experiencing any strange tastes or aftertastes lately?" "Repeat the words that I will softly speak close to each ear."

"Have you been experiencing any strange tastes or aftertastes lately?" Clients receiving chemotherapy may have altered gustatory or olfactory sensations. Asking about taste would be an assessment for this condition. Repeating softly spoken words assesses auditory disturbances, feeling assesses tactile disturbances, and reading assesses visual disturbances.

The nurse is assessing a 15-year-old who was involved in a fight at school. Which client statements would the nurse see as evidence that this child is delayed in Erickson's developmental stages? Select all that apply. "I do not trust anyone." "I want to decide what I do with my life." "I am not good at anything." "I am strong and I want to protect people." "I really don't have many friends, nobody likes me."

"I do not trust anyone." "I am not good at anything." "I really don't have many friends, nobody likes me." Learning to trust occurs in infanthood. Ability to trust should be established by adolescence. Learning to feel adequate is a task of toddlerhood. Feeling of adequacy should be addressed in the school-age child. In adolescence the child tries on new roles (protector in this case) and decides what direction to take in life.

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety? "I will start an IV that will add fluids directly to the blood stream." "I will start an IV with the number 18 catheters." "I will start an IV, which should not cause you too much pain." "I will start an IV, which should not take much time."

"I will start an IV that will add fluids directly to the blood stream." The nurse should explain the procedure and its purpose. The nurse telling the client that it should not take much time does not convey the purpose of the procedure. It is unnecessary for the nurse to inform the client about the technical details of the catheter. Additionally, the nurse should not give false reassurance by telling the client that the procedure will not be painful.

A female adult client comes to the clinic for a routine appointment. The nurse is applying the theory of Levinson when assessing the client's development. Which statement by the client would the nurse correlate as being related to the client's self? Select all that apply. "Walking every day is a great way for me to stay active." "I was raised as a Roman Catholic and it's a very important part of my life." "I think it's important to do everything you can to stay healthy." "I'm busy going to school to further my career as a financial consultant." "I've seen what eating poorly can do to you. That's not what I want."

"I've seen what eating poorly can do to you. That's not what I want." "Walking every day is a great way for me to stay active." "I think it's important to do everything you can to stay healthy." According to Levinson and associates, their theory centered on the belief that the cycle of life at any point in time is formed by the interaction of three components: the self (values, motives), the social and cultural aspects of the person's life (family, career, religion, ethnic background), and the person's particular set of roles (husband, father, friend, student). The statements about staying healthy, keeping active, and seeing what poor eating can do reflect the "self" component of the theory. The statements about school and religion reflect the social and cultural aspects of the person.

The faculty member is reviewing communication techniques with the student nurse. The student has been working with a client who has had an amputation of the lower left leg and is emotionally fragile. The student receives positive feedback from the faculty member for the following response made to the client: "It must be very difficult to have this happen to you." "Why are you so upset today?" "You shouldn't cry. The wound will heal soon." "I'm sure that everything will be all right."

"It must be very difficult to have this happen to you."

The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client? "It sounds as though you are most concerned about how your children will feel." "This just is not fair at all and I do not understand why this is happening to you." "I am so sorry that I am crying with you when you need my support the most." "This is so sad and I feel so bad that you are in this situation."

"It sounds as though you are most concerned about how your children will feel." The nurse is demonstrating empathy when reiterating what the client is saying. This helps the nurse become effective at providing for the client's emotional needs while maintaining detachment. The other responses indicate that the nurse is feeling sympathy for the client, which includes feeling as emotionally distraught as the client. While this may be an unavoidable response, it may not help the client move through the grieving process as effectively.

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation? "I have a client of yours at Jefferson Hospital who is experiencing a change in condition and needs to be seen immediately!" "Good morning, I am calling about Mrs. Jones, who is a client of yours." "My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." "My name is Sue, and I am calling about Mrs. Jones, a client of yours at Jefferson Hospital."

"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." ISBARR was recently revised by the QSEN institute to include initial identification of the nurse and the client. The nurse should identify oneself and one's role during the initial conversation with the physician, as in the answer in which the nurse states the full name and degree. This allows the physician to understand the role of the nurse should the physician need to provide orders or instructions regarding the client. The other responses fail to identify the nurse in the beginning of the conversation or fail to adequately identify the client.

A client says, "I thought my period was late because I was drinking heavily and did cocaine a couple of times lately. But my pregnancy test is positive and I am scared about what I may have done to the baby." What information should the nurse provide about the possible effects of substance use on the infant? Select all that apply. "There is a risk the baby will be born with a low birth weight." "The medical care you get now can reverse any damage." "There is a risk for birth defects in the baby." "Your baby may be born prematurely." "As long as you were eating well, the baby is probably fine."

"There is a risk the baby will be born with a low birth weight." "The medical care you get now can reverse any damage." "Your baby may be born prematurely." Substance use increases the risk for congenital anomalies, low birth weight, and prematurity. Good nutrition will not protect the infant from these effects. Medical care cannot reverse damage already done, but may help prevent further damage.

The focus of nursing is always on which of the four common concepts in nursing theory? Environment Person Health Nursing

All of these concepts are important in nursing theory; however, the focus of nursing is on the person (client).

Which of the following statements best reflects Nightingales' nursing philosophy on health maintenance and restoration? "Did all the clients eat a good breakfast?" "What is the client rating his pain level after his medication?" "Is anyone interested in volunteering to mentor our new graduates?" "Have any clients developed a nosocomial infection last month?"

"What is the client rating his pain level after his medication?"

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement? "Would you like another meal?" "What makes you think the food is poisoned?" "It is okay to eat. The food is not poisoned." "I will get you another meal."

"What makes you think the food is poisoned?" The client is exhibiting delusional behavior. Delusions are beliefs not based on reality that reflect an unconscious need or fear. By asking an open-ended question the nurse can determine why the client is making the statement and create a strategy to change the client's perspective. Asking the client if he or she wants another meal or bringing the client another meal does not address the underlying issue. Telling the client it is okay to eat the meal is not recognizing the client's fear and could damage the nurse-client relationship.

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening? "I understand you are not sure about having the surgery. Why do you think you really do not need the surgery?" "I understand your confused, what do you think you should do?" "You seem unsure. Tell me your concerns about your surgery." "You seem unsure, please let me know if you decide to postpone the surgery until you are no longer unsure."

"You seem unsure. Tell me your concerns about your surgery." To understand the client's perspective, the nurse uses therapeutic communication techniques to encourage verbal expression. The use of active listening facilitates therapeutic interactions. "You seem unsure" demonstrates that the nurse was actively listening and has decoded the content and feelings of the client. "Tell me your concerns about your surgery" is an open-ended statement which will allow the client to express themselves. Giving clients the opportunity to be heard helps them organize their thoughts and evaluate their situation more realistically. "I understand you are confused" and "I understand that you are not sure" are examples of rescue feelings on behalf of the nurse. Saying I understand implies the nurse has the knowledge to fix the problem, especially followed by an explorative statement. Asking the client what he or she thinks he or she should do or why the surgery is not needed will put the nurse in the position to judge the response. "Please let me know if you decide to postpone the surgery until you are no longer unsure" suggests that the client should postpone the surgery and is an example of giving advice. The nurse should not give opinions, attempt to sway a client's opinion, or avoid an uncomfortable discussion.

In what time period did nursing care as we now know it begin?

18th to 19th century

A nurse touches the client's hand while discussing the client's diagnosis. This action is: an auditory channel. a translation. a communication channel. a dynamic process.

A communication channeL A communication channel is a carrier of the message; touch can be a channel. Communication is a dynamic process, but simply touching one's hand is not. Touch is not translation--converting a message from one form to another--but is a channel for the message. Touch is a tactile, not auditory, channel.

In preparing to review different theories, the nurse reviews basic information to assist in understanding the material. Theories are defined as: A group of concepts that describe a pattern of reality Mental formulations of objects or events Statements that describe concepts or connect concepts Aspects of reality that can be consciously sensed

A group of concepts that describe a pattern of reality

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse? A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo. A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. A nurse describes a client on Twitter by giving the room number rather than the name of the client. A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name.

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. A proper use of social media by a nurse would be the use of a disclaimer to verify that any views expressed on Facebook are the nurse's and do not represent those of the employer. The nurse should not use social media in any way to describe a client by room number, medical diagnosis, or accomplished medical goal of any type. Serious consequences can result from a nurse not using social media correctly.

The nurse is aware that which patient is at more risk for sensory deprivation? A patient in the ICU under constant monitoring following a myocardial infarction A patient receiving hospice care for end-stage brain cancer who has multiple visitors each week A tuberculosis patient on airborne isolation precautions A patient who recently had a stroke and has left-sided weakness

A tuberculosis patient on airborne isolation precautions

The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state: A.) "Everything in nature is alive with invisible forces."

A.) "Everything in nature is alive with invisible forces." The theory of animism attempts to explain the cause of mysterious changes in bodily functions. This theory is based on the belief that everything in nature is alive with invisible forces and endowed with power. Good spirits bring health; evil spirits bring sickness and death. In cultures that ascribe to animism, the roles of the physician and the nurse are separate and distinct. The physician is the medicine man who treats disease by chanting, inspiring fear, or opening the skull to release evil spirits (Dolan, Fitzpatrick, & Herrmann, 1983). The nurse usually is the mother who cares for her family during sickness by providing physical care and herbal remedies. Pets are not involved in the theory of animism.

A nurse researcher who plans to collect and analyze data for the purpose of creating a new theory should select which type of research? Qualitative research Basic research Quantitative research Applied research

A.) Basic research Basic research is used to generate or refine theory. Applied research is used to improve clinical practice. Qualitative research uses words or narrative for data rather than numbers. Quantitative research uses numerical values and statistical analysis of data

A nurse practicing in the early Christian period might perform which nursing action characteristic of this era? A.) Making organized visits to the sick B.) Providing physical care and herbal remedies to the mother of a family

A.) Making organized visits to the sick In early Christian time, led by the idea that love and caring for others were important, women called "deaconesses" made the first organized visits to sick people, and members of male religious orders gave nursing care and buried the dead. The time of the Crusades (11th to 13th centuries) was when nursing developed as a respected vocation, and nurses began to provide both physical care and use herbal/plant remedies to care for clients. At the beginning of the 16th century, many monasteries and convents closed, leading to a shortage of individuals to care for the sick. Women who had committed crimes were recruited into nursing in lieu of serving a jail sentence. Nursing tasks based on the orders of the priest-physician were common for centuries, but changed drastically with the impact of World War II, and the move of nursing education from the hospital setting to the college setting.

