Term 4 EAQ: Coordinated Care

Which member of the health care team is held responsible documenting the client's initial admission nursing history?

Registered nurse

Which element is essential to the nurse when delegating a task to another staff member? Select all that apply. One, some, or all responses may be correct.

-Knowledge of the capabilities and competencies of the person the task is being delegated to -Ensuring the task falls within the domain of tasks that can legally be delegated -Effective communication with the person being delegated to -Understanding the client's needs

How many words are expected in the vocabulary of a 5-year-old child?

2000

With which roommate would the nurse place a 4-year-old boy who has been admitted to the hospital with nephrotic syndrome?

A 5-year-old girl with acute glomerulonephritis

Which assessment finding would the nurse expect in a client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Absence of hair on the toes Reports of pain associated with exercising

The day after undergoing an abdominal appendectomy, a school-age child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation?

Administering the prescribed pain medication

A client is discharged home the same day as a hernia repair. Which location was the client most likely discharged from?

Ambulatory surgery center

Which organization's goal was to set educational standards for nurses?

American Society of Superintendents of Training

Which mental health care team member is responsible for designing a meal plan for an inpatient behavioral health client with anorexia nervosa?

Registered dietician

Which health insurance program is a state-operated provider for medical assistance to people with low incomes?

Medicaid

Which statement is true regarding Medicaid?

Medicaid provides services to clients of all age groups.

Which approach to mental health care can be cost effective by preventing duplication of services and fragmentation of care?

Mental health care team

Which risk factor would the nurse include when screening a preoperative client? Select all that apply. One, some, or all responses may be correct.

Obesity Diabetes Smoking Peripheral vascular disease Advanced age with inactivity

Which information will the LPN include in the report to a registered nurse (RN) after a laboring client's membranes spontaneously rupture? Select all that apply. One, some, or all responses may be correct.

Odor Color Time of rupture Fetal heart rate Amount of fluid

Which medication would the nurse administer to specifically lower a client's elevated triglyceride level?

Omega-3 fatty acids

Which nursing theorist addresses an intervention including teaching a client with diabetes to inspect the feet daily and wear well-fitting shoes to prevent foot ulcers?

Orem

Which side effect will the nurse monitor for in an elderly client prescribed selective serotonin reuptake inhibitors (SSRIs) for depression?

Orthostatic hypotension

Which concern explains why generalized phrases should be avoided in documentation?

Overlooking the actual content of the report

An 8-year-old girl visits the school nurse frequently with vague ailments. The nurse spends time listening to the girl, takes her temperature, and always sends her back to class. One Thursday, the girl tells the nurse that she no longer wants to visit her grandfather at his home because he "hugs me too tight and touches me down there" (pointing to her genitals). She has told her mother that she does not want to spend the weekend with her grandparents, but her mother says that she has no choice. Which is the appropriate action by the nurse?

Reporting the alleged abuse to the local child protective agency and encouraging an investigation before the weekend visit

Which basic human need is included in the fourth level of Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct.

Self-worth Achievement

Which is a key feature of assisted living in a residential care setting? Select all that apply. One, some, or all responses may be correct.

Services available 24 hours per day Services provided to promote independence Emphasizes privacy and a homelike environment

Which sign during an assessment of a 3-year-old child would cause the emergency department nurse to consult another team member? Select all that apply. One, some, or all responses may be correct.

Skin burns with well-defined shapes Bruises in different stages of healing Healing lacerations in the presence of new ones Scars that cannot be explained History of multiple limb fractures

Which staff member is part of a core interdisciplinary hospice team? Select all that apply. One, some, or all responses may be correct.

Social worker Medical director Nursing coordinator

Which action would the nurse take after being notified that the latest potassium level for a client in acute renal failure is 6.2 mEq?

Take vital signs and notify the primary health care provider

Which of these is the source of support for visiting nurse associations that provide community health services?

Tax-deductible contributions

Which response is most appropriate for the home health care nurse when asked to straighten the blankets on the bed after completing a follow-up visit?

"Of course. I want to do whatever I can for you."

Which tort in nursing practice involves intentional touching without the client's consent?

Battery

Which condition would require a written prescription before a nurse can cut a client's nails?

