Wellness Exam 1: BSN1

A nurse is cautioning the mother of an 8-month old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? - "My baby loved to play with his crib gym, but I took it away from him." - "I just bought a soft mattress so my baby will sleep better." - "My baby really likes sleeping on the fluffy pillow we just got for him." - "I put the baby's car seat out of the way on the table after I put him in it."

- "My baby loved to play with his crib gym, but I took it away from him."

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? - Assault - Battery - False imprisonment - Invasion of privacy

- Assault

A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PA CU following thoracic surgery. To which of the following staff members should the nurse assign this client? - Charge nurse - RN - Practical nurse (PN) - Assistive personnel (AP)

- RN

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? - Install bath railings and grab bars in bathrooms - Wear a helmet while skiing - Install a carbon monoxide detector - Secure firearms in a safe location - Remove throw rugs from the home

- wear a helmet while skiing - install a carbon monoxide detector - secure firearms in a safe location

Which factors are affecting the nursing shortage? (Select all that apply.) a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses

A., B., D. *The nursing workforce and nursing faculty are aging. The entire population is aging, which increases the need for more nurses. The insufficient number of nurses leads to job dissatisfaction and burnout.

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? - Fidelity - Autonomy - Justice - Nonmaleficence

Autonomy

A 2-year-old child insists on having a drink of water, having a story read to him, and says "Good night, sleep tight" at bedtime every night. The nurse knows the child is exhibiting which type of behavior? a. Controlling b. Ritualism c. Obsession d. Compulsion

B. *Ritualism offers the toddler a sense of security and comfort. The child is not trying to control his behavior with the ritual. Obsession and compulsion are terms commonly used in patients in older age group sand describe maladaptive behaviors.

The nurse is performing a health assessment on a 15-year-old female patient. Which is the best way to obtain accurate information regarding her sexual activity? a. Ask the mother about the girl's sexual activity. b. Privately ask the girl about her sexual activity. c. Warn the girl about the dangers of sexual activity. d. Ask the girl if she wants birth control.

B. *Privately asking the girl about her sexual activity in an open and nonjudgmental fashion is the best way to obtain accurate information. Asking the mother about the girl's sexual activity may be embarrassing for the teen and her mother and may not provide accurate information. Warning the girl about the dangers of sexual activity is making a judgment. It is important to provide a nonjudgmental approach with teens. The teen may have additional questions about sexuality beyond the topic of birth control, so it is important to approach the teen in a manner that encourages open discussion.

Which specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability

B. *Theories establish a specific nursing body of knowledge that is unique to the discipline, which is one criterion of a profession.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ehtical principles? - Fidelity - Autonomy - Justice - Beneficience

Beneficence

Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Leadership

C. *The nurse and other health care workers are exhibiting cultural competence by being responsive to patients' health beliefs and practices that are influenced by the individual's culture.

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the folloiwng examples should the charge nurse should include as a development task for a young adult? - Becoming actively involved in providing guidance to the next generation - Adjusting to major changes in roles and relationships due to losses - Devoting a great deal of time to establishing an occupation - Finding oneself "sandwiched" between and being responsible for two generations

Devoting a great deal of time to establishing an occupation

A nurse questinos a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? - Fidelity - Autonomy - Justice - Nonmaleficence

Nonmaleficence

A nurse is assessing from a 2 week old newborn during a routine checkup. Which of the following findings should the nurse expect? - Sleep 14 to 16 hrs each day - Posterior fontanel closed - Pincer grasp present - Hands remain in a closed position - Current weight same as birth weight

- Sleeps 14 to 16 hr each day - Hands remain in a closed position - Current weight same as birth weight

A nurse is reviewing the CDC's immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? - Rotavirus - Varicella - Herpes zoster - Human papilloma virus - Seasonal influenza

- varicella - human papilloma virus - seasonal influenza

Which action by a 3-month-old infant would the nurse interpret as an example of Piaget's stage of primary circular reaction? a. Deliberately placing the thumb into the mouth b. Accidentally kicking a ball c. Searching for an object under a blanket d. Shaking a rattle

A. *The deliberate action of placing the thumb in the mouth elicits a pleasurable effect. Accidentally kicking a ball is not a deliberate action. Searching for objects and shaking a rattle occur at later stages.

A nurse has performed a physical examination of the patient and reviewed the laboratory and diagnostic test results on the patient's chart. The nurse is performing which specific nursing function? a. Diagnosis b. Assessment c. Education d. Advocacy

B. *the nurse is preforming the first step in the nursing process: assessment.

In comparing the American Nurses Association (ANA) and International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA's definition and is indicative of a more global focus? a. Advocacy b. Health promotion c. Shaping health policy d. Prevention of illness

C. *The ICN's definition of nursing expands on the ANA's definition by providing for the concept of shaping health policy as a responsibility of nursing.