A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state? A.) applying for a reciprocal license in the new state B.) taking the new state's licensing exam

A.) applying for a reciprocal license in the new state Nurses gain legal rights to practice nursing in another state by applying to that state's board of nursing and receiving reciprocal licensure. The nurse does not need to retake the licensure exam. The nursing licenses are not transferable.

After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that: ANA aims at fostering high standards of nursing in the United States. membership is open to all nurses in the United States. members include nurses, other health care providers, and lay people. ANA invites students showing excellence in scholarship to become members.

ANA aims at fostering high standards of nursing in the United States. ANA aims at fostering high standards of nursing in the United States. Membership is not open to all nurses in the United States; only registered nurses can become members. Members of the National League for Nursing, not the ANA, include nurses, other health care providers, and lay people. Sigma Theta Tau, not ANA, invites students showing excellence in scholarship to become members.

A nurse is working in a pediatric clinic. The parent has brought in the 2-year-old toddler for a well-child checkup. The parent asks what the common health problems are common for this age. The nurse's correct reply includes which of the following? Food allergies Accidents Scoliosis Lice infestation

Accidents Accidents are a major health concern for toddlers due to their mobility and exploration of their environment. Food allergies are a common health concern during infancy. Scoliosis and lice infestation are more commonly seen in school-age children.

A nurse is assessing a 45-year-old male at a routine office visit. Applying Gould's developmental concepts, which finding would the nurse expect to assess? Select all that apply. Introspection with self-questioning Active participation in social activities Acceptance of lifespan boundaries Increased levels of self-approval through reflection Belief that personalities are set

Active participation in social activities Acceptance of lifespan boundaries Belief that personalities are set A 45-year-old is Gould's stage of reconciliation and mellowing. At this phase, adults accept the reality of boundaries for the lifespan and believe that personalities are set. They are interested in an active social life, church activities, community service, friends, and spouse. Adults in the midlife decade group tend to continually look inward and question themselves, their values, and life. They see time as having an end and believe they have little time left to shape the behavior of their adolescent children. Adults who are 50 years of age and older are in the stage of stability and acceptance. Previous patterns of reflection and contemplation generally result in increased self-approval and self-acceptance.

Which of the following resources guides faculty on structure and evaluation of the nursing curriculum? Standards of Professional Performance NLNAC Interpretive Guidelines ANA's Standards of Nursing Practice American Association of Colleges of Nursing (AACN) Commission on Collegiate Nursing Education (CCNE) Essentials of Baccalaureate Education

American Association of Colleges of Nursing (AACN) Commission on Collegiate Nursing Education (CCNE) Essentials of Baccalaureate Education

NURS in's professional organization

American Nurses Association

The nurse is caring for a boy 4 years of age who has gone through a painful surgery. During the hospitalization the child has been wetting his bed. The child's mother expresses dismay and anger, saying that her son has been toilet trained for over a year. The nurse needs to recall which of the following general principles of growth and development when responding to the mother? Anticipate possible regression during difficult periods. Male children often have difficulty maintaining urinary continence. Parents often expect perfection from their children. Children most often develop at their own pace.

Anticipate possible regression during difficult periods. It is important for the nurse to teach the client's caregiver to anticipate possible regression during difficult periods or times of crisis, and to accept and support a person's return to a forward progression in development. Children do develop at their own pace, but this does not explain regression during a hospitalization. Growth and development theories do not say that males have difficulty maintaining urinary continence. Parents often do expect perfection from their offspring, but this is not part of a general principle of growth and development.

A nurse is working with a preceptor after transferring to a unit where many of the clients are confused or unconscious. The preceptor determines that teaching is necessary when this nurse interacts with an unconscious client in which manner? Explains the steps of the procedure about to be performed. Turns off the radio playing at the bedside while starting an intravenous line. Approaches the bed, takes the client's hand, and introduces herself. Calls the client by name.

Approaches the bed, takes the client's hand, and introduces herself. The nurse should speak before touching the client. It is unknown if unconscious clients can hear and understand, but the nurse should assume they can. Explaining the steps of a procedure and calling the client by name are appropriate as is turning off background noise while speaking to the client.

A 25-year-old client is a college graduate and is married with one child. During a wellness visit, the client confides, "I just feel like something is missing from my life. Maybe I need to make a career change." How would the nurse familiar with Levenson and associates' theory of development interpret this statement? As a danger sign that the client is about to undergo a damaging transformation. As a normal finding for a client at this stage of development. As indicating this client is advanced in thinking through life development. As indication that the client is lagging in developmental tasks.

As a normal finding for a client at this stage of development. Levinson and associates' stage of "entering the adult world" occurs around ages 22 to 28. People are building on past decision and choices but may feel something is "missing" from their lives. Decisions are made to either find a new direction in life or to make a stronger commitment to previous choices. There is no indication that this transformation will be damaging.

A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? Aggressive Assertive Nonassertive Therapeutic

Assertive The communication is an example of assertive speech. Assertive communication is the ability to stand up for oneself and others using open, honest, and direct communication. Aggressive communication involves asserting one's rights in a negative manner that violates the rights of others. Therapeutic speech is speech a nurse uses when communicating with a client that has a specific purpose or goal. Nonassertive speech would be the opposite of assertive speech, as described above.

An older adult client has been hospitalized for 8 days following skin grafting. The nurse suspects the client is experiencing sensory deprivation. Which strategy will be most effective in this situation? Place the client in soft restraints to prevent injury. Consult a clinical psychiatrist for continued care. Request a prescription for risperidone injection. Assess and reorient the client to time, place, and person as needed.

Assess and reorient the client to time, place, and person as needed. The most effective strategy for the nurse to use in this situation is to assess orientation and reorient the client as needed. Consulting a clinical psychiatrist may not be necessary, as reorientation and sensory stimulation are effective interventions. Requesting a medication used to manage schizophrenia is not appropriate, as the client is experiencing sensory deprivation. Restraints are a last resort and other measures should be attempted first.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication? Provide paper and pencil for written communication Use facial and hand gestures Assess how the client would like to communicate Contact a person skilled in sign language

Assess how the client would like to communicate Clients with hearing impairment pose unique challenges for communication. Assessing how the client communicates best is important. For example, if a deaf client can read and write, writing can facilitate communication. If the client knows sign language, the nurse could use a person trained in sign language. Using hand gestures and exaggerated facial movements does not allow for adequate acquisition of knowledge.

The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply. Inform the family that there is nothing they can do for their loved one. Assist the client with activities of daily living (ADLs). Encourage the family to leave and let the nurse take over care. Refer the client and family to hospice services. Assist the client and family with the preparation for end-of-life.

Assist the client and family with the preparation for end-of-life. Refer the client and family to hospice services. Assist the client with activities of daily living (ADLs). Nurses facilitate client and family coping with altered function, life crisis, and death. Altered function decreases an individual's ability to carry out ADLs and expected roles, and it is appropriate for the nurse to assist in a previously independent client role. Nurses facilitate an optimal level of function through maximizing the person's strengths and potentials, through teaching, and through referral to community support systems such as hospice services. Nurses provide care to both clients and families at the end of life, and they do so in hospitals, long-term care facilities, hospices, and homes. Nurses are active in hospice programs, which assist clients and their families in multiple settings in preparing for death and in living as comfortably as possible until death occurs. Informing the family that there is nothing that they can do for their loved one creates further grieving and a feeling of loss and hopelessness.

The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make? A.) "Does the child have nightmares often?" B.) "Keep all medications in a locked cabinet."

B.) "Keep all medications in a locked cabinet." Anticipatory guidance provides the parent with information that the child will need as the child continues to grow and develop to promote his or her health. The best example of this is telling the parents to keep all medications in a locked cabinet, as the 18-month-old can climb and reach for medications that were placed high where the parents thought the child could not reach. This could prevent accidental medication overdose. An 18-month-old would have difficulty communicating fears about nightmares to the parents. Reporting the weight is health promotion, which lets the parents know that the child is growing. Telling the parents not to give the child a bottle would be inappropriate as the child should be using a cup at this age.

A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care? A.) The nurse as the caregiver B.) The client receiving the care

B.) The client receiving the care The client receiving the care is always the central focus of the nursing care provided. The central focus is not the nurse, the nursing actions, or nursing as a profession.

A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers? A.) They usually have a baccalaureate degree in nursing. B.) They are responsible for the continued development and advancement of nursing.

B.) They are responsible for the continued development and advancement of nursing. Nursing research requires extensive education and is a uniquely specialized field. Nurse researchers are responsible for the continued development and refinement of nursing. They usually have advanced education post baccalaureate degree in nursing and most often work in large teaching hospitals or research centers. Nurse administrators, not nurse researchers, serve as liaisons between staff members and directors of nursing, Nurse researchers may be found with a school of nursing at academic institutions, but not at community health centers and long-term care units.

A middle-aged nurse is concerned about a potential shortage of nurses when the baby boomer generation retires. What proactive intervention can the nurse take to address this anticipated deficit of nurses? A.) recruit more nurses to the acute care facility B.) develop a community program related to healthy nutrition and exercise

B.) develop a community program related to healthy nutrition and exercise The promotion of wellness is important not only in community, but also in nationwide health. Promotion of healthy habits and nutrition/exercise will be able to decrease some of the risk factors leading to acute and chronic illnesses and will lead to a decrease in hospital admissions. If effective, it would contribute to the management of issues that require an increase in the number of nurses required. Nurses fill roles other than in acute care facilities and the recruitment of more nurses to those facilities does not address the issue of the shortage in other areas of nursing. Immunization of children does not affect the nursing shortage directly because there is not a relationship between the lack of immunization increasing the risk of illness to the present nurses employed in the field . Increasing the retirement age can have a detrimental affect on those nurses being required to work with age-related changes affecting health.

One of the primary reasons for conducting nursing research is to: A.) prevent further disease and death. B.) generate knowledge to guide practice.

B.) generate knowledge to guide practice. One of the major reasons for conducting nursing research is to generate knowledge to guide practice. The other answers pertain to other aspects of nursing practice but not to nursing research.

A nurse is reviewing a quantitative research study. Which aspects of this type of study would the nurse need to keep in mind? Select all that apply. Intuition is used for analysis. Control or manipulation is rarely used. Biases are controlled to avoid contamination. Objectivity is valued. Reality is not viewed as a fixed entity.

Biases are controlled to avoid contamination. Objectivity is valued. Objectivity and control of biases are aspects of quantitative research. Qualitative research involves seeing reality not as a fixed entity but as existing in a context with the researcher rarely controlling or manipulating any aspect of the people/environment under study. Subjective interactions are viewed as the primary way to access understanding of the phenomena and intuition is used for analysis.

For which conditions would the nurse assess to determine if a client is suffering from sensory deprivation or overload? Select all that apply. Dreamless sleep Boredom Thought disorganization Anxiety Quickness of thought Decreased sleeping

Boredom Thought disorganization Anxiety When assessing for sensory deprivation or overload, the nurse should observe the client for boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought disorganization, anxiety, panic, delusions, and hallucinations.

The student nurse is learning nursing theories but fails to see how they relate to the nursing process. The professional nurse realizes that nursing theory: Can direct how a nurse uses the nursing process. Has a minor role in professional nursing. is specific to certain patients only. Requires the nursing process to develop knowledge.

Can direct how a nurse uses the nursing process.

A client in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing? Cognitive response Emotional response Physical response Perceptual response

Cognitive responses Cognitive responses involve the client's inability to control the direction of thought content. Typically, attention span and ability to concentrate are decreased. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position, coordination, and equilibrium. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. A physical response does not relate to thought processes.

This theory deals with perception and thinking. Adaptation theory Cognitive theory Psychosocial theory Nursing theory

Cognitive theory Cognitive development theory deals with perception and thinking, focusing on the development of intellectual processes.

A client brought to the emergency room is unconscious and cannot be aroused. The client is breathing and has a heartbeat. What state of awareness is this client exhibiting? Somnolence Stupor Coma Asleep

Coma Unconscious states include asleep, stupor, and coma. Coma is characterized by an inability to be aroused and no response to stimuli. A client in a stupor can be aroused by extreme and/or repeated stimuli. Sleep is a naturally recurring state of mind and body, characterized by unconscious, relatively inhibited sensory activity, inhibition of nearly all voluntary muscles, and reduced interactions with surroundings. During sleep the client can be awakened.

A student nurse is preparing a presentation on sensory overload. What symptoms of sensory overload should the student include? Select all that apply. Confusion Disorientation Increased work performance Fatigue Sleeplessness

Confusion Disorientation Fatigue Sleeplessness Disturbances in memory, reasoning, and problem solving can occur with sensory overload. Decision making may be irrational or dysfunctional. Other common behaviors indicative of cognitive dysfunction include disorientation; verbalizing disconnected thoughts; complaining of too much going on, sleeplessness, and fatigue; inability to think; and poor work performance.

Which is a skill appropriate to use in therapeutic communication? Control the tone of the voice to avoid hidden messages. Be precise and inflexible regarding the intent of the conversation. Use cliches to enhance a client's understanding of information. Avoid the use of periods of silence.

Control the tone of the voice to avoid hidden messages. Conversation skills used in therapeutic communication include controlling the tone of one's voice so that exactly what is intended is conveyed and not any hidden message. Periods of silence have an important role in conversations because they allow for reflection. The nurse should avoid using cliches, and the conversation should be flexible.

During a health history, a middle-aged man tells the nurse, "I will always take care of my children because my parents took care of me." Based on Kohlberg's theory, what level of moral development is the man demonstrating? postconventional preconventional goodness conventional

Conventional The conventional level of moral development in Kohlberg's theory involves identifying with significant others and conforming to their expectations. The person respects the values and ideals of family and friends, regardless of consequences.

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan? Perform routine oral hygiene. Clear pathways for walking in the room and do not rearrange furniture. Clearly communicate that the client is expected to perform all the self-care activities he or she can. Decrease background noises, as much as possible, before speaking.

Decrease background noises, as much as possible, before speaking. Presbycusis is the loss of high frequency, sensorineural hearing. Background noise further aggravates hearing deficit, so limiting noise would help the client to hear better. Clearing pathways in the room would be used for a client with visual impairment. Clear communication regarding self-care activities would be used for a confused client. Routine oral hygiene is useful for clients with taste alterations.

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as: somnolence. dementia. locked-in syndrome. delirium.

Delirium Delirium involves disorientation, restlessness, confusion, hallucinations, agitation, and alternating with other conscious states, whereas dementia is associated with difficulties with spatial orientation, memory, language and changes in personality. Somnolence refers to a state of extreme drowsiness, but the client will respond normally to stimuli. Locked-in syndrome refers to a state of full consciousness where sleep-wake cycles are present, and where quadriplegic, auditory and visual function, and emotion are preserved.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply. Sleeplessness Increased interest in interactions with others Increased appetite Depression Decreased interest in activities

Depression Sleeplessness decreased interest in activities Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.

Nurses who make the best communicators: Maintain perceptual biases. Learn effective psychomotor skills. Like different kinds of people. Develop critical thinking skills.

Develop critical thinking skills

The nurse assesses that a child is in Piaget's preoperational stage of cognitive development. The nurse anticipates which behaviors from Erikson's psychosocial stages in this child? Select all that apply. Development of sense of self Development of purpose Exploration of personal identity Development of competence Beginning interpersonal skills

Development of purpose Beginning interpersonal skills Piaget's preoperational stage of cognitive development and Erikson's psychosocial stage of initiative versus guiltboth occur during preschool to early school years. Initiative versus guilt is characterized by the development of interpersonal skills through activities with others and the development of purpose. Development of competence occurs in industry vs. inferiority. Exploration of personal identity and sense of self occur in identity vs. role confusion.

A parent has brought a 6-year-old child into the clinic. The parent is concerned that the child does not seem to skip as well as the other children in the child's class. In planning assessments and care for this child, the nurse would be best served by choosing which theory as a foundation for decision making? General systems theory Maslow's theory Developmental theory Adaptation theory

Developmental theory Developmental theory is concerned with growth and development across the lifespan and would provide a foundation for assessment and care of this child. None of the other theories listed is concerned with the maturation of the child.

The nurse is caring for a client at risk for the development of cognitive impairment related to a spinal cord injury. When creating the plan of care for this client, what interventions should the nurse include to avoid this development? Select all that apply. Discuss current events or the client's occupation, hobbies, or interests. Have the client assist in self-care as much as possible. If the client begins to have hallucinations, agree with the client to prevent agitation. Keep the client's room quiet with the shades or curtains drawn. Orient the client to the surroundings and environment every 1 to 2 hours.

Discuss current events or the client's occupation, hobbies, or interests. Have the client assist in self-care as much as possible. Orient the client to the surroundings and environment every 1 to 2 hours. The nurse should orient the client to the environment so that he or she may maintain touch with reality. The nurse should encourage the client to provide as much self-care as he or she is able to help reinforce cognitive ability. The nurse should discuss current events or the client's occupation, hobbies, or interests to maintain reality. And the nurse should reinforce reality without arguing with a client who is hallucinating, for example, "No, I don't see a man standing there but the linen hamper may be confusing you."

Which is a focus of medical research rather than nursing research? Prevention of trauma Drug metabolism Health appraisal Promotion of recovery

Drug metabolism Drug metabolism is an example of a focus of medical research. Nursing research is defined as a systematic inquiry into the problems encountered in nursing practice and into the modalities of client care such as health appraisal, prevention of trauma, promotion of recovery, and coordination of health care (Gortner, 1975).

An older adult has come to the clinic for a follow up visit. During the visit, the client tells the nurse, "I've really had a good life. I've been successful in my work and I have a wonderful family. My grandchildren bring me so much joy." The nurse interprets this statement as indicating achievement of which developmental task? Despair Generativity Intimacy Ego integrity

Ego integrity As a person enters the older years, reminiscence about life events provides a sense of fulfillment and purpose, indicating the achievement of ego integrity. Generativity is the developmental task associated with middle adulthood, characterized by involvement with family, friends, and the community, with a concern for the next generation. Despair would be evident in the older adult by statements related to the person's life being a series of failures or missed directions. Intimacy is the developmental task associated with young adulthood.

A nurse is caring for an elderly client in a long term care facility. The resident is reminiscing about his life and his achievements. The nurse understands the client is in which of the following stages of Erik Erikson's Psychosocial Development theory? Generativity Intimacy Ego Integrity Identity

Ego integrity Erik Erikson's Ego Integrity stage includes the elderly discussing their life and life achievements. Identity stage is the time when adolescences are trying different roles and undergoing puberty. Intimacy stage is seen in young adulthood when a sense of self identity emerges. Generativity is from middle adulthood when this age group begins to become concerned for the next generation.

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client? Practicing oral care three times a day Protecting the skin from extremes in temperature Eliminating disturbing odors with adequate ventilation Using earplugs when using loud machinery

Eliminating disturbing odors with adequate ventilation Olfactory or smell disturbances can be aided by eliminating disturbing odors with adequate ventilation. Earplugs help those with auditory disturbances. Oral care is useful for those with taste disturbances. Protecting the skin is important for those with tactile disturbances.

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? Indifference Sympathy Empathy Pity

Empathy The nurse should empathize with the family for their loss. Empathy helps the nurse to provide effective care and support without being emotionally distraught by the family's condition. If the nurse becomes indifferent to the family's condition, the nurse may not be able to assess their needs. The nurse should not pity, or provide sympathy to, the family for their loss, as it would involve the nurse emotionally.

Which action should the nurse implement when working with a medically homeless client? A.) Assist the client in finding a job. B.) Encourage client to utilize the free health care clinic. C.) Assist the client in finding housing. D.) Encourage the client to utilize the emergency room when ill.

Encourage client to utilize the free health care clinic. According to the Association of American Medical Colleges, many Americans are medically homeless and find it difficult to navigate the health care system. Encouraging the client to utilize the free health care clinic will help the client navigate the system and obtain access to health care. While utilizing the emergency room when needed is appropriate, the emergency room should not be utilized for all illnesses, as it increases the burden on the health care system. Assisting the client to find housing or a job will help the client, but is outside of the scope of nursing practice.

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique? Restating Reflection Encouraging elaboration Clarification

Encouraging elaboration Encouraging elaboration involves making simple statements that indicate active listening and comprehension on the part of the nurse and that prompt the client to continue talking. This technique helps the client to describe more fully the concerns or problems under discussion. Clarification involves asking a follow-up question about a statement made by the client to clear up some point that the nurse is not sure about or to elicit more specific details. Reflection and restatement involve the nurse repeating back to the client a comment made by the client to ensure that the nurse has correctly heard or understood the client.

A school nurse is preparing an information session for a group of high school seniors which will provide them with basic information concerning choosing a nursing program. Which factor(s) should the school nurse point out in the presentation? Select all that apply. Can I choose between part-time and full-time classes? How many graduates are still in the field 1 year later? 5 years later? 10 years later? How much will this cost me? What are my main goals? Does the program guarantee employment after graduation?

Factors which can influence the choices of a nursing program include: career goals, geographic location of schools; costs involved, length of program, reputation and success of graduates, flexibility in course scheduling, opportunity for part-time versus full-time employment, and ease of movement into the next level of education. Guarantee of employment is not a factor.

A nurse who works in a pediatric practice assesses the developmental level of children of various ages to determine their psychosocial development. These assessments are based on the work of: Watson. Maslow. Erikson. Rogers.