Diabetes

Which factor is associated with increased vaginal pH? Select all that apply. One, some, or all responses may be correct.

Antibiotics Menopause Hyperglycemia Unprotected sex Menstrual period

Which finding during a follow-up appointment with a client with a history of right-sided heart failure would justify notifying the health care provider (HCP)? Select all that apply. One, some, or all responses may be correct.

Ascites Fatigue Dyspnea 3+ pitting edema 6-lb weight gain

What is the role of a physical therapist on an interdisciplinary team for collaborative care?

Assisting in the client's rehabilitation

Which condition is an example of a disruptive behavioral disorder commonly encountered by school nurses?

Attention-deficit/hyperactivity disorder

Which type of leadership is reflected when a nurse delegates tasks to a rescue team caring for a group of clients who survived an earthquake?

Autocratic

Which data would the nurse collect before administering benazepril?

Blood pressure

Which type of home health care agency is most likely to be owned by corporate chains and be profit oriented?

Proprietary

Which statement is true about do-not-resuscitate (DNR) orders?

The physician consults with the client before writing DNR orders.

Which advantage of inpatient care is important regarding psychiatric care for a client with schizophrenia who admits to hearing people encouraging the client to self-harm?

Care in a safe and secure environment

Which area of the spine is most at risk for traumatic injury?

Cervical

Which member of the hospice care team is responsible for providing respite care to the client's caregiver?

Volunteer coordinator

Which risk factor would the nurse include when teaching a client about atherosclerosis? Select all that apply. One, some, or all responses may be correct.

Diabetes mellitus

Which item is assessed using the "Resolve" portion of the Adaptation, Partnership, Growth, Affection, and Resolve (APGAR) screening tool?

Distribution of finances and space

Which disorder is a low maternal serum alpha-fetoprotein level associated with?

Down syndrome

Which statement is true regarding democratic leadership?

Emphasizes team building through joint efforts of all team members

Which purpose is served by obtaining informed consent?

Enabling the client to make knowledgeable decisions

Which action should a nurse take immediately with a client returning to the unit following a subtotal thyroidectomy?

Ensure that a tracheostomy kit is at the bedside.

Relatives of the victims of a home invasion in which several family members were killed receive crisis intervention services. Which therapy is most beneficial after the immediate event has passed?

Grief

Which action is the staff nurse's ethical obligation when the nurse manager comes to work obviously intoxicated?

Have the supervisor validate the observation.

When an adolescent client tells the nurse, "I have this awful pain during my periods; it never stops," the nurse would encourage her to do take which action?

Having a gynecologic examination

Which statement describes the goal of an interdisciplinary care planning (ICP) meeting?

Health care providers (e.g., physician, nurse, resident, family, therapists) devising a plan of care

Which sign indicates that a client on supplemental oxygen is experiencing acute respiratory distress syndrome (ARDS)?

Hypoxemia

Which information about the importance of adolescents developing their own identity would the nurse provide parents that can help this process?

Include important religious traditions.

Which is the appropriate preoperative goal for an infant born with myelomeningocele?

Keeping the infant infection free

Which response would indicate mass hysteria to the nurse after a local disaster occurs?

Panic

Which criterion would the nurse select when developing a form for teachers to use when referring students to the school counselor? Select all that apply. One, some, or all responses may be correct.

Parental divorce

A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. Which level of prevention does this activity reflect?

Primary

While communicating with the primary health care provider via phone, the nurse wants to repeat the prescription to ensure better understanding. Which method of communication of SBARR would the nurse choose?

Read-back

Which reason for elevating the head when providing postoperative care for a client with esophageal cancer would a nurse explain to the nurse assistant?

Reduces the risk for reflux of gastric materials into the esophagus

Following a thyroidectomy, which problem would the nurse suspect when providing care for a client whose has numbness in mouth, fingers, and toes, as well as muscle tingling and twitching?

Tetany

Which act creates incentives for Medicare and Medicaid providers to improve staffing in long-term care facilities?

The Patient Protection and Affordable Care Act (PPACA.)

Which sign would a nurse look for in a client experiencing a migraine? Select all that apply. One, some, or all responses may be correct.

tearing Nausea Irritability Depression Hypersensitivity to light and sound Severe, unilateral pain in temple or eye area