In Swanson's Middle Range Theory of Caring, the nurse demonstrates caring using several techniques. What action is included in the five caring processes? a. Call patients by their first name to demonstrate a caring attitude. b. Sit at the bedside for at least 5 minutes each hour. c. Use touch based on the nurse's judgment of what is appropriate. d. Ask the patient to identify the most important thing that the patient would like to accomplish during the nurse's shift.

D. *The answer is based on the idea that the patient should always, whenever possible, be included in developing the plan of care and especially in setting his or her own goals. The other three answers are close, but something is wrong with each one. Calling patients by their first name to demonstrate a caring attitude is incorrect because the nurse should call each patient by his or her preferred name. Sitting at the bedside for at least 5 minutes each hour is incorrect because the nurse should sit at the bedside for 5 minutes each shift rather than each hour. Using touch based on the nurse's judgment is wrong because the nurse should allow the patient to decide how much touch is appropriate.

A preschooler's mother is concerned because her child behaves in a mean fashion toward her younger brother. The mother states, "She acts like she has no sympathy for him!" What is the nurse's best response? a. "She is very young to exhibit sibling rivalry." b. "What does her brother do to her to make her act this way?" c. "Do you fight at home? She is probably imitating you." d. "Preschoolers are not capable of putting themselves in another's place."

D. *A characteristic of a preschooler thought is that it is egocentric. That is, preschoolers are not yet able to see a situation from another's point of view. Sibling rivalry commonly appears in the preschool period. The brother's behavior has no bearing on the mother's expressed concern. The child is not necessarily imitating adult behavior but is displaying appropriate developmental characteristics.

A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? - Assault - False imprisonment - Negligence - Breach of confidentiality

False imprisonment

A nurse is talking with the parents of a 10-year old child who is concerned that their son is becoming secretive, such as closing the door when he showers, and dresses. Which of the following responses should the nurse make? - "Perhaps you should try to find out what he is doing behind those closed doors." - "Suggest that he leave the door ajar for his own safety." - "At this age, children tend to become modest and value their privacy." - "You should establish a disciplinary plan to stop this behavior."

"At this age, children tend to become modest and value their privacy."

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? - "I spent my whole life dreaming about retirement, and now I wish I had my job back." - "It's been so stressful for me to have to depend on my son to hep around the house." - "I just heard my friend Al died. That's the third one in 3 months." - I keep forgetting which medications I have taken during the day."

"I keep forgetting which medications I have taken during the day."

A nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? - "My son mimics my husband getting dressed." - "My son temper tantrums every time we tell him to do something he doesn't want to do." - "I thin my son truly believes toys have personalities and talk to him." - "I feel bad when I see my son trying so hard to button his shirt."

- "My son has temper tantrums every time we tell him to do something he doesn't want to do."

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? - Metabolism - Ability to hear low pitched sounds - Gastric secretions - Far vision - Glomerular filtration

- metabolism - gastric secretions - glomerular filtration

A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? - Rolls from back to front - Bears weight on legs - Walks holding onto furniture - Sits unsupported - Sits down from a standing position

- rolls back to front - bears weight on legs - sits unsupported

2. A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? (Select all that apply.) a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism

A. B. C. E. *Nursing as a profession has a code of ethics, licensing, a body of knowledge, and altruism. Because there are multiple paths of education for nursing and not a standard entry into practice, this is one criterion of a profession that is not standard and consistent.

What is the best activity for a hospitalized school-age child to encourage continued appropriate development? a. Watching favorite television shows for 2 hours per day b. Keeping a journal of feelings while in the hospital c. Working on a paint-by-number project that can be completed in an afternoon d. Playing a favorite video game each afternoon

C. *The school-age child is in Erikson's stage of industry. He needs to work on projects that build a sense of accomplishment. A painting project that can be completed in one afternoon gives a sense of accomplishment. Although the other options are activities, they do not contribute to the primary developmental task of the school-age child: developing a sense of industry.

A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? - Fidelity - Autonomy - Justice - Nonmaleficence

Justice

Which nursing theory of care describes how the nurse's presence in the nurse-patient relationship transcends the physical and material world, facilitating development of a higher sense of self by the patient? a. Swanson's Middle Range Theory of Caring b. Madeline Leininger's Cultural Care Theory c. Watson's Theory of Human Science and Human Care

C. * One of the major concepts of Watson's Theory of Human Caring is described in the stem of the question. Watson's theory is based on a holistic paradigm in which both the nurse and the patient transcend time and the physical and material world. Swanson's theory focuses on practical ways the nurse can help the patient through the use of the five caring processes. Leininger's theory focuses on maintaining and preserving the patient's cultural practices and ways of living but never mentions transcending beyond the physical world. Travelbee's theory focuses on the nurse and the patient creating a relationship bond, but the only mention of transcendence is that the nurse and the patient must transcend the roles that each has assumed.