Erikson Erik Erikson based his theory of psychosocial development on the process of socialization, emphasizing how individuals learn to interact with the world. Erikson recognized the role of social, biologic, and environmental factors in development, and defined specific tasks or conflicts that people accomplish or overcome during what he defined as the eight stages of life, based on chronologic age. Abraham Maslow developed his theory of human needs in terms of physical and psychosocial needs considered essential to human life, rather than by chronologic age as Erikson did. Maslow defined five levels of need in a hierarchy, with different needs existing simultaneously. Jean Watson is a nursing theorist who is known for her focus on caring. The central theme of her work is that nursing is concerned with promoting and restoring health, preventing illness, and caring for the sick. Caring is universal and is practiced through interpersonal relationships. Martha Rogers is a nursing theorist who is known for her theory of the individual client being central to the discipline of nursing. Nursing interventions are directed toward repatterning human environment fields or assisting in mobilizing inner resources.

Which developmental theorist created the psychosocial theory of development? Erikson Piaget Freud Maslow

Erikson Erikson's psychosocial theory of development encompassed social and cultural influences.

When looking at a model for evidence-based practice, what is the final step of the process? Formulating a clinical question Searching the literature Appraising evidence Evaluating practice change

Evaluating practice change The fifth and final step in the process of implementing evidence-based practice is to evaluate and critically appraise the change in practice. Formulating a clinical question and searching and appraising the literature precede this step.

What nursing activity forms the bridge between theory and practice? Theoretical writing Case management Client-focused care Evidence-based research

Evidence-based research Evidence-based research is translational research that forms the bridge between theory and practice. Theoretical writing focuses on theory. Client-focused care and case management are focused on practice.

Which activity best helps the nurse apply theory to practice? Evidence-based research Theory development Case management Client-focused care

Evidence-based research Evidence-based research is translational research that forms the bridge between theory and practice. Theory development is how desirable change in society is best achieved. Client-focused care is care provided to a client that maintains the client as a functional component of healthcare team. Case management is when care is provided to an individual client by a healthcare provider.

A patient who is unable to name common objects or express simple ideas in words or writing has: Mental retardation Receptive aphasia Global aphasia Expressive aphasia

Expressive aphasia

The client tells the nurse that he understands most of the information but still has questions concerning the medication after the nurse has provided the client with information regarding the treatment plan for the diagnosis. This response is an example of. Referent Channel Receiver Correct! Feedback

Feedback

Mary Mahoney

First African American professional nurse

Florence Nightingale was a nursing pioneer who challenged prejudices against women and elevated the status of all nurses. Which statement accurately describes one of her accomplishments? She promoted the publication of books about nursing and health care. She established the tenets of the American Red Cross. She promoted the addition of nursing education as part of a medical degree. She established the fact that nursing is the same as medicine.

Florence Nightingale elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. She promoted the publication of books about nursing education and health care. Her belief regarding nursing was that it was separate and distinct from the practice of medicine. She did not believe that nursing education should be a part of a medical degree. Clara Barton established the American Red Cross in 1882.

Clara Barton

Founded the American Red Cross in 1881

The nurse is assessing a neglected child brought to the emergency department. The grandparent of the child reports that the child remains in the crib constantly, and is only removed from the crib when being fed. Which action should the nurse share with the grandparent to avoid sensory deprivation for the child? Frequently talking to and touching the child. Allowing the child to cry to self-soothe. Keeping the room quiet so the child sleeps more. Rocking the child after feeding.

Frequently talking to and touching the child. Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. To prevent sensory deprivation the child requires frequent stimulation through all senses, including auditory and tactile means. Allowing the child to cry or keeping the room quiet so the child can sleep will increase the sensory deprivation.

A nurse is completing a family assessment during a routine home health visit. The parents have a child with special needs, along with six other children, and the older siblings help out with the younger. Which theory would best help the nurse understand this family's functioning? Maslow's Theory General Systems Theory Adaptation Theory Developmental Theory

General Systems Theory Systems theory is described as studying relationships between a whole and identifying how parts interact and behave. This family has adjusted to the size and configuration of the family with a special needs child by manipulating the individual roles of the family members. Adaptation theory is based on an understanding of humans and their interaction with the environment. Developmental theory is based on growth and maturation of humans. Maslow's hierarchy presents basic human needs in the order in which people generally attempt to meet them. These three theories would not be as appropriate as the general systems theory, as adaptation, human development, and basic human needs are not the topic of interest; rather, the interaction among components (individual family members) of a system (the family) is the topic of interest.

Which theory emphasizes the relationships between the whole and the parts, and describes how parts function and behave? Adaptation theory General systems theory Developmental theory Nursing theory

General systems theory General systems theory describes how to break whole things into parts and then learn how the parts work together in "systems." Nursing theory attempts to describe, explain, predict, and control desired outcomes of nursing care practices. Adaptation theory defines adaptation as the adjustment of living matter to other living things and to environmental conditions. Developmental theory outlines the process of growth and development of humans as orderly and predictable.

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique? Giving information Giving false reassurance

Giving false reassurance False reassurance means giving reassurance that is not based on the real situation. It is an attempt to alleviate the client's concerns about a situation by confidently saying that everything will be fine when, in fact, the nurse has no grounds for making such a statement. It minimizes the client's feelings and could cause the client to have false hope, be disillusioned when difficulties arise, and ultimately lose trust in the nurse. Seeking clarification means asking follow-up questions or making follow-up statements to clarify or gain more specific information about something the client has said. Giving information involves sharing accurate information about the client's health and well-being in a timely manner. Encouraging elaboration is a technique used to help the client describe more fully the concerns or problems being discussed.

The nurse is seeing 6-year-old Patrick in the clinic. As the nurse is measuring height and weight for Patrick, his mother comments on how much he has grown since his last checkup. The nurse knows that this increase in size is which of the following? Development Cephalocaudal Prepubescent Growth

Growth Growth is an increase in body size, or changes in body cell structure, function, and complexity. Development is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning. Cephalocaudal means proceeding from head to tail. Pubescence is the time when secondary sex characteristics continue to develop, and ova and sperm begin to be produced by the reproductive organs.

The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication? Remove the COVID protection face mask while speaking with the client. Speak in a loud voice over the volume of the television set. Obtain the client's attention by calling out the client's first name. Identify oneself by name and title with each entry into the client's room.

Identify oneself by name and title with each entry into the client's room. To facilitate communication with an older client who has visual and hearing deficits, the nurse identifies oneself by name and title each time the nurse enters the client's room. This assists with the orientation of the client who can place the interaction into proper perspective. The nurse does not remove one's face mask. The face mask is to minimize the risk for COVID for both the nurse and the client. The nurse with permission of the client would decrease the volume of the television set, or even turn the television set off, so as to not compete with the television program. This will facilitate hearing. People with hearing deficits have difficulty distinguishing simultaneous sounds from each other. The nurse will call the client by the client's preferred name. This demonstrates respect for the client. The client's name preference may not be the client's first name.

A nurse is to participate as part of a team involved in nursing research and will be following the steps of the nursing research process. Place the steps below in the order in which the nurse and team will complete the process. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Formulate the problem statement. 2Identify the research design. 3Develop the proposed research question. 4Identify the theoretical framework. 5Identify the problem area. 6Review the scientific literature.

Identify the problem area. Review the scientific literature. Identify the theoretical framework. Formulate the problem statement. Develop the proposed research question. Identify the research design. The research process follows these steps: problem area identification, review of scientific literature, theoretical framework, formulation of the problem statement, proposed research question or hypotheses, and data management-research design.

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family? Impaired Skin Integrity related to absent tactile sensation Disturbed Thought Processes related to sensory overload Deficient Diversional Activity related to impaired senses Impaired Parenting associated with failure to provide stimuli for growth

Impaired Parenting associated with failure to provide stimuli for growth Based upon lack of stimuli (sensory deprivation), an appropriate nursing diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There is no information that states the child has impaired senses, sensory overload, or impaired skin integrity.

A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?

In-service Education In-service education is designed to increase the knowledge and skills of the nursing staff. Education about a new piece of hospital equipment would fall into this category. Continuing education is educational experiences designed to enrich the nurse's contribution to health. Many state nursing organizations require continuing education hours to maintain licensure. (Done through courses, formal settings). Undergraduate studies are the educational programs for pre-licensure in the field of nursing. For the nurse, this could be a diploma, associate degree, or baccalaureate in nursing. Graduate education would include the educational programs for the advanced practice nurse. This could be master's degree or doctoral preparation.

A 10-year-old girl is excited when she receives the "most improved player" award on her softball team. Although she was not the strongest player on the team, she always tried to perform at her best level and never gave up on practicing her skills. What stage of psychosocial development according to Erik Erikson is this child demonstrating? Identity versus role confusion Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority

Industry versus inferiority Industry versus inferiority focuses on end results of achievements, and the school-aged child gains pleasure from finishing projects and receiving recognition for accomplishments. Autonomy versus shame and doubt occurs during toddlerhood, as the child learns about the environment and gains independence. Initiative versus guilt occurs during the preschool years and is characterized by confidence gained as the child takes the initiative in learning. Identity versus role confusion occurs during adolescence as physical changes occur. The individual also works to acquire a sense of self and the direction in life to follow.

The nurse is best able to provide quality care that benefits both client and family by: Being knowledgeable of the institution's standards of practice Integrating the science and art of nursing into the practice Expressing concern for liability during practice Incorporating caring into the practice

Integrating the science and art of nursing into the practice

The nurse is discussing discharge instructions with a client who was recently diagnosed with type 1 diabetes mellitus and is now taking insulin. The nurse recognizes this as an example of: Nonverbal communication Interpersonal communication Intrapersonal communication Transpersonal communication

Interpersonal communication

Mentally reviewing the steps of a complicated nursing procedure before entering the client's room is an example of: Interpersonal communication Nonverbal communication Correct! Intrapersonal communication Transpersonal communication

Intrapersonal communication

The school nurse is teaching growth and development in a health class. What should the nurse teach the students about development? It is best defined as intellectual growth It is influenced by genetically predisposed alterations It is the process of ongoing change It centers around an increase in body's size

Is the process of ongoing change Development is the process of ongoing change, reorganization, and integration that occurs throughout life. Growth centers around the physical attainment such as body size and genetically predisposed alterations as well as development which focuses on the psycho social elements including intellectual growth. Reference:

Florence Nightingale

Lady with the lamp Changed the image of the nurse to one of respect black stripe on nurse's cap signifies mourning of her death promoted maintenance of client's level of health

Which theory describes, explains, predicts, and controls outcomes in nursing practice? Adaptation theory Systems theory Developmental theory Nursing theory

Nursing theory Nursing theory describes, explains, predicts, and controls outcomes in nursing practice. Systems theory describes how parts interact together. Adaptation theory describes adjustment of living things to other living things and the environment. Developmental theory describes maturation of humans through stages.

