2171 cumulative prepU ch 6, 7, 9, 11, 12, 29, 32, 34 35, 37, 38, 39, 41, 43 44, 45, 46

A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction? A) "Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?" B) "What are you doing immediately prior to your sexual encounters?" C) "Have you had any discharge or pain with urination? D) "Have you always had a hard time obtaining an erection?"

A) "Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?" Common causes of impotence (which may be physiologic or psychological) include various illnesses, treatments for these illnesses, and personal anxieties. Antihypertensive medication and antidepressant medications are a leading cause of impotence in male clients and it is possible to switch medications to help the client with this problem. Reference: Chapter 45: Sexuality, p. 1768.

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child? A) Apple slices B) Chocolate bar C) Almonds D) Tuna salad

A) Apple slices Carbohydrates promote sleep by making tryptophan available to the brain. Simple carbohydrates such as fruit slices or juice are effective. Chocolate provides high sugar content and possibly caffeine exposure which will promote wakefulness. Tuna salad and almonds are protein, not carbohydrates. Reference: Chapter 34: Rest and Sleep - Page 1207-1218

A 35-year-old has chronic back pain. What condition would exacerbate this client's pain? A) Depression B) Constipation C) Smoking D) Exercise

A) Depression Depression and anxiety often lead to increase in pain sensation. Reference: Chapter 35: Comfort and Pain Management, p. 1255.

A nurse is developing a teaching plan for a client diagnosed with obstructive sleep apnea. Which item would the nurse instruct the client to avoid to reduce the disrupted breathing pattern when asleep? Select all that apply. A) alcohol B) tobacco C) sleeping pills D) dairy products E) spicy foods

A) alcohol B) tobacco C) sleeping pills Explanation: Alcohol, tobacco, and sleeping pills increase the breathing disruption that occurs in sleep apnea and therefore should be avoided. Dairy products and spicy foods have not been identified to increase breathing disturbances. Reference: Chapter 34: Rest and Sleep, Sleep-Related Breathing Disorder, p. 1207.

When preparing to administer a large cleansing enema to a client, which solution does the nurse gather? A) tap water B) mineral oil C) soap and water D)hypertonic saline

A) tap water Explanation: The nurse will gather tap water, which is used to distend the rectum and moisten stool. Mineral oil is used for a retention enema. Soap and water are used to irritate local tissue; hypertonic saline irritates local tissue and draws water into the bowel. Reference: Chapter 38: Bowel Elimination - Page 1456

A widow develops cancer within 6 months of her husband's death. This may be a result of: A) social isolation. B) alcohol intake. C) bereavement. D) multiple losses.

C) Bereavement Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable non-bereaved people. Reference: Chapter 43: Loss, Grief, and Dying, p. 1688.

Which does not coincide with Kübler-Ross's stages related to a dying client? A) Clients don't always follow the stages in order. B) Some client regress, then move forward again. C) The dying client usually exhibits anger first. D) The client may be in several stages at once.

C) The dying client usually exhibits anger first. The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward. Reference: Chapter 43: Loss, Grief, and Dying, p. 1689.

When a nurse supports the client's spiritual needs, the nurse supports which level of the Maslow's hierarchy of needs? A) Physiologic needs B) Security needs C) Ego needs D) Self-actualization needs

Self-actualization needs Explanation: In the hierarchy of human needs, spiritual well-being appears to connote fulfillment of needs beyond the self-actualization level. Spiritual well-being has been associated with health and general well-being. Safety needs in Maslow's hierarchy refer to the need for security and protection. When we have our physiological needs for food and water met, our safety needs dominate our behavior. Physiological needs deal with the maintenance of the human body. This lowest category includes the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. There are no ego needs in the hierarchy. Reference: Chapter 46: Spirituality, p. 1799.

A client is being prepared for an elective surgical procedure and the consent form has not been signed. Who should the nurse have obtain consent for the procedure? A) The health care provider performing the surgical procedure B) The client's family or significant other C) The perioperative nurse D) The nursing supervisor

The health care provider performing the surgical procedure Explanation: The nurse should inform the surgeon the consent has not been signed. Obtaining informed consent is the responsibility of the person who will be performing the diagnostic or treatment procedure or the research study. In this particular case, the surgeon, the client, and a witness, all need to sign the consent form. The nurse's roles are to confirm that a signed consent form is present in the client's chart and to answer any client questions about the consent. Reference: Chapter 7: Legal Dimensions of Nursing Practice - Page 133-134

Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety? A) "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." B) "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable." C) "I always tried to do the right thing, so I don't understand why I have to suffer so much now." D) "I guess I should have taken a lot more time to go to church when I was younger."

A) "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." Worry about one's spiritual condition is indicative of the nursing diagnosis of Spiritual Anxiety. Unfamiliarity with the religious character of a care setting suggests Spiritual Alienation, while questions of suffering often indicate Spiritual Pain or Spiritual Despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of Spiritual Guilt. Reference: Chapter 46: Spirituality, p. 1806.

A nurse reads in a client's chart that he or she has gender dysphoria. The nurse determines that the client understands the diagnosis when making what statement? A) "People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria." B) "People who experience sexual fulfillment with a person of the opposite sex have gender dysphoria." C) "Gender dysphoria is a condition in which there are contradictions among chromosomal sex, internal organs, and external genital appearance." D) "People who find pleasure with both opposite-sex and sam-sex partners have gender dysphoria."

A) "People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria." People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria. Heterosexuals experience sexual fulfillment with a person of the opposite sex. People who find pleasure with both opposite-sex and same-sex partners are bisexual. An intersex condition occurs in about 1 in every 2000 babies in which there are contradictions among chromosomal sex, internal organs, and external genital appearance, resulting in ambiguous gender. Reference: Chapter 45: Sexuality, p. 1750.

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate? A) "Tell me about what signs of infection you will report to the health care provider." B) "I would like you to demonstrate how to change the dressing on your leg." C) "Let's see how you irrigate the wound with saline." D) "I notice that you do not have the dressing secured. Place a piece of tape on the wrap."

A) "Tell me about what signs of infection you will report to the health care provider." Explanation: Cognitive domain learning may be evaluated through oral questioning. The return demonstration is an excellent way of evaluating psychomotor domain learning. Providing an opportunity for and encouraging clients to change their own dressing, for example, provides concrete evidence of satisfactory or unsatisfactory performance of the procedure. Reference: Chapter 9: Teaching and Counseling - Page 204

Which six trends in health care reflect the Institute of Medicine's (IOM) focus? A) "The system should be safe, effective, efficient, patient centered, timely, and equitable." B)"The system should be flexible, patient centered, bureaucratic, timely, safe, and efficient." C) "The system should be static, reliable, timely, equitable, efficient, and illness focused." D) "The system should be safe, efficient, centralized, wellness promoting, government driven, and patient centered."

A) "The system should be safe, effective, efficient, patient centered, timely, and equitable." Explanation: A safe, effective, efficient, patient-centered, timely, and equitable system is what the IOM envisions. A bureaucratic, government-driven, illness-focused system is not advocated by the IOM. Reference: Chapter 11: The Healthcare Delivery System - Page 237

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. A) Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. B) Change the dressing midway between meals. C) Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. D) Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. E) Apply an absorbent dressing material as the first layer of the dressing. F) Apply a nonabsorbent material over the first layer of absorbent material.

A) Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. B) Change the dressing midway between meals. C) Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining The nurse would administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The medication would be in the client's system at the time of the dressing change. The nurse would change the dressing midway between meals so that pain and discomfort would be at a minimum at the time of the meal. A protective paste or ointment would protect the surrounding skin from the drainage of the wound. There is no need to apply another layer of protective ointment or paste on top of the previous layer when changing dressings. The nurse would not apply an absorbent dressing material as the first layer of the dressing. The nurse wants to wick the drainage from the wound. The nurse would not apply a nonabsorbent material over the first layer of absorbent material. Again, the nurse wants to wick the drainage from the wound. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1063

The client has intractable cancer pain in the head. The hospice nurse who visits the client in the home daily has written a care plan for Chronic Pain. What pain principles would guide the nurse in the development of interventions with the goal of providing the client adequate pain relief? Select all that apply. A) Administer pain medications around the clock. B) Give oral medications for pain relief. C) Assess the client's pain experience at every visit. D) Contact the primary care provider if the client reports unrelieved pain. E) Frequently remind the client about limitations of the pain medications.