Which statement best describes for new parents how and when children develop first-order beliefs? a. During infancy, and once developed, such beliefs seldom change b. From life experiences during the toddler and preschool years c. Throughout life from firsthand experiences and information provided by authority figures d. From teen and young-adult peer interaction and mentorship of professional role models

C. *Individuals develop first-order beliefs beginning in childhood and continue to acquire them throughout life from first-hand experiences and what they are told by various authority figures. Therefore, first-order beliefs are acquired throughout life and not just in infancy, the first years of life, or adolescence. They form as the result of life experiences and from information provided by people perceived as having authority.

A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism

C. *The nurse is demonstrating accountability by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include altruism (public service over personal gain), autonomy (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although collaboration is important for the health care team, it is not a criterion for a profession.

A new nurse is about to insert a nasogastric tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? (Select all that apply.) a. Offer the patient pain medication to help her calm down. b. Hold the patient's hand while inserting the nasogastric tube. c. Speak calmly while explaining the procedure to the patient beforehand. d. Ask another, more experienced nurse for assistance before initiating care. e. Obtain and insert the nasogastric tube as quickly as possible without explanation.

C., D. *Using a calm voice and seeking help from an experienced nurse exhibit caring for the patient and will help to allay patient anxiety. Medicating a patient for pain before the experience will not automatically alleviate patient anxiety and may cause the patient to experience greater confusion. The nurse will need to use both hands to safely insert the nasogastric tube and promote a positive patient outcome, so the nurse is unable to hold the patient's hand during the procedure.

The nurse knows that which patient is an example of the Wear-and-Tear Theory of Aging? a. A patient who is dying of cancer at age 35 b. A 55-year-old who runs half-marathons c. A patient with depression and suicidal thoughts who is 65 d. An 88-year-old with heart failure, kidney failure, and osteoarthritis

D. *Dr. Weisman believed that aging occurred because of overuse and abuse to body and cells, and that this takes place on the cellular and organ systems level. An 88-year-old with multiple body system failure and damage would be exhibiting signs of wear and tear. A 35-year-old patient dying of cancer would not have overuse. A 55-year-old running in half marathons is not exhibiting wear and tear, although signs of overuse may emerge later in life. A 65-year-old person with depression is not exhibiting wear and tear. Emotional stressors are only one group of factors that can lead to aging and are not a component of the wear-and-tear theory.

Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques? a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching

D. *A nurse educator who is teaching and counseling students is practicing expert coaching and guidance. A nurse educator with a master's degree practices the other competencies of leadership and ethical decision making in other situations. Although a nurse educator may also work as a nurse involved in direct patient care, this is not part of the educator role.

A nurse is teaching the father of a 12-year old boy about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? - Appearance of downy hair on the upper lip - Hair growth in the axillae - Enlargement of the testes and scrotum - Deepening of the voice

Enlargement of the testes and scrotum

A nurse is talking with the parent of a 4 year old child who states that his child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? - Offer the child a large snack before bedtime. - Allow the child to watch an extra 30 min of TV in the evening - Have the child take an afternoon nap - Increase physical activity before bedtime.

Have the child take an afternoon nap.

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? - The client evaluates his behavior after a social interaction - The client states he is learning to trust others - The client wishes to find meaningful friendships - The client expresses concerns about the next generation

The client expresses concerns about the next generation

A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following should the nurse identify as the priority? - "I kind of like this boy in my class, but he doesn't like me back." - "I want to hang out with the kids in the science club, but the jocks pick on them." - "I am so fat, I skip meals to try and lose weight." - "My dad wants me to be a lawyer like him, but I just want to dance."

"I am so fat, I skip meals to try and lose weight."

A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following client statments should the nurse identify as the priority to assess further? - "I have my own apartment now, but it's not easy living away from my parents." - "It's been so stressful for me to even think about having my own family." - "I don't even know who I am yet, and now I'm supposed to know what to do." - "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."

"I don't even know who I am yet, and now I'm supposed to know what to do."

A nurse is reviewing nutritional guidelines with the parents of a two year old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? - "I should keep feeding my son whole milk until he is 3 years old." - "It's okay for me to give my son a cup of apple juice with each meal." - "I'll give my son about 2 tablespoons of each food at mealtimes." - "My son loves popcorn, and I know that it is better for him than sweets."