A boy 8 years of age is looking at his father's razor and shaving cream in the bathroom medicine cabinet. He watches his father shave daily and asks his father when he will need to start shaving. This child is demonstrating characteristics common during which of Freud's psychoanalytic developmental stages? Latency stage Genital stage Anal stage Phallic stage

Latency stage The latency stage (ages 7 to 12 years) makes the transition to the genital stage during adolescence and is characterized by increasing sex-role identification with the parent of the same sex. This stage prepares the child for adult roles and relationships. The anal stage (ages 8 months to 4 years) begins with the development of neuromuscular control to allow control of the anal sphincter. The phallic stage occurs between the ages of 3 and 7 years and the child demonstrates an increased interest in gender differences and his or her own gender. The genital stage (ages 12 to 20 years) is characterized by sexual interest that can be expressed in overt sexual relationships.

The nurse is caring for a woman 68 years of age who is admitted for fixation of an ankle fracture related to a fall at home. The client states that she is thinking of selling her home and moving to a smaller place. Her husband died six months ago and she is unable to physically maintain her home without him. She sounds accepting of this. According to Robert Havighurst, in which of the following developmental stages is the client? Midlife transition Later Maturity Ego integrity versus despair Generativity versus stagnation

Later maturity "Later Maturity" belongs to Robert Havighurst and includes the tasks of adjusting to decreasing physical strength and health, adjusting to retirement and reduced income, and adjusting to the death of a spouse. "Ego integrity versus despair" and "generativity versus stagnation" are Erikson's theories of mid to old adulthood. Levinson and associates propose the theory of "midlife transition" in which the person aged 40 to 45 reappraises his or her goals and values.

A nurse is describing the developmental phases identified by Roger Gould. Place the phases listed below in the proper order (from first to last) as to how the nurse would describe them. 1Stability and acceptance 2Leaving the parents' world 3Mid-life decade 4Questioning and reexamination 5Reconciliation and mellowing 6Getting into the adult world

Leaving the parents' world Getting into the adult world Questioning and reexamination Mid-life decade Reconciliation and mellowing Stability and acceptance According to Gould, development occurs as follows: ages 18 to 22—leaving the parents' world; ages 22 to 28—getting into the adult world; ages 29 to 34— questioning and reexamination; ages 35 to 43—midlife decade; ages 43 to 50—reconciliation and mellowing; ages 50 and over—stability and acceptance.

The nurse is counseling a woman who states: "I'm never going to find a husband; every time I start dating I end up getting hurt. I'm not even going to try anymore." This woman is in what stage of Carol Gilligan's theory of moral development? Level 2—goodness Level 1—selfishness Level 3—nonviolence

Level 1- selfishness This woman is in Level 1 of Gilligan's theory of moral development. In Level 1, the focus is on one's own needs. In Level 2, moral judgment is based on shared norms and expectations, and societal values are adopted. In Level 3, a changed understanding of self and a redefinition of morality allow reconciliation of selfishness and responsibility. Nonviolence (the injunction against hurting) governs all moral judgments and actions.

A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support his sensory needs? Provide an active, stimulating environment. Encourage frequent visitors and tactile stimulation at least hourly. Limit lighting, visual, and vestibular stimulation. Provide changing patterns of light and shade, and the use of bright objects.

Limit lighting, visual, and vestibular stimulation. To facilitate developmentally supportive care, it is recommended that medically fragile infants such as a premature infant should have limited light, visual, and vestibular stimulation to simulate being in the womb. The premature infant is not a full term infant and has developmental issues that are critical to their growth and development. Stimulation such as touch and frequent visitors is not recommended. The use of bright lights are contraindicated as the hospital environment should mimic the intrauterine environment which is quiet and dark.

A student nurse is assisting the school nurse with a health fair at a middle school. The student nurse assesses the students' heights and weights as they file through the station, observing that there is a large variation in physical size and emotional maturity. Which of the following factors may affect emotional growth of children? Choose all that apply. Loving caregivers Praise for doing well Development of trust Colorful toys Availability of books

Loving caregivers Praise for doing well Development of trust A child's growth and development might be facilitated or delayed by genetic heredity; prenatal, individual, and caregiver factors; and environment and nutrition. Erikson's early theories indicate that achieving trust and a sense of initiative and industry will allow for better emotional development. Loving caregivers, praise for doing well, and development of trust are critical elements for the emotional growth of school age children. Colorful toys and books may or may not add to emotional development, depending on the environment.

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? Repeat each direction or question in different terms in order to maximize understanding. Use vocabulary and concepts that are as simple and unambiguous as possible. Use written communication whenever possible in order to minimize the client's frustration. Minimize background noises and ensure that lighting is adequate to see the nurse's face.

Minimize background noises and ensure that lighting is adequate to see the nurse's face. When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading. It would be unnecessary and inappropriate to exclusively use written communication with a client who has moderate hearing loss, or to repeat all questions and instructions in different terms. A hearing deficit is not synonymous with a cognitive deficit; consequently, it is not usually necessary to simplify concepts or vocabulary.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls? Educate the client on the risk for falls. Secure a restraint order from the physician. Monitor the client frequently. Require a family member to be in the room at all times.

Monitor the client frequently. Individualized nurse-client interaction promotes sensory health function. Clients at risk for sensory deprivation may need frequent interaction initiated by the nurse, whereas others may not. In any case, provide appropriate stimuli, such as addressing the client by name, introducing and reintroducing yourself as necessary, explaining all activities, and when leaving, acknowledging when you will return. Family may not be available to assist with client at all times. With a sensory deprivation, the client may not understand the nurse's teaching about fall prevention. Restraints should be used if other less restrictive measures have been exhausted.

A nurse is planning to conduct a nursing research study and is seeking federal funding. Which institution would be most helpful for the nurse to contact regarding acquiring funding? ANA Cabinet on Nursing Research National Institutes of Health National Institute of Nursing Research Institute of Medicine

National Institute of Nursing Research The nurse would most likely contact the National Institute of Nursing Research (NINR), which was established under the National Institutes of Health in response to a 1983 study by the Institute of Medicine. The institute's purpose was to place nursing securely in the sphere of scientific investigation and to support research and training in client care, health promotion, and disease prevention, as well as the mitigation of effects of acute and chronic disabilities. The NINR has continued to fund and support nursing research and is instrumental in the support and dissemination of seminal work in nursing. The ANA Cabinet on Nursing Research was responsible for establishing priorities for nursing research.

A nurse is conducting an in-service education program on moral development for a group of staff nurses. The nurse describes the theories of Kohlberg and Gilligan. The nurse determines that the teaching was successful when the group identifies which area as being associated with women and morality? Justice Rights Needs of others Obligations

Needs of others In Gilligan's theory, men and women have different ways of looking at the world. Men are more likely to associate morality with obligations, rights, and justice, whereas women are more likely to see moral requirements emerging from the needs of others within the context of a relationship.

A nurse moves from Seattle, Washington, to Boston, Massachusetts, and begins working in a hospital. The most important factor for this nurse to consider when moving from one state to another to work is: Nurse Practice Act in each state Clinical ladder of mobility in the new hospital Requirement for in -service education Standard for nursing practice in Boston

Nurse Practice Act in each statE

As a nursing student is visiting a day care to observe growth and development in action. The nursing student completes assessments on infants and toddlers who are learning to walk, talk, and control elimination. According to Freud, in what developmental stage are they? Phallic; genital Relationships and events Trust versus mistrust Oral; anal

Oral; anal During the oral stage, Freud indicates that the infant uses his or her mouth as the major source of gratification and exploration. Pleasure is experienced from eating, biting, chewing, and sucking. Freud goes on to say that toilet training is a crucial issue, requiring delayed gratification as the child compromises between enjoyment of bowel function and limits set by social expectations. Trust versus mistrust is Erikson's theory. The Phallic stage is Freud's preschool theory. The relationships and events theory belongs to Piaget.

The nurse makes a contract with the client during which phase of the nurse-client relationship? Working phase Orientation phase Termination phase Intimate phase

Orientation phase The orientation phase of the relationship represents the first phase of therapeutic work and involves signing of formal contracts. Formal contracts in this setting are a therapeutic tool to help a client develop more insight and control over the client's own behavior. The working phase is when the nurse assists clients in this process by helping them to describe and clarify their experiences, to plan courses of action and try out the plans, and to begin to evaluate the effectiveness of their new behavior. The termination phase is the final phase and the period when a client's goals are assessed and the relationship comes to an end. There is no intimate phase.

A nurse is developing a foreground question for nursing research using the PICO model. Which component would be represented by the statement, "a 45-year-old male with coronary heart disease and atrial fibrillation"? O C I P

P When using PICO, the "P" stands for the patient or problem and its delineation. The "I" signifies the intervention considered; "C" denotes comparison if appropriate, or it may be optional; and "O" represents the outcome of interest or relevant outcomes.

When a person selects, organizes, and interprets sensory stimuli, the process is termed: adaptation. preoccupation. perception. stimulation.

Perception Sensory perception is a conscious process of selecting, organizing, and interpreting sensory stimuli that requires intact and functioning sense organs, neuronal pathways, and the brain.

There are four concepts common in all nursing theories. Which one of the four concepts is the focus of nursing? Nursing Environment Person Health

Person

A student nurse is enrolled in a growth and development class. Which of the following Freudian stages should the student nurse recognize in a child with an increase in gender difference awareness? Latency Stage Anal Stage Oral Stage Phallic Stage

Phallic stage The Phallic Stage is the stage in which a child develops an increased awareness of gender differences. The Oral Stage is when the infant uses his or her mouth as a major source of satisfaction. The Anal Stage is when toilet training is taking place with the child. The Latency Stage involves identification with the same sex parent.

A student nurse is assisting the school nurse with a health fair at a middle school. The student nurse assesses the students' height and weight as they file through her station, where she observes that there is a large variation in physical size and emotional maturity. Which of the following factors may affect physical growth of children? Choose all that apply. Physical activity Availability of books Heredity Prenatal nutrition Colorful toys

Physical activity Heredity Prenatal nutrition Many different factors influence both growth and development. Growth and development might be facilitated or delayed by genetic heredity; prenatal, individual, and caregiver factors; and environment and nutrition. Colorful toys and books help create a stimulating environment, but probably do not contribute to physical growth.

The nurse is providing prenatal education for a group of pregnant teenagers. The nurse talks about substance use during pregnancy and relates that use to which possible newborn consequences? Select all that apply. Low birth weight Congenital anomalies Poor development of superego Development of mistrust Premature birth

Premature birth Low birth weight Congenital anomalies Substance use by a pregnant woman increases the risk for congenital anomalies, low birth weight, and prematurity in the developing fetus. Poor development of superego and development of mistrust may occur after birth, but are not caused by substance use during pregnancy. If developed, these may occur during the emotional growth stage.