A) Administer pain medications around the clock. B) Give oral medications for pain relief. C) Assess the client's pain experience at every visit. D) Contact the primary care provider if the client reports unrelieved pain. Explanation: Many people who have cancer suffer from pain needlessly. Cancer pain remains undertreated. The nurse is the client's advocate. To provide better relief for the client experiencing intractable cancer pain, the nurse adheres to principles guiding treatment for cancer pain. Interventions would include administering pain medications around the clock (instead of on an as-needed basis), giving oral medications for ease and convenience, assessing the client's pain experience at every visit, and contacting the primary care provider if the client reports unrelieved pain. The nurse remains optimistic about pain relief and seeks other treatment modalities to provide the client with pain relief. The nurse does not frequently remind the client about limitations to pain medications. Reference: Chapter 35: Comfort and Pain Management, Employing Cancer or Chronic Pain Management Treatment Regimens, pp. 75-76.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? A) Apply a skin protectant to the skin around the incision. B) Apply a skin protectant to the incision site. C) Apply a sterile gauze sponge over the incision site. D) Apply a transparent dressing over the incision site.

A) Apply a skin protectant to the skin around the incision. Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1082

The nurse is working on the neurological unit and caring for Mr. Thom, a 39-year-old man who has suffered a severe head injury and is comatose. Then nurse is providing education to the family and visitors about communication with the client. What will the nurse include? Select all that apply. A) Assume the person can hear the conversation. B) Speak to the person before touching. C) Speak loudly to be sure the client can hear the conversation. D) Keep environmental noises at low levels. E) Talk about things that would normally be discussed.

A) Assume the person can hear the conversation. B) Speak to the person before touching. D) Keep environmental noises at low levels. E) Talk about things that would normally be discussed. Explanation: Hearing is believed to be the last sense lost in a client who is comatose; therefore, the person is often likely to hear what is being said, even though there does not appear to be a response. Assume the person can hear the conversation taking place. Talk with the person in a normal tone of voice about things that would ordinarily be discussed. Be careful of what is said in the person's presence. Speak to the person before touching. Remember that touch can be an effective means of communicating with the unconscious person. Reference: Chapter 44: Sensory Functioning, p. 1739.

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing? A) Certification B) Licensure C) Accreditation D) Validation

A) Certification The process of certification involves the attainment and validation of specialized nursing knowledge and skills. Certification is often necessary to ensure that the nursing care provided in specialized and high-acuity settings is safe and appropriate. Accreditation is the process by which an educational program, rather than an individual nurse, is identified as meeting standards. The process of licensure involves the determination that a nurse meets minimum requirements to practice but not necessarily that the nurse has the specialized knowledge that is necessary for some care settings. Validation is not a specific aspect of the process of credentialing. Reference: Chapter 7: Legal Dimensions of Nursing Practice - Page 124

The nurse is educating a client with an ileal conduit about the effects of food and fluid intake on the amount and quality of urine produced by the body. Which teaching points should the nurse include? Select all that apply. A) Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. B) Fluid overload leads to excretion of a large quantity of dilute urine. C) Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. D) Consumption of alcoholic beverages leads to increased urine production due to their stimulation of antidiuretic hormone. E) Ingestion of foods and beverages high in sodium content leads to increased urine formation. F) Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine.

A) Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. B) Fluid overload leads to excretion of a large quantity of dilute urine. C) Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. E) Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine. Explanation: Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. Fluid overload leads to excretion of a large quantity of dilute urine. Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. Consumption of alcoholic beverages leads to increased urine production due to their inhibition of antidiuretic hormone release. Ingestion of foods and beverages high in sodium content leads to decreased urine formation due to sodium and water reabsorption and retention. Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine. Reference: Chapter 37: Urinary Elimination, p. 1346.

Nursing practice consistent with the Code of Ethics for Nurses includes which actions? Select all that apply. A) Delivering culturally safe care B) Empathizing with clients and establishing friendships when appropriate C) Acknowledging that the client is the focus and center of care and remains a part of the treatment team D) Protecting the client's right to confidentiality and privacy E) Assuming responsibility for care with limited collaboration with other healthcare professionals

A) Delivering culturally safe care C) Acknowledging that the client is the focus and center of care and remains a part of the treatment team D) Protecting the client's right to confidentiality and privacy Explanation: Nurses should always deliver culturally safe care, as well as protect the client's right to confidentiality and privacy in healthcare settings. Nurses also should put the client at the center of care and incorporate the client as a part of the healthcare team. As such, nurses must collaborate closely with other members of the healthcare team and include all healthcare professionals caring for the client. Nurses should not cross professional boundaries with their clients by establishing friendships. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 101

Which example most accurately depicts the ethical principle of autonomy? A) Describing a surgery to a client before the consent is signed B) Changing a dressing on a wound as needed C) Administering a morning dose of insulin before breakfast D) Transporting a client to a scheduled physical therapy appointment

A) Describing a surgery to a client before the consent is signed Autonomy is the capacity to make an informed, uncoerced decision. Describing a surgery to a client before a consent is signed provides the client with all of the information needed to make an informed decision and thus an autonomous one. The nurse changing a dressing on a wound does not require the client to make an informed decision, nor does administering a morning dose of insulin or transporting a client. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 101-104

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? A) Discuss the use of protective undergarments to avoid embarrassment from incontinence. B) Encourage the client to confide in family members and tell them about the accidents. C) Inform the client that this is not normal and make a referral to a urologist. D) Tell the client that this happens to all people when they get older.

A) Discuss the use of protective undergarments to avoid embarrassment from incontinence. Explanation: The nurse will promote the client's self-esteem by openly discussing adult undergarments. The client has no other health problems, and can benefit by learning how to self-manage this concern. Encouraging the client to tell family members does not support the client's desire to refrain from telling others about this issue. The client does not need referral to a urologist at this time. Reassuring the client that others have this concern is nontherapeutic and does not directly meet the client's concern. Reference: Chapter 37: Urinary Elimination, p. 1362.

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include? select all that apply. A) Do not drive while taking pain medication. B) Do not smoke without someone else present. C) Avoid alcohol. D) Avoid diary products. E) Take medication on an empty stomach.

A) Do not drive while taking pain medication. B) Do not smoke without someone else present. C) Avoid alcohol. Explanation: The teaching plan developed by the nurse should include instructions to take the medication with food to prevent stomach irritation. It should also include not smoking without someone else present to decrease the risk of the client falling asleep and starting a fire. The client should also be instructed to avoid alcohol and to avoid driving. The client does not need to avoid diary products. Reference: Chapter 35: Comfort and Pain Management, p. 1266.

The nurse is preparing to teach a client how to perform incentive spirometry. Which concept should the nurse include? A) Incentive spirometry provides visual reinforcement of deep breathing. B) Proper, frequent use of incentive spirometry can improve pulmonary circulation. C) Oxygen saturation is expected to decrease during the first few minutes of incentive spirometry. D) The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue.

A) Incentive spirometry provides visual reinforcement of deep breathing. Incentive spirometry assists the client to perform adequate deep breathing. Incentive spirometry affects ventilation rather than perfusion. Oxygen saturation should increase with the use of incentive spirometry, not decrease. Incentive spirometry is used to enhance inspiratory effort; thus, the client should inhale through the incentive spirometer, not exhale through it. Reference: Chapter 39: Oxygenation and Perfusion - Page 1503-1504

The nurse is caring for Emily, an 81-year-old client who is struggling to adapt to worsening vision as she ages. The nurse performs which interventions to assist Emily in adapting to this sensory deficit? Choose all that apply. A) Make sure her glasses are available. B) Provide adequate lighting. C) Provide large print books. D)Orient to person, place, and time. E) Speak so she can observe lip movements.

A) Make sure her glasses are available. B) Provide adequate lighting. C) Provide large print books. Explanation: Wearing her glasses, having adequate lighting, and having large print books are all strategies to assist a client with a visual deficit. Orientation to person, place, and time is not necessary because Emily is not disoriented. Emily does not have a hearing problem, so it is not necessary for her to observe lip movements. Reference: Chapter 44: Sensory Functioning, p. 1728.