"I'll give my son about 2 tablespoons of each food at mealtimes"

A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? - "I already had my immunizations as a child, so I'm protected in that area." - It is important to schedule routine health care visits even if I am feeling well." - "I will just go to urgent care center for my routine medical care." - "There's not reason to seek help if I am feeling stressed because it's just part of life."

"It is important to schedule routine health care visits even if I am feeling well."

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? - "I am struggling to accept that my parents are aging and need so much help." - "It's been so stressful for me to think about having intimate relationships." "I know I should volunteer my time for a good cause, but maybe I'm just selfish." - "I love my grandchildren, but my son expects me to relive my parenting days."

"It's been so stressful for me to think about having intimate relationships."

A nurse is talking with parents of a 12-year old child. Which of the following issues verbalized by the parents should the nurse identify as the priority? - "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." - "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." - "We think our son is trying too hard to excel in math just to get the top grades in his class." - "Our son is always afraid the kids in school will laugh at him because he likes to sing."

"We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping"

A nurse is evaluating teaching about nutrition with the parents of an 11 year old child. Which of the following statements should indicate to the nurse an understanding of the teaching? - "She wants to eat as much as we do, but we're afraid she'll soon be overweight." - "She skip slunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." - "We limit fast-food restaurant meals to three times a week now." - "We reward her school achievements with a point system instead of pizza or ice cream."

"We reward her school achievements with a point system instead of pizza or ice cream."

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives. - "I'd rather have my brother make decisions for me, but I know it has to be my wife." - "I know they won't go ahead with the surgery unless I prepare these forms." - "I plan to write that I don't want them to keep me on a breathing machine." - "I will get my regular doctor to approve my plan before I hand it in at the hospital."

- "I plan to write that I don't want to keep me on a breathing machine."

The mother of a 7 month old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? - "It might be good to add bananas, as they can help with loose stools." - "Let's make a list of foods he is eating so we can spot any problems." - "Did the changes begin after you started one particular food?" - "Has he been vomiting since he started these new foods?" - "Most babies react with a little indigestion when you start new foods."

- "Let's make a list of the foods he is eating so we can spot any problems." - "Did the changes begin after you started one particular food?" - Has he been vomiting since he started these new foods?"

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? - A client who has terminal cancer requests hospice care in her home. - A client asks about community resources available for older adults - A client states that she wants her child baptized before surgery - A client requests an electric wheelchair for use after discharge - A client states that he does not understand how to use a nebulizer

- A client who has terminal cancer requests hospice care in her home - A client asks about community resources available for older adults - A client requests an electric wheelchair for use after discharge

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? - A nurse on a medical-surgical unit demonstrates signs of chemical impairment - A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. - A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. - A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

- A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? - Bathing - Ambulating - Toileting - Determining pain level - Measuring vital signs

- Bathing - Ambulating - Toileting - Measuring vital signs

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? - Collaborating with providers to perform obesity screenings during routine office visits - Ensuring the availability of specialized beds in rehab centers for clients who have obesity - Providing specialized intraoperative training regarding surgical treatments for obesity - Educating acute care nurses on postoperative complications

- Collaborating with providers to perform obesity screenings during routine office visits

A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his past admission 6 months ago. Which of the following instructions should the nurse be including in the teaching? - "Eat three large meals a day." - "Eat your meals in front of the television." - "Eat foods that are easy to eat, such as finger foods." - "Invite family members to eat meals with you." - "Exercise every day to increase appetite."

- Eat foods that are easy to eat, such as finger foods - Invite family members to eat with you - Exercise every day to increase appetite

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? - Monitoring evidence based practice for clients who have a specific diagnosis - Ensuring that health care providers comply with regulations - Setting quality standards for accreditation of health care facilities - Determining if medications are safe for administration to clients

- Ensuring that health care providers comply with regulations

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? - Establish consistent boundaries for the toddler - Place the toddler in a room with the door closed - Inform the toddler how you feel when he misbehaves - Use favorite snack to reward the toddler

- Establish consistent boundaries for the toddler

A nurse is planing diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? - Building models - Working with clay - Filling and emptying containers - Playing with blocks - Looking at books

- Filling and emptying containers - Playing with blocks - Looking at books

A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? - Reassure the child an injection will not hurt - Mix oral medications in a large glass of milk - Offer the child choices when possible - Have the parents bring in a favorite toy from home - Engage the child in pretend play with a toy medical kit

- Have the parents bring in a favorite toy from home - Engage the child in pretend play with a toy medical kit