A mother, 13 years of age, delivers a low-birth-weight neonate. The neonate is transferred to the neonatal intensive care unit. The mother reports receiving occasional prenatal care and has a history of excessive alcohol consumption. The growth and development of this neonate has been influenced by which of the following? Caregiver factors Individual factors Spiritual factors Prenatal factors

Prenatal factors Fetal development can be altered by prenatal factors such as maternal age (with risk greater in those under age 15 and over age 35), maternal substance use, inadequate prenatal care, and inadequate maternal nutrition. Individual factors might result in altered development from birth through adolescence and may include congenital or genetic disorders, brain damage from accidents, or abuse, sensory impairments, and substance use. Caregiver factors that negatively affect development are neglect and abuse, mental illness, intellectual disability, or a severe learning disability. Spiritual factors, such as religious beliefs, are not a factor in this situation.

A nursing student is visiting a day care to observe growth and development in action. The nursing student completes screening assessments on preschoolers who are learning to feed, dress, and toilet themselves, as well as expanding their motor and verbal abilities. According to Piaget, in what development stage are they? Preoperational Autonomy versus shame and doubt Concrete operational Sensorimotor

Preoperational Piaget's preoperational stage is characterized by the beginning use of symbols, through increased language skills and pictures, to represent the preschooler's world. Sensorimotor is Piaget's birth to 24-month stage. Concrete operational is Piaget's 7- to 11-year-old stage. Autonomy versus shame and doubt is Erikson's theory.

A group of nurses is planning to investigate the effectiveness of turning immobilized stroke clients more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which element will the "O" in the team's PICO question refer to? Clients who have experienced a stroke The currently used turning schedule Preventing skin breakdown Turning clients more frequently

Preventing skin breakdown Within the PICO question framework, the "O" denotes the outcome of interest. In this case, the desired outcome is the prevention of skin breakdown. Stroke clients are the "P," or population of interest, whereas turning clients more frequently is the "I," or intervention. The current turning schedule is the "C," referring to the comparison of interest.

The older adult client, who lives alone, has been admitted to the intensive care unit (ICU) following a stroke. She is now agitated and complaining about the noise. What will the nurse add to her care plan? Provide pet therapy. Provide a consistent, predictable pattern of stimulation. Instruct the client in self-stimulation methods such as singing. Offer frequent back rubs.

Provide a consistent, predictable pattern of stimulation. In some clients, especially those coming from a quiet environment with unvarying stimuli, the experience of being hospitalized quickly results in sensory overload. One nursing action to decrease excessive stimulation is to provide a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment. The other options are nursing interventions used for sensory deprivation, as they increase stimulation.

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? Immediately complete a thorough assessment. Put the client in a room with a client who is hearing impaired, Provide a private room and limit stimulation. Talk loudly to the client and encourage ambulation.

Provide a private room and limit stimulation.

A nurse researcher must decide on the method for conducting the research. The researcher that plans to emphasize collection of numerical data and analysis would select which method of research? Qualitative research Basic research Quantitative research Applied research

Quantitative research Quantitative research utilizes numerical values and statistical analysis of data. Basic research is utilized to generate or refine theory. Applied research is utilized for its application in clinical practice. The stem of the question did not provide information as to the application of the study. Qualitative research utilizes words or narrative for data rather than numbers.

What is the involuntary motion of retracting the body from painful stimuli? Reception Sensation Reaction Perception

Reaction

A nurse is caring for a 6-year-old boy who is hospitalized for observation following a motor vehicle accident. Based on Havighurst's developmental tasks, what would be the best choice for a diversional activity for this client? Watching television Playing video games Speaking to school friends on the telephone Reading a storybook

Reading a storybook Havighurst (1972) believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Development tasks of early childhood would include developing fundamental skills in reading and achieving personal independence, to name a few. The best answer above would be reading a story book. The other diversional activities would be appropriate for the adolescent.

A nurse is observing a child pick up a rattler and shake it to hear a sound. The nurse understands that the child is considered to be in which of the following of Piaget's Cognitive Development stages? Concrete Operational stage Sensorimotor stage Preoperational stage Formal Operational stage

Sensorimotor stage A child who picks up a rattler to shake it is considered to be in Piaget's Sensorimotor stage. This shows the child relating his or her own behavior to the environment. In the Preoperational stage the child uses symbols and pictures to represent themselves. In the Concrete Operational stage the child can manipulate objects. With formal Operational stage the child uses abstract thinking.

Which is the best example of evidence-based nursing practice? Continuing to prescribe an antibiotic that is no longer recommended in the literature based on 20 years of personal success in treating clients using this antibiotic Using central line dressing kits to reduce infection rates in clients based on 10 years of experience working in the ICU Recommending ginger to alleviate nausea and vomiting in obstetric clients based on a literature review Consulting with a prescribing health care provider about a client on the cardiac floor who does not take daily aspirin, a practice recommended in a nursing journal article for people 50 years and older

Recommending ginger to alleviate nausea and vomiting in obstetric clients based on a literature review Identifying a client problem (nausea and vomiting), performing a literature review to learn about solutions to this problem that have been studied (use of ginger), and applying the information gained to clients in one's practice (recommending ginger to obstetrical clients with nausea and vomiting) are a great example of evidence-based nursing practice. Basing interventions on personal experience, personal observation, and personal success in treating clients - despite the length of that experience - are not examples of evidence-based practice. Evidence from a single article in a nursing journal for use of an intervention with a single client who may or may not be a part of the population studied is not the best example of evidence-based nursing practice.

The nurse is seeing a male client 6 years of age in the clinic. As the nurse is measuring height and weight for the client, his mother comments on how coordinated he is becoming. The nurse knows that this increase in coordination is which of the following? Part of being prepubescent A reflex Due to growth Related to development

Related to development Growth is an increase in body size, or changes in body cell structure, function, and complexity. Development is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning. Pubescence is the time when secondary sex characteristics continue to develop, and ova and sperm begin to be produced by the reproductive organs. Developing coordination is not a reflex.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for "R"? Reminisce Relax Respect Reassure

Relax "Sit squarely"; "Open posture"; "Lean towards the other"; "Eye contact; "Relax"

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation? Ask the client what one was doing in 1949 and what hotel the client is in. Provide hints during conversation as to the correct year and place. Reorient the client to place and time. Thank the client for the responses and document the cognitive status.

Reorient the client to place and time. It is appropriate to reorient clients with dementia who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient the client. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed by reorientation.

Newborns are capable of activities such as grasping objects and displaying basic reflexes. To which of the following of Piaget's cognitive developmental stages do the newborns belong? Formal operational Sensorimotor Preoperational Concrete operational

Sensorimotor Newborns belong to the sensorimotor stage of cognitive development, characterized by activities such as grasping and displaying basic reflexes. The preoperational stage is characterized by assigning meaning or identity to an object governed by own perceptions. The concrete operational stage is characterized by concrete thinking and using more logic. The formal operational stage emerges around 12 years of age and is characterized by the ability to think abstractly.

A client who is blind is said to be experiencing: sensory overstimulation. sensory overload. sensory deprivation. sensory deficit.

Sensory deficit Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care.

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing: sensoristasis. sensory perception. sensory deprivation. sensory overload.

Sensory overload Sensory overload occurs when a person is unable to process or manage the intensity or quantity of incoming sensory stimuli. Imparting information to a client may lead to sensory overload. Some examples include educating a client on a procedure, informing a client about a diagnosis, making requests of a client, or helping the client solve a problem.

A 38-year-old male comes to the clinic for a routine visit. During the interview, the client tells that nurse that he is really striving to make his family work better. He says, "I focused on gaining respect and making my life the best it can be." The nurse interprets this information applying the theory by Levinson as indicating which phase of development? Entering the adult world Mid-life transition Age 30 transition Settling down: building a second adult life structure

Settling down: building a second adult life structure In the settling-down phase (age 33-40), the adult invests energy into the areas of life that are most personally important. The areas of investment are primarily family, work, and community. The person strives to gain respect, status, and a sense of authority. The age 30 transition represents a transition time (ending around age 33) during which the overriding task of the novice phase—to establish a place in the world and create a viable, suitable life structure—is evaluated. This time of reflection allows for reconsideration of choices and to make changes. The Entering the adult world phase encompasses the years of the middle to late 20s (age 22-28). This is a time to build on previous decisions and choices, and to try different careers and lifestyles. Mid-life transition (age 40-45) involves a reappraisal of goals and values. The person's established lifestyle may continue, or he/she may choose to reorganize and change careers.

According to Freud, which of the following influences is the primary force that drives an individual's development? Sexuality Autonomy Faith Security

Sexuality According to Sigmund Freud, the stages of development are based on sexual motivation. Sexuality supersedes security and autonomy, though both are highly significant and are influenced by sexual motivation. Faith is not a central construct in Freud's theory of development.

As the nurse is preparing an immunization for a male client 2 years of age, his mother discovers that he has soiled his underpants. She scolds him and calls him a "bad boy" because he "dirtied" his underwear. The nurse gives the immunization and provides some education to the mother about appropriate expectations for this age group. The nurse knows that according to Erikson's theory for this client's age group, he is at risk to develop which of the following? Shame and doubt Guilt Inferiority Isolation

Shame and Doubt According to Erikson, the toddler's task is to achieve autonomy versus shame and doubt. If the caregivers are overprotective or have expectations that are too high (such as the client's mother), shame and doubt, as well as feelings of inadequacy, might develop in the child. During the initiative versus guilt stage, children begin to assert their power and control over the world through directing play and other social interaction. Industry versus inferiority is the fourth stage of Erik Erikson's theory of psychosocial development. The stage occurs during childhood between the ages of approximately six and eleven. Children are at the stage where they will be learning to read and write, to do sums, to do things on their own. Intimacy versus isolation is the sixth stage of Erik Erikson's theory of psychosocial development. This stage takes place during young adulthood between the ages of approximately 19 and 40. During this period, the major conflict centers on forming intimate, loving relationships with other people.

The client does not speak the dominant language. The nurse plans on providing preoperative teaching and uses an interpreter to communicate with the client. What intervention(s) will the nurse employ to aid in interpretation? Select all that apply. Speak slowly, using nontechnical terms. Inform the interpreter of the expected outcome of the communication exchange. Allow the interpreter to elaborate extensively in the client's language. Look at the client while speaking. Position the interpreter to sit between the nurse and the client.

Speak slowly, using nontechnical terms. Inform the interpreter of the expected outcome of the communication exchange. Look at the client while speaking. When communicating with a client who has no or limited understanding of the dominant language, the nurse ensures the interpreter understands the purpose of the communication. This is to facilitate understanding with the interpreter regarding the conversation. The nurse will sit between the client and the interpreter, looking at the client through most of the exchange. These acts promote communication and demonstrate the importance of the client to the client. To ensure the content is communicated, the nurse instructs the interpreter to only interpret what is being said. The nurse takes time for the communication process, speaking slowly and using simple, nontechnical terms.

A client returning from the operating room is unconscious. What guidelines should the nurse consider when communicating with this client? Gently shake the client's hand or arm before speaking to him or her. There are no guidelines to consider because the client cannot hear the nurse. Provide loud environmental stimuli to assist in arousing the client. Talk to the client in a normal tone of voice.

Talk to the client in a normal tone of voice. As a client is recovering from unconsciousness, the nurse should assume the person can hear them. The nurse should be careful of what is said in the person's presence and speak in a normal tone of voice. Speak to the person before touching because touch is an effective means of communication but in this case, the nurse should talk to the person first.

A nurse meets with the registered dietician and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? Informatics Teamwork and collaboration Patient-centered care Safety

Teamwork and collaboratioN

The referent in the communication process is: That which motivates one person to communicate with another. the means of conveying messages information shared by the sender the person who initiates the communication

That which motivates one person to communicate with another.

A parent of a preschooler brings the child to the health center for a visit. During the visit, the parent says, "It's just one question after another. Why does this happen? How does it happen? I'm at a loss as to what to say to my child." When providing anticipatory guidance to this parent, which information would the nurse incorporate? The child is taking the initiative in learning to achieve initiative. The child is probably exhibiting mistrust from inconsistent actions by the parents. The child is not meeting the parents' expectations. The child is experiencing shame and doubt from a loss of independence.

The child is taking the initiative in learning to achieve initiative. Confidence gained as a toddler allows the preschooler (ages 4 to 6 years) to take the initiative in learning so that the child actively seeks out new experiences and explores the how and why of activities. This is important for the preschooler to achieve the task of initiative. There is no indication that the child is experiencing a loss of independence, mistrust from inconsistent parental actions, or an inability to meet the parents' expectations.

The nurse using Fowler's theory of faith development has established that a client is in the mythical-literal stage. Which findings support that assessment? Select all that apply. The client says, "The fairest thing we can do is share the cookies evenly." The client affirms faith in God. The client says, "I grew up in church, but I am not certain I believe." The client assumes responsibilities for personal attitudes. The client is 9-years-old.

The client is 9-years-old. The client says, "The fairest thing we can do is share the cookies evenly." The client affirms faith in God. The mythical-literal stage of faith development predominates in the school-age child. The child accepts the existence of a deity and appreciates the concept of reciprocal fairness. In the synthetic-conventional faith stage, the person begins to question religious practices. In the individuative-reflective faith stage people become responsible for their own attitudes about religion.

Which short term goal may be appropriate for a client experiencing sensory overload? The client will maintain the functioning of existing senses. The client will demonstrate achievement of self-care. The client will remain safe at all times. The client will achieve sensoristasis.

The client will remain safe at all times. Client goals are individualized but focus on achieving optimal sensory function, for achieving client safety. The client needs to remain safe and that can be achieved by a variety of ways. Being sensitive to how visual stimuli, noises, and touch are stimulating the client, combined with paying attention to the client's need for privacy and for social interaction, can significantly reduce disturbances in sensory perception and keep the client safe. The optimal arousal state of the RAS is a general drive state called sensoristasis. When overloaded, the client will lose some of the functioning of the existing sense to compensate for sensoristasis. Self care may be compromised in sensory overload as the client is not able to determine the importance of self care activities.

The nurse is preparing a care plan for a client with disturbed sensory perception. What would be appropriate goals for the client to achieve? Select all that apply. The client will not fall during the hospital stay. The nurse will assist the client with ADLs as needed during the hospital stay. The client will develop effective communication during the hospital stay. The nurse will use a communication board when speaking with the client. The client will state feeling rested after sleeping.

The client will state feeling rested after sleeping. The client will not fall during the hospital stay. The client will develop effective communication during the hospital stay. Goals are client-directed statements, not nurse directed. Examples of appropriate client goals for Disturbed Sensory Perception may include the following: the client will remain safe, the client will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them, the client will maintain the functioning of existing senses, or the client will develop an effective communication mechanism.

The nurse shares with a client that, "The CNA will be here in 20 minutes to complete your ADs." This nurse-initiated communication will likely result in client confusion or noncompliance because: The timing of the conversation was poorly chosen The conversation relied on terms familiar only to health care providers The nurse assumed that the client would accept the nursing assistant's help The client was not actively involved in the decision-making process

The conversation relied on terms familiar only to health care providers

A nurse working on a busy acute care unit is planning care for a group of clients. Which nursing action best exemplifies the primary focus of the nurse's role? The nurse adjusts the environment of the client to facilitate provision of care. The nurse comforts a client who received bad results from a diagnostic test. The nurse concentrates on the health status of a client. The nurse focuses on the procedures being performed for clients that day.

The nurse comforts a client who received bad results from a diagnostic test. The focus of nursing is promoting health and wellness in partnership with individuals, families, communities, and populations. With this in mind, the nurse would comfort the client who received bad results from a test. By focusing on this intervention of the four listed, the nurse is providing physical, emotional, and spiritual support for the client. The nurse would not concentrate on the health status of the client. The nurse would not focus on the procedures to be performed for clients that day. The nurse would not adjust the environment of the client to facilitate provision of care.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. The nurse keeps communication simple and concrete. If there is no response, the nurse does not repeat what is said and takes a break. The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse communicates in a busy environment to hold the client's attention. The nurse gives lengthy explanations of the care that will be given.

The nurse keeps communication simple and concrete. The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. There are several nursing actions that would be appropriate to facilitate. The nurse would maintain eye contact with the client. The nurse shows patience and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse would not communicate in a busy environment because this could be distracting to the client. The nurse would not give lengthy explanations to the client regarding the care to be given. The nurse would repeat the information if no response was shared by the client.

The nurse is conducting a community assessment that focuses on Healthy People 2030 health promotion guidelines. What would be important for the nurse to include when performing the community assessment to meet the Healthy People 2030 goals? Select all that apply. violent crime rate sudden infant death syndrome (SIDS) rate number of homes with air conditioning number of individuals living in a household number of health clinics

The nurse would assess for the number of health clinics, violent crime rate, and SIDS rate in the community. These are methods for assessing the following Healthy People 2030 Leading Health Indicators: access to health care; injury and violence; and maternal, infant, and child health. Other Healthy People 2030 Leading Health Indicators include clinical preventive services; environmental quality; mental health; nutrition, physical activity, and obesity; oral health; reproductive and sexual health; social determinants; and substance use. The nurse would not need to assess the number of homes with air conditioning or the number of individuals living in a household to meet the Healthy People 2030 health promotion goals.

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply. A.) Statistician B.) Communicator C.) Financier D.) Teacher E.) Counselor

The roles and functions of the nurse are many and include caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are not the roles of the nurse.

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario? The working phase The introduction phase The orientation phase The termination phase

The working phase There are three phases of a helping relationship: the orientation phase, the working phase, and the termination phase. The introduction phase is not a valid phase, yet the nurse introduces oneself during the orientation phase. The scenario defines characteristics of the working phase, during which the nurse and client work together to meet the client's physical and psychosocial needs. During the orientation phase, the nurse and client establish the tone and guidelines for the relationship . The termination phase occurs when the nurse and client acknowledge that they have met the goals of the initial agreement or that the client would be better served by another nurse or health care provider.

During a well-child visit, the nurse observes a 3-year-old girl who climbs up into her father's lap and says, "I am going to marry you when I grow up, Daddy." What determination does the nurse make about this observation? This is a strong clue that this child may be being sexually abused. This child is experiencing the Electra complex which is normal at this age. This child is developing an unhealthy attachment to her father. This child is in the latency stage of Freud's theory of the mind.

This child is experiencing the Electra complex which is normal at this age. The Electra complex is based on feelings of intimate sexual possessiveness for the opposite-sex parent. It is normal during the phallic stage of development and will likely resolve. The latency stage does not begin until much later in childhood (age 7). There is no indication that this child is being sexually abused by the father or has an unhealthy attachment to him.

Why are nursing organizations important for the continued development and improvement of nursing as a whole? To provide socialization and networking for members To regulate work activities for members To set standards for nursing education and practice To provide information to nurses about legal requirements

To set standards for nursing education and practice Professional organizations set educational and practice standards for nursing education and practice. They also are concerned with current issues in nursing and health care, and influence health care policy and legislation. Although professional organizations may provide outlets for networking, regulate work activities, and provide information about legal requirements, setting standards for education and practice is a primary focus.

A nurse is discussing dietary issues with a Latino client in the clinic. The client states, "My grandmother always told me that I needed to include beans in my diet so that my muscles would grow." The information that the client is expressing is known as what? Authoritative knowledge Traditional knowledge Philosophical knowledge Scientific knowledge

Traditional knowledge Traditional knowledge is known as knowledge that is passed down from one generation to the next. A grandmother passing information is an example of traditional knowledge. Authoritative knowledge is information that is gleaned from an expert based on their perceived experience. Scientific knowledge is derived through the scientific method. Philosophy is the study of wisdom and one perceptions of life.

The nurse observes a client with head bowed and hands folded seemingly in prayer. The nurse recognizes this as an example of: Transpersonal communication Interpersonal communication Intrapersonal communication Nonverbal communication

Transpersonal communication

A nurse is performing an admission assessment with a client who does not speak the dominant language. Which action(s) can the nurse take to enhance communication? Select all that apply. Request assistance from an agency interpreter. Contact a telephone-based medical interpreter. Speak loudly and slowly. Ask the client's teenage daughter to interpret. Use an electronic translator.

Use an electronic translator. Contact a telephone-based medical interpreter. Request assistance from an agency interpreter. Some options for working with clients who do not speak the dominant language include requesting assistance from a trained agency interpreter. If one is not available, using a trained telephone interpreter or an electronic translator may assist in obtaining information. Using family members is not appropriate, since it is a violation of the client's HIPAA rights. In addition, clients may not feel comfortable explaining all of their symptoms using a family member, and medical terminology may not be translated correctly. Speaking loudly will not assist the client in understanding another language.

For the client experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? Speaking loudly Speaking in short sentences Using a picture board Writing directions so client can read them

Using a picture board

A nurse is presenting a workshop for a group of young women. Part of the workshop focuses on the moral development of women. The nurse integrates information about Gilligan's theory into the presentation, describing the various levels that a woman goes through as morality develops. When describing level 1, the nurse would focus on which area? Acceptance by others Adoption of social values Woman's own needs Move from selfishness to responsibility

Woman's own needs In level 1, the focus is on the girl's or woman's own needs. Should and would are the same. The transition that follows this level is characterized by the move from selfishness to responsibility—a move that integrates the responsibility to care for oneself with the desire to care for others. In level 2, moral judgment is based on shared norms and expectations, and societal values are adopted. Acceptance by others becomes critical, and the ability to protect and care for others becomes the defining characteristic of female goodness.

A nurse is preparing to conduct a research study and uses the PICO format to develop the foreground question which is: "In adults, does reducing salt intake, compared to no change in salt intake, lower blood pressure?" The nurse identifies the "P" as: reducing salt intake. no change in salt intake. adults. lower blood pressure.

adults. Using the PICO(T) format, "P" refers to the population, which in this case is adults. "I" refers to the intervention, which is reducing salt intake. "C" refers to comparison, which is no change in salt intake. "O" refers to the outcome, which would be lower blood pressure. "T" refers to the time of interest, if relevant

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration? demonstrating a wide variety of syringes and techniques using numerous handouts and detailed education plan requesting hearing aids to help the client receive information allowing more time for the processing of the information

allowing more time for the processing of the information As a person approaches 60 to 70 years of age, marked decrements in sensory/perceptual behaviors begin. This reduction in efficiency means that older people cannot process sensory input as rapidly as they did when they were young.

Which client is at greatest risk of sensory overload? an 8-year-old in isolation in a private room in a hospital an 88-year-old on a ventilator in an intensive care unit a 55-year-old, newly diagnosed with diabetes in a private room in a hospital a 17-year-old on bed rest after a surgical procedure

an 88-year-old on a ventilator in an intensive care unit Explanation: Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload. Private rooms, mobility restraints (such as traction or bed rest), isolation, and few visitors are all risk factors for sensory deprivation

Which action by the nurse best represents the evaluative portion of the nursing process? educating a client on how to take one's own blood pressure every morning determining that a client is at risk for a fall while in the hospital assessing a client's blood pressure after teaching stress reduction techniques assessing a client's blood pressure after giving a cup of coffee

assessing a client's blood pressure after teaching stress reduction techniques The nursing process consists of assessing, diagnosing, planning, implementing, and evaluating. Assessing the client's blood pressure after the nurse implements stress reduction techniques is an example of evaluation. Assessing a client's blood pressure after a cup of coffee is not an effective evaluation. Educating a client to take his or her blood pressure is an intervention. Determining a client is at risk for fall is part of the assessment process.

According to Havighurst, learning behaviors are based upon developmental tasks. In assessing an adult client, the nurse is aware that a common developmental task of middle adulthood includes: adjusting to retirement and reduced income. learning to live with a marriage partner. preparing for a career. assisting children to become responsible adults.

assisting children to become responsible adults. Assisting children to become responsible adults is a developmental task of middle adulthood. Preparing for a career is a task of adolescence. Learning to live with a marriage partner is a developmental task of young adulthood. Adjusting to retirement and reduced income is a developmental task of later maturity.

According to Havighurst, learning behaviors are based upon developmental tasks. In assessing an adult client, the nurse is aware that a common developmental task of middle adulthood includes: assisting children to become responsible adults. adjusting to retirement and reduced income. learning to live with a marriage partner. preparing for a career.

assisting children to become responsible adults. Assisting children to become responsible adults is a developmental task of middle adulthood. Preparing for a career is a task of adolescence. Learning to live with a marriage partner is a developmental task of young adulthood. Adjusting to retirement and reduced income is a developmental task of later maturity.

A nurse mentoring second-year nursing students from a community college plans clinical experiences for them. These students will most likely graduate in which time frame? in 3 more years at the end of the year in 2 more years in 1 more year

at the end of the year Nursing students from a community college are most likely students attempting to obtain an associate degree, which is a 2-year program. Therefore, the nurse should plan clinical experiences for students who will most likely graduate at the end of the year, as this is their second year.

characteristics of a profession include which of the following? basic education with LPN or ADN level research and philosophy dynamic and ever-changing autonomy and accountability

autonomy and accountabilitY

A novice nurse is excited to finally be able to put all the training to use on the inpatient unit. Which factor should the nurse be sure to prioritize when beginning to interact with clients? advise clients on the best plan of action be an advocate for appropriate care ensure families are kept informed ensure the families do not get sick

be an advocate for appropriate care The American Nurses Association defines nursing as: protection, promotion and optimization of health and abilities; prevention of illness or injury; alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. This would include being an advocate for the appropriate care for each client. The nurse should help prevent illness or injury, but alleviating illness in the families would not be possible. The nurse should only keep families informed if the client has given permission to share the information. For the nurse to share this information without authorization would be unethical and illegal. Nurses are responsible for educating clients concerning their situation and possible responses; however, the nurse must not advise the client on the best plan of action. The client needs to make that decision after having all the information to make an informed decision.

The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called: assistive functioning. authoritative functioning. independent functioning. collaborative functioning.

collaborative functioning. Nurses manage collaborative problems using both nurse- and health care provider-prescribed interventions to reduce the risk of complications. In this situation, the nurse is not operating authoritatively or independently, but within the parameters established by the health care provider. The nurse is not merely acting in an assistive capacity, as the nurse is performing interventions in the absence of the health care provider.

A nurse recognizes that a helping relationship is established with a client if the communication: occurs spontaneously throughout the nurse-client relationship. encourages the client to express his thoughts and feelings. is equally reciprocal between the nurse and client. has no time limits.

encourages the client to express his thoughts and feelings.

The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population? good management of illness such as hypertension Avoid places full of people to prevent spread of infection. Schedule eye examinations every 4 years. Continue driving a car to maintain memory skills.

good management of illness such as hypertension Client education to promote sensory health and function focuses on ways to prevent sensory loss and to maintain general health. Education topics include the importance of frequent eye examinations (yearly) and close control of chronic illnesses such as hypertension and diabetes. Age related changes in eyesight and motor function may affect the ability to drive. Avoiding places full of people can prevent infection but may cause sensory overload in the elderly.

Which action by the nurse is the best indication that the nurse is incorporating the quality and safety education for nursing (QSEN) competency of teamwork and collaboration in the plan of care for a client?

including the client in the morning rounds of the health care team The QSEN competencies include client-centered care, teamwork and collaboration, quality improvement, safety, evidence-based practice, and informatics. The competency of teamwork and collaboration is best indicated by including the client in the morning rounds of the health care team, which fosters open communication, mutual respect, and shared decision making among team members. Keeping the side rails up on the bed of a client who is confused is an example of the competency of safety. Using a new technique for client care based on the latest research is an example of the competency of evidence-based practice. Gaining input from a client regarding personal goals for rehabilitation is an example of the competency of client-centered care.

A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student? associate of science registered nursing program diploma nursing program baccalaureate of science registered nursing program licensed or vocational nursing program

licensed or vocational nursing program A licensed practical or vocational nursing program will allow the student to earn a technical certificate in 1 year and sit for the state board of nursing examination to be licensed as an LPN or LVN. This would allow employment that will allow the graduate to provide client care and to assist professional nurses with routine technical procedures as desired. An associate program will take 2 years and a baccalaureate program will take 4 years; additionally these prepare new nurses to work in a more independent role than this person is seeking. There are very few diploma programs remaining in the U.S., and these programs typically take 3 years to complete.

In the role of entrepreneur, the nurse's primary responsibility is: A.) managing a health-related business. B.) administering resources.

managing a health-related business. A nurse entrepreneur is primarily concerned with organizing, developing, and managing a clinic or health-related business. Although a nurse entrepreneur may also administer resources, manage personnel, and teach, the primary responsibility of this role is managing a health-related business. A nurse administrator is primarily concerned with administering resources and managing personnel. A nurse educator is primarily concerned with teaching in a clinical setting.

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established? Orientation phase Evaluation phase Termination phase Working phase

orientation phase During the orientation phase, the nurse discusses with the client when visits will occur and how long they will last. The working phase is usually the longest phase of the nurse-client relationship. During this phase, the nurse works together with the client to meet the client's physical and psychosocial needs. Interaction is the essence of the working phase. The termination phase occurs when the nurse and client acknowledge that the agreement on which the relationship is based is concluding. There is no evaluation phase of the nurse-client relationship (evaluation is the final step in the nursing process).

The examination for registered nurse licensure is exactly the same in every state in the United States. This examination: ensures that honest and ethical care is provided ensures standardized nursing care for all patients provides a minimal standard of knowledge for a registered nurse in practice guarantees safe nursing care for all patients

provides a minimal standard of knowledge for a registered nurse in practice

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation? providing a backrub with morning and evening care orienting the client to his environment delivering meticulous oral care placing a calendar and clock on the client's bedside table

providing a backrub with morning and evening care Tactile stimulation includes backrubs, foot soaks, turning and repositioning, passive range-of-motion exercises, hugs, and touching. Orienting a client to his environment is cognitive input. Placing a calendar and clock on the client's bedside table is visual stimulation. Oral care is gustatory and olfactory stimulation.

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his: prefrontal cortex. limbic system. cerebellum. reticular activating system (RAS).

reticular activating system (RAS). The RAS is the network that mediates arousal. The limbic system is a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Cerebellum is the part of the brain that coordinates and regulates muscular activity. The prefrontal cortex is a part of the brain located at the front of the frontal lobe and is involved in a variety of complex behaviors and personality development.

The nurse is working in the intensive care unit (ICU) caring for an older adult client who has been in the unit for 2 days that is experiencing auditory and visual hallucinations. What are the most likely contributing factors related to this problem for this client? Select all that apply. sleep deprivation sensory deprivation sensory overload loneliness of environment too much noise

sensory overload too much noise sleep deprivation Severe sensory alterations can occur, especially in certain areas, such as the critical care or intensive care units (termed intensive care unit [ICU] psychosis). Factors contributing to severe sensory alteration include sensory overload, sensory deprivation, sleep deprivation, and cultural care deprivation. The ICU is not an lonely environment, and clients in ICU are not likely to experience sensory deprivation.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: swaddling the child and gently stroking its head. offering the neonate infant formula. staring into the neonate's eyes and smiling. softly humming a song near the neonate.

swaddling the child and gently stroking its head. Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or long-term care facility care. Vision, taste, and hearing are not as fully developed as touch in the neonate.

A school nurse is using Havighurst's developmental theory to teach parents of adolescents what to expect at this developmental stage. Which behaviors are typical of adolescents? Select all that apply. The adolescent acquires an ethical system as a guide to behavior. The adolescent achieves social and civic responsibility. The adolescent learns to get along with peers. The adolescent learns physical skills necessary for games. The adolescent achieves emotional independence from parents. The adolescent accepts his or her body and uses it effectively.

the adolescent accepts his or her body and uses it effectivelythe adolescent achieves emotional independences from parentsthe adolescent acquires an ethical system as a guide to behavior