Which type of home healthcare agency is a local health department? A) Official or public agency B) Private not-for-profit agency C) Private, proprietary agency D) Institution-based agency

A) Official or public agency Explanation: Health departments are public agencies supported through tax dollars and benefit the community in which they are located. Private not-for-profit agencies are supported by donations, endowments, charities, and insurance reimbursement. Private, proprietary agencies are usually for-profit organizations governed by individual owners or national corporations. Institution-based agencies operate under a parent organization, such as a hospital. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 284

The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems? A) Plan and coordinate a multidisciplinary team conference including the chaplain. B) Provide client education on negative spiritual implications on suicide. C) Encourage the client to watch movies when alone. D) Explore past negative coping mechanisms used.

A) Plan and coordinate a multidisciplinary team conference including the chaplain. The nurse should facilitate a care-planning conference involving the social support network including family and friends. Initiating a multidisciplinary social network of conferences facilitates a sense of acceptance, love, and belonging. The nurse should work with the client to explore and build on past positive coping mechanisms, which helps enhance a sense of self-control and self-esteem. Encouraging the client to watch movies when alone does not allow the client to interact and find positive elements of his or her life. Although spiritual review can be helpful, the nurse should not "scare" the client away from action by mentioning negative spiritual outcomes. Reference: Chapter 46: Spirituality, p. 1807.

The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply. A) Position client onto the side immediately. B) Remove oropharyngeal airway. C) Provide oral suctioning and mouth care. D) Raise the head of the bed to 90 degrees. E) Assess for bleeding in the mouth.

A) Position client onto the side immediately. B) Remove oropharyngeal airway. C) Provide oral suctioning and mouth care. Explanation: The nurse should quickly position client into a lateral position to prevent aspiration, remove the oropharyngeal airway, and then suction or provide oral hygiene as needed. Raising the head of bed to 90 degrees is unnecessary, because the client should be positioned on one side. There is no indication that trauma to the mouth has occurred, so the nurse would not need to assess for bleeding. Reference: Chapter 39: Oxygenation and Perfusion, p. 1515.

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self-care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated? A) Provide the teaching. B) Notify the surgeon. C) Alert the charge nurse in surgery. D) Advise the client to delay the surgery.

A) Provide the teaching. Explanation: The nurse assesses what has been done prior to the day of surgery and tailors the care plan to meet the client's needs. In this case, the client should receive information about postoperative self-care, including written instructions. The nurse, not the surgeon or charge nurse, should provide the teaching. There is no need to delay the client's surgery; moreover, it would be the surgeon's responsibility to decide whether to delay the surgery, not the nurse's. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 278

Which statement regarding pay for performance is most accurate? A) Quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. B) Financial incentives are employed to reward providers for the achievement of a range of client objectives. C) Pay for performance includes only demonstrated delivery efficiencies and improved quality and client safety. D) Pay for performance is to be instituted primarily in small community hospitals with fewer than 100 beds, as client outcomes are worse there.

A) Quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. Explanation: In pay for performance, quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. Financial incentives are offered to health care providers for achieving certain clinical measures established by the payer, not client objectives. These clinical measures include not only delivery efficiencies, improved quality, and patient safety, but also submission of data to the payer. Pay for performance is not limited to any particular hospital size. Reference: Chapter 11: The Healthcare Delivery System - Page 241

A nurse encourages a young female whose leg was amputated to continue to pursue her dream to become a dancer. How does the nurse identify this need to reach one's potential through full development of one's unique capability? A) Self-actualization B) Self-concept C) Self-esteem D) Ideal self

A) Self-actualization Explanation: Self-actualization refers to the need to reach one's potential through full development of one's unique capabilities. Self-concept includes personal identity, body image, self-esteem, and role performance. Self-esteem is the need to feel good about oneself and to believe that others hold one in high regard. Ideal self constitutes the self one wants to be. Reference: Chapter 41: Self-Concept, p. 1633.

A nurse who comments to coworkers at lunch that a client with a sexually transmitted infection has been sexually active in the community may be guilty of what tort? A) Slander B) Libel C) Fraud D) Assault

A) Slander Defamation of character is an intentional tort in which one party makes derogatory remarks about another, with those remarks harming the other party's reputation. Slander is spoken defamation of character; libel is written defamation. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Reference: Chapter 7: Legal Dimensions of Nursing Practice - Page 125-126

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness? A) Somnolence B) Coma C) Stupor D) Asleep

A) Somnolence When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli. Reference: Chapter 44: Sensory Functioning, p. 1721.

An appropriate nursing diagnosis for a bedridden hospitalized client who tells the nurse that he has not missed a Methodist church service in 50 years would be: A) Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt B) Spiritual Need as evidenced by verbalizations and distress at missing Methodist church services C) Dysfunctional Grieving related to inability to attend church services as a result of his medical condition D) Potential for Enhanced Spiritual Well-Being related to distress at missing Methodist church services

A) Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt Persons suffering spiritual dysfunction or distress may verbalize such distress or express a need for help. Reference: Chapter 46: Spirituality, p. 1805.

Which qualities are essential for a community-based nurse? Select all that apply. A) Strong knowledge foundation B) Effective communication skills C) Keen physical assessment skills D) Ability to delegate client care tasks to unlicensed assistive personnel E) Competence in assisting with minor surgical procedures

A) Strong knowledge foundation B) Effective communication skills C) Keen physical assessment skills Explanation: Community-based nurses must possess several key qualities: they must be knowledgeable and skilled in their practice (including strong and effective communication and physical assessment skills), able to make decisions independently, and willing to remain accountable. They are less likely need skills in delegating client care or assisting with minor surgical procedures, as the nurse will typically work alone and as surgical procedures are not performed in the home care setting. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 267

Which statement is true when comparing home care with acute care? A) The nurse is the guest in the client's home. B) The nurse directs all aspects of the home. C) The client directs the education of all caregivers. D) The nurse and the client work independently of each other.

A) The nurse is the guest in the client's home. An essential difference in home care versus acute care is that the home care nurse is a "guest" in the client's home. In the home, clients and families retain the power and control that they give to providers in other settings. Nurses in the home usually work as members of a therapeutic team that includes the client and other members of the health care team working collaboratively. The client does not direct the education of the caregivers. Reference: Chapter 11: The Healthcare Delivery System - Page 252-253

The nurse is assessing a client and determines that they are in rapid eye movement (REM) sleep. What finding indicates to the nurse that the client is in this stage? A) There is rapid eye movement under the eyelids. B) There is muscle jerking that may awaken the individual. C) Respirations are regular. D) The individual is transitioning from wakefulness to sleep.

A) There is rapid eye movement under the eyelids. REM is a deep stage of normal sleep. The body and brain go through several changes, including rapid movement of the eyes, fast and irregular breathing, increased heart rate (to near waking levels), changes in body temperature, increased blood pressure, and brain activity similar to that seen while awake. Muscular jerking, regular respiration, and transitioning to wakefulness are not indicative of REM sleep. Reference: Chapter 34: Rest and Sleep - Page 1202

The nurse has just finished injecting a medication intramuscularly, and needle is still in the client's arm. Which is the correct immediate next step? A) Wait 10 seconds and then withdraw the needle B) Gently pull back on the syringe plunger and observe for blood in the syringe C) Move the syringe slightly left and right to facilitate absorption of the medication D) Withdraw the needle immediately

A) Wait 10 seconds and then withdraw the needle Explanation: The immediate next step would be to wait 10 seconds and then withdraw the needle. Waiting allows the medication to begin to diffuse into the surrounding muscle tissue. Aspiration, or pulling back on the plunger to check that a blood vessel has been entered, is not necessary nor recommended. Moving the syringe could cause damage to the tissues and inadvertent administration into incorrect area, so this should not be done. Reference: Chapter 29: Medications - Page 900-904

Which are recommended guidelines to prevent the spread of infection in the home care setting? Select all that apply. A) Wearing gloves when contacting body fluids B) Using standard precautions C) Performing hand hygiene after reaching into the bag for supplies D) Using sterile technique when reaching into the bag for supplies E) Placing the bag on a liner before setting it down in the client's home

A) Wearing gloves when contacting body fluids B) Using standard precautions E) Placing the bag on a liner before setting it down in the client's home Explanation: Nurses use standard precautions during home care visits, including wearing gloves when contacting blood, body fluids, secretions, excretions, and contaminated items. Clean disposable gloves should be put on just before touching areas of broken skin or mucous membranes. To prevent the spread of infection, nurses should also use appropriate technique when handling their equipment bags, including the following: perform hand hygiene before reaching into the bag for supplies, clean any equipment removed from the bag before returning it to the bag, and place the bag on a liner when setting it down in the patient's home. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 286

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means? A) aggressive management of symptoms B) treatment of the disease process C) eliminating all forms of medical and nursing care D) providing counseling related to the stages of death and dying

A) aggressive management of symptoms The goal of palliative care is to provide clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. There is no treatment goal for the life-threatening illness for palliative care. Aggressive management of symptoms includes medical and nursing care for the client. Providing counseling related to the stages of death and dying is pursued after aggressive management of symptoms. Reference: Chapter 43: Loss, Grief, and Dying, p. 1690.