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? - Home health care - Rehab centers - Diagnostic centers - Skilled nursing facilities - Oncology centers

- Home health care - Rehab facilities - Skilled nursing facilities

A nurse is reviewing the CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? - Influenza - Measles, mumps, rubella - Pertusis - Tetanus - Polio

- Influenza - pertussis - tetanus

A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? - Intensive care unit - Oncology treatment center - Burn center - Home health care

- Intensive care unit - Oncology treatment center - Burn center

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? - Make sure the surgeon obtained the client's consent - Witness the client's signature on the consent form - Explain the risks and benefits of the procedure - Describe the consequences of choosing not to have the surgery - Tell the client about alternatives to having the surgery

- Make sure the surgeon obtained the client's consent - Witness the client's signature on the consent form

A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financial mechanisms are federally funded? - Preferred provider organization (PPO) - Medicare - Long-term care insurance - Exclusive provider organization (EPO) - Medicaid

- Medicare - Medicaid

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? - Social worker - Certified nursing assistant - Registered dietician - Occupational therapist

- Occupational therapist

A client who is postoperative following a knee arthroplasty is concerned about the adverse effects on the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? - Provider - Certified nursing assitant - Pharmacist - Registered nurse - Respiratory therapist

- Pharmacist - Provider - Registered nurse

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? - Human papilloma virus immuniaztion - Pneumococcal immunization - Yearly eye examination - Periodic mental health screening - Annual fecal occult blood test

- Pneumococcal immunization - Yearly eye examination - Periodic mental health screening - Annual fecal occult blood test

A nurse is reviewing car seat safety with the parents of a 1 month old infant. When reviewing car seat use, which of the following instructions should the nurse include? - Use a car seat that has a three-point harness system. - Position the car seat so that the infant is rear facing - Secure the car seat in the front passenger seat of the vehicle - Convert to a booster seat after 12 months

- Position the car seat so that the infant is rear-facing

A nurse on a medical-surgical unit has received change-of-shit report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? - Feeding a client who was admitted 24 hr ago with aspiration pneumonia - Reinforcing teaching with a client who is learning to walk using a quad cane - Reapplying a condom catheter for a client who has urinary incontinence - Applying a sterile dressing to a pressure ulcer

- Reapplying a condom catheter for a client who has urinary incontinence

A nurse has noticed several occasions in the past week when another nurse on the unity seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? - Alert the American Nurses Association - Fill out an incident report - Report the observations to the nurse manager on the unit - Leave the nurse alone to sleep

- Report the observations to the nurse manager on the unit

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? - Right client - Right supervision and evaulation - Right direction and communication - Right time -Right circumstances

- Right supervision and evaluation - Right direction and communication - Right cirumstances

A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? - Social worker - Certified nursing assitant - Occupational therapist - Speech-language pathologist

- Speech-language pathologist

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? - Develop an acceptance of diminished strength and increased dependence on others - Spend time focusing on improving job preformance - Welcome opportunities to be creative and productive - Commit to finding friendship and companionship - Become involved with community issues and activities

- Spend time focusing on improving job performance - Welcome opportunities to be creative and productive - Become involved with community issues and activities

A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? - Suggest that his parents bring in video games for him to play - Provide a television and DVDs for the adolescent to watch - Limit visitors to the adolescent's immediate family - Involve the adolescent in treatment decisions when possible - Allow the adolescent

- Suggest that his parents bring in video games for him to play - Provide a television and DVDs for the adolescent to watch - Involve the adolescent in treatment decisions when possible - Allow the adolescent to perform his own morning care

An RN is making assignment for a practical nurse (PN) at the beginning of the shift. Which of the following assingments should the PN question? - Assisting a client who is 24hr postoperative care to use an incentive spirometer - Collecting a clean-catch urine specimen from a client who has a wound infection - Providing nasopharyngeal suctioning for a client who has pneumonia - Teaching a client who has asthma to use a metered-dose inhaler

- Teaching a client who has asthma to use a metered-dose inhaler

A nurse is delegating the ambulation of a client who had knee arhtroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? - The roommate ambulates independently - The client ambulates with his slippers on over his antiembolic stockings - The client uses a front-wheeled walker when ambulating - The client had pain medication 30 min ago - The client is allergic to codeine - The client ate 50% of his breakfast this morning

- The client ambulates with his slipper on over his antiembolic stockings. - The client uses a front-wheeled walker when ambulating - The client had pain medication 30 minutes ago

A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? - assembling puzzles - pulling wheeled toys - using musical toys - playing with puppets - coloring with crayons

- assembling puzzles - using musical toys - playing with puppets - coloring with crayons

A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? - Building models - Playing video games - Reading books - Using toy carpentry tools - Playing board games

- building models - playing video games - reading books - playing board games

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? - skin thickening - decreased height - increased saliva production - nail thickening - decreased bladder capacity

- decreased height - nail thickening - decreased bladder capacity

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? - Eye examination every 1-3 years - Decrease intake of calcium supplements - DXA screening for osteoporosis - Increase intake of carbs in the diet - Screening for depressive disorders

- eye examination every 1-3 years - DXA screening for osteoporosis - increase intake of carbohydrate in the diet - screening for depressive disorders

A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? - Increase protein intake to increase muscle mass. - Decrease fluid intake to prevent urinary incontinence - Increase calcium intake to prevent osteoporosis - Limit sodium intake to prevent edema - Increase fiber intake to prevent constipation

- increase protein intake to increase muscle mass - increase calcium intake to prevent osteoporosis - limit sodium intake to prevent edema - increase fiber intake to prevent constipation

A nurse is preparing a wellness presentation for families about health screening for adolscents. Which of the following information should the nurse include? - Obtain a periodic mental status evaluation - Discuss prevention of sexually transmitted infections - Regularly screen for tuberculosis - Provide education about drug and alcohol use - Teach monthly breast examinations for girls

- obtain a periodic mental status evaluation - discuss prevention of sexually transmitted infections - regularly screen for tuberculosis - provide education about drug and alcohol

A nurse is planning a health promotion and primary prevention class for the parents of school-age children. Which of the following information should the nurse include? - Provide information about the risk of childhood obesity - Discuss the danger of substance use disoders - Promote and discuss sexual issues - Recommend the school-age child sit in the front seat of the car - Reinforce stranger awareness

- provide information about the risk of childhood obesity - discuss the danger of substance use disorders - promote discussion about sexual issues - reinforce stranger awareness

A nurse is giving a presentation about accident prevention to a group of parents and toddlers. Which of the following accident-prevention strategies should the nurse include? - Store toxic agents in locked cabinets - Keep toilet seats up - Turn pot handles towards the back of the stove - Place safety gates across stairways - Make sure balloons are fully inflated

- store toxic agents in locked cabinets - turn pot handles toward the back of the stove - place safety gates across stairways

A mother tells the nurse that her 2-year old toddler has temper tantrums and says "no" every time the mother tries to help her get dressed. The nurse should recognize, the toddler is manifesting which of the following stages of development? - Trying to increase her new independence - Developing a sense of trust - Establishing a new identity - Attempting to master a skill

- trying to increase her independence

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? - Haemophilus influenzae type B - Varicella - Polio - Hepatitis A - Seasonal influenza

- varicella - polio - seasonal influenza

From the nurse's knowledge about the emerging adult according to Arnett's theory, which behavior by a 21-year-old hospitalized male patient is most appropriate for his age group? a. Talking about college courses that he is taking while working part-time at a restaurant b. Requesting that his mom be present when his IV line is started c. Stating that he cares for his disabled father and his 2-year-old daughter d. Becoming upset that he is not giving back to his community

A. *According to Arnett (2006), emerging adults are shifting their choices, and many are unstable; they explore more possibilities and move gradually toward enduring choices. The young adult is often slow in transitioning due to pursuing higher education. This 21-year-old is pursuing education while working part time, which fits within Arnett's theory for this age group. A 21-year-old male would be exhibiting regression if he needed his mom with him during an IV start. Caring for his father and daughter would be more typical of middle adults, who are called the "sandwich" generation. Giving back to one's community is generativity, which is Erikson's middle adult developmental task.

A teenage girl faces a long hospitalization after surgery. How can the girl's continued development be fostered? a. Encourage her to write her feelings in a journal. b. Divert her attention by playing video games. c. Encourage her to work on craft projects. d. Make sure her parents are constantly by her side.

A. *Teenagers are capable of abstract thought and often find it helpful to verbalize their feelings either by talking or by journaling. Diverting her attention by playing video games and encouraging her to work on craft projects are measures that may be used to help her pass the time but are not methods of fostering teen development. A teen usually does not wish parents to be at their side constantly and may want some private time away from them.

When an injury to a child is suspicious for abuse, which findings are important to document? (Select all that apply.) a. Size and location of bruising b. Distinguishing characteristics of injuries c. Height and weight of the child d. Time of last meal e. General state of health of the child

A., B., C., E. *The size and location of the bruising, distinguishing characteristics of injuries, height and weight of the child, and the general state of health of the child all are considerations in determining possible child abuse or neglect. The exact location and the nature of the injury are important to document. A child who has been abused over time may be small and have other health problems stemming from the abuse. The time of the last meal may be important information but usually is not related to suspected abuse.

