Week 5 Chapter 16 Prep U questions

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? a. Coordinating b. Supervisory c. Supportive d. Psychosocial

c. Supportive

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? a. Surveillance b. Educational c. Maintenance d. Supervisory

b. Educational

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? a. The outcome should indicate what the nurse will do. b. The nurse has not made any error in writing the outcome. c. The nurse has omitted the time frame. d. The nurse has omitted the defining characteristics.

c. The nurse has omitted the time frame.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a. initial planning. b. comprehensive planning. c. discharge planning. d. ongoing planning.

c. discharge planning.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? a. Identify the appropriate nursing diagnoses. b. Include the rationale for the interventions. c. Expect to modify the plan significantly. d. Individualize the plan to the client.

d. Individualize the plan to the client.

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met? a. "I walk daily wearing low-heeled shoes." b. "I removed scatter rugs from my home." c. "I turn on lights at night so I won't fall." d. "I take extra calcium to make my bones stronger."

a. "I walk daily wearing low-heeled shoes."

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? a. Outcome b. Process c. Structure d. Cost-effectiveness

a. Outcome

Which is an example of a nurse-initiated intervention? a. Teach the client how to splint an abdominal incision when coughing and deep breathing. b. Administer a 1000-mL soap suds enema. c. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. d. Administer oxygen at 4 L/min per nasal cannula.

a. Teach the client how to splint an abdominal incision when coughing and deep breathing.

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? a. "Do you want to be discharged without treatment?" b. "Please tell me your thoughts about treating this diagnosis." c. "You need to stop smoking for us to effectively combat this disease." d. "What are your plans after discharge?"

b. "Please tell me your thoughts about treating this diagnosis."

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome? a. Choosing actions that do not solve the problem b. Developing the plan without client input c. Beginning the plan without family to help d. Failing to update the written plan of care

b. Developing the plan without client input

Which action should the nurse perform during the planning phase of the nursing process? a. Analyze the client's response to medicines. b. Identify measurable goals or outcomes. c. Assess the client's overall health. d. Identify the client's health-related problems.

b. Identify measurable goals or outcomes.

The nurse recognizes that identifying outcomes/goals must include: a. input from the physician. b. involvement of the client and family. c. involvement of the nurse manager and other staff nurses. d. input from the multidisciplinary team.

b. involvement of the client and family.

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? a. "I will take my medications between meals for maximum effect." b. "I will mix insulin glargine with insulin lispro at bedtime." c. "I will take insulin until my blood sugar levels are normal." d. "I will test my glucose level before meals and use sliding scale insulin."

d. "I will test my glucose level before meals and use sliding scale insulin."

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? a. Client lipids are within range. b. Client is drowsy after lunch. c. Client reports no headache. d. Client is normotensive.

d. Client is normotensive.

Which outcome for a client with a new colostomy is written correctly? a. The client will demonstrate proper care of the stoma by 3/29/20. b. The client will know how to care for the stoma by 3/29/20. c. Explain to the client the proper care of the stoma by 3/29/20. d. The client will be able to care for stoma and cope with psychological loss by 3/29/20.

a. The client will demonstrate proper care of the stoma by 3/29/20. b. The client will know

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? a. Nurses are responsible for reminding physicians to implement orders. b. Nurses do carry out interventions in response to a physician's order. c. Nurses are not legally responsible for these interventions. d. Nurses do not carry out physician-initiated interventions.

b. Nurses do carry out interventions in response to a physician's order.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? a. As soon as possible after the client's surgery b. On the client's admission to the hospital c. Once the client is admitted to the nursing unit from postanesthetic recovery d. Once the client has received a discharge order

b. On the client's admission to the hospital

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan? a. Initial b. Standardized c. Discharge d. Ongoing

b. Standardized

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? a. A 68-year-old woman with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning b. A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly c. A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious d. An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who is talking rapidly on a cell phone

c. A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious