Term 1 Unit 2 Exam

The nurse is conducting a health interview with an older adult client. During this introductory phase, which action should the nurse take to effectively establish the nurse-client relationship?

Greet the client by asking by which name he or she prefers to be addressed.

A nurse has become involved in political efforts to ensure that a greater percentage of Americans have access to affordable health care, regardless of their individual circumstances. This view of health is reflective of what belief?

Health is a right.

A nurse caring for client who is unconscious knows that communication is important even if the client does not respond. Which nonverbal action by the nurse would communicate caring?

Holding the client's hand while talking

Upon entering the hospital system, the nurse discusses the rights and responsibilities that the client is entitled to in the institution. The information the nurse discusses is commonly referred to as:

Patient's Bill of Rights.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

Which developmental consideration is a nurse assessing when the nurse determines that an 8-year-old is not equipped to understand the scientific explanation of a disease?

intellectual development

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

A nurse does not assist with ambulation of a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse?

negligence

A client is brought to the clinical agency and will be seen by one of the nurses assigned to the unit. Which nurse would present the most positive image to the client?

nurse who is wearing a clean, winkle-free uniform

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?

nursing care rounds

A client reports that she is in an abusive relationship and does not know how to break it off. Which of Maslow's hierarchy of needs does the nurse need to prioritize most for this client?

safety and security

A palliative care nurse possesses numerous skills that have enhanced the nurse-client relationship and communication in the past. One of these skills that has benefited previous clients is affective touch. Before using this technique, the nurse must consider:

the client's culture.

A client arrives at a health care facility complaining of pain in the abdomen and diarrhea. The health care provider diagnoses the client with colitis, an acute illness. Why is colitis considered an acute illness?

the onset is sudden

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

Which health care insurance program is most suitable for a client 68 years of age?

Medicare

The nurse is interacting with a new client who reported to the clinical facility for a health problem. Place the following statements by the nurse in the order of the nurse-client relationship. Use all options.

"Hello. I am the nurse assigned to you. My name is...." "What health problem are you seeking help for?" "This medication has been prescribed by the health care provider to treat your problem." "The health care provider has recommended you to return in 1 week."

A client, who has just been diagnosed with a chronic condition, asks the nurse what a "chronic condition" means. What would be the nurse's best response?

"Chronic conditions usually come on slowly and may have periods of remission and exacerbation."

The child of a client who just died in a hospice unit arrives and asks, "May I please stay and sit at the bedside? I really wanted to be here so my dad would not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

In the computer, the nurse needs to document the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took his medication at 1530 hours?

03:30 p.m.

A rapid onset of symptoms that lasts a relatively short time indicates which condition?

An acute illness

The alert and oriented client has just been notified of a terminal cancer diagnosis and the need for surgery to extend life. The client tells the nurse, "I am leaving. I am not having the surgery." The client refuses to wait and talk to the primary care provider. What is an appropriate action by the nurse?

Ask the client to sign a form stating that the client is being discharged against medical advice

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing?

Assault

Which ethical principle is related to the idea of self-determination?

Autonomy

The nursing supervisor is giving a performance evaluation to an employee. Which communication technique by the nursing supervisor sends the message of disinterest in the employee?

Avoiding eye contact

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

Battery

A nurse will be finishing work for the day at 1900. Besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty at 1900?

Change of shift reports

An exacerbation refers to the reactivation of a disease. Which condition is associated with exacerbation?

Chronic illness

A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating?

Cognitive

A nurse finds that a colleague is intoxicated while on duty. What appropriate action should the nurse take?

Inform the nursing supervisor

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value?

Integrity

Which action by the nurse would facilitate the nurse-client relationship during the orientation phase?

Introducing oneself to the client by name

Which statement reflects the World Health Organization's definition of health?

It is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity

A client informs the nurse that the client wants to discontinue treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation?

Let the client go after signing a document stating that the client is going against medical advice

What is an entitlement program designed to serve the poor that is administered by the state?

Medicaid

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?

Positive feedback

The nurse has completed teaching. Which client behavior demonstrates understanding within the psychomotor domain?

Provides return demonstration of use of inhaler

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing

SOAP charting

In SBAR, what does R stand for?

Recommendations

A nurse has a duty of nonmaleficence. Which action would be considered a contradiction to that duty?

Refusing to administer pain medication as prescribed

Which organization audits charts regularly?

The Joint Commission

What governing body has the authority to revoke or suspend a nurse's license?

The State Board of Nurse Examiners

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the health care provider and completes the incident report. Which statement should the nurse document in the incident report?

The client was found lying on the floor.

A child, age 4 years, has leukemia but is now in remission. What does it mean to be in remission when one has a chronic illness?

The disease is present, but symptoms are not experienced.

A recent nursing graduate has been making a concerted effort to ensure that clients receive holistic nursing care. Which action best demonstrates the principle of holism?

The nurse attempts to meet the physical, social, emotional, and spiritual health needs of clients.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

Which action by the nurse demonstrates respect for the client as an individual?

The nurse is administering medication to a client the nurse addressed as "Ms. Taylor."

A middle-aged client is distraught at receiving a diagnosis of type 2 diabetes in spite of being conscientious about her health for the majority of her adult life. The client tells the nurse, "I can't believe I no longer have my health." The nurse should be aware that the World Health Organization defines health as:

a state of physical, mental, and social well-being.

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is:

an advance directive.

The nurse communicates with a newly admitted client. Which nonverbal behavior will the nurse note?

client's gestures

Which type of learner processes information more adequately by listening or reading facts?

cognitive

A nurse is caring for a client who is a celebrity in the area. A person claiming to be a family member inquires about the medical details of the client. The nurse reveals the information but later comes to find out that the person was not a family member. The nurse has violated:

confidentiality.

The nurse understands that an idiopathic illness is a condition whose cause is unexplained. Which is an example of idiopathic illness?

fever of undetermined origin

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

A nursing student asks the instructor about the leading cause of death. What would the instructor identify as the most common cause of death in clients?

heart disease

According to Maslow, which category of needs represents the most basic on the hierarchy?

physiologic needs

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

retrieval of information is more efficient.

The nurse is preparing a plan of care for a client with nutritional deficits. Which is the priority intervention for this client?

teaching about intake of food and vitamins

A nurse is driving on a back country road when a man flags the nurse down and yells that his wife is having a baby. The registered nurse is eager to help. The nurse recalls being covered under the Good Samaritan law. This law states:

that the nurse's license is protected if the nurse acts in a reasonable manner given the circumstances.

A competent adult client is scheduled for surgery. Who signs the informed consent form to allow the surgery?

the client