224 TestBank Final

The student nurse is examining the dispersion of data in a research study. Which measurements should this student expect to review? 1. Mean, median, and mode 2. Range, variance, and standard deviation 3. Mean, range, and standard deviation 4. Measures of central tendency

2. Range, variance, and standard deviation

A nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the increased risk a poor physical environment creates for this client, on what should the nurse focus during the intake phase of the interview? 1. Lack of social support 2. Recent history of chills and body aches 3. Improper nutrition 4. Few personal resources

2. Recent history of chills and body aches

A client with a postoperative infection is afebrile but still receiving IV antibiotics. The nurse should realize that this client is receiving which level of prevention? 1. Primary 2. Secondary 3. Tertiary 4. Critical

2. Secondary

The student nurse contacts a number of other students to create a study group. What behavior is the student nurse demonstrating? 1. Governance 2. Socialization 3. Service orientation 4. Specialized education

2. Socialization

The nurse is working with a client who, during her interview, expresses feelings of groundedness. The nurse interprets this to mean that the client 1. is full of energy. 2. feels connected to her reality. 3. is focused on her center of energy. 4. feels down in the dumps.

2. feels connected to her reality.

A client who has been blinded as result of an injury informs the rehabilitation staff of planning to return to her counseling practice and working full-time. The nurse should realize that this client is demonstrating which aspect of values clarification? 1. Choosing 2. Prizing 3. Acting 4. Clarifying

3. Acting

The nurse is preparing to assess a group of assigned clients with chronic illnesses who use essential oils. For which health problem should the nurse particularly assess the clients? 1. Hypertension 2. Cardiac problems 3. Asthma 4. Cancer

3. Asthma

The nurse has adopted a healthy lifestyle. What action demonstrates that the nurse is being successful in this endeavor? 1. Exercising every day, at least for an hour and a half 2. Buying only fat-free foods and allowing absolutely no deviation from this 3. Balancing good nutrition and exercise in moderation 4. Exercising more on days when feeling guilty about a snack

3. Balancing good nutrition and exercise in moderation

The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? 1. Client will understand the importance of eating healthy. 2. Client will be able to lose weight. 3. Client will list foods that are nutritionally sound, low fat, and high fiber. 4. Client will appreciate the value of using the Food Guide Pyramid.

3. Client will list foods that are nutritionally sound, low fat, and high fiber.

A nurse enters a clients room and asks about his level of pain. The client, grimacing, says Its fine. Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude

3. Congruence

The manager determines that a new graduate nurse needs additional training on the principles of delegation. What delegation to unlicensed assistive personnel did the manager observe to make this decision? Select all that apply. 1. Bathing a patient recovering from surgery 2. Weighing a patient who is prescribed diuretics 3. Discharge instruction teaching 4. Transferring and ambulating a client after hip replacement surgery 5. The care of an intravenous access device

3. Discharge instruction teaching 5. The care of an intravenous access device

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment

3. Emergency assessment

The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment

3. Evaluation

A young adult has never lived away from his parents and feels unable to make decisions on his own. According to Freuds theory of development, the nurse should suspect that this person would be fixated at which stage of development? 1. Phallic 2. Latency 3. Genital 4. Anal

3. Genital

A client who resides in a long-term care facility has no family or visitors. Her only social contacts are with the staff. The client is confined to bed and is not able to communicate verbally. As part of the clients care plan, the nurses provide massage therapy three times a week. What is the main benefit of this intervention for this client? 1. Stretch and loosen the muscles 2. Speed the removal of metabolic waste products 3. Help satisfy the need for caring and nurturing touch 4. Relieve pain

3. Help satisfy the need for caring and nurturing touch

The nurse is working in a clinic setting and is meeting a new client for the first time. In order to convey cultural sensitivity, how should the nurse introduce herself? 1. I'm Jane, and Ill be your nurse today. 2. I'm Dr. Smiths nurse, Jane. 3. I'm Jane Brown, and Im a nurse here at the clinic. 4. I'm glad to meet you. You can call me Jane.

3. I'm Jane Brown, and Im a nurse here at the clinic.

A nurse is helping a hospice client who has had difficulty with making end-of-life decisions. The nurse has encouraged the client to focus on her self-worth, her accomplishments, and having positive self-esteem in order to process through some of these decisions. The nurse is helping the client to achieve balance in which component? 1. Environmental 2. Physical 3. Mental 4. Spiritual

3. Mental

A client is the child of an African American father and Asian American mother. The client has been exposed to cultural foods, traditions, and customs from both parents throughout life. What term should the nurse use to describe this clients cultural development? 1. Diversity 2. Subculture 3. Multicultural 4. Cultural sensitivity

3. Multicultural

The nurse forgets to put the call light within the clients reach and then leaves the room. The client reaches for it and falls out of bed. With what should the nurse expect to be charged? 1. Assault 2. Battery 3. Negligence 4. Criminal intent

3. Negligence

The parents of a newborn ask what their baby can see. What should the nurse respond to these parents? 1. Babies arent able to see until they are around 4 months old. 2. Babies wont track moving objects until about 5 months. 3. Newborns blink in response to bright lights and sound and will follow large objects. 4. Newborns arent able to focus, so everything looks blurry to them.

3. Newborns blink in response to bright lights and sound and will follow large objects.

The nurse is assisting a client and his family after the client had a stroke and is no longer able to return to his previous employment. The nurse has made a referral to vocational rehabilitation for assistance in retraining the client in a different occupation. With which component of wellness is the nurse assisting this client? 1. Intellectual 2. Environmental 3. Occupational 4. Emotional

3. Occupational

A young adult client recovering from an injury that resulted in partial paralysis plans to live independently as before the injury. Which referral should the nurse identify as being the best for this client? 1. Paramedical technologist 2. Physical therapist 3. Occupational therapist 4. Case manager

3. Occupational therapist

The nurse completes collecting data from a client and determines a list of problems. Which step in the nursing process should the nurse perform next? 1. Assess 2. Diagnose 3. Plan 4. Evaluate

3. Plan

A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to health care and live in poverty. According to Dunns high-level wellness grid, the nurse will be working with clients in which quadrant? 1. Emergent high-level wellness in an unfavorable environment 2. Protected poor health in a favorable environment 3. Poor health in an unfavorable environment 4. Protected poor health in an unfavorable environment

3. Poor health in an unfavorable environment

Before a client goes to surgery, he requests to have his spiritual leader present and pray over him. According to the HEALTH traditions model, which traditional method is the client invoking? 1. Maintaining HEALTH 2. Protecting HEALTH 3. Restoring HEALTH 4. Changing HEALTH

3. Restoring HEALTH

A staff nurse is serving as a preceptor for nursing students. In which level of Benners proficiency is this nurse practicing? 1. Stage II 2. Stage III 3. Stage IV 4. Stage V

3. Stage IV

A nurse educator is explaining the concept of health and parallels this with interruption of body systems and symptoms of disease or injury. This educator is interpreting health according to which model? 1. Healthillness continua 2. Eudemonistic 3. Adaptive 4. Clinical

4. Clinical

The nurse struggling with a demanding client focuses on experiencing a sense of true empathy for the clients situation. Which assumption of Parses human becoming theory is the nurse using? 1. Meaning 2. Rhythmicity 3. Intersubjectivity 4. Cotranscendence

4. Cotranscendence

A nurse manager has been dealing with staffing problems and high patient acuity on the unit. The director of nursing unit has been sensitive to other issues in the past, so the nurse manager decides to approach her with these new concerns. Which aspect of caring is the nurse manager demonstrating? 1. Knowing 2. Trust 3. Humility 4. Courage

4. Courage

The staff nurse asks why unlicensed assistive personnel are responsible for stocking the unit refrigerator with refreshments when dietary personnel place the items on the shelf in the kitchen. What characteristic of critical thinking is this nurse demonstrating? 1. Curiosity 2. Clinical reasoning 3. Setting priorities 4. Developing rationales

4. Developing rationales

A nurse is conducting a family assessment and is focusing, for the moment, on the family members communication patterns. Which observation indicates that there are existing or potential problems with family communication? 1. All members are participating in the discussion equally, some quite vocally. 2. The verbal communication is congruent with the nonverbal messages. 3. A few of the members just sit and listen. 4. Disagreements are not addressed among members; rather, they are ignored by the person who does the most talking.

4. Disagreements are not addressed among members; rather, they are ignored by the person who does the most talking.

After a community was hit by a tornado, the nurses of the local Red Cross Chapter helped to make sure people had adequate food and clothing. Which function of community were these nurses focused on restoring? 1. Social control 2. Social interparticipation 3. Mutual support 4. Distribution of goods and services

4. Distribution of goods and services

After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart. 4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it.

4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it.

Prior to providing client care, the nurse reviews previous shift charting and the responses to nursing interventions. Which decision-making action is the nurse using? 1. Set the criteria 2. Examine alternatives 3. Implement 4. Evaluate the outcome

4. Evaluate the outcome

A client diagnosed with hypertension has had well-controlled follow-up of her blood pressure for the past 6 months. At todays clinic appointment, the clients blood pressure is 98/58. The client insists she has been taking her prescribed antihypertensive medication as prescribed, but also added an herbal tablet because she heard it was supposed to be good for her. Which is most likely interfering with the clients antihypertensive? 1. Valerian 2. Milk thistle 3. Ginseng 4. Garlic

4. Garlic

A community health nurse is planning adult health education classes. According to Eriksons stages of development, the nurse should address which task with this age group? 1. Industry versus inferiority 2. Identity versus role confusion 3. Intimacy versus isolation 4. Generativity versus stagnation

4. Generativity versus stagnation

A client recovering from a stroke does not want to perform prescribed shoulder exercises. What should the nurse say to the client that demonstrates critical thinking with creativity? 1. Youll only get worse if you dont do these exercises. 2. As soon as you get these into your routine, youll feel better. 3. Your physician wouldnt have ordered these if they werent important. 4. Heres a marker. See how many circles you can make on this board in 10 minutes.

4. Heres a marker. See how many circles you can make on this board in 10 minutes.

The nurse is creating a community education program on health promotion and wellness. Which topic should the nurse use for this program? 1. Prenatal and infant care 2. Prevention of sexually transmitted disease 3. Exercise class for clients who have had a stroke 4. Home accident prevention

4. Home accident prevention

A client has just lost her second baby to preterm complications. Which statement demonstrates the best therapeutic response for the nurse to make? 1. Dont be so sad. You can always try again. 2. Didnt your doctor advise you about genetic counseling? 3. I know how you feel. I have children of my own. 4. I am so sad for you. Ill stay with you for a while if you need to talk.

4. I am so sad for you. Ill stay with you for a while if you need to talk.

A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. It's going to take time for me to understand this whole thing. 2. Let's make sure my spouse is around before you start explaining. 3. I wish my doctor would have explained this more in depth. 4. I'm feeling nauseous, but go ahead and start anyway.

4. I'm feeling nauseous, but go ahead and start anyway.

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the clients problem, health risks, and strengths.

4. Identify the clients problem, health risks, and strengths.

A client is being seen in the mental health clinic for antisocial behavior. According to Eriksons stages of development, the nurse realizes 1. Initiative versus guilt 2. Industry versus inferiority 3. Intimacy versus isolation 4. Identity versus role confusion

4. Identity versus role confusion

To help a home health client with a difficult medication regime, the nurse contacts the pharmacist for ideas to facilitate the process. Which behavior did the nurse demonstrate when caring for this client? 1. Hands-on care 2. Direct care 3. Advocacy 4. Indirect care

4. Indirect care

A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan

4. Individualized care plan

A nurse educator is working with students and assisting them in addressing their clients spiritual needs. The educator understands that most traditional, second-year college students are aware of their own spiritual development or working to develop their own system of spirituality. The educator realizes that the students are in which stage of Fowlers developmental theory? 1. Mythic-lyrical 2. Intuitive-projective 3. Universalizing 4. Individuating-reflexive

4. Individuating-reflexive

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions

4. Ineffective airway clearance, related to increased secretions

An older male client comes to the clinic and states to the nurse that he hasnt been interested in sexual intercourse lately. He states: I guess this is part of getting old, too. What should the nurse explain about decreased sexual interest in older clients? 1. It does decrease and gradually disappears. 2. It should not be taken as seriously as it would be if the client were a younger person. 3. It is caused by decreased hormone activity and there is little that can be done about it. 4. It decreases but does not disappear.

4. It decreases but does not disappear.

In the review of an elderly clients chart, the nurse reads that the client has sarcopenia. What should the nurse expect the client to report? 1. Weight loss and nausea 2. Hair loss and thin skin 3. Bleeding and bruising tendencies 4. Lack of strength and tiring easily

4. Lack of strength and tiring easily

The nurse is researching the concept of caring as it relates to specific situations in the clinical area. More specifically, the nurse is interested in caring as it relates to cultural differences. Of the following theorists, which would be of the most help to this nurse researcher? 1. Florence Nightingale 2. Jean Watson 3. Dorothea Orem 4. Madeline Leininger

4. Madeline Leininge

The parents of a newborn male ask the nurse about pain during circumcision. What should the nurse respond to these parents? 1. Newborns cant feel pain, so dont worry about it. 2. Well make sure to bring your baby to you right after the procedure, so you can comfort him. 3. Ill have the pediatrician speak to you about it. 4. Newborns pain experience is real. Well use some medication to help your baby feel more comfortable.

4. Newborns pain experience is real. Well use some medication to help your baby feel more comfortable.

A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling? 1. Autonomy 2. Justice 3. Beneficence 4. Nonmaleficence

4. Nonmaleficence

The nurse carries out a medication order, incorrectly written by the physician and subsequently filled by the pharmacist. Who, in this situation, is legally liable for the action? 1. Physician 2. Pharmacist 3. Hospital 4. Nurse

4. Nurse

The nurse has starting working in a state other than the one in which the nursing education program was located. Which of the following should the nurse consult in order to understand the implications of this change of venue? 1. American Nurses Association (ANA) 2. National League for Nursing (NLN) 3. National Council of State Boards of Nursing (NCSBN) 4. Nurse State Practice Act

4. Nurse State Practice Act

A client is in the end stages of cancer. Which type of service should the nurse consider as being the best for this client? 1. Rehabilitation 2. Health restoration 3. Acute care 4. Palliative care

4. Palliative care

A nursing student would like to do an observation on one of the inpatient units at a hospital. In assisting the student to meet this desire, the educator would look for which type of nurse? 1. Mentor 2. Manager 3. Team leader 4. Preceptor

4. Preceptor

The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing

4. Promotes a taxonomy of nursing

Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? 1. Implementing nursing intervention 2. Determining the nurses need for assistance 3. Supervising delegated care 4. Reassessing the client

4. Reassessing the client

During a home visit, the client with terminal cancer undergoes respiratory arrest. The client has agreed to a DNR (do not resuscitate) order; however, the spouse tells the nurse to call 911. What action should the nurse take? 1. Assess vital signs. 2. Call 911. 3. Start CPR. 4. Remind the spouse of the clients desires.

4. Remind the spouse of the clients desires.

The nurse reviews clients records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent 2. Peer review 3. Nursing audit 4. Retrospective

4. Retrospective

A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslows human needs theory, at which level should the nurse recognize that the client is struggling? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem

4. Self-esteem

A nurse manager is responsible for scheduling the staff of all units in a critical care hospital. Which program should the manager use for computerized scheduling? 1. Database 2. Word processing 3. Graphics program 4. Spreadsheet

4. Spreadsheet

The nurse is considering leaving a position in an organization that utilized differentiated practice. Which type of delivery system should the nurse consider as being the most similar to differentiated practice? 1. Case method 2. Shared governance 3. Functional method 4. Team nursing

4. Team nursing

During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? Select all that apply. 1. What you did was wrong. 2. Who do you think you are? 3. You shouldnt have done that. 4. Tell me more about the supplements. 5. Explain the reasoning behind your decision.

4. Tell me more about the supplements. 5. Explain the reasoning behind your decision.

A client is being seen in the clinic for the final follow-up appointment after an extensive course of rehabilitation. According to Neumans model, which level of intervention should the nurse realize this patient is experiencing? 1. Primary prevention 2. Secondary prevention 3. Resistant prevention 4. Tertiary prevention

4. Tertiary prevention

Before providing care, the nurse reviews the clients pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The clients medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex

4. The Kardex

The community health nurse is caring for teenage mothers and their children. For what should the nurse assess these patients when determining their degree of vulnerability? 1. Distance separation from their nuclear families 2. Increased levels of poverty 3. Raising children without the support of family 4. The normal difficulties of adolescence

4. The normal difficulties of adolescence

A nurse who is opposed to abortion works in a hospital where abortions are performed. According to the Supreme Courts conscience clause, which action should the nurse take? 1. The nurse should not take action, because the nurse cannot interfere with a womans constitutional right to privacy. 2. The nurse should voluntarily terminate employment. 3. The nurse should counsel women before they have an abortion. 4. The nurse should refuse to participate in abortions.

4. The nurse should refuse to participate in abortions.

An older adult client comes to the clinic with reports of not being able to hold her urine, stating: I feel so terrible. This shouldnt happen at my age. How should the nurse respond? 1. You shouldnt feel badly. Lots of people have this trouble. 2. Youll probably have to start wearing incontinence briefs. Then you wont be worried about accidents. 3. Getting old isnt much fun, is it? 4. There could be a number of causes for this. I need to ask you some more questions about it.

4. There could be a number of causes for this. I need to ask you some more questions about it.

A middle-aged client is struggling with life changes, including menopause. What is the best response by the nurse to this client? 1. Dont worrymenopause cant last forever. 2. There are some very good antidepressants you can take. 3. What did your mother do to get through menopause? 4. There is a menopause support group that meets every 2 weeks.

4. There is a menopause support group that meets every 2 weeks.

A parent is concerned that her 5-year-old is beginning to masturbate. How should the nurse, familiar with Freuds stages of development, respond? 1. All children are curious, but make sure the child knows that this behavior might be offensive to others. 2. You should probably consult a child psychologist if youre this concerned. 3. Lets make sure to ask your physician at the next appointment. 4. This behavior is a normal part of your childs development.

4. This behavior is a normal part of your childs development.

The nurse systematically tries a variety of products to help with healing of a clients wound. Which problemsolving method is the nurse using? 1. Intuition 2. Scientific method 3. Research process 4. Trial and error

4. Trial and error

The nurse is caring for clients in Stage II/III Alzheimers disease. If Orems theory is applied, which type of nursing system should the nurse use when providing client care? 1. Supportive 2. Educative 3. Partly compensatory 4. Wholly compensatory

4. Wholly compensatory

The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that 1. information given to this group is written at a third-grade level. 2. teaching includes a variety of approaches. 3. information includes pictures. 4. there is ample time for teaching.

4. there is ample time for teaching.

The nurse is reviewing the Good Samaritan acts. For which situation should the nurse realize that these laws apply? 1. Giving CPR to a client brought to the emergency department, when the client later is found to have a Do Not Resuscitate order 2. Giving first aid to a child injured in a sporting event 3. Permitting a nursing student to try to insert an airway in an unconscious client 4. Leaving the scene of an emergency to call for help 5. Helping deliver the baby of a neighbor during a snowstorm

5. Helping deliver the baby of a neighbor during a snowstorm

The nurse is reviewing the ANA (American Nurses Association) Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code? 1. It is a formal statement. 2. It contains the same standards as legal standards. 3. It is shared by group members. 4. It reflects legal judgments. 5. It serves as a standard for professional actions.

5. It serves as a standard for professional actions

The nurse is planning to apply to graduate school to earn a masters degree in nursing. On what should the nurse expect the programs curriculum to focus? 1. An advanced leadership role 2. Case manager 3. Wound care specialist 4. Intravenous therapy specialist

1. An advanced leadership role

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

1. Assessment

The nurse wants to search for articles having to do with a client care problem. Which database should the nurse use to find this information? 1. CINAHL 2. Google 3. ERIC 4. PsychINFO

1. CINAHL

The nurse is designing a teaching plan for a client to learn a new psychomotor skill. What strategies can the nurse use to facilitate learning for this client? Select all that apply. 1. Demonstration 2. Practice 3. Modeling 4. Discovery 5. Role playing

1. Demonstration 2. Practice 3. Modeling

The nurse is reviewing feedback from other staff members on leadership behaviors. Which characteristics are consistent with being an effective leader? Select all that apply. 1. Energetic 2. Creative 3. Optimistic 4. Open 5. Risk taking

1. Energetic 2. Creative 3. Optimistic 4. Open

During a home visit with a new community member, the nurse suspects that a client has a chronic illness. What did the nurse assess to make this clinical decision? Select all that apply. 1. Experienced symptoms for 8 months 2. Has periods where the symptoms disappear 3. Altered activities of daily living because of the illness 4. Problem disappeared with over-the-counter medication 5. Symptoms appeared abruptly and disappeared after treatment

1. Experienced symptoms for 8 months 2. Has periods where the symptoms disappear 3. Altered activities of daily living because of the illness

During an interaction between a nurse and client, the nurse conveys respect and an attitude that shows the nurse takes the clients opinions seriously. In which stage of the working relationship are the nurse and client engaged? 1. Exploring and understanding thoughts and feelings 2. Facilitating and taking action 3. Confrontation 4. Concreteness

1. Exploring and understanding thoughts and feelings

A client woke in the middle of the night, confused and unaware of the surroundings. Although the call light was within reach, the client got out of bed unassisted, tripped on the bedside chair, and fell. Which element of malpractice should the clients attorney realize is missing in this case? 1. Foreseeability 2. Damages 3. Injury 4. Duty

1. Foreseeability

The nurse is hired to provide care in a hospital that offers services in all specialty areas. How should the nurse categorize this type of health care facility? 1. General hospital 2. Specialty hospital 3. Long-term care hospital 4. Short-term hospital

1. General hospital

The nurse is reviewing Mayeroffs philosophy of caring prior to providing care to a client. What should the nurse include to demonstrate caring to the client? 1. Honesty 2. Trust 3. Humility 4. Professionalism 5. Courtesy

1. Honesty 2. Trust 3. Humility

The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion? Select all that apply. 1. Incorrect completion of previous hospitalizations form 2. Client refusing to sign forms because eyeglasses are at home 3. Client saying he forgot to report for laboratory testing 4. Score of 6 on the Newest Vital Sign assessment tool 5. Questioning the dosage pattern on a newly prescribed medication

1. Incorrect completion of previous hospitalizations form 2. Client refusing to sign forms because eyeglasses are at home 3. Client saying he forgot to report for laboratory testing

The nurse desires to improve critical thinking skills when providing client care. On which attributes should the nurse focus when developing these skills? Standard Text: Select all that apply. 1. Independence 2. Egocentricity 3. Intellectual humility 4. Fair-mindedness 5. Confidence 6. Perseverance

1. Independence 3. Intellectual humility 4. Fair-mindedness 5. Confidence 6. Perseverance

The nurse is reviewing a clients plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? Standard Text: Select all that apply. 1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms. 5. The client has apologized to his family for drug abuse behaviors.