During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care? A) condom catheter B) indwelling catheter C) intermittent catheterization at bedtime D) toileting the client every 2 hours

A) condom catheter Explanation: A condom catheter may be used in the care of male clients who lack voluntary control of urination. This is preferable to invasive catheterization (which presents an infection risk). Frequent toileting such as every 2 hours may prevent episodes of incontinence but would significantly disrupt the client's sleep quality. Reference: Chapter 37: Urinary Elimination, p. 1388.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief? A) coping strategies B) self-care activities C) pain management D) spiritual distress

A) coping strategies Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed. Reference: Chapter 43: Loss, Grief, and Dying, p. 1699.

A client admitted with cellulitis of the leg has been prescribed amoxicillin-clavulanate potassium. After 3 days of antibiotic therapy, the client develops severe diarrhea, and the nurse notifies the health care provider. The nurse would anticipate which course of action in response to the client's diarrhea? A) discontinuation of the amoxicillin and the administration of a different antibiotic B)administration of an antidiarrheal drug and continuance of the amoxicillin C) increase in the client's dietary fiber and continued administration of amoxicillin D) discontinuation of the amoxicillin and administration of an antidiarrheal drug

A) discontinuation of the amoxicillin and the administration of a different antibiotic Explanation: When a patient is receiving treatment with broad-spectrum antibiotics, there is a disruption in the normal intestinal flora, allowing the microorganism to flourish within the intestine. C. difficile causes intestinal mucosal damage and inflammation, resulting in diarrhea and abdominal cramping. The antibiotic should be changed but an antidiarrheal medication should not be prescribed because its use would prolong the exposure of the intestinal mucosa to the irritating effect of the antibiotic. Fiber would not be added as this does not change the diarrhea from the antibiotic. The antibiotic is necessary so changing to a different one is best instead of discontinuation of the amoxicillin and administration of an antidiarrheal drug. Reference: Chapter 38: Bowel Elimination, p. 1424.

Following an allergic reaction to a medication, the nurse should: A) instruct the client to wear an identification bracelet addressing the allergy. B) instruct the client to be sure the allergy is on his medical record. C) inform the client that an allergic reaction can be transient. D) inform the client that the medication may cause an allergy only one time.

A) instruct the client to wear an identification bracelet addressing the allergy. Explanation: Allergic reactions result from an immunologic response to a substance to which the client is sensitized. The client should wear identification noting the medication to which the client is allergic. Reference: Chapter 29: Medications - Page 826-834

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects: A) invasion of privacy. B) defamation of character. C) professional negligence. D) false imprisonment.

A) invasion of privacy. The nurse's action reflects an invasion of the client's privacy. Disclosing confidential information to an unaauthroized third party subjects the nurse to liability for invasion of privacy, even if the information is true. Defamation of character includes false communication that results in injury to a person's reputation. Negligence is an act of omission or commission. Prevention of movement or unjustified retention of a person without consent may be false imprisonment. Reference: Chapter 7: Legal Dimensions of Nursing Practice - Page 126

A nurse working in a health clinic assesses sleep patterns during each health assessment. Based upon the nurse's knowledge regarding sleep needs, the nurse recognizes which age group as generally needing the least amount of sleep? A) older adults B) infants C) adolescents D) young adults

A) older adults As people age, the number of hours of needed sleep decreases. An average of 5 to 7 hours of sleep is usually adequate for the older adult age group. Infants sleep an average of 12-15 hours. Adolescents sleep an average of 9-10 hours. Young adults average about 7.5-8 hours. Reference: Chapter 34: Rest and Sleep - Page 1203

A client who has awakened from a coma after a car accident and states, I knew about a news story reported during the time I was in the coma." What does the nurse identify is occuring with the client? A) reticular activating system's stimulation. B) sleep latency phase of sleep-wake cycle. C) circadian rhythm for 24 hours. D) sensory perception in a conscious process.

A) reticular activating system's stimulation. Explanation: Destruction of the reticular activating system produces coma and an electroencephalograph pattern consistent with sleep. When the nervous system is oriented to a stimulus and receptive toward it, the neurons of the RAS arouse the brain, facilitating information reception (Widmaier, Raff, & Strang, 2008). The RAS is highly selective. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 44: Sensory Functioning, p. 1720.

A client comes to the clinic for an annual physical exam. During the history, the client tells the nurse about starting a new job but being unsure about success in this new role because since the expectations are unknown. What does the nurse determine this indicates for the client? A) role ambiguity. B) role strain. C) intrapersonal role conflict. D) role transition.

A) role ambiguity. The client is exhibiting role ambiguity, which occurs when the person lacks knowledge of role expectations, which fosters anxiety and confusion. Role strain occurs when the person perceives himself as inadequate or unsuited for a role. Intrapersonal role conflict exists when role expectations conflict with the person's values, such as a nurse being asked to assist with an abortion when she believes it is immoral. Role transitions occur due to aging and growth or with a change in relationships. Reference: Chapter 41: Self-Concept, p. 1643.

A pregnant teenager did not understand the process of fertilization. The school nurse's best explanation of fertilization is that: A) the fertilization process occurs in the outer third of the fallopian tube. B) fertilization is a process that occurs in the lower portion of the cervix. C) an ovum can be fertilized during a period of 1 week after intercourse. D) the first 2 months after fertilization is critical for the embryo.

A) the fertilization process occurs in the outer third of the fallopian tube. Explanation: Fertilization of one ovum with one spermatozoon normally occurs in the outer third of the fallopian tube. The time period in which the woman can be impregnated is only a few days. Reference: Chapter 45: Sexuality, p. 1777.

The nurse is providing education for a client with frequent constipation about the use of bisacodyl to improve defecation. What statements made by the client indicate that the teaching is effective? Select all that apply. A) "Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." B) "This will help add bulk to my stools to ease defecation." C) "It will improve defecation by increasing motility." D) "I should increase my fluid intake to help with my bowel movements. E) "This will help soften the stool but won't stimulate motility."

ALSO MAY HELP FOR PHARM A) "Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." C) "It will improve defecation by increasing motility." D) "I should increase my fluid intake to help with my bowel movements. Explanation: Stimulant laxatives, such as bisacodyl and senna, improve defecation by increasing motility through irritation of the intestinal mucosa and increased water in the stool. Bulk-forming laxatives such as psyllium hydrophilic mucilloid work by absorbing water into the intestine to soften the stool and increasing stool bulk, but bisacodyl is not considered a bulk forming laxative. Bisacodyl is not a stool softener. Reference: Chapter 38: Bowel Elimination, p. 1434.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? A) An infant with a respiratory rate of 20 rpm B) A 4-year-old with a respiratory rate of 40 rpm C) A 12-year-old with a respiratory rate of 20 rpm D) A 70-year-old with a respiratory rate of 18 rpm

An infant with a respiratory rate of 20 bpm Explanation: The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute. Reference: Chapter 39: Oxygenation and Perfusion, p. 1489.

A nurse is obtaining a health history from a middle-age client. Which question would initially be appropriate to ask? A) "Have you ever had testing for HIV?" B) "How many children do you have?" C) "Do you have a sexually transmitted infection?" D) "What is your gender identity?"

B) "How many children do you have?" A health history should include information regarding a client's reproductive and sexual health, depending on the circumstances in which the client is receiving care. Information is best obtained from the client by beginning with nonthreatening questions (number of children) and progressing to more sensitive concerns (HIV and other STIs). Asking about gender identity is a higher level question in the sexual health interview and requires the interviewer to have more sophisticated preparation and skills, such as a sex therapist. Reference: Chapter 45: Sexuality, p. 1765.

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary? A) "I will keep track of my sleep information for 2 months." B) "I will record the time I go to bed and how long it takes me to fall asleep." C) "I will write down all my morning activities." D) "I will only keep track of my sleep habits at home, not when I am traveling out of town."

B) "I will record the time I go to bed and how long it takes me to fall asleep." Explanation: Keeping notes of times of sleep and waking are important details to record in a sleep diary. The notes are usually maintained for 14 days and include specifics such as all wakeful activities and sleep patterns in strange environments. Reference: Chapter 34: Rest and Sleep, p. 1214.

The new community health nurse is learning to care for lesbians, gay males, bisexuals, and transgender (LGBT) individuals. Which statement indicates to the preceptor that the nurse understands the needs of this group? A) "Lesbian and bisexual females are likely to be underweight." B) "Lesbians are less likely to get preventive services for cancer." C) "Bisexual individuals are less likely to have health insurance." D) "LGBT populations have moderate rates of tobacco, alcohol, and other drug use."

B) "Lesbians are less likely to get preventive services for cancer." Explanation: Healthy People 2020 (2017) identified significant LGBT health disparities and the much-needed collaboration from health care professionals to address them. One of its findings was that lesbians are less likely to get preventive services for cancer. The other findings include that lesbians and bisexual females are likely to be overweight or obese, transgender individuals are less likely to have health insurance, and, LGBT populations have the highest rates of tobacco, alcohol, and other drug use. Reference: Chapter 45: Sexuality, p. 1780.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role? A) Identifying individuals who are at risk of developing diabetes mellitus B) Collaborating with all agencies to provide for the client's home health needs C) Verifying that all documentation is updated prior to surgery D) Providing client education related to colostomy care

B) Collaborating with all agencies to provide for the client's home health needs Explanation: As the various components of the ACA are phased in, nurses have begun to play an influential role in the implementation of new health policy. The newest opportunity is collaborating with all agencies to provide for the client's home health needs. Nurses have already been involved in screening individuals for type 2 diabetes mellitus and providing postoperative teaching for ostomy care. Nurses recheck paperwork for consent prior to surgery, but this is not just limited to nurses. Other health care providers also review consent prior to surgery. Reference: Chapter 11: The Healthcare Delivery System - Page 257-258

The nurse is caring for a client who has had a cerebrovascular accident. Prior to administering oral medications, what is the nurse's appropriate action? A) Give the client water to drink. B) Consult with a speech therapist for dysphagia. C) Mix medications in applesauce or pudding. D) Convert orders for oral medications to intravenous or intramuscular.

B) Consult with a speech therapist for dysphagia. To prevent aspiration, the nurse will not administer oral medications, but will ask the provider to consult with a speech therapist who can evaluate dysphagia and recommend safe methods of medication administration. The nurse cannot automatically convert an order for medications to a different route; this would have to be considered by the health care provider. Reference: Chapter 29: Medications - Page 84

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? A) Use clean technique when inserting the catheter. B) Ensure that the catheter is removed as soon as possible. C) Irrigate the catheter with sterile water once per shift. D) Administer prophylactic antibiotics, as ordered.

B) Ensure that the catheter is removed as soon as possible. Explanation: To prevent UTIs, the nurse should leave the catheter in place for as short a time as possible. Strict aseptic technique is used for insertion, not clean technique. Frequent irrigation increases the risk of UTIs. For most clients with intact immune systems, prophylactic antibiotics are not used. Reference: Chapter 37: Urinary Elimination, pp. 1391-1397.

A female client is brought to the emergency room with matted hair, bruising, and malnutrition. The nurse suspects physical abuse and neglect. The nurse states, "This happens to many women." Which type of ethical approach is the nurse exhibiting? A) Paternalism B) Feminist C) Values clarification D) Moralizing

B) Feminist A feminist approach is one in which the focus is on specific problems and concerns faced by women. The statement that "this happens to many women" is an example of a feminist approach. Paternalism is action limiting a person's or group's liberty or autonomy that is intended to promote their own good (e.g., if the nurse stated that "I must make all decisions about this client's care for her, as she's not in any shape to do so herself"). Values clarification is a self-assessment process that enables a person to discover the content and strength of the person's own system of values. An example of this would be if the nurse stated, "I feel bad for the client, as no one deserves this." Moralizing is to comment on issues of right and wrong, typically with an unfounded air of superiority. An example of this would be if the nurse stated, "If she was a good girl, this would have never happened to her." Reference: Chapter 6: Values, Ethics, and Advocacy - Page 104

An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed? A) Unintentional tort B) Invasion of privacy C) Defamation of character D) Negligence of duty

B) Invasion of privacy The nurse has committed the tort of invasion of privacy. Personal names and identities should be concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably. Reference: Chapter 7: Legal Dimensions of Nursing Practice - Page 126

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time? A) Save a sample of the stool in a container. B) Perform a screening test on stool samples. C) Send the stool sample to the laboratory. D) Inform the client to report the occurrence if it happens again.

B) Perform a screening test on stool samples. Explanation: The nurse should independently perform a screening test on the stool samples to determine the presence of blood. Once the nurse confirms the presence of blood, the nurse can keep the stool sample in a covered container and then report to the physician. The nurse does not send the stool sample to the laboratory because it is the physician who may order more specific laboratory or diagnostic tests. Immediate action is required and should not be postponed until it can happen again. Reference: Chapter 38: Bowel Elimination, p. 1428.

A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The client has a barrel chest and clubbed fingers. What is the nurse's priority intervention? A) Teach the client deep-breathing exercises B) Place client in the tripod position C) Ambulate the client D) Assist the client with incentive spirometer

B) Place client in the tripod position Explanation: Placing the client in the tripod position would relieve shortness of breath and increase the client's oxygen saturation level. Ambulating the client would exacerbate the symptoms, and assisting the client with the incentive spirometer is not appropriate at this time. The client will be unable to perform deep breathing exercises if hypoxic. Reference: Chapter 39: Oxygenation and Perfusion, p. 1522.

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation? A) Place the sterile solution on the bed. B) Prime the tubing with the solution. C) Empty the balloon with a syringe. D) Clean around the urinary meatus.

B) Prime the tubing with the solution. When providing continuous irrigation, the nurse must prime the tubing with the irrigation solution to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe and also cleans the urinary meatus when removing the catheter—not when irrigating the catheter. Reference: Chapter 37: Urinary Elimination, p. 1371.

What nursing function would be most commonly found in an ambulatory care facility? A) Serving as an administrator or manager B) Providing direct client care C) Educating individuals or groups D) Assessing the home environment

B) Providing direct client care Ambulatory care centers and clinics (agencies that deliver outpatient medical care) may be located in hospitals, may be a freestanding service provided by a group of health care providers who work together, or may be managed by an advanced practice registered nurse. Although a nurse may serve as an administrator or manager in such a facility, the nursing function most commonly found in this setting is providing direct client care. Educating individuals or groups would be a nursing function more commonly found in a primary care facility. Assessing the home environment would be a nursing function more commonly found in home health care. Reference: Chapter 11: The Healthcare Delivery System - Page 253

A nurse caring for a client of the Jewish faith knows the importance of asking about any food preferences when discussing diet. This is important for which reason? A) Religious practices and beliefs make caring for clients interesting. B) Religious practices and beliefs can directly influence a client's self-care practices. C) Religious practices and beliefs are not that important in relation to the client's illness. D) Religious practices and beliefs are difficult to understand.

B) Religious practices and beliefs can directly influence a client's self-care practices. Explanation: Nurses are better able to meet clients' spiritual needs when they understand their religious beliefs. These beliefs can directly influence clients' responses to illness and suffering, self-care practices such as diet and hygiene, spiritual practices, and moral codes. Religious practices and beliefs can be easy to understand and if asking a client about them, a nurse is exemplifying care and compassion in the client and their beliefs. Reference: Chapter 46: Spirituality, p. 1795.

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's mostappropriate action? A) Reassure the client that this is a normal effect of a sitz bath and monitor the client closely. B) Stop the sitz bath, call for help, and help the client to the toilet to sit down. C) Stop the sitz bath and help the client ambulate back to the client room. D) Call a code blue because the client may be experiencing a myocardial infarction.

B) Stop the sitz bath, call for help, and help the client to the toilet to sit down. Explanation: If the client complains of feeling light-headed or dizzy during a sitz bath: Stop the sitz bath. Do not attempt to ambulate the client alone. Use call light to summon help. Let the client sit on the toilet until feeling subsides or help has arrived to assist the client back to bed. This does not necessarily warrant a code blue unless the nurse suspects an acute onset of a serious health problem. Reference: Chapter 32: Skin Integrity and Wound Care, p. 1088.

A nurse is developing a plan of care to meet a client's spiritual needs. When identifying appropriate interventions, which concept would the nurse need to integrate as the foundation for all the interventions? A) Prayer B) Supportive presence C) Strength D) Religion

B) Supportive presence A nurse's supportive presence must underlie all other types of intervention to meet the client's spiritual needs. The aim of this intervention is to create a hospitable and sacred space ("holy ground") in which clients can share their vulnerabilities without fear. Supportive presence communicates value and respect. Prayer, strength and religion are not foundational to spiritual interventions. Reference: Chapter 46: Spirituality, Offering Supportive or Healing Presence, p. 1808.

Traditionally, the male sexual response is thought to be broken up into three phases. Which occurrence is part of the plateau phase? A) A rapid erection of the penis occurs. B) The circumference of the penis thickens at the coronal ridge and a few drops of fluid appear at the urethral meatus. C) A decrease in vasocongestion occurs. D) The spermatic cords shorten, causing a partial elevation of both testes.

B) The circumference of the penis thickens at the coronal ridge and a few drops of fluid appear at the urethral meatus. Explanation: During the plateau phase, the circumference of the penis thickens at the coronal ridge. The size of the testes also increase by 50% and a few drops of fluid appear at the urethral meatus. Reference: Chapter 45: Sexuality, p. 1758.

The nurse is met in the staff lounge by the nurse who has been caring for the client team on this shift. The off-going nurse says, "Sorry, but I have to get out of here." The nurse then gives a quick overview of each client on the team and says, "All the rest is in the chart if you need anything." Which essential part of the handoff is missing? A) The chance for the oncoming nurse to assess the clients B) The opportunity for the oncoming nurse to ask questions C) The oncoming nurse's chance to check intravenous (IV) sites and fluids D) The oncoming nurse's opportunity to meet new clients

B) The opportunity for the oncoming nurse to ask questions Explanation: Handoffs should always include a chance for the oncoming nurse to ask questions and to clarify anything that is unclear. The nurse should not expect an opportunity to assess the clients, check IV sites, or meet new clients prior to the previous nurse leaving. In instances where bedside report is given, the nurse may have some of these opportunities, but they are not required in a handoff. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 269

A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory? A) asking client how sensory stimuli produces pain B) administering backrub when client's head hurts C) removing items from the room that remind client of former spouse D) requesting health care provider to order the client's opioid medication

B) administering backrub when client's head hurts Explanation: Administering a backrub reflects the Gate Control Theory. Asking the client how sensory stimuli produces pain reflects the Pattern Theory. Removing items that remind the client of a former spouse reflects the Neuromatrix Theory. Having the health care provide order the client's opioid medication reflects the endogenous opioid theory. Reference: Chapter 35: Comfort and Pain Management, p. 1236.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? A) autolytic debridement B) biosurgical debridement C) enzymatic debridement D) mechanical debridement

B) biosurgical debridement Explanation: In biosurgical debridement, fly larvae are used to clear the wound of necrotic tissue. This is accomplished by an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, as in surgical debridement. Reference: Chapter 32: Skin Integrity and Wound Care, p. 1072.

A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have: A) moral agency. B) personal values. C) ethics. D) legal obligations.

B) personal values. The only information given here tells us that this nurse has personal values on a particular issues. Personal values are ideas or beliefs a person considers important and feels strongly about. Moral agency is the ability to do the ethically right thing because one knows it is the right thing to do. Ethics is a systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing. Legal obligations are behaviors and actions required by law. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 98

A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced? A) urge B) total C) reflex D) stress

B) total Explanation: Total incontinence takes place without a pattern or warning, and without client control, often in the presence of altered consciousness. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Reference: Chapter 37: Urinary Elimination, p. 1361.

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn? A) "May I have something to eat?" B) "The pain in my chest has gone." C) "I am having difficulty breathing." D) "Finally, I am getting medical attention."

C) "I am having difficulty breathing." Explanation: The statement "I am having difficulty breathing" indicates that the client is not physically well and that the client is unable to learn effectively until comfort is restored. "The pain in my chest has gone" and "May I have something to eat?" is suggesting that the client is physically well and is ready to learn. "Finally, I am getting medical attention" is suggesting that the client is psychologically ready to learn. Reference: Chapter 9: Teaching and Counseling - Page 195

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development? A) Hemoglobin A1C 5% B) Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) C) Albumin 2.8 mg/dL (28.0 g/L) D) White blood cell count 14,800 mm3 (14.8 x 109/L)

C) Albumin 2.8 mg/dL (28.0 g/L) An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure injury. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1066

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program? A) Disease-specific quality standards have been found to be slightly worse than when clients are treated in the hospital. B)Clients and their family members have been found to be happier with stays in the hospital in which they have 24/7 access to the healthcare team. C) Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting. D) Clients in the acute care setting require fewer chemical and physical restraints.

C) Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting. Explanation: Clients who receieve care in their own homes, surrounded by familiar family and friends, have been found to recover more quickly than those in inpatient acute care settings. The other statements are not accurate. Reference: Chapter 11: The Healthcare Delivery System - Page 254

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges? A) Clients are in the hospital for a longer period of time. B) Clients are locked into prenegotiated payment rates that have remained unchanged. C) Clients with high home care needs are being discharged into the community. D) Client use of ambulatory care has decreased.

C) Clients with high home care needs are being discharged into the community. Explanation: Clients are returning to the community with more health care needs, many of which are complex, thus increasing the need for home health care. Clients are not in the hospital for longer periods of time. Clients are not locked into payment rates that have remained unchanged. Client use of ambulatory care has not decreased but increased. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 283

The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports barriers to each action and continues to smoke. What is the best action of the nurse? A) Inform the client that the results are disappointing. B) Refer the client for cognitive behavioral therapy. C) Discuss the client's case with a colleague. D) Inform the client that the client will be unable to quit without medication.

C) Discuss the client's case with a colleague The focus is not to have the client please the nurse, but to improve client health behaviors. Telling a client that the client's efforts are disappointing is not an effective communication technique and can result in disruption of the therapeutic trust relationship between the nurse and client. The client does not necessarily need therapy just because initial attempts have been unsuccessful. The client desires not to have medication, so arranging for medications goes against the client's wishes in the plan of care. A colleague may shed light on additional actions based on experience with similar issues in the past. Reference:. Chapter 9: Teaching and Counseling - Page 208

A nurse is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure? A) Position the client supine, as dictated by client comfort and condition. B) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. D) Instruct the client not to bear down while extracting feces in order to prevent vagal response.

C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Explanation: For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal. Reference: Chapter 38: Bowel Elimination, p. 1442.

A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase? A) Water loss B) Blurred vision C) Headache D) Calmness

C) Headache Premenstruation is characterized by the appearance of one or more of the following symptoms several days before the onset of menstruation: (1) emotional symptoms such as depression, irritability, anxiety, changes in sleep habits, changes in sexual desire, poor concentration, crying, anger, and social withdrawal; and (2) physical symptoms such as appetite changes, breast tenderness, bloating and weight gain, aches and pains, swelling, acne, gastrointestinal issues, and fatigue. Blurred vision may be an ominous sign that is unrelated to premenstrual syndrome. Reference: Chapter 45: Sexuality, p. 1777.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? A) Contact the surgeon for debridement. B) Using sterile technique, debride the wound. C) Off-load pressure from the heel. D) Place an antiembolism stocking on the client's leg.

C) Off-load pressure from the heel. Explanation: The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel wound. Reference: Chapter 32: Skin Integrity and Wound Care, p. 1063.

The nurse is caring for a client who has had a stroke. Prior to administering oral medications, what is the appropriate nursing action? A) Change the medication route to intramuscular. B) Mix the drug with pudding. C) Request that the provider obtain a speech therapist's evaluation. D) Administer the medication with water to drink.

C) Request that the provider obtain a speech therapist's evaluation. Explanation: To prevent aspiration, the nurse will ask the provider to consult with a speech therapist for evaluation of dysphagia. The nurse cannot convert orders for medications to a different route. Water or pudding may increase the risk for aspiration if a dysphagia evaluation has not been completed. Reference: Chapter 29: Medications - Page 844

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept? A) The nurse is the expert in the teaching-learning environment. B) The nurse must be able to handle criticism during the process. C) The client and the nurse are equal participants. D) Assimilation and application of psychomotor concepts is essential.

C) The client and the nurse are equal participants. Effective learning occurs when clients and health care professionals are equal participants in the teaching-learning process, not when the nurse is viewed as the expert. Although it is important for the nurse to be able to handle criticism and to understand and apply psychomotor concepts when teaching, these are not as important as viewing the client and nurse as equal participants. Reference: Chapter 9: Teaching and Counseling - Page 161-162

The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client? A) The client will stay in bed at all times. B) The client will learn how to communicate needs. C) The client will remain safe. D) The client will consistently follow instructions.

C) The client will remain safe. Explanation: Client goals are individualized but focus on achieving optimal sensory function. A nursing diagnosis for the client is Disturbed Sensory Perception. The priority goals for this client is ensuring the client remains safe. Developing an effective communication mechanism is a secondary goal. If the client is confused, he or she may or may not be able to communicate needs or follow instruction. A client may have toileting needs that may make it difficult to remain in the bed at all times. In this care, the nurse cannot assume that this intervention is appropriate. Reference: Chapter 44: Sensory Functioning, p. 1732.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? A)The nurse uses wet-to-dry dressings continuously. B) The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. C) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. D) The nurse packs the wound cavity tightly with dressing material.

C) The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously. Chapter 32: Skin Integrity and Wound Care - Page 1072

Which is a characteristic of the care-based approach to bioethics? A) The need to emphasize the relevance of clinical experience B) The rightness or wrongness of an action independent of its consequences C) The promotion of the dignity and respect of clients as people D) The need for an orientation toward service

C) The promotion of the dignity and respect of clients as people The care-based approach to bioethics focuses on the specific situations of individual clients, and characteristics of this approach include promoting the dignity and respect of clients as people. The need to emphasize the relevance of clinical experience and the need for an orientation toward service are part of the criticisms of bioethics. The deontologic theory of ethics says that an action is right or wrong independent of its consequences. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 101

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider? A) Respiratory rate B) Temperature C) Thrill and bruit D) Pedal pulses

C) Thrill and bruit The client is experiencing decreased circulation to the left arm that has an AV graft for hemodialysis. There is increased risk for the AV graft to clot and create a circulatory emergency. Obtaining a full set of vital signs would be indicated to evaluate overall status of the client; however, the health care provider would need to know if thrill and bruit are present over the AV graft. Absence of thrill and bruit is a medical emergency. Reference: 37: Urinary Elimination, pp. 1375-1376.

The nurse is caring for a client who reports having "kidney pain from a urinary tract infection" for 3 days. How will the nurse describe this pain when reporting off via SBAR? Select all that apply. A) cutaneous B) somatic C) visceral D) referred E) neuropathic F) acute G) chronic

C) visceral F) acute Explanation: Visceral pain (discomfort arising from internal organs) is associated with disease or injury. It is sometimes referred or poorly localized. Acute pain (discomfort that has a short duration) lasts for a few seconds to less than 6 months. Other answers are incorrect. Reference: Chapter 35: Comfort and Pain Management, p. 1237.

The nurse is caring for four clients with diarrhea. When reviewing the client's chart, the nurse would contact the health care provider if which client has a prescription for an antidiarrheal agent? A) Client with Crohn's disease B) Client with food poisoning C) Client with a bowel tumor D) Client with alcohol use

Client with food poisoning Explanation: Clients with acute diarrhea (food poisoning) should not receive an antidiarrheal until a bacterial causative agent is ruled out. Clients with chronic diarrhea (Crohn's disease, bowel tumor, and alcohol use) may require pharmacologic intervention. Reference: Chapter 38: Bowel Elimination, p. 1437.

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? A) Cough medicine with a high sugar content B) Cough medicine with iodine C) Cough medicine with an antihistamine D) Cough medicine with a decongestant

Cough medicine with an antihistamine Explanation: The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants. Chapter 39: Oxygenation and Perfusion - Page 1505

Which documentation example best reflects the complexity of client teaching by the nurse? A) "Told client to take antibiotic as ordered." B) "Client return demonstrated how to use glucometer." C) "Taught client about peak flows; client verbalized understanding." D) "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

D) "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal." Explanation: The nurse should document who the teaching was provided to, what was taught, the teaching method, and the evidence of learning. The other answer choices are not as comprehensive and, therefore, are not the best examples of teaching. Reference: Chapter 9: Teaching and Counseling - Page 205

Which example best describes feminist ethics? A) A combination of elements of utilitarian and deontologic theories that offer specific action guidelines for practice B) Attention directed to the specific situation of individual clients viewed within the context of their life narratives C) The formal study of ethical issues that arise in the practice of nursing D) An approach critiquing existing patterns of oppression and domination in society

D) An approach critiquing existing patterns of oppression and domination in society Feminist ethics offer an approach critiquing existing patterns of oppression and domination in society, especially as they affect women and the poor. The principle-based approach to ethics combines elements of utilitarian and deontologic theories and offers specific action guidelines for practice. The care-based approach directs attention to the specific situation of individual clients viewed within the context of their life narratives. The formal study of ethical issues that arise in the practice of nursing describes nursing ethics. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 104

A middle-age client reports to the nurse that he has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. Which instruction does the nurse provide to the client? Select all that apply. A) Include a nap in the afternoon if difficulty sleeping occurred the previous night. B) Watching television in bed will aid in inducing sleep. C) Drink hot chocolate prior to bedtime. D) Avoid activities after 5 p.m that are stimulating. E) Participate in a quiet activity, such as reading, prior to attempting to fall asleep.

D) Avoid activities after 5 p.m that are stimulating. E)Participate in a quiet activity, such as reading, prior to attempting to fall asleep. Explanation: To promote good sleep hygiene, the client should avoid any stimulating behaviors after 5 p.m. Quiet activities, such as reading, are acceptable. The client should avoid taking naps and ingesting caffeine. Chocolate has caffeine. Bed should be used for sex and sleep only, not watching television. Reference: Chapter 34: Rest and Sleep - Page 1206

The nurse is performing a psychosocial assessment on an older adult client. For which issue of clients in their later adult years should the nurse assess as a priority? A) Cognitive abilities because all aging people develop some form of dementia B) Self-knowledge and understanding of body changes C) How realistic the adult's expectations are and the incentive they provide for growth and development D) Depression and substance use

D) Depression and substance use An overlooked assessment is often the one addressing the signs of depression and substance use in the later age groups. This is a priority, because it may affect all physiological activity. Adult expectations for growth and development are seen in adulthood and not late adulthood. Assessing self-knowledge of body changes are found within the adolescent age group. Aging does not automatically include dementia, and cognitive ability may be assessed secondary to depression and substance use. Reference: Chapter 41: Self-Concept, p. 1638.

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client? A) Disturbed Sensory Perception: Kinesthetic related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." B) Disturbed Sensory Perception: Tactile as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." C) Disturbed Sensory Perception related to client statement of "Get the bugs off my bed, I can feel them crawling on me." D) Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me."

D) Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." Explanation: The correctly written nursing diagnosis is Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." Since the nursing diagnosis is not a "risk for" diagnosis, it must have a "related to" and "as evidenced by" statement. Reference: Chapter 44: Sensory Functioning, p. 1718.

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws? A) Any emergency care given when consent is obtained B) A negligent act performed in an emergency situation C) Medical advice given to a neighbor regarding a child's rash D) Emergency care for a choking victim in a restaurant

D) Emergency care for a choking victim in a restaurant Good Samaritan laws are designed to protect health practitioners when they give aid to people in emergency situations in which the practitioner is off duty, such as providing emergency care to a choking victim in a restaurant. The other examples listed are not situations covered by the Good Samaritan law. Reference: Chapter 7: Legal Dimensions of Nursing Practice - Page 141

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client? A) Acute B) Chronic C) Diffuse D) Intractable

D) Intractable Malignant pain is acute pain episodes, persistent chronic pain, or both associated with a progressive malignant-type process. The etiology for malignant pain is resistant to cure, and the pain may be described as intractable. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 35: Comfort and Pain Management, p. 1237. Chapter 35: Comfort and Pain Management - Page 1237

A nurse attempts to administer a tap water enema to a client who is dehydrated and finds that the client cannot retain the enema for the prescribed amount of time. What nursing action would be appropriate for this client? A) Do not attempt to re-administer the enema because part of the solution has already been absorbed; notify the health care provider. B) Place the client in a sitting position on the toilet and lower the enema solution. C) Stop the enema and reposition the rectal tube or remove it to check for any fecal contents. D) Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees.

D) Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. Explanation: If the client cannot retain the enema solution for an adequate amount of time, place the client on the bedpan in a supine position while receiving the enema. Elevate the head of the bed 30 degrees for the client's comfort. If still unable to retain the solution, notify the physician. The nurse does not need to reposition the rectal tube but needs to assist the client by repeating the procedure with a slight variation. Reference: Chapter 38: Bowel Elimination, pp. 1439-1440.

Which action would cause a charge nurse to have concerns about a nurse's moral agency? A) The nurse often must stay after shift change to complete documentation. B) A family member complained that the nurse was slow answering call lights. C) The nurse was unable to pass a required dosage calculation examination. D) The nurse was seen at a grocery store after calling in sick.

D) The nurse was seen at a grocery store after calling in sick. The only option with an ethical component possibility is the nurse being seen at the grocery store after calling in sick. It may be that the nurse had no other choice but to go to the grocery store, even if sick, but it would cause the charge nurse to be suspicious. The other options do not reflect an ethical issue because they did not lead to other unethical behaviors, just job performance issues. Reference: Chapter 6: Values, Ethics, and Advocacy - Page 105

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives? A) The nurse writes one or two broad objectives rather than several specific objectives. B) The nurse writes general statements for learner objectives that could be accomplished in any amount of time. C) The nurse plans learner objectives with another nurse before obtaining input from the client and family. D) The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

D) The nurse writes one long-term objective for each diagnosis, followed by several specific objectives. Explanation: The statement that best describes the proper method for writing objectives would be that the nurse writes one long-term objective for each diagnosis, followed by several specific objectives. The nurse would not use general statements that could be accomplished in any amount of time because this action is not addressing the specific needs of the client, and the setting in which the client is in. The nurse would not plan learner objectives with another nurse and would not always obtain input from the family of the client. The objectives need to be specific so the outcomes can be measured in the evaluation phase. Reference: Chapter 9: Teaching and Counseling - Page 198

The nurse should obtain a sleep history on which clients as a protocol? A) only clients who have been suffering from a sleep disorder B) only clients who suffer from a sleep disorder or have been unconscious C) clients who suffer from a sleep disorder or who are spending time in the CCU D) all clients admitted to a health care agency

D) all clients admitted to a health care agency Explanation: Interview questions help identify the client's sleep-wakefulness patterns, the effect of these patterns on everyday functioning, the client's use of sleep aids, and the presence of sleep disturbances and contributing factors. If the client's sleep is adequate and poses no problems, the sleep history may be brief but should still be conducted. As issues or concerns are identified in the general assessment, more detailed questions can be asked to gather more information. Reference: Chapter 34: Rest and Sleep, p. 1208.

A nurse is teaching a sex education class to a group of teenage girls. They ask the nurse about the sexual response cycle in females. Which physiologic response does the nurse tell them is onlyseen in females? A) increase in heart rate B) nipples become hard and erect C) refractory period after orgasm D) loss of muscular control during orgasm causing spastic contractions

D) loss of muscular control during orgasm causing spastic contractions During the excitement phase, some of the physiologic changes common in both men and women include an increased heart rate and blood pressure. Male and female nipples become hard and erect. In the orgasm phase, females have a loss of muscular control, which causes spastic contractions and twitching of the arms and legs. In the resolution phase, men experience a period during which the body does not respond to continued sexual stimulation, called the refractory period. Reference: Chapter 45: Sexuality, p. 1758.

Which is a major organ of the upper respiratory tract? A) trachea B) bronchi C) lungs D) pharynx

D) pharynx Explanation: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract. Reference: Chapter 39: Oxygenation and Perfusion, p. 1482.

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to: A) provide client education. B) evaluate the effectiveness of the hospitalization. C) determine hospital-based services needed by the client. D) prepare the client for home care.

D) prepare the client for home care. Explanation: Given that this client is being discharged from the acute care facility following a stroke, it is most likely that the nurse is calling a meeting of the entire health care team and the client and family to prepare the client for home care. Simply providing client education or evaluating the effectiveness of hospitalization could be done by the nurse alone and would not warrant calling a meeting with the entire health care team. As the client is being discharged, there is no reason to discuss hospital-based resources that the client might need. Reference: Chapter 12: Collaborative Practice and Care Coordination across Settings - Page 284

Which instruction by the nurse could assist the client in estimating the amount of medication in the canister? A) Shake the canister. B) Press down on the canister once. C) Insert the canister into the holder. D) Look on the canister and see how many puffs the canister contains

Look on the canister and see how many puffs the canister contains Explanation: The most reliable method is to look on the canister and see how many puffs the canister contains. Divide this number by the number of puffs used daily to ascertain how many days the MDI will last. For instance, if the MDI contains 200 puffs and the patient takes 6 puffs per day, the MDI should last for 33 days. Keep a diary or record of inhaler use and discard the inhaler on reaching the labeled number of doses. The canister helps distribute the drugs in the pressurized chamber and is therefore incorrect. Pressing down on the canister once releases the medication and is therefore incorrect. Inserting the canister into the holder is incorrect, as this is the first step in preparing to take the medication. Reference: Chapter 29: Medications - Page 866

A client with a new diagnosis of asthma has been prescribed a corticosteroid by metered-dose inhaler (MDI). What teaching point should the nurse include in health education? A) "Wait at least 15 seconds before taking a second puff of your medication." B) "Avoid inhaling too deeply after you take a dose of your medication." C) "Avoid eating or drinking during the 15 minutes before you take a dose." D) "Rinse your mouth with water after each dose of your medication."

MAY BE GOOD TO LOOK AT FOR PHARM D) "Rinse your mouth with water after each dose of your medication." It is important to rinse the mouth after using an MDI with a steroid. Food and drinks do not need to be avoided prior to use and the client should wait 1 to 5 minutes between puffs. Deep inhalation is appropriate with MDI use. Reference: Chapter 29: Medications - Page 865

A nurse is providing end-of-life care to a terminally ill client. Which action should the nurse take to remove mucus and saliva from the client's mouth? A) Apply mineral oil to the lips. B) Position the client in the supine position. C) Perform suction in the client's mouth. D) Administer oxygen to the client.

Perform suction in the client's mouth. Explanation: Suctioning helps to remove mucus and saliva that the client cannot swallow or expectorate. A lateral, not supine, position keeps the mouth and throat free of accumulating secretions. The lips may need periodic lubrication because they may become dried from mouth breathing or administration of oxygen. Reference: Chapter 43: Loss, Grief, and Dying, p. 1707.