The nurse is caring for a group of older adults. Which patients in this group are exhibiting normal signs of aging? (Select all that apply.) a. The patient with knee pain and wrinkles around the eyes b. The patient who needs reading glasses and states that the food tastes bland c. The patient who is confused and does not know the current year d. The patient who states that constipation is an increasing problem e. The patient who is showing signs of depression and hopelessness

A., B., D. *Normal aging includes signs of decline in many organ systems. Knee pain, skin wrinkles, need for reading glasses, decline in taste buds, and constipation all can occur with aging. Normal aging does not include dementia or depression, even though these can both be diagnosed in the older adult population.

Which statements describe a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. Conceptual makeup of the hospital administration d. The illness and health concept e. Safety aspect of medication administration

A., B., D. *There are four components that a nursing theory discusses: 1) the patient, 2) health, 3) environment, and 4) nursing - not the hospital administration.

Which components are included in the American Nurses Association (ANA) standards? (Select all that apply.) a. Standards for professional performance b. A code of ethics c. Standards of care d. Legal scope of practice e. Licensure requirements

A., C. *ANA standards have two parts: one is standards for professional performance, and the other is standards of care. ANA has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.

The mother of a 5-month-old infant is concerned because her child is not yet sitting on his own. What is the nurse's best response to her concerns? a. Informing the mother that this is not normal and recommending further evaluation b. Telling the mother that this is normal development for a 5-month-old c. Encouraging the mother to do sit-ups with the child to encourage muscle development d. Asking the mother if the child had any trauma at birth

B. *According to the American Academy of Pediatrics, 7 month olds will first sit with help and then sit on their own. A 5 month old is not expected to sit alone. Although sit-ups may help muscle development, the child's neurologic system must develop enough to maintain a sitting position. Asking about birth trauma is not necessary because the child is not exhibiting delayed development.

While assessing a patient for domestic violence, the nurse knows that which statement is true regarding domestic violence? a. It is a health risk factor only during young adulthood. b. It occurs across socioeconomic levels and cultural boundaries. c. Young women aged 20 to 24 have the lowest incidence of rape and sexual assaults. d. Women are the only victims of domestic violence whom nurses should be concerned about.

B. *All socioeconomic levels are affected by domestic violence. It is a health risk for adults of all ages from young to older adulthood. Young women have the highest rate of rape and sexual assault. Women are not the only victims of domestic violence. Men also may be victims of domestic violence and sexual assaults, although they are less likely to report it or to seek care.

A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The nurse knows that the child is exhibiting which scheme according to Piaget? a. Adaptation b. Assimilation c. Accommodation d. Equilibration

B. *Assimilation occurs when the child attempts to use a new object in the same fashion as for a more familiar object. Adaptation is the process of adjusting schemes to new applications. Accommodation occurs when the child understands that the object is different from a more familiar object and cannot be used in the same way. Equilibration occurs when a balance is achieved between the old understanding and the new.

Which behavior by the young adult patient indicates an understanding of patient education aimed at reducing the health risks for that age group? a. Smoking only one pack of cigarettes per day b. Limiting alcohol use to an occasional drink c. Using drugs found in a roommate's drawer for anxiety d. Having a relationship with a partner who was threatening in the past

B. *Having an occasional drink shows control and moderation. Smoking any amount is damaging, and education for cessation is needed. Using any drugs that are not directly prescribed for the person shows a lack of understanding of the risks of drugs. Staying in a relationship that has been dangerous in the past increases the risk of intimate partner violence.

How is the toddler's need for autonomy best met? a. The parents' consistently meeting the child's needs b. Allowing the child limited choices c. Encouraging imaginative play d. Promoting experimentation to determine cause and effect

B. *The toddler's need for autonomy can best be supported by allowing the child choices within limits. Parents consistently meet the child's needs during the infant period. In later developmental stages, imaginative play is encouraged, and experimentation is promoted to determine cause and effect.

As the nurse is explaining preoperative instructions to a patient, the patient's older brother suddenly steps into the doorway and yells, "People who go under the knife always die. Don't do it! They're going to kill you." What type of higher-order belief is the patient's older brother displaying? a. Distress b. Stereotype c. Prejudice d. Denial

B. *The patient's brother is making generalizations that is a stereotype, which is a belief about a person, group, or an event that is thought to be typical of all others in that group. Although it is true that people occasionally die during surgery, it does not always happne as the brother fears. Distress is incorrect; the male is distressed, but distress is not a higher-order belief. Prejudice is incorrect because a prejudicial belief is a preformed opinion, usually an unfavorable one, about an entire group of people based on insufficient knowledge. Denial is wrong because he is not in denial, which is defined as a behavior of refusing to admit something is true.

A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu because it is summer and the hospital is offering only chicken and fish, which in his culture are "hot" foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger's theory? a. Discourage the family from bringing in food, explaining that the idea of "hot" and "cold" foods is a superstition without scientific basis. b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient's blood pressure is supported. c. Explain that the patient will need to have home-prepared foods evaluated by the dietary staff to ensure that they are acceptable options. d. Tell the family to bring in any foods they want, to help preserve the patient's cultural practices and dietary preferences.

B. *According to Leininger's theory, negotiation and adaptation are part of what nurses do to accommodate the patient's cultural ways of life. As long as the foods from home have low concentrations of sodium or other ingredients that are known to affect blood pressure, the nurse can accommodate the patient's beliefs and cultural dietary practices as well as the medical plan of care. Rejecting the patient's cultural traditions and/or accepting them without regard for the well-being of the patient are unacceptable actions. Food given to patients from family members does not need to be evaluated by the dietary staff before consumption.

The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child's mother, she smells cigarette smoke on the mother's breath. The nurse asks the mother if she has been smoking and the mother responds, "Yes, and I know they've told me before I can't smoke around him." What should the nurse do next? a. Ask the patient's mother what she values most, her child or her habit. b. Ask the patient's mother to explain what she believes about smoking and asthma. c. Ask the patient's mother about her prejudicial feelings about continuing to smoke.

B. *The nurse should begin by asking the mother what she believes because the nurse does not know at this point. When working with a patient who has an addiction, the nurse should begin at the assessment phase of the nursing process and attempt to build a trusting relationship with the patient. Asking the mother what she values more, her child or her habit, is incorrect because the issue is not about the mother's values but about what she knows and what she believes. Asking the mother about her prejudicial attitude toward smoking is incorrect because there is nothing in the stem to indicate the mother is prejudiced toward or against smoking. Confronting the mother about the values conflict she is experiencing is incorrect because there is nothing in the question to indicate the mother is having a values conflict. She may not believe what the health care professionals are telling her or she may not believe that she can quit smoking. She may need to be convinced that she can do it, and the best way to make that happen is to build a trusting relationship with her rather than alienate her with accusatory remarks.

A patient is struggling with the decision of whether to accept experimental treatment for cancer. The nurse begins to offer information to a patient and the patient says, "I've already heard all of that before and I don't agree with any of it." How should the nurse proceed? a. Ask why the patient is so defensive. b. Encourage the patient to discuss his beliefs. c. Question the patient's prejudicial attitude. d. Confront the patient about his values conflict.

B. *The purpose of the question is contained in the stem, to determine whether the student can distinguish between a belief and a value. By asking the patient to explain what he or she believes, the nurse is asking an open-ended question to find out what part of the what the nurse is saying the patient believes and doesn't believe. Asking the patient to explain his or her values is incorrect because there is not mention in the stem about the patient saying his or her values are different from what the nurse is trying to say. Asking the patient about his or her prejudicial attitude is incorrect because there is nothing in the stem that indicates a prejudicial attitude. Confronting the pt about the values conflict he or she is experiencing is incorrect because there is nothing in the stem that indicates the pt is experiencing a values conflict. He or she simply does not believe the same thing the nurse believes.

A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which interventions would be most appropriate for the nurse to implement in this situation? (Select all that apply.) a. Explain that it is unlikely that he will ever need dialysis even if he has only one kidney. b. Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide factual information to the patient that may help him to make an informed decision. d. Ask for his permission to contact the kidney donation team to answer any questions he may have. e. Suggest that the patient seriously consider cancelling his plan to donate a kidney.

B., C., D. *Encouraging the patient to make a decision based on his personal values, providing necessary information, and offering consultation with individuals most familiar with the kidney donation process are all excellent interventions. It would be impossible to predict whether a patient will need dialysis in the future, making this type of statement misleading.

After admitting a homeless patient to the floor, the nurse tells a colleague that "homeless people are too dumb to understand instructions." What action should the colleague take first? a. Ignore the nurse's prejudicial comment without responding. b. Offer to trade assignments and care for the homeless patient. c. Ask the nurse about the patient's personal history assessment data. d. Challenge the nurse's thinking, pointing out the ability of all people.

C. *The colleague should first ask the nurse to share information about the patient's background. This should encourage the nurse to consider the feelings and values of the patient and hopefully help the nurse to view the patient as a total individual. Ignoring the statement, offering to change assignments, or challenging the nurse's statement does not promote an enhanced nurse-patient relationship and may prevent the nurse from professional growth or make the nurse defensive.