1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms.

The nurse is interested in specializing in forensics. What should the nurse expect to learn prior to assuming the role of a forensics nurse? Standard Text: Select all that apply. 1. Knowledge about the legal system 2. Approaches to collecting evidence 3. Budgeting, staffing, and planning programs 4. Information necessary when providing testimony in court 5. Training in identification, evaluation, and documentation of injuries

1. Knowledge about the legal system 2. Approaches to collecting evidence 4. Information necessary when providing testimony in court 5. Training in identification, evaluation, and documentation of injuries

The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM

1. Lasix, 20 mg, po bid

When completing a community assessment, the community health nurse will take several aspects into account. What is the first stage of this assessment that the nurse will complete? 1. Learn about the people in the community. 2. Understand the major illnesses present in the community. 3. Identify the boundaries of the community. 4. Make sure resources are available in the community.

1. Learn about the people in the community.

A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex

1. MDS

A nursing units records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records? 1. Nursing audit 2. Peer review 3. Individual audit 4. Concurrent audit

1. Nursing audit

A hospital is implementing a computerized charting system, and all nursing staff is required to be oriented to the system by a specific deadline. Which type of change is occurring with the staff? 1. Overt change 2. Covert change 3. Unplanned change 4. Drift

1. Overt change

A seasoned RN is especially competent in knowledge of the computerized charting system in a facility and is able to assume the team leader role on a regular basis. In which type of care delivery system is this nurse most likely providing care? 1. Primary nursing 2. Team nursing 3. Differentiated practice 4. Case method

1. Primary nursing

The nurse is reviewing the preamble of the International Council of Nurses Code of Ethics. On which responsibilities should the nurse focus when reviewing this preamble? Standard Text: Select all that apply. 1. Promote health. 2. Restore health. 3. Inform the public about minimum standards of nursing conduct. 4. Provide self-regulation in the profession. 5. Prevent illness. 6. Alleviate suffering.

1. Promote health. 2. Restore health. 5. Prevent illness. 6. Alleviate suffering.

The nurse is planning care for an older adult client. On what should the nurse focus if following the Functional Consequences Theory on aging? Standard Text: Select all that apply. 1. Promote safety. 2. Promote mental health. 3. Improve quality of life. 4. Promote spiritual health. 5. Promote growth and development.

1. Promote safety 3. Improve quality of life.

A client approaching middle age asks for information to keep mentally sharp. What should the nurse explain about the cognitive abilities of the middle-aged client? Standard Text: Select all that apply. 1. Reaction time stays much the same. 2. Memory is maintained during this time. 3. Learning declines and cannot be completed. 4. Problem-solving ability is maintained during this time. 5. Cognitive and intellectual abilities change very little at this time.

1. Reaction time stays much the same. 2. Memory is maintained during this time. 4. Problem-solving ability is maintained during this time. 5. Cognitive and intellectual abilities change very little at this time.

A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor? Standard Text: Select all that apply. 1. Time management 2. Healthy eating habits 3. Exercise after stroke 4. Bicycle safety for children 5. Performing self-examination of the breasts

1. Time management 2. Healthy eating habits 4. Bicycle safety for children

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation

2. A variance

The nurse researcher is testing the effects of a new dressing preparation on certain participants, while continuing to use older but more familiar products on others. Which type of research design is the nurse using? 1. Quasi-experimental 2. Experimental 3. Nonexperimental 4. Pilot study

2. Experimental

The parents of a baby born prematurely during the sixth month of pregnancy question the nurse about the hair all over their baby. What is the nurses best response? 1. All babies are hairy. It is more noticeable on preemies. 2. Fine downy hair helps keep the baby insulated in utero. 3. You should be more concerned with the babys respiratory function. 4. Dont worry about how the baby looks. All preemies look funny.

2. Fine downy hair helps keep the baby insulated in utero.

The nurse is preparing a menu for a Jewish client who observes kosher customs. Which food items would be appropriate to serve this client, assuming all have been properly inspected and prepared? 1. Hamburger, fruit, and milk 2. Fish, vegetables, and hot tea 3. Ham, baked potato, and fresh fruit 4. Cream soup, sausage, and toast

2. Fish, vegetables, and hot tea

The community health nurse is using the Heritage Assessment Interview tool with a group of community members. Which data indicate heritage consistent? Select all that apply. 1. A client frequently visits the old country neighborhood he grew up in. 2. A client is raised by a single parent. 3. The clients education occurred at a religious school. 4. The client participates in religious festivals and cultural events. 5. The client has been the first of his family to earn a college degree.

1. A client frequently visits the old country neighborhood he grew up in. 3. The clients education occurred at a religious school. 4. The client participates in religious festivals and cultural events.

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the units information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets

1. A firewall to protect the server from unauthorized access 3. Expectation to log off a terminal after using it 5. Requirement to shred all computer-generated worksheets

A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? Standard Text: Select all that apply. 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication

1. A root cause analysis 2. Paperwork about a sentinel event

While assisting in a community health project for middle-aged adults, the nurse attempts to identify members of the community who have been successful in the tasks identified by Erikson. What characteristic should the nurse identify in the community members? 1. Ability to have satisfaction in their volunteer activities 2. Ability to find an acceptable social group 3. Satisfaction with rearing children 4. Ability to manage a home

1. Ability to have satisfaction in their volunteer activities

The nurse has been promoted to the role of manager for a client care area. What responsibilities of the nurse will this new role include? Select all that apply. 1. Accomplish the goals of the organization. 2. Use the organizations resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards. 5. Manage relationships.

1. Accomplish the goals of the organization. 2. Use the organizations resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards.

A client visits a clinic that integrates Western medicine with complementary therapies. Which therapies might the client utilize and believe to keep the flow of qi at a therapeutic level? 1. Acupressure and reflexology 2. Therapeutic touch and Reiki 3. Aromatherapy and naturopathic remedies 4. Chiropractic and massage therapy

1. Acupressure and reflexology

The nurse observes during a dressing change that the clients wound has become infected. When asked by the client how the wound looks, the nurse says it looks fine but the nurses facial expression doesnt support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity

1. Adaptability

The nurse is explaining the definition of being a nurse to a new nursing assistant. Which themes should the nurse include when talking with the assistant? Standard Text: Select all that apply. 1. Adaptive 2. Client-centered 3. Goal-directed according to the needs of the client 4. Diagnosis and treatment of disease 5. An art 6. A science

1. Adaptive 2. Client-centered 5. An art 6. A science

An elderly client who has had a stroke is ready for hospital discharge. How should the gerontological nurse case manager support this clients independence? 1. Allow the client to be actively involved in all decisions made. 2. Make arrangements based on what the nurse feels is in the best interest of the client. 3. Work closely with the social worker and physician to make the decisions necessary for the client. 4. Set up a meeting with the family members so decisions can be made.

1. Allow the client to be actively involved in all decisions made.

The nurse is providing care to an assigned client. Which action indicates that the nurse supports the clients respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the clients needs 4. Presenting information to the clients family about the clients condition

1. Allowing the client to complete hygienic care when possible

A client with degenerative joint disease comes to the clinic and states that he has been reading a lot about essential oils that are helpful for stomach problems. The nurse should offer the client information about the use of which oil? 1. Chamomile 2. Eucalyptus 3. Lavender 4. Tea tree

1. Chamomile

The nurse is helping in discharge planning of a client who needs extensive rehabilitation and is on a complicated medication schedule. Which individual should the nurse include in this clients plan? 1. Clients spouse 2. Physician 3. Pharmacist 4. Social worker

1. Clients spouse

Two nursing students, both single parents, have decided to move into a larger house. Part of their rationale includes providing support for studying and sharing the responsibilities of parenting. Which type of living arrangement are these students implementing? 1. Cohabiting family 2. Blended family 3. Foster family 4. Intragenerational family

1. Cohabiting family

The nurse is explaining the difference between community and population to a group of community members. What should the nurse use as an example for population? 1. Commuters on the subway 2. A grade school class 3. Graduating nursing students 4. A group of employees at a local plant

1. Commuters on the subway

The admitting nurse explains the process of signing forms to allow for the clients insurance company to be billed for services. If the insurance fails to pay for services, the client is responsible for payment. Which type of law did the nurse explain to the client? 1. Contract law 2. Tort law 3. Statutory law 4. Administrative law

1. Contract law

A student nurse resists when encouraged to be creative when providing client care. What should the nurse educator say to encourage this student to be creative? 1. Creativity allows unique solutions to unique problems. 2. Not all your answers are going to be from your textbook. 3. Creativity makes nursing more fun. 4. Youll get bored if you dont learn to be creative.

1. Creativity allows unique solutions to unique problems.

Nursing students are researching how cultural practices affect the dying process of terminal cancer clients. For their research, which theory will the students most likely explore? 1. Critical theory 2. Midlevel theories 3. Grand theories 4. Stability models

1. Critical theory

A client reports feelings of spiritual anguish and depression as a result of experiencing numerous somatic complaints that make the client feel like everything is out of order. Which nursing diagnosis should the nurse identify for this client? 1. Energy-field disturbance 2. Powerlessness 3. Hopelessness 4. Anxiety

1. Energy-field disturbance

A client is being discharged after a 23-hour stay for a surgical procedure. When preparing the instructions for this client, what does the nurse need to do? Select all that apply. 1. Ensure the clients safe transition to home. 2. Include information about what the client has been taught. 3. Include what the client still needs to learn when discharged. 4. Check the clients insurance for hospitalization coverage. 5. Call the clients prescriptions in to the clients local pharmacy.

1. Ensure the clients safe transition to home. 2. Include information about what the client has been taught. 3. Include what the client still needs to learn when discharged.

A registered nurse is supervising several LPNs who provide patient care. Which responsibility should the registered nurse expect to complete? 1. Evaluating the care provided to the client 2. Administering intramuscular (IM) medications 3. Performing dressing changes 4. Delegating appropriate tasks to unlicensed client care providers (such as a nurses aide)

1. Evaluating the care provided to the client

The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? Standard Text: Select all that apply. 1. Growth involves physical change and increase in size. 2. Skills and function increase with growth. 3. Most humans experience a similar pattern of growth. 4. Being able to adapt to ones environment is an indicator of growth. 5. Childrens growth is monitored by height, weight, bone size, and dentition.

1. Growth involves physical change and increase in size. 3. Most humans experience a similar pattern of growth. 5. Childrens growth is monitored by height, weight, bone size, and dentition.

The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective? Standard Text: Select all that apply. 1. I can look up interventions according to the nursing diagnosis that Ive selected. 2. The interventions connected to a diagnosis are appropriate for any client with that diagnosis. 3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions. 4. Care plans are best written when the interventions are broad and flexible. 5. I find NIC interventions a really good place to start when Im working on client interventions.

1. I can look up interventions according to the nursing diagnosis that Ive selected. 3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions. 5. I find NIC interventions a really good place to start when Im working on client interventions.

The nurse needs to insert an intravenous access device into a toddler who is crying and scared. The parent asks if the procedure is painful. When practicing veracity, what should the nurse respond to the parent? 1. I wont lie to you. It may be easier for you if you step out until we get the line in. 2. Well take every care not to hurt your child. 3. It shouldnt be too bad and Ill be quick. 4. We do this all the time, so dont worry.

1. I wont lie to you. It may be easier for you if you step out until we get the line in.

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. Im going to set up your physical assessment now. Do you have any questions? 2. Tell me more about how you feel. 3. Could you give examples of what types of other treatments youve had? 4. Is there anything youre worried about?

1. Im going to set up your physical assessment now. Do you have any questions?

Parents ask why invasive diagnostic tests were prescribed for their ill child. The nurse has just gotten out of report and has not had a chance to review additional information. What should the nurse respond to the parents? 1. Im not sure I can answer your question just now. 2. Its a good idea to listen to what your physician wants. 3. Your childs doctor is the best there is. I dont see why you wouldnt follow his advice. 4. Maybe you should get another opinion if youre not comfortable with your doctor.

1. Im not sure I can answer your question just now.

The nurse is planning to use the structural-functional theory when assessing a family new to a community. What should the nurse include when conducting this assessment? Standard Text: Select all that apply. 1. Individuals in the family 2. The familys sense of purpose 3. Relationships among family members 4. Strategies to restrict outside influences on the family 5. The approach the family uses to socialize new family members

1. Individuals in the family 2. The familys sense of purpose 3. Relationships among family members 5. The approach the family uses to socialize new family members

A nurse educator has always believed that lectures with focused outlines are the best way to present theory content in class. A colleague, who teaches the same group of students, but a different subject, utilizes group work and in-class activities to teach difficult content and finds that students perform as well, or better, on their tests. The first educator in this situation is starting to rethink her position. What behavior is the first educator demonstrating? 1. Integrity 2. Perseverance 3. Fair-mindedness 4. Humility

1. Integrity

The nurse researcher is determining the best way to formulate a research problem. What should the nurse identify if implementing the PICO format? Standard text: Select all that apply. 1. Intervention to use 2. Problem of interest 3. Comparison of treatments 4. Outcome of the treatments 5. Individuals to perform actions

1. Intervention to use 2. Problem of interest 3. Comparison of treatments 4. Outcome of the treatments

A nurse is working with an elderly male client on a medical unit. Which statement demonstrates elderspeak by the nurse? 1. It's time for us to go to physical therapy. 2. I think it would be better if you were planning to go to a nursing home after discharge. 3. Your children must really love their dad. 4. Your wife must be having trouble adjusting to your illness.

1. Its time for us to go to physical therapy.

The nurse working on an acute psychiatric unit learns that a client with bipolar disorder is being admitted and says to a coworker, We better be ready for a busy night. This nurse is exemplifying which process of Swansons theory of caring? 1. Knowing 2. Being with 3. Doing for 4. Enabling

1. Knowing

During a home visit, the nurse is concerned that a client recovering from hip replacement surgery is at risk for falling in the home. What information from the home assessment did the nurse use to come to this conclusion? Select all that apply. 1. Laminated floors highly polished 2. Scatter rugs in the kitchen and bathroom 3. Smoke detector battery low in the bedroom 4. Cleaning solution placed in an unlabeled jar 5. Expired medication in the bathroom cabinet

1. Laminated floors highly polished 2. Scatter rugs in the kitchen and bathroom

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position

1. Looking directly at the client to ensure good eye contact 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position

A client makes the following statement: I must be paying for all the wrongs I did in my life, to have such a diagnosis as this. The nurse suspects that this client views health from which type of belief? 1. Magico-religious belief 2. Holistic health belief 3. Biomedical health belief 4. Folk medicine

1. Magico-religious belief

The nurse is identifying strategies to support a clients empowerment. What strategies should the nurse use? Standard Text: Select all that apply. 1. Making it possible for the client diagnosed with mild Alzheimers disease to continue to dance regularly, as it has always been a passion of hers 2. Being sure to polish the clients nails now that she is not able to do it herself, as it has always been important to her that she have pretty hands 3. Suggesting to a clients family members that they should insist that the client move into an assisted living facility so as to ensure her safety 4. Helping the clients family identify community support services that will make it possible for the client to remain in her own home 5. Encouraging the client to use a walker and stay indoors, just in case she might fall

1. Making it possible for the client diagnosed with mild Alzheimers disease to continue to dance regularly, as it has always been a passion of hers 2. Being sure to polish the clients nails now that she is not able to do it herself, as it has always been important to her that she have pretty hands 4. Helping the clients family identify community support services that will make it possible for the client to remain in her own home

A nurse researcher is considering the use of various nonpharmacological distraction techniques that have shown success for behavior control in troubled adolescents. Which criteria is this researcher considering to use? 1. Significance 2. Researchability 3. Feasibility 4. Interest

1. Significance

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Standard Text: Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The clients clothes are soiled. 6. The client has obvious body odor.

1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 5. The clients clothes are soiled. 6. The client has obvious body odor.

A client wishes to discontinue cancer treatment. If acting as the client advocate, which statement should the nurse make to the clients physician? 1. The client is making his own decision. 2. The client would benefit from additional information about treatment options. 3. The family must be involved in this decision. 4. Lets educate the family about the consequences of this decision.

1. The client is making his own decision.

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the schools activities.

1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families.

The staff nurse is helping a new graduate understand the relationship between care concepts and planned interventions. What value would it be for the staff nurse to encourage the new graduate to use a concept map? Standard Text: Select all that apply. 1. Used to highlight key areas 2. Provides a visual representation 3. Can be quicker than taking notes 4. Takes years to study how to create 5. Aids in developing critical thinking

1. Used to highlight key areas 2. Provides a visual representation 3. Can be quicker than taking notes 5. Aids in developing critical thinking

The nurse is completing a spiritual assessment with a middle-aged client. What should the nurse recognize as expected characteristics of moral development in this client? Standard Text: Select all that apply. 1. Uses religion for comfort 2. Seeks religious explanations for death 3. Compares characteristics of various religions 4. Questions the purpose of religion in ones life 5. Relies upon spiritual beliefs to help with illness

1. Uses religion for comfort 2. Seeks religious explanations for death 5. Relies upon spiritual beliefs to help with illness

The nurse is identifying communication strategies for a client unable to speak. What would be appropriate for the client in this situation? 1. Using a picture board to facilitate communication 2. Facing the client when speaking 3. Employing an interpreter 4. Making sure that the language spoken is the clients dominant language

1. Using a picture board to facilitate communication

The nurse is beginning a physical assessment of a client who is freelance computer information technologist. On which areas should the nurse place particular emphasis during this assessment? Select all that apply. 1. Vision 2. Hearing 3. Back flexibility 4. Hand range of motion 5. Range of motion of arms

1. Vision 3. Back flexibility 4. Hand range of motion 5. Range of motion of arms

A school health nurse is working on education programs for high school students. As part of the plan, the nurse wants to address health concern topics besides the dangers of unprotected sex or drug and alcohol abuse. Which class topic should the nurse present to these students? 1. Warning signs of depression for peers to identify among their classmates 2. Injury prevention 3. Early signs of cancer and heart disease 4. Normal physiological changes of this age group

1. Warning signs of depression for peers to identify among their classmates

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the clients room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the clients condition.

2. Administer pain medication.

The nurse is notified about new state practice act regulations. Which type of law should the nurse expect to implement and enforce the nurse practice act regulations? 1. Statutory law 2. Administrative law 3. Common law 4. Public law

2. Administrative law

A client is hospitalized with numerous acute health problems. According to Maslows basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client? 1. Risk for Injury related to unsteady gait 2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients 3. Self-Care Deficit related to weakness and debilitation 4. Powerlessness related to chronic disease state

2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients

A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physicians orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication. 4. Call the physician and ask what the medication is and what it is for.

2. Call the pharmacy and do further investigating before administering the medication.

When making an assessment of the clients learning needs, the nurse will focus on which elements? Select all that apply. 1. Nurses own knowledge 2. Clients age 3. Clients understanding of health problem 4. Sensory acuity 5. Learning style

2. Clients age 3. Clients understanding of health problem 4. Sensory acuity 5. Learning style

The nurse working with students on a medical unit describes the pathophysiology of a client with a respiratory acidosis condition as well as specific assessment findings. Which type of knowledge is the nurse demonstrating? 1. Aesthetic 2. Empirical 3. Personal 4. Creative

2. Empirical

The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing? 1. Environmental control 2. Information dissemination 3. Health risk appraisal and wellness assessment 4. Lifestyle and behavior change

2. Information dissemination

The nurse is reviewing the Healthy People 2020 primary goals. Which plan should the nurse realize is in alignment with one of the goals? 1. Providing free screening to schoolchildren 2. Opening a wellness clinic 3. Developing better insurance controls 4. Developing new pharmacological treatments

2. Opening a wellness clinic

A nurse manager is working on new job descriptions for all nursing units of the hospital. Which management function is this nurse conducting? 1. Planning 2. Organizing 3. Directing 4. Coordinating

2. Organizing

A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by clients report

2. Pain related to unknown etiology

A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions? 1. Interpersonal influences 2. Perceived benefits of action 3. Situational influences 4. Perceived self-efficacy

2. Perceived benefits of action

The nurse is caring for a client with Parkinsons disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone.

2. Provide assistive devices and educate client to use grab bar and large handled utensils.

A client has had Alzheimers dementia for a period of time and continues to live at home with his spouse. What would be one of the gerontological nurses responsibilities? 1. Make sure the client is being prescribed appropriate medication. 2. Provide support for the spouse. 3. Assess the client early to ensure proper care. 4. Find a suitable long-term care facility for the client.

2. Provide support for the spouse.

The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? Standard Text: Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention

2. Reassessing the client 4. Supervising delegated care 5. Implementing the nursing intervention

A client has requested that she have a special item present in her room and explains that it gives her a feeling of comfort and a sense of organization. On which psychosocial component is this client focusing? 1. Culture 2. Religion 3. Ethnicity 4. Socialization

2. Religion

A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client

2. Require that the nurse use sound judgment and knowledge of the client

A client has had a severe brain injury and has been in a rehabilitation hospital for several months. Recently, the client developed pneumonia and is currently on intravenous antibiotic therapy. Which level of prevention should the nurse use to address the health problem of pneumonia? 1. Primary 2. Secondary 3. Tertiary 4. Acute

2. Secondary

A group of elderly women come to the community center for exercise classes taught by the community health nurse. This activity will help lead to which outcome for these clients? 1. Reverse the effects of aging and cure pain. 2. Slow bone density loss and decrease muscle atrophy. 3. Eliminate the risk for osteoporosis. 4. Prevent pathologic fractures.

2. Slow bone density loss and decrease muscle atrophy.

The nurse is completing a health history with a client who is 10 weeks pregnant. Which factor should the nurse identify as increasing this clients risk for a spontaneous abortion? 1. Having taken a medication that is a known teratogen 2. Smoking 3. Having low levels of folic acid 4. Genetic history

2. Smoking

The nurse is caring for a nurse who provided care to soldiers during the Vietnam War. What information in this patients history should the nurse use to understand the patients nursing career? 1. The patient was still a student when serving in the war. 2. The patients first patient care experiences were during a time of war. 3. The patient decided to leave the profession after serving in the war. 4. The patient contracted long-term illnesses from being overseas in a war.

2. The patients first patient care experiences were during a time of war.

A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. In order to make sure all of your information is complete, I need to ask these questions. 2. Youre right. Let me know if theres anything you need right now. 3. Ill be done shortly, just give me a few more minutes. 4. You shouldnt be upset. Were only doing our jobs.

2. Youre right. Let me know if theres anything you need right now.

A non-Englishspeaking client is needs to have an emergency surgical procedure. The hospital has an interpreter available. When the interpreter arrives to explain the procedure and help with the consent form, the nurse provides the best support when 1. asking the interpreter to use words the client is familiar with for the best understanding. 2. requesting that the interpreter translate, as closely as possible, the same words used by the professional staff. 3. suggesting that the questions be directed to the interpreter, so nothing is omitted. 4. addressing the questions to the clients family.

2. requesting that the interpreter translate, as closely as possible, the same words used by the professional staff.

A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation? 1. An individual who has been struggling with following nursing directives regarding discharge goals 2. The client who has just moved in and is already waiting for discharge 3. A client who is excited to learn about his new prosthesis 4. A client who has been there the longest and is a great coach for newcomers

3. A client who is excited to learn about his new prosthesis

When consulting Eriksons developmental theory, the nurse determines that which older adult will have the least difficulty being successful with the task of this stage? 1. A client who felt success through her childrens accomplishments 2. A client who held his job and work status as the defining feature of his life 3. A client who maintained a balance between work and home 4. A client who planned to really enjoy life once she retired

3. A client who maintained a balance between work and home

While reviewing a health insurance plan, the nurse learns that a client has coverage for durable medical equipment (DME). What care need should the nurse identify as being covered by the clients health plan? 1. Dressings and bandages 2. Medications 3. A hospital bed 4. Visits by the home health nurse

3. A hospital bed

The nurse manager is concerned that a staff nurse provides client care with a cultural prejudice. Which situation did the manager observe to come to this conclusion? 1. Making an assumption that all members of each culture are alike 2. Believing that all culture members will have the same beliefs 3. Bringing previous negative information and experiences into this situation 4. Taking general knowledge from literature and applying it to the situation

3. Bringing previous negative information and experiences into this situation

The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying? Select all that apply. 1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing

3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing

While completing a community assessment, the nurse needs to learn the location of main health facilities and the number of who receive welfare. Where should the nurse access this information? 1. Police department 2. City health planning board 3. County health department 4. State census data

3. County health department

The nurse is explaining the difference between dementia and delirium to the spouse of a client with Alzheimers disease. What should the nurse say to make this distinction? 1. Delirium is easily distinguished from dementia. 2. Dementia is reversible and treatable. 3. Delirium is an acute and reversible syndrome. 4. Dementia is the only condition that is characterized by changes in memory, judgment, language, mathematic calculation, abstract reasoning, and problem-solving ability.

3. Delirium is an acute and reversible syndrome.

A nurse is conducting a community assessment to determine which diseases are prevalent and most likely to occur. The nurse is basing the assessment on which model of health? 1. Role performance 2. Eudemonistic 3. Ecological 4. Adaptive

3. Ecological

A nurse is caring for a client with a severe head trauma. Each shift, the nurse pays attention to the lighting, atmosphere, and surroundings the client is exposed to. The nurse is functioning according to the assumptions of which nursing theorist? 1. Dorothea Orem 2. Martha Rogers 3. Florence Nightingale 4. Jean Watson

3. Florence Nightingale

The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the childrens health is the nurse assessing? 1. Development 2. Health 3. Growth 4. Bone size

3. Growth

A client has been undergoing therapy as a victim of severe emotional abuse. The goal of the clients therapy is to gain self-control of the situation, improve self-esteem, and become self-sufficient. Which application should the nurse suggest become a part of the clients therapy sessions? 1. Yoga 2. Meditation 3. Hypnotherapy 4. Guided imagery

3. Hypnotherapy

The nurse is accessing information about standard classification of terms prior to documenting in a clients computerized clinical record. Which systems should the nurse consider using for this documentation? Select all that apply. 1. ANA 2. HIPAA 3. NANDA 4. The Omaha system 5. HHCC 6. NOC

3. NANDA 4. The Omaha system 5. HHCC 6. NOC

A nurse who works in a busy neonatal intensive care unit has been having difficulty with concentration after a long days work. Which therapy should the nurse consider doing to help with this problem? 1. Guided imagery 2. Hypnotherapy 3. Qigong 4. Aromatherapy

3. Qigong

The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which is the most appropriate diagnosis for this client? 1. Risk for Situational Low Self-Esteem 2. High Risk for Caregiver Role Strain 3. Readiness for Enhanced Coping 4. Readiness for Enhanced Nutrition

3. Readiness for Enhanced Coping

A nursing student was involved in a very difficult situation with a client, the clients family, and a physician. The student felt like she was caught in the middle and wasnt sure how to respond to some of the questions that were being asked about care, treatment, and scheduling. Instead of getting her instructor, the student fielded these questions as best she could. In order to help the student work through this situation, the nursing instructor might advise the student to try which action? 1. Meditation 2. Guided imagery 3. Reflection 4. Music therapy

3. Reflection

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity

3. Reports of fatigue

A client scheduled for surgery has signed the consent form but refuses to have a Foley catheter placed, saying Thats not part of the surgery. What should the nurse do? 1. Explain that this is part of the surgical prep and continue with the procedure. 2. Explain that the client has already signed the consent, and place the catheter. 3. Respect the clients wishes and document accordingly. 4. Offer to call the physician.

3. Respect the clients wishes and document accordingly.

The nurse is offering free occult blood screening at a community health fair. Which level of practice is the nurse providing? 1. Promoting health and wellness 2. Illness prevention 3. Restoring health 4. Rehabilitation

3. Restoring health

A client is getting ready to go home from an intermediate care facility following surgery and a lengthy recovery period. On which item should the home health nurse focus to determine effectiveness of discharge teaching? 1. Activity restrictions 2. Follow-up appointment dates 3. Return demonstration of dressing change 4. Signs of complications

3. Return demonstration of dressing change

The nurse has defined a research problem. What action should the nurse take next? 1. Formulate a hypothesis. 2. Define variables. 3. Review the literature. 4. Select a design.

3. Review the literature.

A clinic in a rural area depends primarily on the services of a nurse practitioner. Which legislation provided the opportunity for the nurse practitioner to have this position? 1. Medicare 2. Medicaid 3. Rural Health Clinics Act 4. National Health Planning and Resources Development Act

3. Rural Health Clinics Act

A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity

3. Simplicity

A nurse manager allows the staff members to make their own schedules and do their own client assignments on their shifts. However, during a code situation, the nurse manager will make decisions for the staff by instructing which nurse to assume which responsibility. This manager is exemplifying which style of leadership? 1. Permissive 2. Democratic 3. Situational 4. Bureaucratic

3. Situational

A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public

3. Social

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDAs Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting.

3. Submitting the diagnosis to NANDAs Diagnostic Review Committee

A nurse is teaching a wellness class for older adults. In order to address the sensory loss that accompanies the aging process, the nurse should recommend that these clients take which action? 1. Use hearing aids and glasses. 2. Wear shaded glasses indoors to reduce glare. 3. Switch to brighter lighting in their home. 4. Exercise more and increase calcium intake.

3. Switch to brighter lighting in their home.

The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher.

3. Take assessment notes and utilize information from textbooks for comparison.

A client needs discharge teaching regarding the use of a walker before going home. The clients room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do? 1. Wait until just prior to discharge, then do the teaching in the hospital lobby. 2. Close the door to the clients room and make sure there is no clutter on the floor before the teaching session begins. 3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the clients room. 4. Make sure a physical therapist is available to do the teaching and can see the client before discharge.

3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the clients room.

A public health nurse is working with a group of home health nurses in an isolated, mountainous region where access to smaller communities and individuals is quite difficult, especially in the winter and early springseasons when the health needs of these individuals are quite high. The public health nurse has set up video conferencing and video clinics for these home health nurses regarding various client teaching and health promotion activities. What activity did the public health nurse conduct? 1. Community-based nursing 2. Parish nursing 3. Telenursing 4. Collaborative health care

3. Telenursing

A nurses co-worker makes a practice of telling offensive jokes or stories with a sexual undertone during the shift. Which action should the nurse take first? 1. Ignore the co-worker and walk away. 2. Report the incident to the nurse manager. 3. Tell the co-worker to stop the activity because the conduct is offensive. 4. Ask to be scheduled opposite this co-worker.

3. Tell the co-worker to stop the activity because the conduct is offensive.

A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-orkers discussing their clients conditions

3. Whirring of ventilators

The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report.

3. Write N/A on the flow sheet in the areas that are not applicable to that client.

The nurse is reviewing the four stages of development in Westerhoffs spiritual theory. In which order should the nurse review these stages to match the life cycle? Standard Text: Click and drag the options below to move them up or down. Choice 1. Owned faith Choice 2. Affiliative faith Choice 3. Experienced faith Choice 4. Searching faith

4, 2, 1, 3

Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis? 1. A child who is used to getting ready for school alone 2. A teenager whose circle of friends includes single parents of the same age 3. An elderly person who has just moved to a long-term care facility 4. A young adult who is in a long-term relationship

4. A young adult who is in a long-term relationship

A Chinese client is hospitalized with a fever of unknown origin and follows a very traditional, cultural view of illness. Which food should the nurse offer the client? 1. Hot tea 2. Warm soup 3. Spicy meat 4. Cold liquids

4. Cold liquids

A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis? 1. The data collected would support the diagnosis. 2. The diagnosis is directly related to the data presented. 3. The nursing diagnosis is not relevant to the data. 4. The data are not sufficient enough to support this diagnosis.

4. The data are not sufficient enough to support this diagnosis.

The nurse researcher is using an instrument that provides similar results each time its implemented. Which term should the researcher use to describe the quality of this instrument? 1. Validity 2. Reliability 3. Consistency 4. Variability

2. Reliability

The nursing staff is informed that the current system of record keeping is going to be changed to make it more efficient. In which stage of change is the nursing staff? 1. Refreezing 2. Unfreezing 3. Moving 4. Drift

2. Unfreezing

A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3F, chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory compromise? 1. Deductive reasoning 2. Inductive reasoning 3. Socratic questioning 4. Critical analysis

1. Deductive reasoning

A client is experiencing metabolic acidosis, a condition that involves the bodys pH level, carbon dioxide level, and bicarbonate balance. According to Roys model, to which mode should the nurse realize that this client is responding? 1. Physiologic 2. Self-concept 3. Role function 4. Interdependence

1. Physiologic

According to the National Council of State Boards of Nursing (NCSBN), which rights of delegation should the nurse follow? Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task

1. Supervision 2. Evaluation 5. Task

The nurse is preparing to teach a client on skin care and application of a stoma device. What should the nurse keep in mind when teaching the client this information? Select all that apply. 1. Address the clients concerns first. 2. Assess what the client knows already. 3. Address anxietyproducing issues last. 4. Teach the basics before complicated tasks. 5. Leave time for review and answering questions.

1. Address the clients concerns first. 2. Assess what the client knows already. 4. Teach the basics before complicated tasks. 5. Leave time for review and answering questions.

Prior to delegating a task, the nurse reviews the rights of delegation; these include which rights? Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task

1. Supervision 2. Evaluation 5. Task

A group of older clients is interested in living options available in the community when they may need some assistance with their daily needs. What should the nurse suggest as possibilities to meet these needs? 1. Adult foster care 2. Group homes 3. Retirement villages 4. Long-term care facilities 5. Adult day-care centers

1. Adult foster care 2. Group homes 5. Adult day-care centers

The parents of a schoolage child are concerned about the child learning right from wrong. In which order should the nurse instruct the parents of a school-age child that moral development will develop in their child? Standard Text: Click and drag the options below to move them up or down. Choice 1. Punishment and obedience Choice 2. Law-and-order orientation Choice 3. Instrumental-relativist orientation Choice 4. Good boynice girl stage

1, 4, 2, 3

A baby was born with flaccid muscle tone, regular respirations with crying, a heart rate of 85, and blue extremities. What would the Apgar score be? 1. 6 2. 7 3. 5 4. 8

1. 6

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing

1. 60 to 90 degrees during feeding times

The nurse is taking a tour of a home care agency as part of the interview process. Which services should the nurse recognize as being provided through this health agency?Select all that apply. 1. A case manager arranging services to meet the clients need for physical therapy after a fall 2. A nurse educating the pregnant teenager on the signs of premature labor 3. A durable supply company delivering a wheelchair to a client with spina bifida 4. A nurse assessing the feet of a homebound diabetic client 5. A grocery store delivering groceries to a client recovering from cancer surgery

1. A case manager arranging services to meet the clients need for physical therapy after a fall 3. A durable supply company delivering a wheelchair to a client with spina bifida 4. A nurse assessing the feet of a homebound diabetic client

A community health nurse is testing the theory of locus of control (LOC). Which client demonstrates the internal control concept of this theory? 1. A client who takes an active role in all health decisions 2. A client who allows the primary care provider to make all the decisions 3. A client who does not make any decisions without his or her spouses input 4. A client who relies on information from the local hospital for his or her health needs

1. A client who takes an active role in all health decisions

A client was in a motor vehicle crash where he sustained injury to his spinal cord that has resulted in difficulty with balance and holding his posture. Which should the nurse suggest the client consider? 1. Animal-assisted therapy 2. Hypnotherapy 3. Chelation therapy 4. Detoxification

1. Animalassisted therapy

The nurse is documenting the teaching plan for a client. What should be included in this documentation? Select all that apply. 1. Actual information to be taught 2. Teaching strategies to use 3. Skills to be taught 4. Amount of time needed to teach each topic 5. Vital signs before and after each teaching session

1. Actual information to be taught 2. Teaching strategies to use 3. Skills to be taught 4. Amount of time needed to teach each topic

A multi-organization medical system is designing a community-based facility to support the health care needs of members who live in an urban area. What should the medical system keep in mind when designing the new facility? Select all that apply. 1. Affordable 2. Easy to travel to the facility 3. A focus on the needs of mothers and children 4. Many services available to meet community members needs 5. Communication of care needs to the community members other health care providers

1. Affordable 2. Easy to travel to the facility 4. Many services available to meet community members needs 5. Communication of care needs to the community members other health care providers

A nurse educator believes computers can enhance student learning. Which actions should the instructor take to demonstrate this belief? Select all that apply. 1. Allow students to research a nursing topic either by going to the library or via an online literature search. 2. Require a student to remediate after a failed test by completing appropriate computer-assisted instruction modules. 3. Use PowerPoint slides to reinforce complex concepts during classroom lectures. 4. Assign a collaborative group project to students enrolled in an online course. 5. Use computer-generated graphics to make written material less monotonous.

1. Allow students to research a nursing topic either by going to the library or via an online literature search. 2. Require a student to remediate after a failed test by completing appropriate computer-assisted instruction modules. 3. Use PowerPoint slides to reinforce complex concepts during classroom lectures. 4. Assign a collaborative group project to students enrolled in an online course.

A nurse is providing bathing assistance to a young client who was seriously injured and is unable to care entirely for herself. Which action demonstrates the nurse implementing the doing for process in Swansons theory of caring? 1. Allowing the client to wash her perineal area 2. Drying the client completely 3. Seeing the client is uncomfortable with the whole bathing process 4. Touching the clients shoulder when she starts to cry

1. Allowing the client to wash her perineal area

A family struggles with clear communication, and members of the family often seek the help of other systems for personal validation and gratification. What should the nurse identify as an appropriate nursing diagnosis for this family? 1. Altered Family Processes related to communication patterns 2. Impaired Verbal Communication related to inability to communicate 3. Ineffective Family Coping evidenced by assistance from outside sources 4. Knowledge Deficiency (communication patterns) related to dysfunctional patterns of communication

1. Altered Family Processes related to communication patterns

The ANAs proposal for entry level for professional practice initiated debate among nurses. Which nurse would be at greatest risk if the ANA proposal were implemented? 1. An RN with an associate degree who has a head nurse position 2. An RN with a BSN who is a staff nurse 3. An RN with a diploma who works overtime 4. An RN with an associate degree who is currently in school

1. An RN with an associate degree who has a head nurse position

An occupational health nurse is surveying employees. Which employee should the nurse identify as being predisposed to an illness? 1. An employee who is in a middle-management position and takes stress from administration as well as the employees 2. An employee who works in the janitorial department 3. An employee who works 12-hour days, 3 days a week 4. An employee who works 4 days on and 3 days off

1. An employee who is in a middle-management position and takes stress from administration as well as the employees

After analyzing behavior, the nurse determines that a client is demonstrating defense mechanisms. According to Freud, what should the nurse realize as being the cause of this behavior? Standard Text: Select all that apply. 1. Anxiety created by conflicts 2. Activation of the conscience 3. Conflict between the ids impulses 4. Immediate pleasure and gratification 5. Underlying motivation for development

1. Anxiety created by conflicts 3. Conflict between the ids impulses

Several nurses at the county health department are involved in planning community health. In order to create a plan that will be acceptable to members of the community, who else should be involved in this venture? 1. As many people from the community as possible 2. Physicians and other nurses 3. Members of the chamber of commerce and governing board of the community 4. Just the nurses at the county health department

1. As many people from the community as possible

A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the clients lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day.

1. Ask how many times per day the client practiced the coughing and deep breathing exercises.

The school nurse is conducting head lice screenings. Before checking the head of an Asian child, the nurse should first take which action? 1. Ask permission. 2. Make sure the child understands the reason for the contact. 3. Put gloves on. 4. Ask the child to wait until last, to avoid embarrassing the child.

1. Ask permission.

The nurse using evidence-based practice to guide care has identified a study in which the findings would be appropriate to address a clients health care need. What actions should the nurse take before implementing these findings? Standard text: Select all that apply. 1. Ask the client if the findings can be used. 2. Immediately apply the findings to client care. 3. Examine how the findings fit with the clients health needs. 4. Determine if resources are available to implement the findings. 5. Identify organization policies to support or address the findings.

1. Ask the client if the findings can be used. 3. Examine how the findings fit with the clients health needs. 4. Determine if resources are available to implement the findings. 5. Identify organization policies to support or address the findings.

A client tells the nurse that he has no questions about his illness, as he did a search for information on the Internet. What should the nurse do? 1. Ask the client to share the information obtained from the Internet search. 2. Document that the client has received instruction. 3. Tell the client that the Internet is a form of entertainment, not instruction. 4. Document that the client refused instruction.

1. Ask the client to share the information obtained from the Internet search.

On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one.

1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.

The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? Select all that apply. 1. Asking, What can I do to make you feel safe? 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client out for a walk 4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the clients favorite magazine

1. Asking, What can I do to make you feel safe? 2. Observed intently listening to the client describe how being alone makes her feel 5. Managing to get a copy of the clients favorite magazine

The nurse educator is considering ways to impact the learning of students through the use of computer technology. Which actions should the educator take to achieve this goal? Select all that apply. 1. Assign distance learners to conduct a research study of current evidence-based articles on caring for the diabetic client. 2. Expect that notification of clinical absences be provided by e-mail. 3. Require a clinical group to make daily reflective entries in an online journal. 4. Provide extra credit for academic work that is created on a computer as an electronic file. 5. Encourage the learners to access online NCLEX review questions as a way to assess their classroom learning.

1. Assign distance learners to conduct a research study of current evidence-based articles on caring for the diabetic client. 3. Require a clinical group to make daily reflective entries in an online journal. 5. Encourage the learners to access online NCLEX review questions as a way to assess their classroom learning.

A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? Select all that apply. 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Consistent with the teaching topics

1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 5. Consistent with the teaching topics

The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? Select all that apply. 1. Becoming familiar with the clients social history by reading the admission interview 2. Orienting the client to the physical layout of the facility as well as to the facilitys policies 3. Gaining the clients trust by consistently keeping promises to return and visit 4. Respecting the clients wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu

1. Becoming familiar with the clients social history by reading the admission interview 3. Gaining the clients trust by consistently keeping promises to return and visit 4. Respecting the clients wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu

The nurse is planning to conduct a physical assessment with a client from a different culture. What is the best way for the nurse to show cultural sensitivity when addressing the personal questions required of the nursing history? 1. Break the assessment into shorter intervals and discuss general topics first. 2. Thoroughly explain the reason for asking many questions before beginning the assessment. 3. Pick a time when the family is present and can help with the admission assessment questions. 4. Wait until the nurseclient relationship has been established.

1. Break the assessment into shorter intervals and discuss general topics first.

The home health nurse has scheduled a visit to a client who lives in a neighborhood that is known to be unsafe because of gang activity. Before going to the clients home, what should the nurse do? 1. Call for an escort. 2. Call the client to let the client know the nurse is on the way. 3. Ask if the client could meet the nurse at the agency. 4. Take a second nurse along on the visit.

1. Call for an escort.

The nurse is confident that a client has met the developmental guidelines for a preschooler. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Can print her own name. 2. Proudly announces, I put my own toys away. 3. Shares that, I know I shouldnt hit, even when Im mad. 4. Effectively brushes her own teeth. 5. Washes her hands after toileting without prompting.

1. Can print her own name. 2. Proudly announces, I put my own toys away. 4. Effectively brushes her own teeth.

The nurse ensures that a patient is covered during a bath. In which nursing role is the nurse functioning? 1. Caregiver 2. Communicator 3. Teacher 4. Client advocate

1. Caregiver

When providing client care the nurse demonstrates practices that are designed to provide legal protections from liability. Which actions is the nurse demonstrating? Standard Text: Select all that apply. 1. Checking the clients name band prior to the administration of a preoperative medication 2. Asking for help when moving a comatose client because the client can not be safely handled by one nurse 3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility 4. Delegating only those tasks that he or she cant personally perform 5. Reviewing the five rights of medication administration when the client states, This doesnt look like my usual pill

1. Checking the clients name band prior to the administration of a preoperative medication 2. Asking for help when moving a comatose client because the client can not be safely handled by one nurse 3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility 5. Reviewing the five rights of medication administration when the client states, This doesnt look like my usual pill

A community health nurse is learning about the REACH initiative and has decided to implement community education on this approach. What topics should the nurse include in this education? Select all that apply. 1. Child and adult immunizations 2. Cardiovascular disease 3. Chronic lower respiratory disease 4. Stroke 5. Infant mortality

1. Child and adult immunizations 2. Cardiovascular disease 5. Infant mortality

The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: Select all that apply. 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan

1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan

The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? Select all that apply. 1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care. 3. Client is unable to identify changes in skin around the stoma. 4. Client tells the nurse that he does not want to do the care. 5. Client asks his wife to learn how to perform the care so he will not have to do it.

1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care.

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities.

1. Client will ambulate without a walker by 6 weeks.

A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month.

1. Client will be able to set up and administer a nebulizer treatment by the end of the day.

Several nurses are working with other health care providers to provide care for a group of community members who have complications of diabetes mellitus and require extensive dressing changes and comprehensive education. In what capacity are the nurses and care providers working? 1. Collaboration 2. Case management 3. Health promotion 4. Health education

1. Collaboration

A nurse has been working a 12-hour shift in a labor and delivery unit. A client was admitted early in the shift and is now ready to deliver. The client had a difficult labor experience, was worried and anxious throughout, and had physiological problems with blood pressure as well as pain management. The nurse decides to stay until the delivery is over, after having it approved by her manager. What is this nurse demonstrating? 1. Compassion 2. Competence 3. Confidence 4. Conscience

1. Compassion

A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior? 1. Competing preferences 2. Competing demands 3. Situational influences 4. Interpersonal influences

1. Competing preferences

The nurse needs to complete mandatory continuing education on client safety as part of a regulatory requirement for the hospital. Which computerized approach should the nurse consider to complete this required education? 1. Complete a computerized tutorial on client safety 2. Read information on safety from a web site 3. Review the online hospital policies about client safety 4. Complete a literature review on client safety

1. Complete a computerized tutorial on client safety

The nurse is participating in the development of a research study. What elements of the computer should the nurse ensure are in place before the study begins? Select all that apply. 1. Computer speed adequate 2. Print drivers installed 3. Word processing program 4. Computer storage capacity adequate 5. Appropriate software programs

1. Computer speed adequate 3. Word processing program 4. Computer storage capacity adequate 5. Appropriate software programs

The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? Standard Text: Select all that apply. 1. Congruent with the clients values, beliefs, and culture 2. Are within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available 5. Must be safe and appropriate for the clients age

1. Congruent with the clients values, beliefs, and culture 2. Are within established standards of care 4. Achievable with the resources available 5. Must be safe and appropriate for the clients age

A client who is from a different culture than the nurse has not been able to achieve this goal: Client will select low-fat foods from a list by the end of the month. What should the nurse do? 1. Consider whether the clients belief system has been an influencing factor. 2. Extend the time frame and give the client a longer period to achieve the goal. 3. Make sure that the client understands the importance of the goal. 4. Select a different goal.

1. Consider whether the clients belief system has been an influencing factor.

The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making? 1. Considering how the loss of a clients job will affect the regulation of the clients diabetes 2. Making sure to do complete teaching regarding pharmacological interventions 3. Following physician treatments on schedule 4. Prioritizing the needs of the client assigned according to Maslows hierarchy

1. Considering how the loss of a clients job will affect the regulation of the clients diabetes

The nurse is completing an assessment to determine an older patients development of moral reasoning. Which observation indicates that the client has developed moral reasoning as anticipated? 1. Considers relationships as well as justice in moral decisions 2. Approaches moral decisions based upon the consequences to self 3. Follows societys rules of conduct in response to the expectations of others 4. Bases moral judgments on connectedness to others and the value of relationships

1. Considers relationships as well as justice in moral decisions

The nurse working in a community health office that is often frequented by young adults is assessing clients for suicide. Which factors should the nurse identify as indicating a problem in this area? 1. Decreased interest in work 2. Weight loss 3. Depression 4. Brain dysfunction, including tumors 5. Sleep disturbances

1. Decreased interest in work 2. Weight loss 3. Depression 5. Sleep disturbances

The nurse is planning to complete a family assessment. For which reasons is the nurse completing this assessment? Standard Text: Select all that apply. 1. Determine the level of family functioning. 2. Identify family strengths and weaknesses. 3. Provide legal guidelines for consent to health care. 4. Clarify family interaction patterns. 5. Describe the health status of individual members

1. Determine the level of family functioning. 2. Identify family strengths and weaknesses. 4. Clarify family interaction patterns. 5. Describe the health status of individual members

The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination? Select all that apply. 1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication. 5. Determine whether there is enough time.

1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication.

The nurse is reviewing the nursing process with a firstyear nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented.

1. Develop a list of problems. 2. Identify client strengths. 5. Identify problems that can be prevented.

The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information? Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught

1. Diagnosed learning needs 3. Client outcomes 4. Need for additional teaching 5. Topics taught

The nurse has completed a teaching session for a client with a tracheostomy. What should the documentation include? Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught

1. Diagnosed learning needs 3. Client outcomes 4. Need for additional teaching 5. Topics taught

The nurse has been promoted to a position that includes the supervision of first-level management and responsibility for activities in a specific department. This nurse will most likely have which title? Select all that apply. 1. Supervisor 2. Nurse manager 3. Head nurse 4. Primary care nurse 5. Vice president

1. Supervisor 2. Nurse manager 3. Head nurse

The school of nursing professor is preparing a classroom activity to assist the students in acquiring professional values. Which actions should the professor select for this assignment? Standard Text: Select all that apply. 1. Discuss codes of ethics with the students. 2. Recommend that the students avoid ethical issues. 3. Encourage the students to discuss experiences. 4. Invite other professors to participate in a discussion. 5. Have the students interview each other about experiences.

1. Discuss codes of ethics with the students. 3. Encourage the students to discuss experiences. 4. Invite other professors to participate in a discussion. 5. Have the students interview each other about experiences.

The nurse is confident that a young adult has successfully achieved psychosocial development. What observations about the client did the nurse make to come to this conclusion? Standard Text: Select all that apply. 1. Discusses plans to expand his exercise routine to include running 2. Is optimistic about finding a new job 3. Volunteers weekly at the local senior center 4. Recognizes that professional sports may be enjoyed but does not aspire to participating 5. May be too bald to play Santa Claus

1. Discusses plans to expand his exercise routine to include running 2. Is optimistic about finding a new job 4. Recognizes that professional sports may be enjoyed but does not aspire to participating

Nursing students have been studying the stability model of nurse theorists. What phrases or terms should the students use to describe this model? Standard Text: Select all that apply. 1. Dominant 2. Systems framework 3. Stress/adaptation framework 4. Martha Rogerss theory 5. Caring/complexity framework 6. Callista Roys theory

1. Dominant 2. Systems framework 3. Stress/adaptation framework 6. Callista Roys theory

A nursing student is presenting a teaching project to the class using each of Blooms domains. The student has several activities included in the project. Which activity is an example of the affective domain? 1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education. 2. All members must list the technical skills theyve learned. 3. Members must demonstrate a favorite nursing skill at the end of the class period. 4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.

1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.

The nurse practices responsibility when functioning in the role of manager of a care area. What will the nurse manager demonstrate as evidence of responsibility? Select all that apply. 1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives 4. Problem solving 5. Managing the work team

1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives

The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? Standard Text: Select all that apply. 1. Effectively assessing the clients needs 2. Selecting the appropriate nursing diagnosis related to the clients needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase

1. Effectively assessing the clients needs 2. Selecting the appropriate nursing diagnosis related to the clients needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes

The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory? Select all that apply. 1. Empathy 2. Encouraging the client to establish goals 3. Encouraging the client to participate in self-directed learning 4. Multisensory teaching strategies 5. Providing a physical environment conducive to learning

1. Empathy 2. Encouraging the client to establish goals 3. Encouraging the client to participate in self-directed learning

The nurse needs to determine the apical pulse of a client from a different culture. In order to show appropriate sensitivity to the client, the nurse should take which action? 1. Explain the procedure, then wait for permission to continue. 2. Explain to the client what will occur during the assessment. 3. Ask the client to stay quiet because the nurse will be listening to the heart. 4. Take the baseline vital signs, then determine if cardiac auscultation is necessary.

1. Explain the procedure, then wait for permission to continue.

During a family assessment, the nurse asks How, as a family, do you deal with disappointments or stressful changes that occur and affect the members of your family? What is the nurse attempting to identify? 1. Family coping mechanisms 2. Whether the family experiences stress 3. Which family members are most stressed 4. Family dynamics

1. Family coping mechanisms

A father of a family was killed in a motor vehicle crash. What should the nurse consider a normal reaction to this event? 1. Family disorganization may occur. 2. Family members become detached from extended family. 3. The family feels that their place in the community has been eliminated. 4. The family withdraws into seclusion during the grief process.

1. Family disorganization may occur.

During a family assessment, the nurse determines that a family functions according to the systems theory. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Family members work together towards goals. 2. Family members seek out and use community resources. 3. Family members interact with other community systems. 4. Healthy boundaries are used to regulate influence by other systems. 5. Family members are encouraged to hold fast to beliefs and practices.

1. Family members work together towards goals. 2. Family members seek out and use community resources. 3. Family members interact with other community systems. 4. Healthy boundaries are used to regulate influence by other systems.

The nurse educator is reviewing internal variables that affect peoples health status. On which variables is this nurse focusing? Select all that aply. 1. Genetic makeup 2. Age 3. Developmental level 4. Environment 5. Spiritual and religious beliefs

1. Genetic makeup 2. Age 3. Developmental level 5. Spiritual and religious beliefs

During a clinic appointment, a client prescribed medication for glaucoma reports vision problems. When taking a medication history, which herbal preparation should the nurse identify as being problematic for this client? 1. Ginseng 2. Echinacea 3. Valerian 4. St. Johns wort

1. Ginseng

The nurse has identified a coping problem in a family that recently lost their house and all of their belongings in a fire. What should the nurse identify as this familys external support systems? Standard Text: Select all that apply. 1. Grandparents 2. The parents siblings 3. Local social services agencies 4. The familys religious leader 5. The familys communication skills

1. Grandparents 2. The parents siblings 3. Local social services agencies 4. The familys religious leader

A client has been diagnosed with post-traumatic stress syndrome and has difficulty sleeping because of recurrent nightmares. In working with this client to overcome the problem, what should the nurse implement as part of therapy? 1. Guided imagery 2. Hypnotherapy 3. Yoga 4. Meditation

1. Guided imagery

The nurse is using Kalishs adaptation of Maslows hierarchy of needs when planning client care. Which client should the nurse identify as exhibiting a level of Kalishs adaptation? 1. Has a homosexual encounter for the first time 2. Has a need to participate in school sports and be on the team 3. Strives to become the CEO of a company 4. Is sleep deprived because of musculoskeletal discomfort

1. Has a homosexual encounter for the first time

A nurse is preparing an education program on safety concerns for elderly adults living in their own homes. To address the sensory changes in this age group, what should the nurse recommend to this group? 1. Have carbon monoxide detectors that are checked on a scheduled basis. 2. Place a list of emergency numbers near the phone. 3. Install telephones that use a blinking light instead of a ringer. 4. Ask someone to do their cooking for them.

1. Have carbon monoxide detectors that are checked on a scheduled basis.

A client in the hospital is concerned about the cost of receiving hospitalized care. What should the nurse realize is causing the increase in the clients medical expenses? Select all that apply. 1. Health care of the older adult 2. Number of uninsured population 3. Changes in birth rate over last 20 years 4. Cost of prescription drugs 5. State of inflation 6. Amount of diagnosed chronic illnesses

1. Health care of the older adult 2. Number of uninsured population 4. Cost of prescription drugs 5. State of inflation 6. Amount of diagnosed chronic illnesses

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. Hello, Im your nurse and Ill be taking care of you today. 2. Youre luckythere are no students on the unit today. 3. Good morning, is there anything you need right now? 4. Hi. If you need anything, put on your call light.

1. Hello, Im your nurse and Ill be taking care of you today.

The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client? 1. Help the client look for available community resources that may be of assistance. 2. Tell the client that she needs to take the prescribed amount. 3. Report the situation to the physician. 4. Weigh the client on a weekly basis to monitor weight gain or loss.

1. Help the client look for available community resources that may be of assistance.

A home health client having difficulty keeping his medication schedule organized says There are so many pills and the names are all confusing to me. I dont even understand what theyre for. What should the nurse do? 1. Help the client remember color and size in relationship to dosing time. 2. Write out the generic and trade name of all the pills for the client. 3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system. 4. Have the physician talk to the client about his medications.

1. Help the client remember color and size in relationship to dosing time.

The nurse is assessing a childs growth and development. What questions should the nurse ask the parents that demonstrate an understanding of the factors that affect growth and development processes? Standard Text: Select all that apply. 1. How tall the parents are 2. Whether noises seem to bother their child 3. How many ounces of formula their child drinks daily 4. What their yearly income is 5. Whether their child will receive daycare services

1. How tall the parents are 2. Whether noises seem to bother their child 3. How many ounces of formula their child drinks daily

The nurse is preparing a teaching session for pregnant clients that reviews the fetal growth and development that occurs in the first 3 weeks post-conception. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. How the embryo has attached to the wall of the uterus 2. Development of the fetal membranes and the amniotic sac 3. How the embryo will be covered with a protective substance called vernix caseosa 4. How development of the fetal placenta has begun 5. How the embryo is covered with a soft, downy hair

1. How the embryo has attached to the wall of the uterus 2. Development of the fetal membranes and the amniotic sac 4. How development of the fetal placenta has begun

The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. How would you describe your sleep pattern? 2. Can you describe your coughing pattern? 3. Is there anything that makes your breathing worse? 4. What medications are you on?

1. How would you describe your sleep pattern?

The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance? 1. I'm glad to know about my medications. It makes taking them a lot easier. 2. I already knew most of what you told me. 3. I think you should have waited until I was ready to go home. Maybe I'd remember better. 4. If I take my medications as prescribed, I'll feel better.

1. I'm glad to know about my medications. It makes taking them a lot easier.

A labor and delivery nurse wants to conduct research focused on the response of new parents toward their babies. The approach the nurse would like to use suggests that caring is a nurturing process. The nurse should review the ideas of which theorist because they are best in line with this research? 1. Swanson 2. Watson 3. Roach 4. Benner

1. Swanson

The nurse is using the central concepts of nursing when providing client care. What actions is this nurse performing? Standard Text: Select all that apply. 1. Including a clients family in discussions regarding the clients discharge health needs 2. Assessing a physically dependent clients spouse for indications of caregiver stress 3. Asking clients to define what healthy and well means to them 4. Suggesting wound care supplies with the priority of cost 5. Advocating for a client who is not responding to current pain control treatment

1. Including a clients family in discussions regarding the clients discharge health needs 2. Assessing a physically dependent clients spouse for indications of caregiver stress 3. Asking clients to define what healthy and well means to them 5. Advocating for a client who is not responding to current pain control treatment

The nurse implements a quicker way to set up and initiate an intravenous infusion while still following safe practice. Which attitude of critical thinking is this nurse practicing? 1. Independence 2. Intellectual courage to challenge the status quo or rituals 3. Integrity 4. Confidence

1. Independence

The nurse is reviewing the principles of the Affordable Care Act with a client. What information should the nurse include when discussing the act with the client? Select all that apply. 1. Individuals will be fined if they do not have health insurance. 2. Employers must offer health insurance if they meet identified requirements. 3. Insurance can be purchased through exchanges. 4. Individuals with preexisting health conditions cannot be denied health insurance coverage. 5. Health insurance is free.

1. Individuals will be fined if they do not have health insurance. 2. Employers must offer health insurance if they meet identified requirements. 3. Insurance can be purchased through exchanges. 4. Individuals with preexisting health conditions cannot be denied health insurance coverage.

An expectant parent asks the nurse about health problems of newborns. On what should the nurse provide information to this client? Standard Text: Select all that apply. 1. Infant colic 2. Respiratory tract infections 3. Failure to thrive 4. Injuries 5. SIDS

1. Infant colic 3. Failure to thrive 5. SIDS

Grounding nursing research in theories from other disciplines is argued to be undesirable by some scholars. What should the nurse identify as reasons why grounding theory is not desired? Standard Text: Select all that apply. 1. It detracts from developing nursing as a separate discipline. 2. It makes nursing less relevant. 3. It helps bring a broader perspective and insight to nursing. 4. Other disciplines are not unique to the human condition. 5. Other disciplines get the benefit of nursings research.

1. It detracts from developing nursing as a separate discipline. 2. It makes nursing less relevant. 5. Other disciplines get the benefit of nursings research

After completing an initial assessment, the nurse identifies teaching that the client will need. Why did the nurse identify learning needs for this client? 1. Lack of knowledge related to health conditions and self-care 2. The fact that there is little time to complete education in the acute care setting 3. The fact that teaching someone who is willing to learn is easier in the home 4. The need for reimbursement for education by Medicare

1. Lack of knowledge related to health conditions and self-care

A client has received a high score on the Life-Change Index. For which part of the clients assessment should the nurse use this information? 1. Life stress review 2. Social support systems review 3. Lifestyle assessment 4. Health beliefs review

1. Life stress review

The nurse is engaging a client in the introductory phase of the helping relationship. Which stages will be completed during this phase? Select all that apply. 1. Opening the relationship 2. Clarifying the problem 3. Structuring and formulating the contract 4. Planning before the interview 5. Understanding thoughts and feelings

1. Opening the relationship 2. Clarifying the problem 3. Structuring and formulating the contract

The nurse manager determines that a new staff nurse is demonstrating characteristics of a critical thinker. What did the manager observe the nurse perform? Standard Text: Select all that apply. 1. Listening with empathy to a client who recently has been diagnosed. 2. Waiting for the medical team to determine the focus of the clients supportive care. 3. Questioning a medication order that does not appear to meet the clients needs for pain management. 4. Exhibiting a willingness to try alternate methods of addressing a clients care needs. 5. Practicing nursing in a culturally competent fashion.

1. Listening with empathy to a client who recently has been diagnosed. 3. Questioning a medication order that does not appear to meet the clients needs for pain management. 4. Exhibiting a willingness to try alternate methods of addressing a clients care needs. 5. Practicing nursing in a culturally competent fashion.

A nurse is working in a clinic that emphasizes cost control, customer satisfaction, health promotion, and preventive services. In which type of health system is this nurse providing care? 1. Managed care 2. Case management 3. Differentiated practice 4. Patient-focused care

1. Managed care

The nurse has accepted a position as a case manager. What should the nurse expect to perform when functioning in this role? 1. Managing a clients hospital stay 2. Delegating activities to other nurses 3. Evaluating the performance of ancillary workers 4. Identifying areas of client concern or problems

1. Managing a clients hospital stay

A client undergoing chemotherapy becomes very anxious and stressed just before the treatments. Which would be an appropriate therapy for this person to learn? 1. Meditation 2. Aromatherapy 3. Homeopathy 4. Yoga

1. Meditation

The staff nurse is considering membership in the National League for Nurses. What should the nurse expect as a member of this organization? 1. Members that are non-nurses 2. Assistance with getting into graduate school 3. Opportunities to be awarded scholarships 4. Assistance with finding employment

1. Members that are non-nurses

A family member is hospitalized with an illness. What should the nurse assess to determine the impact this illness will have on the family? 1. Nature of the illness 2. Duration of the illness 3. Cause of the illness 4. Financial impact of the illness 5. Effect of the illness on future family functioning

1. Nature of the illness 2. Duration of the illness 4. Financial impact of the illness

The nurse is scheduled to attend a continuing education program to learn about the latest urinary catheterization care. Which type of credential should the nurse expect to earn after attending this program? 1. None because this program is designed to enhance a skill 2. Advanced degree 3. Certification as a renal nurse 4. Credit hours toward an advanced degree

1. None because this program is designed to enhance a skill

The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses? Standard Text: Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely

1. Nonjudgmental statements 3. Must be legally advisable 4. Cause/effect correctly stated 6. Diagnosis worded specifically and precisely

The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurses advocacy? Select all that apply. 1. Participating in a community-focused 5-mile run. 2. Attending the local high schools football games. 3. Providing an educational program to senior citizens on blood pressurecontrol strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques.

1. Participating in a community-focused 5-mile run. 3. Providing an educational program to senior citizens on blood pressurecontrol strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques.

The nursing instructor is explaining the present economic challenges in health care to students in a community health course. What should the instructor emphasize as being important for the students to be aware of? 1. Passage of the Affordable Care Act 2. Consumer presence on the boards of nursing associations and regulatory agencies 3. Diagnostic-related groups (DRGs) 4. Advances in science and technology

1. Passage of the Affordable Care Act

During a clinical conference, a staff nurse states that critical thinking is essential when providing client care. What additional statements should this nurse make to support the use of critical thinking? Standard Text: Select all that apply. 1. Patient acuity is so much greater than it was even 10 years ago. 2. Care delivery systems are only as good as the nurses delivering care. 3. Nurses have always relied on commonsense thinking to provide quality, appropriate nursing care. 4. With health care being so expensive, nursing has to take on responsibility to keep the costs controlled. 5. My practice involves caring for clients who require care that didnt even exist when I went to school.

1. Patient acuity is so much greater than it was even 10 years ago. 2. Care delivery systems are only as good as the nurses delivering care. 4. With health care being so expensive, nursing has to take on responsibility to keep the costs controlled. 5. My practice involves caring for clients who require care that didnt even exist when I went to school.

The nurse planning an educational session for adult clients should include which andragogy concepts? Select all that apply. 1. People move from dependence to independence with maturity. 2. Previous experiences can be used as a resource for learning. 3. Learning is related to an immediate need or problem. 4. Learning is reinforced by prompt feedback. 5. Adults are oriented to learning when the material is useful sometime in the future.

1. People move from dependence to independence with maturity. 2. Previous experiences can be used as a resource for learning. 3. Learning is related to an immediate need or problem. 4. Learning is reinforced by prompt feedback.

The nurse is planning to provide culturally responsive care to a minority client and family. What actions should the nurse perform when providing this care? Standard Text: Select all that apply. 1. Personally reflecting on feelings related to the clients nationality 2. Making an effort to direct all assessment questions initially to the client 3. Involving the family with the clients permission 4. Assessing the clients interest in alternative healing methods 5. Educating the client and family when appropriate

1. Personally reflecting on feelings related to the clients nationality 3. Involving the family with the clients permission 4. Assessing the clients interest in alternative healing methods 5. Educating the client and family when appropriate

A client being discharged needs physical therapy for progressive ambulation, wound care to treat a postoperative wound, and assistance with the payment of hospital bills. Before the nurse contacts a home care agency, who should write the order for the client to receive home care? 1. Physician 2. Nurse 3. Social worker 4. Physical therapist

1. Physician

In order to comply with the U.S. Department of Health and Human Services most current health care goals as stated in Healthy People 2020, what should the nurse do? Select all that apply. 1. Plan a depression screening for senior citizens who regularly have lunch at the senior center. 2. Attend an educational in-service on the use of a new automated blood pressure monitor. 3. Advocate for psychiatric health care for those with no private insurance coverage. 4. Organize a park cleanup day to assure that the communitys children have a safe place to play. 5. Counsel older clients regarding programs available to assist them to live in their homes independently.

1. Plan a depression screening for senior citizens who regularly have lunch at the senior center. 3. Advocate for psychiatric health care for those with no private insurance coverage. 4. Organize a park cleanup day to assure that the communitys children have a safe place to play. 5. Counsel older clients regarding programs available to assist them to live in their homes independently.

The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans? Standard Text: Select all that apply. 1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment. 6. Plans are standardized and generalized for all clients.

1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment.

The nurse serves as an educator of other health care personnel. In what capacity will this nurse participate in education? Select all that apply. 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children

1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students

The clinical nursing instructor determines that a nursing student understands the legal responsibilities to clients when providing care. What did the instructor observe to come to this conclusion? Standard Text: Select all that apply. 1. Prepared to discuss the clients medical diagnosis in pre-conference 2. Overheard stating, My care is held to the same standards as that of the unit nurses 3. Offers to stay with the client who is about to experience a painful diagnostic procedure 4. Addresses the staff and clients respectfully and by their full names 5. Asks for help with a dressing change involving techniques he or she has not yet performed alone

1. Prepared to discuss the clients medical diagnosis in pre-conference 2. Overheard stating, My care is held to the same standards as that of the unit nurses 5. Asks for help with a dressing change involving techniques he or she has not yet performed alone

A group of middle-aged clients is inquiring about nutritionrelated health problems inherent in their age group. In order to best address these concerns of this specific age group, the nurse should take which action? 1. Provide information, including a website, regardingage specific diet plans. 2. Give all clients a handout on diets recommended by the ADA. 3. Tell the clients to check with their physician before dieting. 4. Have them write to the U.S. Department of Agriculture for more information.

1. Provide information, including a website, regardingage specific diet plans.

A nurse is presenting an educational session regarding psychosocial development to a group of middle-aged adults. According to Eriksons theory, what activity should the nurse select to best meet the needs of this stage? 1. Providing opportunities to mentor school-age children 2. Giving the group handouts regarding peer socialization 3. Helping the members of this group find appropriate civic responsibility 4. Assisting the group members to look at their life accomplishments

1. Providing opportunities to mentor school-age children

After implementing interventions and reassessing the clients response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process? Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion

1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments

A seasoned nurse uses past experiences and knowledge gained from previous care situations to care for a client with complex health issues. Which attribute of critical thinking is this nurse practicing? 1. Reflection 2. Context 3. Dialogue 4. Time

1. Reflection

The nurse manager is concerned that a staff nurses care demonstrates gross negligence. What actions did the manager use to make this determination? Standard Text: Select all that apply. 1. Removed a clients central line 2. Reconnected contaminated intravenous tubing to a client 3. Accessed the computerized documentation system with a password 4. Walked a client with a blood pressure of 70/58 mm Hg to the bathroom 5. Delegated nasotracheal suctioning for a client to unlicensed assistive personnel

1. Removed a clients central line 2. Reconnected contaminated intravenous tubing to a client 4. Walked a client with a blood pressure of 70/58 mm Hg to the bathroom 5. Delegated nasotracheal suctioning for a client to unlicensed assistive personnel

A nurse on the unit notices that a co-worker exhibits a pattern of behavior suggestive of drug abuse. What should the nurse do? 1. Report the situation to the unit charge nurse. 2. Send an anonymous letter to the director of nursing. 3. Let other co-workers know about the situation. 4. Report the situation, then let management take care of it.

1. Report the situation to the unit charge nurse.

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 3. Physicians orders 4. A list of current medications 5. Information about the clients cultural preferences 6. Discharge instructions

1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 4. A list of current medications 5. Information about the clients cultural preferences

Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse.

1. Retake the vital signs.

The nurse is preparing to complete a spiritual assessment with a client. Which theorist should the nurse review before completing this assessment? 1. Roy 2. Neuman 3. Nightingale 4. Peplau

1. Roy

The nurse is evaluating the results of a study prior to implementing its findings into practice. Which action should the nurse take when scientifically validating the research results? 1. Scrutinizing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its findings 2. Assessing how the studys findings compare to findings from other studies about the problem 3. Determining how the studys findings will transfer from the research conditions to the clinical practice conditions in which they will be used 4. Identifying practical or feasibility considerations that need to be addressed when applying the findings in practice

1. Scrutinizing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its findings

While working a scheduled shift the nurse focuses on actions to protect the privacy of a client with local notoriety. What actions should the nurse take at this time? Standard Text: Select all that apply. 1. Secure the clients medical record. 2. Review the clients care with the media. 3. Remove the clients name from the door. 4. Permit family to view the clients record. 5. Fax the clients lab values with a cover sheet.

1. Secure the clients medical record. 3. Remove the clients name from the door. 5. Fax the clients lab values with a cover sheet.

The nurse is emulating the characteristics of caring, as described by Mayeroff. Which action demonstrates knowing, in relationship to caring? 1. Seeing that a client is withdrawn and sullen, and spending extra time when providing cares or treatments 2. Understanding the reason a clients lab values are elevated 3. Seeing the connection between the pathophysiology of the cardiac condition and treatment and giving the rationale for certain medications when the client asks 4. Getting an extra blanket when the client says he is cold

1. Seeing that a client is withdrawn and sullen, and spending extra time when providing cares or treatments

The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? Standard Text: Select all that apply. 1. Selecting a mate 2. Rearing children 3. Achieving civic responsibility 4. Finding a congenial social group 5. Developing adult leisure-time activities

1. Selecting a mate 2. Rearing children 4. Finding a congenial social group

A nurse is identified as being an effective leader. With this designation, the nurse will most likely demonstrate which characteristics? Select all that apply. 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others 5. Focus on systems

1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others

The manager identifies a staff nurse to serve as a change agent for the implementation of a computerized documentation system. What attributes did the manager observe to designate the staff nurse to have this role?Select all that apply. 1. Self-confident 2. Skilled in teaching 3. Hesitant with decision making 4. Excellent communication skills 5. Effective utilization of resources

1. Self-confident 2. Skilled in teaching 4. Excellent communication skills 5. Effective utilization of resources

At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique 4. If the wound heals

1. Shared by the nurse and client

A nurse researcher is exploring and formulating research problems. Which criteria should the nurse researcher consider in this process? Standard Text: Select all that apply. 1. Significance 2. Confidentiality 3. Researchability 4. Design 5. Feasibility 6. Interest to the researcher

1. Significance 3. Researchability 5. Feasibility 6. Interest to the researcher

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the clients chair. 4. Stand at the counter to take notes during the interview.

1. Sit next to the client, a few feet apart.

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis

1. Syndrome diagnosis

The community health nurse is identifying approaches to support a communitys health care needs. Which programs should the nurse select to support community-based health care? Select all that apply. 1. Smoking cessation classes 2. Personal safety classes for women 3. Blood pressure measurement clinic 4. Outpatient clinic for minor ailments 5. Allergy injection clinic on weekends

1. Smoking cessation classes 2. Personal safety classes for women 3. Blood pressure measurement clinic

The spouse of a client referred to hospice care asks why the client needs the change in services. How should the nurse respond to this question? 1. So we can see if theres any way to improve your spouses life. 2. There is no need for acute care any longer. 3. Its best for your spouse to be cared for at home. 4. Hospice care is cheaper than acute care.

1. So we can see if theres any way to improve your spouses life.

When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the clients chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting

1. Source-oriented record

A college-age client shares that he is struggling with feelings of both independence and dependence regarding his family. The nurse recognizes this as which stage of development, according to Roger Gould? 1. Stage 2 2. Stage 3 3. Stage 4 4. Stage 5

1. Stage 2

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex

1. Standardized care plans

The high school graduate desiring to attend nursing school reviews the schools for accreditation. Which regulatory bodys actions is the student analyzing? 1. State board of nursing 2. NLNAC 3. CCNE 4. ANA

1. State board of nursing

After the data have been analyzed, the nurse realizes that the probability has a value of less than .05. What should this finding indicate to the nurse? 1. Statistically significant 2. Statistically insignificant 3. Chance occurrences 4. Generalized

1. Statistically significant

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the clients coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse wont have to spend time going over the pathology of the clients disease.

1. Strengths can be an aid to mobilizing health and the healing process.

The client states: I really dont want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning

1. Subjective data

The nurse instructs the older client to access the Internet to complete a post-hospitalization survey and update health information. The client tells the nurse that he does not have a computer and would not know how to use one. What should the nurse do? Select all that apply. 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction.

1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center.

The nurse concludes that a young adult client is completing developmental tasks within Havighursts early adulthood age period. What did the nurse assess to come to this conclusion? 1. Taking on civic responsibility 2. Developing adult leisure-time activities 3. Getting started in an occupation 4. Relating oneself to ones spouse as a person 5. Managing a home

1. Taking on civic responsibility 3. Getting started in an occupation

Several nurses are working to open a clinic that focuses on health promotion. Which activity should the nurses expect to perform once this clinic opens? 1. Teaching biofeedback techniques for stress reduction 2. Providing immunization clinics 3. Evaluating regional industrial centers for environmental pollution 4. Teaching smoking cessation classes to adolescents

1. Teaching biofeedback techniques for stress reduction

A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic

1. Technical

A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children? 1. Temperament 2. Physical characteristics 3. Environment 4. Culture

1. Temperament

New parents ask if their 8monthold baby is performing activities that are expected at this age. What should the nurse suggest to screen this babys developmental level? 1. The Denver Developmental Screening Test (DDST-II) 2. Growth and development charts from the Centers for Disease Control and Prevention (CDC) 3. Assessment tools utilized by the state education department 4. The Apgar scoring system

1. The Denver Developmental Screening Test (DDST-II)

A parent brings her baby in for a well-child checkup. Which action of the child should the nurse identify as an indicator of positive resolution of the central task of this age? 1. The child does not cry when the parent allows the nurse to hold the child. 2. The child shows mistrust when strangers approach. 3. The child becomes willful when disciplined. 4. The child does not play with other children.

1. The child does not cry when the parent allows the nurse to hold the child.

A 20-year-old client with Down syndrome is diagnosed with an illness. Even though the client is able to live in an assisted environment and work part-time for a local bookstore, the parents of the client are adamant about not initiating a course of treatment whose side effects are unknown with Down syndrome clients. According to the nursing code of ethics, to whom is the nurses first loyalty? 1. The client 2. The parent 3. The physician 4. The nurse

1. The client

The nurse determines that an older client is in the medical care contact stage of an illness. What did the client demonstrate to cause the nurse to make this decision?Select all that apply. 1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion. 5. The client stated that treatment is accepted and will be completed as identified.

1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion.

A community health nurse works with a variety of cultures providing health care services that include preventive care, acute treatment, and education. Of the following clients, which is most likely to use folk medicine? 1. The client who speaks little English and does not have a job 2. A family who has numerous relatives in a Spanish-American sector of the city 3. A female client whose culture is one of male dominance 4. A Chinese client who has a small, familyrun business in the area

1. The client who speaks little English and does not have a job

The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism? Select all that apply. 1. The clients heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. 3. A childs bone growth occurs in spurts. 4. Decreased secretion of insulin occurs when food is not ingested. 5. Lactation occurs in a pregnant woman.

1. The clients heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. 4. Decreased secretion of insulin occurs when food is not ingested

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The clients record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake.

1. The clients record contained an incorrect DRG

The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this clients plan? Select all that apply. 1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content

1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 5. The amount of time needed to cover the content

The nurse educator teaches students about caring nursing practice. Which situation demonstrates a nurse implementing the whole idea of caring? 1. The nurse who takes time for a favorite hobby, at least once a week 2. The nurse who volunteers at church and school events 3. The nurse who makes lists every morning so the day stays organized and planned 4. The nurse who takes care of his elderly parents as well as providing care to his immediate family

1. The nurse who takes time for a favorite hobby, at least once a week

After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals interventions 3. The ones that focus on the clients primary illness 4. The ones that have standardized care available

1. The ones that the nurse is licensed to treat

While a nurse is conducting a health assessment, the individual asks why the term patient is being used. What should the nurse explain about the implication of the term patient? 1. The person is seeking assistance because of illness. 2. The individual is proactive in his or her health care needs. 3. The person is a collaborator in his or her care. 4. The individual is using a service or commodity.

1. The person is seeking assistance because of illness.

An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the emergency department, the client was given sedation for pain before a surgical permit was signed. What should be done to obtain consent? 1. The physician should have the clients wife sign the consent form. 2. The physician should wait until the effects of the medication wear off and have the client sign the form. 3. Because the client has been medicated, the nurse should thoroughly explain the consent form to the client. 4. This would be considered an emergency situation and consent would be implied.

1. The physician should have the clients wife sign the consent form.

The nurse case manager is concerned about a particular client being discharged from the hospital. Which factors should alert the nurse to possible problems with this clients adherence to treatment? 1. The prescribed therapy is costly and of unknown duration. 2. The therapy will require no lifestyle changes of the client. 3. The client has not had difficulty understanding the regimen. 4. The clients culture is supportive of Western medicine.

1. The prescribed therapy is costly and of unknown duration.

The nurse is preparing to assess a family regarding the impact of one of its members being diagnosed with diabetes. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. The seriousness of the disorder 2. Whether the family has ever dealt with a chronic illness before 3. The age of the affected member 4. The financial impact the illness will have on the family 5. The number of members of the family

1. The seriousness of the disorder 2. Whether the family has ever dealt with a chronic illness before 4. The financial impact the illness will have on the family

The nurse is confident that a family is functioning appropriately. What findings did the nurse use to make this determination? Standard Text: Select all that apply. 1. The teenage son keeps the money he earns from cutting grass for his car fund. 2. All the children are expected to excel in the sport of their choice. 3. A parent reads the preschool child a bedtime story each night. 4. All the children have household chores once they reach school age. 5. A young adult child moves back home after losing his job.

1. The teenage son keeps the money he earns from cutting grass for his car fund. 3. A parent reads the preschool child a bedtime story each night. 4. All the children have household chores once they reach school age. 5. A young adult child moves back home after losing his job

A kindergarten class is being screened by a group of nursing students using a Snellen E chart. Few of the children have 20/20 vision. Most have 20/30, and some have 20/40. What should the nursing students report to the instructor about these childrens vision? 1. These children have normal vision abilities. 2. We should check into the health of these children. Maybe their diets are lacking in essential vitamins because they all have poor eyesight. 3. These kids will all be wearing glasses when we come back next year. 4. We should use a different eye chart. Maybe the kids would understand it better.

1. These children have normal vision abilities.

The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client. Which characteristics should the nurse keep in mind during this assessment? Select all that apply. 1. They are self-regulating. 2. They are compensatory. 3. They are regulated by negative feedback systems. 4. They can require several feedback mechanisms to correct only one physiologic imbalance. 5. They are related to a closed system.

1. They are self-regulating. 2. They are compensatory. 3. They are regulated by negative feedback systems. 4. They can require several feedback mechanisms to correct only one physiologic imbalance.

The school nurse determines that a 14yearold student has reached an expected level of cognitive development. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Thinks logically 2. Thinks about the future 3. Makes rational statements 4. Uses a trialanderror process 5. States things as they could be

1. Thinks logically 2. Thinks about the future 3. Makes rational statements 5. States things as they could be

A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which statement should the nurse make that demonstrates the theory of principles-based reasoning? 1. This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make. 2. I need to try and help the family understand the clients decision so they can work through this situation together. 3. This clients health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death. 4. The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die.

1. This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make.

During an interview assessment, the client states a belief in nutritional lifestyle counseling and that the bodys vital energy circulates through the body, which can be manipulated through specific anatomical points. Which type of healing practice should the nurse identify that this patient is following? 1. Traditional Chinese medicine 2. Native American healing 3. Ayurveda 4. Curanderismo

1. Traditional Chinese medicine

A nurse educator uses Madeleine Leiningers model and describes a formal area of study and practice focused on comparative human-care differences and similarities of the beliefs, values, and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people. What type of nursing is the educator practicing? 1. Transcultural nursing 2. Cultural competence 3. Cultural knowledge 4. Competent nursing

1. Transcultural nursing

A new graduate nurse is working in a busy emergency department of a hospital, situated in a culturally diverse area of the city. In striving to be culturally sensitive, what should the nurse do? 1. Try to learn about the attitudes toward health care and traditions of the different cultures in that area. 2. Understand and attend to the total context of the clients situation, using knowledge, attitudes, and skills. 3. Possess the underlying background knowledge that will provide these clients with the best possible health care. 4. Continuously strive to be culturally competent.

1. Try to learn about the attitudes toward health care and traditions of the different cultures in that area.

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia

1. Unfamiliarity of disease process

The nurse is preparing a teaching session for a group of parents with newborn children. What should the nurse include about Bowlbys attachment theory during this presentation? Standard Text: Select all that apply. 1. Use the attachment figure as security 2. Desire to be near the attachment figure 3. Plan to separate from the attachment figure 4. Return to the attachment figure when threatened 5. Express anxiety when the attachment figure is absent

1. Use the attachment figure as security 2. Desire to be near the attachment figure 4. Return to the attachment figure when threatened 5. Express anxiety when the attachment figure is absent

An occupational health nurse is providing a hypertension screening at a local manufacturing plant. Among the employees, the nurse should focus on which population? 1. Males and females, equally 2. African American males 3. Asian American females 4. White females

2. African American males

The new graduate nurse has committed to improving self-care activities. Which behaviors exemplify that the nurse is following through on this personal commitment? Standard Text: Select all that apply. 1. Using meditation to de-stress at the end of a long day at work 2. Eating a low fat-diet, as there is a family history of heart disease 3. Attending workshops designed to enhance professional skills at least twice yearly 4. Volunteering to cover a friends weekend shifts so the friend can fully recover from a sprained ankle 5. Making sure to reserve the time to read a favorite book between 12 hours of shift work

1. Using meditation to de-stress at the end of a long day at work 2. Eating a low fat-diet, as there is a family history of heart disease 5. Making sure to reserve the time to read a favorite book between 12 hours of shift work

A staff nurse has been identified by others as being an effective leader. With this designation, the nurse implements which principles? Select all that apply. 1. Vision 2. Influence 3. Serve as a role model 4. Planning 5. Organizing

1. Vision 2. Influence 3. Serve as a role model

The nurse wants to gain information about a clients situation. Which question should the nurse use to maximize communication with this patient? 1. What brings you to the hospital? 2. Are you having pain? 3. Does your pain feel better or worse today? 4. Is there anything I can do for you?

1. What brings you to the hospital?

The nurse educator assigns students an activity to implement Socratic questioning in their daily lives. Which question provided by a student demonstrates this reasoning technique? 1. What makes you think cramming for a test is an ineffective way to study? 2. What other ways of studying could you implement? 3. If you didnt study for your test, what is the probability you will fail? 4. If you study all the unit outcomes, what effect will that have?

1. What makes you think cramming for a test is an ineffective way to study?

A nurse is working with a school-age client who is learning how to use a peak flow meter to monitor his asthma. The child has been frustrated at first, but now is able to give the reason to use the meter on a daily basis. Remembering the growth and development characteristics of the adolescent, how should the nurse respond to this client? 1. You should feel very proud for understanding and using your meter. 2. Think of using the meter as one of your daily chores. 3. Maybe you could make a game out of the daily use of your meter. 4. Its too bad if you dont want to use the meter, its just something youll have to do.

1. You should feel very proud for understanding and using your meter.

An elderly client comes to the clinic for follow-up after a long hospitalization. When the client asks about increasing strength and endurance, what should the nurse respond? 1. Your muscles can be strengthened, which might help you function better. 2. It wont matter if you exercise. At your age, theres little room for improvement. 3. Once muscle mass is decreased, theres nothing that can be done for strength improvement. 4. Maybe you should think about going to a nursing home. At least the people there will be able to help with your needs

1. Your muscles can be strengthened, which might help you function better.

A school nurse is planning a program for adolescents about positive lifestyle choices. The nurse should keep in mind that content presented to this age group must be: (Select all that apply.) 1. based on learning outcomes. 2. current. 3. adjusted to the adolescent client. 4. based on sources available within the school system. 5. accurate.

1. based on learning outcomes. 2. current. 3. adjusted to the adolescent client. 5. accurate.

In planning any health program for elderly adults, the nurse will implement Eriksons theory of task development. The nurse realizes that in this stage of life, the successful completion of the task allows the person to 1. have a feeling of satisfaction from past accomplishments. 2. make connections with the younger generation. 3. wish he or she could live life over again. 4. live out his or her last years in physical health.

1. have a feeling of satisfaction from past accomplishments

A nurse is working in a community of factory workers and is planning an educational session for wellness, targeting the young adult group. In order to address one of the health problems of this group, the nurse plans to: 1. help the group become more aware of marketing efforts by tobacco companies. 2. tell this group that smoking is unacceptable. 3. make sure the group is aware of the increased risk of liver disease and cancer of the esophagus. 4. counsel the group regarding addiction.

1. help the group become more aware of marketing efforts by tobacco companies.

A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this clients interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated

2. After the client has settled in and been oriented to the room

The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordons health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location

2. Age 3. Time 4. Health status 6. Location

A nurse is working with the residents of an assisted living complex. When planning care for the old-old stage, the nurse realizes that what action will be important? 1. Provide as much care to the residents as possible. 2. Allow as much independence for the residents as possible. 3. Make sure to provide safety measures as needed. 4. Make sure the residents maintain peer interactions and social groups.

2. Allow as much independence for the residents as possible.

The nurse is reviewing sources of federal funding for health care services provided to clients. For which clients should the nurse recognize as most likely having health care paid through a federal funding source? Select all that apply. 1. 35-year-old self-employed house painter 2. 72-year-old retired schoolteacher 3. 52-year-old nurse who runs the family farm 4. 29-year-old mentally challenged sheltered workshop employee 5. 40-year-old factory worker

2. 72-year-old retired schoolteacher 4. 29-year-old mentally challenged sheltered workshop employee

A student asks the nursing instructor which types of knowledge are important in the clinical area. How should the instructor respond to the student? 1. Empirical knowledgeyou have to know the physiology of the problem before you decide which interventions to use. 2. A good nurse will have a mix of all four types of knowledge. 3. Ethical knowledgenurses must be able to identify principles and norms, handle conflicts, and be sensitive to sensitive issues. 4. Aesthetic knowledgea nurse must appreciate the special qualities of each client and the individual situation.

2. A good nurse will have a mix of all four types of knowledge.

A nurse is working with clients in an assisted living facility. In the past month, there have been several deaths among the residents and their spouses. In helping the remaining residents deal with these deaths, the nurse understands that adjustment may be easier for which resident? 1. A resident who spent most of her days attending to her partner who is now deceased 2. A resident who had a wide circle of friends, besides her spouse 3. A resident who was not inclined to participate in any activities offered at the facility 4. A resident who started to become more dependent on the nursing staff at the facility

2. A resident who had a wide circle of friends, besides her spouse

A nurse has agreed to delay a clients treatment until the matriarch of the family can be present. Understanding that this is an important consideration for this clients cultural practices, which of Leiningers intervention modes is the nurse implementing? 1. Preservation and maintenance 2. Accommodation, negotiation 3. Restructuring 4. Repatterning

2. Accommodation, negotiation

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as its his record. How should the nurse respond to this clients request? 1. Youll have to ask your doctor for permission to do that. 2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records. 3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have to worry about those details. 4. Theres a new law that protects your records, so youre not going to be able to have access to them.

2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records.

A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the clients care plan includes working on coping with her current limitations since the injury. This nurse is working within which model of health? 1. Role performance 2. Adaptive 3. Eudemonistic 4. Clinical

2. Adaptive

A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration? 1. Rest and exercise 2. Adjusting to physiologic changes and limitations 3. High obesity percentages 4. Safety promotion and injury prevention

2. Adjusting to physiologic changes and limitations

A client who has been the recipient of home health care has made the decision to discontinue hemodialysis. The client understands all the consequences of this decision and is not supported by his family. The nurse is meeting with the family to help them understand the significance of the clients decision and to help them support the client during this difficult time. In which role is the nurse functioning? 1. Caregiver 2. Advocate 3. Educator 4. Counselor

2. Advocate

Some nursing students are doing their first clinical rotation in a long-term care facility. What should the nurse educator remind the students to do to meet the needs of this particular client group? 1. Do all care for the clients, as theyre unable to do it independently. 2. Always remember that the clients self-respect must be maintained in all interactions of the students. 3. Make sure the clients care is done in a timely manner, and sometimes that means doing things for the client. 4. Treat this group of clients with a greater level of respect than younger clients.

2. Always remember that the clients self-respect must be maintained in all interactions of the students.

The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily.

2. Ambulate with client, using a gait belt, twice daily for 15 minutes.

A client living in a long-term care center has been withdrawn and subdued, and does not eat in the dining room because of embarrassment about her physical decline. What might the nurse suggest that provides opportunities for unconditional love, achievement of trust, responsibility, and empathy toward others? 1. Chelation therapy 2. Animal-assisted therapy 3. Meditation 4. Pilates

2. Animal-assisted therapy

The nurse notes that assessment data indicate a change in a clients condition. What should the nurse ask before changing this clients plan of care? Standard Text: Select all that apply. 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? 5. Will the primary medical provider agree with the need to alter the care plan?

2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan?

A female client is being discharged after a lengthy hospitalization. The family is from a male-dominated culture. Before discharge instructions are given, which action should the nurse take? 1. Make sure instructions are understood by the client. 2. Arrange for teaching when the spouse is available. 3. Make sure that the physician gives the instructions. 4. Ask the client when the best time for teaching would be.

2. Arrange for teaching when the spouse is available.

The nurse is implementing Watsons Assumptions of Caring philosophy. Which actions demonstrate that the nurse is using this philosophy? Standard Text: Select all that apply. 1. Asking the client to explain the impact that his culture and religion will have on required nursing care 2. Asking clients when they prefer to be given the opportunity to bathe 3. Feeling empathy toward the clients loss of mobility as a result of a fractured hip 4. Always assuring that the client has an unobstructed view out his rooms window 5. Arranging to fulfill a clients request to stay with him during a painful diagnostic test

2. Asking clients when they prefer to be given the opportunity to bathe 3. Feeling empathy toward the clients loss of mobility as a result of a fractured hip 5. Arranging to fulfill a clients request to stay with him during a painful diagnostic test

The nurse is identifying health promotion needs for an older adult client. What should the nurse consider for this client? Standard Text: Select all that apply. 1. Offering to arrange a pneumococcal vaccine for a client turning 60 years old 2. Assessing the 62-year-old client for situational depression. 3. Discussing smoking cessation classes with a 64-year-old 4. Asking a 78-year-old client whether he had his cholesterol tested within the last 3 years 5. Measuring the 79-year-old clients height and weight

2. Assessing the 62-year-old client for situational depression. 3. Discussing smoking cessation classes with a 64-year-old 5. Measuring the 79-year-old clients height and weight

A nurse is working with a home health client whose spouse was not born in the United States. During the home visit, the nurse realizes that the client has acquired the identity of her spouses culture and has adopted some of the health practices of that culture. Which process should the nurse identify as occurring with the spouse? 1. Acculturation 2. Assimilation 3. Diversity 4. Heritage consistency

2. Assimilation

According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Make sure that he or she is able to get to the clients home. 2. Assist the client in finding an alternative plan for the achieving the therapys outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility.

2. Assist the client in finding an alternative plan for the achieving the therapys outcomes.

The nurse is planning interventions for a client based upon Hendersons fundamental needs. Which interventions should the nurse include in the plan of care? Standard Text: Select all that apply. 1. Sleep 4 to 5 hours each night. 2. Attend to spiritual needs as desired. 3. Wear clothing suitable for the weather. 4. Bathe and keep the body well-groomed. 5. Restrict fluids with an elevated body temperature.

2. Attend to spiritual needs as desired. 3. Wear clothing suitable for the weather. 4. Bathe and keep the body well-groomed.

An adolescent comes to the school nurses office seeking advice about his friends and feeling pressure to participate in activities with which he isnt comfortable, such as drinking parties and sexual explorations. What should the nurse do? 1. Tell the adolescent to stay away from friends like that. 2. Be open to the concerns and provide accurate information about any questions. 3. Encourage the adolescent to accept psychosocial counseling. 4. Give the adolescent pamphlets on sexually transmitted diseases.

2. Be open to the concerns and provide accurate information about any questions.

The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? Standard Text: Select all that apply. 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly

2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly

A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse? 1. Make sure that the classes are held at specific times. 2. Begin classes when a group of clients are gathered. 3. Mail letters ahead of time to make sure clients are informed about the upcoming class. 4. Make posters and place them in areas of the community frequented by these groups.

2. Begin classes when a group of clients are gathered.

A high school graduate is considering entering a nursing program that offers a baccalaureate degree. What organization accreditation should the nurse use to help select a nursing program? 1. NLN (National League for Nursing) 2. CCNE (Commission on Collegiate Nursing Education) 3. NCLEX (National Council Licensure Examination) 4. NCSBN (National Council of State Boards of Nursing)

2. CCNE (Commission on Collegiate Nursing Education)

A client has been complaining of pain, even though the nurse has given the client the maximum amount of medication as ordered by the physician. Which action demonstrates the nurses respect for the clients autonomy? 1. Telling the client that he will have to tough it out 2. Calling the physician for further orders 3. Telling co-workers that this client has no pain tolerance 4. Believing the client is drug seeking

2. Calling the physician for further orders

The nurse is consulting other professionals as well as educating, supporting, and managing a clients chemotherapy regimen. In which role is this nurse functioning? 1. Nurse practitioner 2. Clinical nurse specialist 3. Nurse educator 4. Nurse entrepreneur

2. Clinical nurse specialist

A nurse manager has had to handle a particularly difficult physician who is demanding as well as demeaning. Through this situation, the nurse manager has learned that accuracy and honesty are attributes of which skill necessary for managers? 1. Critical thinking 2. Communication 3. Networking 4. Responsibility

2. Communication

While listening to a client describe current symptoms, the nurse considers the clients entire situation. Which attribute of critical thinking is the nurse practicing? 1. Reflection 2. Context 3. Dialogue 4. Time

2. Context

A parish nurse is helping a group of new parents within the congregation find appropriate health care providers within the community who specialize in infant/child and family health care needs. In which role is the nurse functioning? 1. Health educator 2. Referral source 3. Facilitator 4. Integrator

2. Referral source

A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: Im never going to understand what to do, when to do it, and why I should be doing all these things. Which nursing diagnosis should the nurse formulate for this client? 1. Health-Seeking Behavior related to desire to prevent heart problems 2. Deficient Knowledge (diet and medication regimen) related to inexperience 3. Noncompliance related to situational factors 4. Risk for Myocardial Infarction related to deficient knowledge

2. Deficient Knowledge (diet and medication regimen) related to inexperience

A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment, the nurse finds that the child cannot stand next to furniture and does not try to pull himself up from a sitting position. In which process should the nurse identify that this child is lagging? 1. Growth 2. Development 3. Height 4. Behavior

2. Development

The nurse is teaching health and wellness principles to junior high students. According to Orems theory, which category of self-care requisite is the nurse using to guide this teaching? 1. Universal 2. Developmental 3. Health deviation 4. Deficit

2. Developmental

The nurse enrolled in graduate courses is able to continue studies while visiting abroad. What has this nurses nursing school implemented to make this possible? 1. Classroom technology 2. Distance learning 3. CAI 4. Informatics

2. Distance learning

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the clients symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped.

2. Document that the problem has been resolved and discontinue the care for the problem.

The nurse is providing care to a group of clients. For which situation would the nurses use of critical thinking be a priority? 1. Administering IV push meds to critically ill clients 2. Educating a home health client about treatment options 3. Teaching new parents car seat safety 4. Assisting an orthopedic client with the proper use of crutches

2. Educating a home health client about treatment options

A client who has a terminal diagnosis has been using her time to help family members deal with her impending death. Among her activities, she collected pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task? 1. Body transcendence versus body preoccupation 2. Ego transcendence versus ego preoccupation 3. Ego differentiation versus work-role preoccupation 4. Integrity versus despair

2. Ego transcendence versus ego preoccupation

The student nurse is reviewing the code of ethics prior to beginning a clinical assignment. On what areas should the nurse focus when providing client care? Standard Text: Select all that apply. 1. Support lifelong learning. 2. Ensure the safety of all clients. 3. Maintain client confidentiality. 4. Provide care in a professional manner. 5. Collaborate with students and faculty.

2. Ensure the safety of all clients. 3. Maintain client confidentiality. 4. Provide care in a professional manner.

The nurse being oriented to a new position is reviewing the hospitals standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? Select all that Apply. 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurses time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur

2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurses time

A nurse educator is explaining primary health care (PHC) and the extension of its boundaries beyond traditional health care services to a group of community members. What issues related to PHC should the nurse include in this discussion? 1. Distribution and participation 2. Environment, agriculture, and housing 3. Consumerism and governmental subsidies 4. Low life expectancies and high mortality rates among children

2. Environment, agriculture, and housing

A newly immigrated client is constantly attended to by family members. This has presented a problem to the nursing staff and the delivery of nursing care. In order to address this issue in a culturally sensitive manner, the nurse should take which action? 1. Explain to the client that he has to limit visitors. 2. Evaluate the benefits of family participation in the clients care. 3. Question the family members as to how they see their interaction with the client. 4. Have the physician limit the number of visitors the client can have.

2. Evaluate the benefits of family participation in the clients care.

A client is asked during an admission interview to describe her family. She proceeds to list parents, siblings, grandparents, aunts, uncles, and cousins. Which type of family should the nurse document for this client? 1. Nuclear 2. Extended 3. Traditional 4. Blended

2. Extended

After completing a health history the nurse reviews the content to determine metaparadigms that contribute to the clients health. Which metaparadigm should the nurse categorize as being a part of the clients environment? Standard Text: Select all that apply. 1. Diet 2. Family 3. Friends 4. Blood pressure 5. Significant others

2. Family 3. Friends 5. Significant others

The nurse is providing pre-employment physicals to a group of adults, aged 30 to 40. In which generation should the nurse categorize these adults? 1. Baby Boomers 2. Generation X 3. Generation Y 4. Millennials

2. Generation X

A nurse is conducting a family assessment as part of the process for services provided through the community. Which part of the assessment should provide the nurse with the best information in identifying existing or potential health problems? 1. Ecomap 2. Genogram 3. Cultural assessment 4. Family communication patterns

2. Genogram

A teenage girl spends most of her free time with friends. In sharing their concerns about this behavior with the school nurse, the parents are worried about their child seeming to draw away from them. What should the nurse respond to the parents? 1. You should really keep better track of your child. Its hard to tell what kinds of trouble she may be getting into. 2. Independence is really important for this age group. Try to be extra attentive when your child does spend time at home. 3. Use stricter guidelines for curfew and punishment if curfew is broken. 4. Is it possible that your child might be taking drugs?

2. Independence is really important for this age group. Try to be extra attentive when your child does spend time at home.

The nurse case managers office is in a cluster of offices that share a fax machine. Which action by the nurse ensures that HIPAA requirements are met? 1. Have the client sign a consent form for information to be released. 2. Have sending agencies call ahead before any information is sent. 3. Do not utilize the fax machine; depend on the mail system. 4. Take relevant information over the phone.

2. Have sending agencies call ahead before any information is sent.

A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This client is modeling which behavior? 1. Health promotion 2. Health protection 3. Tertiary prevention 4. Primary prevention

2. Health protection

Nursing staff members from an acute psychiatric unit have been asked to establish a nurse theorist they can easily identify with in their practice. Understanding the importance of developing a therapeutic relationship between themselves and their clients, especially in this unit, to which theorist would they most likely be drawn? 1. Florence Nightingale 2. Hildegard Peplau 3. Jean Watson 4. Dorothea Orem

2. Hildegard Peplau

A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn? 1. I'm so afraid I'll hurt my baby with all these tubes. 2. I want to make sure my spouse is here, in case I don't hear everything thats said. 3. When my baby is just a little bigger, I'll be able to handle him. 4. You'll give us written instructions before we go home, correct?

2. I want to make sure my spouse is here, in case I dont hear everything thats said.

During an auditory screening of third graders, the school nurse identifies a hearing deficit for one of the students. When the parents ask the nurse about the findings, how should the nurse respond? 1. Hearing acuity is not fully developed in your child. Lets recheck next year. 2. Id like to recheck at the clinic. Then we may need to have your child be seen by an auditory specialist. 3. It was too noisy when we were testing, so I wouldnt be concerned if I were you. 4. Your child will probably need a hearing aid.

2. Id like to recheck at the clinic. Then we may need to have your child be seen by an auditory specialist.

An elderly client comes to the clinic after checking his blood pressure several times in the local discount store. The nurse checks the blood pressure and finds that it is 146/80. What should the nurse say to this client? 1. Having blood pressure a little high is normal at your age. Yours is fine. 2. Ill recheck this in a while, but your systolic pressure is too high. 3. Well wait and see what the doctor says, but I doubt he will be concerned. 4. You should be on medicine for high blood pressure.

2. Ill recheck this in a while, but your systolic pressure is too high.

A nurse educator incorporates stress, power, authority, and personal space along with other concepts and considers these concepts essential knowledge for use by nurses. From which theorist is the educator applying principles into the curriculum? 1. Dorothea Orem 2. Imogene King 3. Jean Watson 4. Hildegard Peplau

2. Imogene King

A client complaining of extreme low back pain is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse suspects that the blood pressure and heart rate will be elevated. What thought process did the nurse use to come to this conclusion? 1. Fact 2. Inference 3. Judgment 4. Opinion

2. Inference

A client asks what is done to keep computerized personal health information confidential. How should the nurse respond? 1. Dont worry; your information is always safe. 2. Information in our system requires a password to retrieve. 3. Our system was designed with a lot of input from nursing staff. 4. I can see why youre worried, with all the computer hackers out there these days.

2. Information in our system requires a password to retrieve.

The nurse who just moved from an urban area to a sparsely populated rural area understands that certain customs and practices the nurse follows may be quite foreign to the people in the new area. Which attitude of critical thinking is the nurse demonstrating? 1. Fair-mindedness 2. Insight into egocentricity 3. Intellectual humility 4. Intellectual courage to challenge the status quo and rituals

2. Insight into egocentricity

The nurse is teaching a client from a culture that is present oriented about a dressing change that should be performed twice a day. How should the nurse address the cultural issue? 1. Allow the client to select the times the dressing will be changed. 2. Instruct the client to change the dressing after breakfast and before going to bed. 3. Explain that the client should complete the dressing change at 10 AM and 4 PM. 4. Suggest that the dressing change can be performed whenever the client chooses, as long as it gets done twice daily.

2. Instruct the client to change the dressing after breakfast and before going to bed.

A large community clinic provides health education, illness prevention, acute care, screening, and rehabilitation and health promotion services for the chronically ill. What should the community health nurse identify this approach to health care as being? 1. Community-based setting 2. Integrated health care system 3. Wellness center 4. Community outreach center

2. Integrated health care system

A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the clients scheduled procedure; and documented the situation in the clients medical record. What did this nurse demonstrate? 1. Altruism 2. Integrity 3. Social justice 4. Human dignity

2. Integrity

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic

2. Interpersonal

The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes

2. Intervention

A nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distance 4. Public distance

2. Intimate distance

A clinical instructor senses that a student has been struggling with clinical skills learned in lab. To combat this, the educator pairs the student with a staff nurse who has clients with a variety of treatments and cares. Which type of problem solving is the instructor using? 1. Trial and error 2. Intuition 3. Research process 4. Experience

2. Intuition

The nurse enters the room of a critically ill child after sensing that something isnt right. Once the nurse determines the child is stable, the nurse continues to perform a check of all the lines and equipment in the room and finds that the last IV solution hung by the previous nurse was not the correct solution. Which problemsolving method did this nurse use? 1. Trial and error 2. Intuition 3. Judgment 4. Scientific method

2. Intuition

A nurse has implemented the use of noncontact therapeutic touch. Which theorist is the nurse using as a basis for this intervention? 1. Florence Nightingale 2. Martha Rogers 3. Virginia Henderson 4. Rosemarie Parse

2. Martha Rogers

A parent tells the nurse that his child is quite creative and learning how to pretend with almost anything in the house. According to Piaget, the nurse realizes this child is demonstrating which stage/phase? 1. Tertiary circular reaction: stage 5 2. Inventions of new means: stage 6 3. Preconceptual phase 4. Concrete operations phase

2. Inventions of new means: stage 6

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do? 1. Review the data and make sure that the diagnosis is relevant. 2. Investigate whether the best nursing interventions were selected. 3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase.

2. Investigate whether the best nursing interventions were selected.

A toilettrained 4-year-old hospitalized for several days with an acute illness has been wetting the bed at night and is having incontinent accidents during the day. How should the nurse address the parents concern about this behavior? 1. Maybe your child should be seen by a specialist, just to make sure there are no physical problems. 2. It is normal for some children to go through a stage of regression after separation from their family or after an acute illness. Try not to be too discouraged. 3. Youll have to be very strict with discipline, so your child knows this behavior is not acceptable. 4. Id be upset too. It must be hard to go back to using diapers.

2. It is normal for some children to go through a stage of regression after separation from their family or after an acute illness. Try not to be too discouraged.

The nurse has been asked to participate on the hospitals Shared Governance Committee. To which nurse leader should the nurse attribute the ability for nurses to control the profession? 1. Mary Breckinridge 2. Lavinia Dock 3. Margaret Higgins Sanger 4. Virginia Henderson

2. Lavinia Dock

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4. Pale and diaphoretic

2. Leave me alone

A hospice nurse has been working closely with a client who, on several occasions, has asked about guidance and support in ending her life. What information should the nurse use when making an ethical and moral decision about this clients request? 1. Passive euthanasia is an easy decision to arrive at. 2. Legal issues are not the same as moral or ethical ones. 3. Active euthanasia is supported in the Code for Nurses. 4. Assisted suicide is illegal in all states.

2. Legal issues are not the same as moral or ethical ones.

A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the childs parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the childs doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions.

2. Let the child handle the equipment first, then demonstrate on the childs doll.

Several nurses are looking for an agency to sponsor a program that would meet the needs of a community group lacking in health promotion education. Which agency should the nurse approach to fill this need? 1. State health department 2. Local health department 3. Local hospital 4. Federal government

2. Local health department

The manager identifies that a nurse is practicing professionalism. What did the manager observe to come to this conclusion? 1. Recognizing characteristics considered to be professional 2. Maintaining specific character and spirit 3. Learning about the influences of Florence Nightingale 4. Promising to uphold the standards of the profession

2. Maintaining specific character and spirit

During an educational session regarding physical changes of the middle-aged adult, a participant asks about typical weight changes. How should the nurse respond? 1. Weight loss is no different during this time than at any other time of your life. 2. Metabolism slows during middle age, which may result in weight gain. 3. As long as you exercise appropriately, weight loss will be ensured. 4. Weight loss is always a good idea, regardless of your age.

2. Metabolism slows during middle age, which may result in weight gain.

The nurse is reviewing changes occurring within the health care industry. What should the nurse identify as factors that have an effect on health care delivery?Select all that apply. 1. Increased use of complementary and alternative medicine 2. More knowledgeable consumers 3. Increase in the number of elderly 4. Decrease in chronic disease 5. Technological advances 6. Economics

2. More knowledgeable consumers 3. Increase in the number of elderly 5. Technological advances 6. Economics

A nurse working on an Alzheimers unit notes that just before the supper hour, many of the residents become more anxious and confusedexhibiting typical sundowners syndromemaking the evening meal an unpleasant ordeal. As a method to try to decrease their turmoil during this time, which therapy should the nurse introduce into the daily routine? 1. Biofeedback 2. Music therapy 3. Pilates 4. Spiritual therapy

2. Music therapy

The nurse notes that a client has the outcome goal Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which client statement should the nurse use to evaluate this goal? 1. Im getting really sleepy from that medication. I think Ill take a nap. 2. My pain is a 4. 3. I still have some pain. 4. Will the pain ever go away?

2. My pain is a 4.

The nurse educator develops the research question Do students who study in groups score better on the NCLEX exam when compared to students who study independently? Which phrase should the educator identify as the dependent variable? 1. Number of students in a study group 2. NCLEX scores of both groups 3. Students college GPAs 4. Time between graduation and sitting for the NCLEX

2. NCLEX scores of both groups

The nurse manager determines that a staff nurse demonstrates understanding of the professional responsibility to advocate for a clients health, safety, and rights. What did the manager observe to come to this conclusion about the staff nurse? Standard Text: Select all that apply. 1. Reporting a medication error that he was responsible for making 2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol 3. Being sure the computer screen is not visible to visitors when charting 4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant 5. Calling the health care provider to clarify a confusing prescription for a clients pain

2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol 3. Being sure the computer screen is not visible to visitors when charting 4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant 5. Calling the health care provider to clarify a confusing prescription for a clients pain

A client has been receiving home care for several weeks. Which individual should the nurse realize is responsible for ensuring that the client is receiving care at the appropriate times and in the appropriate amounts? 1. Client 2. Nurse 3. Physician 4. Clients spouse

2. Nurse

A home health client has a complicated case involving occupational therapy, respiratory therapy, a dietitian, the nurse, and a nurses aide who provides assistance with bathing, housekeeping, and grocery shopping. Which care provider should be prepared to coordinate this clients care? 1. Physician 2. Nurse 3. Social worker 4. Home health agency

2. Nurse

The nurse has been working with a family at the community health office and is concerned about signs of family violence. Which finding should the nurse identify as most concerning? 1. The baby always seems to have a cold. 2. One of the children never speaks and seems on guard when in the presence of a parent. 3. The familys clothes are relatively clean, but the children usually have some kind of dirt stain on their shirts or pants. 4. The family does not have a regular physician

2. One of the children never speaks and seems on guard when in the presence of a parent

During a particularly heated staff meeting regarding staff assignments, the nurse manager makes this comment: When you all can come to a decision, let me know and well move on from there. This leader is best identified as which of the following? 1. Democratic leader 2. Permissive leader 3. Bureaucratic leader 4. Situational leader

2. Permissive leader

The nurse is observing a group of young adults engaged in a discussion regarding work schedules over the holidays. What should the nurse realize that these adults will use to balance the emotional as well as logical side of the discussion? 1. Formal operational stage 2. Postformal thought process 3. Kohlbergs theory of moral development 4. Fowlers spiritual development theory

2. Postformal thought process

A home health nurse has a weekly visit to a client living in less than desirable cleanliness. The client has a central venous access device and requires weekly infusion therapy. What is the best way for the nurse to protect the client against infection? 1. Have the client wash her hands before the infusion begins. 2. Practice strict aseptic technique during the infusion process. 3. Help the client clean the room before starting the infusion. 4. Suggest that the client have a housekeeper come on the morning of the infusion.

2. Practice strict aseptic technique during the infusion process.

A parent reports to the nurse that his child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase? 1. Intuitive thought phase 2. Preconceptual phase 3. Concrete operations phase 4. Formal operations phase

2. Preconceptual phase

A group of nursing students is helping to set up an immunization clinic. In which level of prevention are these students functioning? 1. Educational 2. Primary 3. Secondary 4. Tertiary

2. Primary

The nurse is caring for several acutely ill patients. What nursing action demonstrates professional autonomy? 1. Delivering medications and prescribed treatments in a timely manner 2. Prioritizing client according to client needs 3. Communicating with peers when help is needed 4. Informing the supervisor about high acuity level and staff-to-client ratio

2. Prioritizing client according to client needs

A client has specific cultural needs that affect the plan of care. In which part of the clients problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

2. Problem list

A nurse needs to evaluate the effectiveness of a teaching session with a client. Which approach would provide the best feedback? 1. Client communication 2. Process recording 3. Therapeutic communication 4. Verbal communication

2. Process recording

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan 2. Protocol 3. Standards of care 4. Policy and procedure manual

2. Protocol

A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Blooms domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation

2. Psychomotor

While evaluating how care is delivered at various hospitals, the nurse identifies a facility where caring in the emergency department is perceived differently than caring in the rehabilitation unit. Whose theory of caring is the nurse observing in action? 1. Leininger 2. Ray 3. Roach 4. Boykin and Schoenhofer

2. Ray

An adult client who cannot read needs surgery and is competent to make his own decisions. What is the best action that the nurse should take? 1. Tell the client in the nurses own words what the surgical procedure involves. 2. Read the consent form to the client and have the client state understanding. 3. Make sure the physician explains the procedure to the client. 4. Have a family member who can read sign the consent form.

2. Read the consent form to the client and have the client state understanding.

The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions

2. Reassessing the client 4. Supervising delegated care 5. Implementing the nursing interventions

A home health client lives alone in a small apartment and has only one phone, which is a land line. What safety recommendation should the visiting home health nurse make for this particular client? 1. Suggest that the client move to a nursing home or assisted living dwelling. 2. Recommend that the client be enrolled in an emergency response system. 3. Enroll the client in a program that places all of the clients vital medical information in one place for emergency personnel. 4. Have the client post a list of emergency numbers (fire, police, ambulance) near the phone.

2. Recommend that the client be enrolled in an emergency response system.

A nurse is caring for a client in the emergency department (ED) who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the clients back and arms. When questioned, the client is distracted and ambiguous with her answers. Which action should the nurse take? 1. Report the situation to law enforcement. 2. Report the situation to social services. 3. Question the adult child who brought the client to the ED. 4. File a written report in the clients chart.

2. Report the situation to social services.

The nursing student completes a literature review on evidence-based practice (EBP). Which action indicates that the student understands EBP? 1. Presenting a paper about EBP 2. Repositioning a client at risk for skin breakdown every 2 hours 3. Explaining EBP to fellow students 4. Trying to find other problems to implement EBP

2. Repositioning a client at risk for skin breakdown every 2 hours

The nurse researcher is considering whether the findings of a project may present uncertain results in the clinical area. Upon which criteria is the researcher reflecting? 1. Significance 2. Researchability 3. Confidentiality 4. Variables

2. Researchability

Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents decision? 1. Showing respect for the family 2. Respecting the parents decision 3. Referring the parents to social services 4. Asking to be assigned to a different client

2. Respecting the parents decision

A nursing instructor is researching the implementation of assigning study guides for homework points and the effect this has on the students test grades. The instructor reports group data for published research. Which research right did the instructor implement? 1. Right of full disclosure 2. Right of privacy 3. Right of self-determination 4. Risk of harm

2. Right of privacy

The nurse educator provides developmental testing for kindergarten through third grade students. Which level of prevention is the nurse performing? 1. Primary 2. Secondary 3. Tertiary 4. Community

2. Secondary

A client with unstable cardiac dysrhythmias has orders for medications, one of which is by oral route, the other by IV delivery. The nurse realizes that the IV route would be fastest, but is also concerned about the side effects that this drug may produce and the fact that the client has never taken the drug, so any adverse effect is unknown. Which part of the decision-making process is the nurse using? 1. Identify the purpose 2. Seek alternatives 3. Project 4. Implement

2. Seek alternatives

A group of community health nurses work together in the same office. They are each responsible for their own caseloads and scheduling of appointments. Their major leadership directives come from the state health office, several hundred miles away. This group of nurses is functioning under what type of leadership? 1. Charismatic 2. Shared 3. Transformational 4. Transactional

2. Shared

A client is attending classes on building positive relationships with significant others as well as learning skills to be open-minded and respectful to those whose opinions are different. The nurse realizes that this client is focusing on which component of wellness? 1. Physical 2. Social 3. Emotional 4. Environment

2. Social

A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated? 1. Management 2. Structure 3. Process 4. Outcome

2. Structure

The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? Select all that apply. 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome

2. Structure 4. Process 5. Outcome

Several nurses have been assigned to develop a rotation schedule that provides adequate staffing of all shifts. In which type of group are these nurses functioning? 1. Self-help group 2. Task group 3. Teaching group 4. Therapy group

2. Task group

The nurse is planning client care while keeping in mind Orems self-care deficit theory. Which methods of helping should the nurse include when determining the best care for the client? Standard Text: Select all that apply. 1. Balancing rest 2. Teaching 3. Supporting 4. Guiding 5. Preventing hazards to life

2. Teaching 3. Supporting 4. Guiding 5. Preventing hazards to life

The nurse notes that a 20-month-old child is lagging in stage 6 of Piagets phases of cognitive development. Which activity did the nurse observe that indicates that this child is struggling at this stage? 1. The child wants the same toy to sleep with during naptime and bedtime. 2. The child merely watches as the other children pretend-play. 3. The child cries when the parents leave the unit. 4. The child does not cooperate with some of the treatments.

2. The child merely watches as the other children pretend-play.

A community health nurse is doing a screening for cervical cancer at a womens health fair. Which client should the nurse identify as having the highest risk factor for cervical cancer? 1. The client who had a difficult vaginal delivery 2 years ago 2. The client who has a history of genital herpes 3. The client who was married at age 27 4. The client who has a sister with breast cancer

2. The client who has a history of genital herpes

The nurse is planning to provide care according to Leiningers theory of culturally congruent care. What should the nurse include when providing care to the client? Select all that apply. 1. Care should be influenced by the organizational structure. 2. The clients familiar lifeways are preserved. 3. Accommodations should be satisfying to clients. 4. Nursing care must be repatterned to help the client move toward wellness. 5. Care should be structured to fit the nurses needs

2. The clients familiar lifeways are preserved. 3. Accommodations should be satisfying to clients. 4. Nursing care must be repatterned to help the client move toward wellness.

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care? 1. The clients eyes are closed. 2. The clients skin is pale and mottled. 3. The clients spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up.

2. The clients skin is pale and mottled.

During orientation with a home care agency, the nurse is learning the difference in care delivery between home health nursing and community nursing. What should the nurse understand as being the focus of home health care nursing? 1. Individuals, families, and groups 2. The individual and his or her family 3. The terminally ill client and his or her family 4. The client in a home setting

2. The individual and his or her family

The nurse manager learns that vital signs delegated to unlicensed assistive personnel (UAP) were not recorded accurately. With which care provider should the manager discuss this finding? 1. The UAP 2. The nurse 3. Both the UAP and the nurse 4. The team leader

2. The nurse

The nurse educator is reviewing concerns about the use of research for evidence-based practice. What particular concerns should the nurse highlight when discussing the use of research with the students? Standard Text: Select all that apply. 1. When evidence-based practice is done appropriately, the process often becomes cost-prohibitive. 2. The research environment results in strictly constructed and controlled circumstances. 3. There is a best solution or practice for any specific research question. 4. Evidence-based practice is most applicable to physiological problems. 5. Research evidence can be flawed when applied to various cultures and ethnic groups.

2. The research environment results in strictly constructed and controlled circumstances. 3. There is a best solution or practice for any specific research question. 4. Evidence-based practice is most applicable to physiological problems. 5. Research evidence can be flawed when applied to various cultures and ethnic groups.

The nurse is concerned that the spouse of a home care client with multiple sclerosis is experiencing caregiver role strain. What did the nurse observe to come to this conclusion? Select all that apply. 1. The home appears cluttered. 2. The spouse expresses feelings of anger. 3. The spouse reports decreased energy. 4. The spouse reports that she is learning how to manage finances. 5. The client asks when the nurse will return for the next visit.

2. The spouse expresses feelings of anger. 3. The spouse reports decreased energy.

A client comes to the clinic with a chief complaint of feeling dirty inside and asks the nurse how colonics would work to improve the clients overall well-being. What should the nurse respond to this client? 1. Colonics is a dangerous and not useful technique that no one should try. 2. There is much controversy about colonics. What do you know about it? 3. This is a good way to get rid of toxins in your system. 4. Youd better ask your doctor about this.

2. There is much controversy about colonics. What do you know about it?

The nurse learns that two new home care agencies are opening in a community. What should the nurse consider as reasons why home care agencies are increasing in numbers? Select All That Apply: 1. The need for custodial care 2. Third-party payers who support cost control measures 3. The increase in the older adult population 4. The decreasing need for acute care 5. The focus on the needs of the community

2. Third-party payers who support cost control measures 3. The increase in the older adult population

The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care? Standard Text: Select all that apply. 1. To make sure all clients have the same type of care 2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurses time 4. To eliminate care disparities among clients 5. To minimize health care costs

2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurses time

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures.

2. Use the translation services supplied by the hospital.

A pregnant client says her main concern is that her baby will be born healthy, even though she admits to drinking alcohol on a regular basis. With what should the nurse realize this client is struggling? 1. Values transmission 2. Values clarification 3. Morals 4. Ethics

2. Values clarification

After communicating with the client and family, the nurse compares a clients problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns

2. Verifying

A client with an acute, serious illness has been hospitalized. Upon entering the room, the nurse observes the client praying. The client states to the nurse: I dont know how people manage to get through difficult times without their faith. Its where I get my strength. With which theorist should the nurse associate this clients belief? 1. Fowler 2. Westerhoff 3. Gilligan 4. Kohlberg

2. Westerhoff

A nursing student is assigned to develop a research question using a quantitative approach. Which question should the student write that demonstrates this approach? 1. How do siblings react to a new baby of a second marriage after divorce of their parents? 2. What dressing selections work best for a wound dehiscence? 3. What support do terminal cancer clients find least beneficial in hospice care? 4. Does expression of client spirituality affect recovery time?

2. What dressing selections work best for a wound dehiscence?

During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client? 1. Its OK to be worried. Surgery is a big step. 2. What kind of questions do you have about your surgery? 3. I think these are things you should be asking your doctor. 4. Have you had surgery before?

2. What kind of questions do you have about your surgery?

An older client being discharged from an acute care facility is prescribed home care. When should the home care nurse see the client to understand needs for safety and mobility? 1. At the initial home visit, in order to see the client in the home environment 2. While the client is still a patient in the acute care hospital 3. After the client has been home for a few days and can help the nurse decide what is needed 4. When the spouse is available to assist in the assessment

2. While the client is still a patient in the acute care hospital

The nurse is attending a seminar that focuses on the changes within the home health care industry. Which statements that the nurse makes indicate an understanding of home care as a primary health service delivery system?Select all that apply. 1. Its unfortunate that clients can be screened for illnesses in the privacy of their own home. 2. With people living well into their 70s and 80s, the healthcare system is being stressed immensely. 3. The cost of acute hospital-based health care has become an economic burden to most people. 4. A clients chronic cardiac problems can be monitored well with in-home health services. 5. It relieves so much stress when care can come to them instead of their going to the health provider.

2. With people living well into their 70s and 80s, the healthcare system is being stressed immensely. 3. The cost of acute hospital-based health care has become an economic burden to most people. 4. A clients chronic cardiac problems can be monitored well with in-home health services. 5. It relieves so much stress when care can come to them instead of their going to the health provider.

The nurse can identify movement into Kohlbergs postconventional level when the client, after being asked about work, makes which statement? 1. Oh, the work isnt so bad anymore. Im getting close to retirement. 2. Work is fine, but my family and friends are so much more important to me. 3. Ive done a good job for the company. Im proud of my years there. 4. I dont like to talk about work when Im not there.

2. Work is fine, but my family and friends are so much more important to me.

At the end of a busy clinical day a staff nurse asks the instructor if a student would like to administer a Z-track injected medication. This is a skill that the students have not yet been exposed to yet. What should the instructor respond to the staff nurse that supports timing and learning environment? 1. It will take me a moment to explain the procedure to the students because weve not practiced this, but Ill find somebody to administer it. 2. Would it be OK if the students observed today? Then, well do it next time were here. 3. Were leaving now, but thanks for asking. 4. Ill check with the students and see if one of them would like to volunteer.

2. Would it be OK if the students observed today? Then, well do it next time were here.

Parents of a newborn ask the nurse why their newborns head seems lopsided and not round, as they thought it should be. How should the nurse respond to these parents? 1. I dont think it looks unusual; actually the head is beautifully shaped. 2. Your babys head had to shape itself to the birth canal. It will look round in a few days. 3. Youre right. Well make sure your doctor checks this out. 4. Babies heads always look funny. Once his hair grows out, youll hardly notice it.

2. Your babys head had to shape itself to the birth canal. It will look round in a few days.

A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The clients spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? 1. I know youre worried about your loved one. Im sure this is a difficult situation for you. Do you have any questions right now? 2. Your spouses heart stopped. All these people are here to help get it started. 3. Your spouses physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now. 4. Is there someone you would like to call? Im sure this is a scary situation and you may feel more comfortable if someone were with you during this time.

2. Your spouses heart stopped. All these people are here to help get it started.

A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should 1. provide written instructions before discharge. 2. address any healing beliefs the family has. 3. make sure the child comes back for the follow-up appointment. 4. make sure the parents can set up the treatments for their child.

2. address any healing beliefs the family has.

A hospitalized older client is recovering from an acute illness. As the client nears the end of his hospitalization, he questions the nurse about medications and care after discharge. The gerontological nurse should 1. inform the physician that the client needs to go to a nursing home. 2. assess the clients independence and ability to function in his own home before discharge. 3. tell the client not to worry about going home. 4. invite the clients family to come to the hospital so the nurse can explain the clients care to them.

2. assess the clients independence and ability to function in his own home before discharge.

A nurse who works in a long-term care facility has noticed that one of the residents has been showing signs of impaired cognitive and selfcare abilities over the last 2 weeks. The nurse should 1. remember that memory loss is a normal, age-related change. 2. investigate for possible physiologic problems. 3. instruct the staff to be extra attentive, as this person needs more assistance. 4. inform the residents family that the resident probably has some form of dementia.

2. investigate for possible physiologic problems.

The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information? 1. Vygotsky 2. Skinner 3. Kohlberg 4. Piaget

3. Kohlberg

The nurse is concerned that the hospital will not receive payment for care provided to a client. Which client health problems are causing the nurse this concern? Select all that apply. 1. Intravenous fluids were prescribed for 4 days. 2. X-rays of the left leg and left arm were prescribed. 3. A stage II pressure ulcer developed on the clients heels. 4. A urinary tract infection occurred because of an indwelling urinary catheter. 5. Physical therapy treatments were prescribed for 7 days for crutch walking.

3. A stage II pressure ulcer developed on the clients heels. 4. A urinary tract infection occurred because of an indwelling urinary catheter.

The nurse is applying Neumans systems model during client care. Which response should the nurse identify as an intrapersonal stressor to a client? 1. Inadequate health insurance coverage 2. Family members who quarrel frequently about the clients care 3. Adverse reaction to medication 4. Expectations regarding rehab

3. Adverse reaction to medication

The pediatric nurse implements Watsons assumption regarding a caring environment. Which action did the nurse take to implement this assumption? 1. Providing for all needs and cares of the nurses clients 2. Ensuring that a zone of professionalism is present between the nurse and client 3. Allowing the clients to have choices, as appropriate, in their care 4. Selecting games and activities that are age appropriate for the clients

3. Allowing the clients to have choices, as appropriate, in their care

The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement risk management? Arrange the choices in order. Choice 1. Analyzing, classifying, and prioritizing risks Choice 2. Evaluating and modifying risk reduction programs Choice 3. Anticipating and seeking sources of risk Choice 4. Developing a plan to avoid and manage risk Choice 5. Gathering data that indicate success at avoiding or minimizing risk

3. Anticipating and seeking sources of risk 1. Analyzing, classifying, and prioritizing risks 4. Developing a plan to avoid and manage risk 5. Gathering data that indicate success at avoiding or minimizing risk 2. Evaluating and modifying risk reduction programs

A student is attending a school with a high first-time pass rate on the NCLEX. Which student statement articulates a belief that the nursing student has about faculty in the program? 1. Expect high academic standards from their students 2. Are concerned with job placement of their graduates 3. Are most concerned with the successful licensure of each student 4. Work hard to make sure students are successful

3. Are most concerned with the successful licensure of each student

The client asks whether herbal medicines are a good idea. What should the nurse respond? 1. Things found in nature are always healthy. 2. If your doctor didn't prescribe it, don't take it. 3. Are there specific ones you're wondering about? 4. Everything is good in moderation.

3. Are there specific ones you're wondering about?

A client being discharged from an acute care hospital requires IV antibiotics, is not able to complete activities of daily living without assistance, and has no family available to assist in the recovery phase. Which type of recommendation should the nurse make for this client? 1. Stay in the hospital until the client is fully capable of self-care. 2. Remain in the hospital until the antibiotic course is completed. 3. Be discharged to an extended care facility. 4. Go to a nursing home.

3. Be discharged to an extended care facility.

A faculty member is speaking to prospective students interested in enrolling in the BSN program at the university. What should the faculty member emphasize as a major incentive for students to select a BSN program over an ADN program? 1. Ability to work in critical care areas 2. Easier transition to graduate school 3. Better opportunity for career advancement 4. Liberal arts education

3. Better opportunity for career advancement

A group of nurses is researching how care providers of Stage I/II Alzheimers clients use prior coping skills in dealing with their current situation. Which qualitative research tradition are these nurses using? 1. Grounded theory 2. Ethnography 3. Phenomenology 4. Substantive dimension

3. Phenomenology

A nurse educator is teaching students about the philosophy of caring in nursing and states that nurses can only be truly caring if they are true to themselves first. This action then emphasizes the importance of nurses knowing themselves, which brings about a process that allows the nurse to be with another person. Whose theory is the educator using to teach the concept of caring? 1. Roach 2. Ray 3. Boykin and Schoenhofer 4. Watson

3. Boykin and Schoenhofer

A client tells the nurse about research information on the Internet to learn more about a new health problem. What should the nurse respond to this client? 1. Information from the Internet isnt always accurate. 2. Its best to check this information with your physician. 3. Bring your information to the clinic so we can go through it together. 4. Id prefer you rely on information you havent received from our office.

3. Bring your information to the clinic so we can go through it together.

A small nursing program has limited access to clinical sites, especially those with specialty areas. What should the nurse educators consider as an option to allow students hands-on simulated clinical experience in these areas? 1. A field trip to a larger nursing institution 2. Videos 3. CAI 4. Workbook with written study guides

3. CAI

A seasoned nurse is a mentor for a new graduate. Which of the standards of professional performance is the seasoned nurse practicing? 1. Collaboration 2. Leadership 3. Collegiality 4. Evaluation

3. Collegiality

The nurse suspects that an adolescent is working through the stages of spiritual development. What observations did the nurse make to come to this conclusion? Standard Text: Select all that apply. 1. Imitated behavior demonstrated by parents 2. Conceptualized angels and devils with the use of imagination 3. Compartmentalized differences between spiritual beliefs with friends 4. Determined differences between spiritual beliefs as being right or wrong 5. Met with the church priest to talk about the differences in spiritual beliefs

3. Compartmentalized differences between spiritual beliefs with friends 4. Determined differences between spiritual beliefs as being right or wrong 5. Met with the church priest to talk about the differences in spiritual beliefs

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the clients lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily.

3. Consult other professionals and colleagues.

Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying? 1. Termination stage 2. Preparation stage 3. Contemplation stage 4. Action stage

3. Contemplation stage

Before applying for re-licensure, the nurse attends continuing education programs. Which action is the nurse performing to adhere to the state board of nursing expectation? 1. Licensure 2. Competency 3. Credentialing 4. Certification

3. Credentialing

A nurse practitioner feels it is important to participate in nursing research. Which activity is most appropriate for this nurses level of education and position? 1. Helping to identify clinical problems in direct client care 2. Using research findings to develop policies and procedures 3. Critically analyzing and interpreting research for application to practice 4. Participating in data collection

3. Critically analyzing and interpreting research for application to practice

The nurse questions the practice of administering rectal suppositories to residents in a long-term care facility at bedtime, rather than earlier in the day. When told that this is the best time for staff and thats the routine that has been practiced for a long time, the nurse continues to research whether there would be a better time, especially in the best interest of the residents. Which critical thinking attitude is this nurse demonstrating? 1. Confidence 2. Perseverance 3. Curiosity 4. Integrity

3. Curiosity

A nurse educator has taught the same courses for the past 5 years and each year implements a few minor changes. Over this time, the educator has stored the grade data, including homework and assignment scores, in order to track trends following the implemented changes. What is the educator using to maintain this information? 1. Informatics 2. Student record management 3. Data warehousing 4. Management information system (MIS)

3. Data warehousing

A client has been diagnosed with dementia. The family wants to know how to plan for the future. What is the best response by the nurse? 1. Your family members symptoms will get worse, but there are medications to stop the progress. 2. You should plan right now on which long-term care facility you will want to utilize when the time comes. 3. Dementia is a progressive deterioration. Its important for you to clearly understand what to look for in symptoms. 4. Dementia can be treated once the cause is known.

3. Dementia is a progressive deterioration. Its important for you to clearly understand what to look for in symptoms.

A new graduate nurse is looking for employment and is hoping to find a facility that utilizes nursing personnel based on their educational preparation and skill set. In which type of facility should the new graduate apply for a position? 1. Patient-focused care 2. Shared governance 3. Differentiated practice 4. Managed care

3. Differentiated practice

A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information? 1. Past statistics about organ donors 2. Written pamphlets 3. Directions about how to become an organ donor 4. Information on how this group can influence their children

3. Directions about how to become an organ donor

A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with staff and reads the medical record. The nurse realizes that the attorney is performing which activity? 1. Burden of proof 2. Complaint 3. Discovery 4. Civil action

3. Discovery

The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurses efficiency. 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next clients medications and treatments.

3. Document all care in the progress notes.

A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back is to the rest of the room so as not to be heard by passersby.

3. Draw curtains around the client and nurse to provide as much privacy as possible.

During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse hooks the client to the medication infusion. Which role is the nurse performing at this time? 1. Caregiver 2. Advocate 3. Educator 4. Coordinator

3. Educator

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this clients care? 1. The admitting nurse 2. All nurses who work with the client 3. Everybody involved in this clients care 4. The client and the clients support system

3. Everybody involved in this clients care

During a hospital stay, the client has taken control of her recovery and rehabilitation and is utilizing available resources for her needs. In which level of Peplaus model should the nurse determine that this patient is functioning? 1. Orientation 2. Identification 3. Exploitation 4. Resolution

3. Exploitation

While the nurse is teaching a group of parents and their teenage sons about puberty and sexual growth, a parent asks if fertility coincides with ejaculation. What should the nurse respond to this question? 1. Yes, if your son is ejaculating, he also possesses fertility. 2. Sexual maturity does not occur until age 18, so dont worry about anything until then. 3. Fertility follows several months after the first ejaculation. 4. Youll have to ask your physician about this because it is a sensitive subject.

3. Fertility follows several months after the first ejaculation.

A charge nurses responsibilities include the day-to-day management and coordination of therapies for the clients, client assignments, and scheduling. Which type of management is the charge nurse performing? 1. Top level 2. Middle level 3. First level 4. Upper level

3. First level

A client has the goal statement Client will be able to state two positive aspects of rehab therapy by the end of the week. What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by weeks end. 4. Goal incomplete, client not able to positively state anything about rehab.

3. Goal met, client able to state two positive aspects of therapy by weeks end.

The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan

3. Goal statement of the traditional care plan

A client is brought to the emergency department after being involved in a motor vehicle crash. Although the client is conscious, her condition is critical and will require emergency surgery. The client does not speak English. Which action should the nurse take? 1. Read the consent form and have the client sign it anyway. 2. Explain the form to the best of the nurses ability using pictures and gestures. 3. Have the hospital interpreter explain the procedure. 4. Proceed with surgery, as implied consent would be the case in this situation.

3. Have the hospital interpreter explain the procedure.

A client comes to the clinic with a history of pain in his testicle. During the interview assessment, what information should be of concern to the nurse? 1. The client works as an auto-detailer. 2. He smokes half a pack of cigarettes per week. 3. He has not had a yearly exam for 5 years. 4. He does not perform testicular self-exams.

3. He has not had a yearly exam for 5 years.

After implementing health promotion activities and plans to prioritize health problems, the community must evaluate the effectiveness of the interventions. Which groups should be involved in this process? 1. Health care providers at the community level 2. Hospital and clinic personnel who administered health care needs 3. Health care providers, consumers, community leaders, and politicians 4. Those consumers who were directly affected by the services provided

3. Health care providers, consumers, community leaders, and politicians

A new nurse has just started work on an oncology unit. One of the clients has decided to discontinue treatment, even though he understands that his life will be shortened extensively if he does. The nurse is having difficulty with this situation and decides to approach a seasoned nurse for insight and a way to help support this particular client. The nurse is exemplifying which aspect of caring? 1. Hope 2. Humility 3. Honesty 4. Patience

3. Honesty

A client with terminal cancer is refusing food and fluids, and pushes the caregivers hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is starving to death. What should the nurse do? 1. Honor the familys wishes and have them sign a consent form. 2. Talk to the physician so he or she can move forward with the familys wishes. 3. Honor the clients refusal and help the family come to terms with the situation. 4. Take the case to the hospitals ethics committee.

3. Honor the clients refusal and help the family come to terms with the situation.

The nurse is assessing a clients level of pain. Which open-ended question should the nurse use for this situation? 1. Is your pain worse at night? 2. What brought you to the clinic? 3. How has the pain impacted your life? 4. Youre feeling down about having pain, arent you?

3. How has the pain impacted your life?

The graduate nurse learns of failing the NCLEX-RN examination but realizes that passing the examination is a challenge worth achieving. To improve her outlook, the graduate nurse writes positive affirmations that are reviewed daily before studying for the examination. Which affirmations would be the most beneficial for the graduate nurse to use? Standard Text: Select all that apply. 1. I will focus on a new career. 2. I should have studied harder . 3. I am doing what brings me joy. 4. This is an opportunity to grow. 5. I cannot remember everything.

3. I am doing what brings me joy. 4. This is an opportunity to grow.

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients.

3. Identify client needs and deliver care to meet those needs.

When a client who had a stroke gives up all hope of any amount of recovery, the nurse solicits a visit from a former stroke client who has physical limitations but has since gone back to work and, through adaptation, can function independently at home. This nurse has fulfilled which role, according to Parse? 1. Mobilizing transcendence 2. Synchronizing rhythm 3. Illuminating meaning 4. True presence

3. Illuminating meaning

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

3. Implementation

The client presents her hand when the nurse makes this statement: I need to start an IV so you can get your antibiotics. Which behavior did the client demonstrate? 1. Informed consent 2. Express consent 3. Implied consent 4. Compliance

3. Implied consent

A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In describing Healthy People 2010, which goal should the nurse emphasize for this group? 1. Eliminating health disparities 2. Believing that individual health is closely related to community health 3. Increasing quality and years of life 4. Developing partnerships between individual and community health

3. Increasing quality and years of life

The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth

3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment

3. Inference

The nurse is considering a position with a home health agency. What type of care should the nurse realize will be provided when working for this type of agency? Select all that apply. 1. Providing ventilatory support 2. Completing a health and wellness visit 3. Instructing about care of a surgical wound 4. Providing intravenous antibiotics once a day 5. Teaching about medications for self-management of diabetes

3. Instructing about care of a surgical wound 4. Providing intravenous antibiotics once a day 5. Teaching about medications for self-management of diabetes

A nurse is working with a particular cultural group in which it is not uncommon for grandparents to live with their married children and to assist with childrearing and discipline issues. For which type of family should the nurse plan care for these clients? 1. Two-career family 2. Blended family 3. Intragenerational family 4. Traditional family

3. Intragenerational family

A young female client comes into the emergency department with vague physical symptoms and does not make eye contact with the nurse during the interview. In order to best assess the client, what should the nurse ask the client? 1. Can you tell me whats been going on in your life lately? 2. What kind of problems are you having? 3. Is someone hurting you? 4. Can you explain what your family life is like?

3. Is someone hurting you?

A nurse is presenting a health education program to a group of older adults at a senior citizens center. Considering the physiological changes of this age group, how should the nurse set the temperature of the room? 1. It should be set at a temperature that is comfortable for the nurse. 2. It should be set cooler than what is comfortable for the nurse. 3. It should be set warmer than the nurses preference. 4. The temperature of the room is not one of the nurses concerns.

3. It should be set warmer than the nurses preference.

The nurse implements being authentically present to clients by supporting them in their beliefs and helping to instill hopefulness in their recovery. Which theorist is the nurse using when performing these actions? 1. Florence Nightingale 2. Hildegard Peplau 3. Jean Watson 4. Rosemarie Parse

3. Jean Watson

The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowlers position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat.

3. Keep client in low-Fowlers position to prevent reflux.

A toddler shows fear and begins to cry when her parent leaves her at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting? 1. Building wholesome attitudes toward oneself 2. Learning to get along with age-mates 3. Learning to relate emotionally 4. Achieving personal independence

3. Learning to relate emotionally

The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant? 1. Telling the parents everything the nurse is doing and why 2. Letting the parents watch a video after the bath 3. Letting the parents bathe the baby with direction and guidance from the nurse 4. Giving lots of advice and suggestions about different methods

3. Letting the parents bathe the baby with direction and guidance from the nurse

The nurse documents in a clients medical record: The client is a drug addict and is always asking for more medication than what is necessary. With what might the nurse be charged? 1. Defamation 2. Slander 3. Libel 4. Incompetence

3. Libel

A client in the ambulatory clinic asks if there are any community programs to help with health and wellness issues. What should the nurse access to locate these types of activities? 1. Online computer services 2. Recreational directors 3. Local newspapers 4. Telephone book

3. Local newspapers

A client complaining of shortness of breath has no pallor, cyanosis, or use of accessory muscles with respirations. The clients respiratory rate is 16 breaths per minute. The nurse is concerned that the clients report and the physical findings conflict. Which standard of critical thinking is the nurse using? 1. Clarity 2. Accuracy 3. Logical reasoning 4. Significance

3. Logical reasoning

A nurse is teaching a class to new parents on how to handle some of the behaviors that could be demonstrated by toddlers. One of the parents asks what to do when her child throws a temper tantrum. How should the nurse respond to this parent? 1. Try to be more attentive to the behaviors that lead into a tantrum. Then you can avoid them. 2. Put the child in a room alone and ignore the tantrum. 3. Make sure the child is safe, then walk away. 4. Hold the child tightly until he stops crying.

3. Make sure the child is safe, then walk away.

A gerontological nurse is helping a potential home health client acquire the supplies that will be needed once the client is discharged from acute care. When considering these supplies, what should the nurse recall? 1. Medicare will cover supplies, but only with a physicians written order. 2. Between insurance supplements and Medicare, the older client shouldnt have any difficulty with coverage. 3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible. 4. Clients have to be responsible for their own supplies.

3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible.

The parents of a toddler are concerned that their child is so messy during eating, so they feed him instead of allowing him to feed himself. What should the nurse respond to the parents? 1. Thats probably best. Im sure it makes your mealtime more pleasant. 2. At least youre sharing meals as a family. Thats the most important. 3. Motor skills keep improving with age. Try not to get frustrated with the mess. 4. Your child will never learn if you dont let him experience.

3. Motor skills keep improving with age. Try not to get frustrated with the mess.

A 68yearold client is concerned about paying for extended hospitalization and expensive medications to treat his health problem. What should the nurse respond to this client? 1. Dont worry. Im sure everything will work out OK. 2. You need to focus on recovering, not worrying about finances. 3. Much of your care will be covered by Medicare. 4. Ill have someone from the business office come and talk to you about your bill.

3. Much of your care will be covered by Medicare.

The nurse makes chronological entries in a clients chart that include documentation about the routine care provided, assessment findings, and client problems during a 12hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care

3. Narrative charting

The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial to the client? 1. You know, there are children who can learn to do this. 2. Maybe it would be better if we taught your spouse to help you with this. 3. Next time, dart the needle in your skin, instead of pushing it in. 4. If you dont learn this, you cant be discharged.

3. Next time, dart the needle in your skin, instead of pushing it in.

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis

3. Nursing care focus

Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data

3. Objective data

A nurse is working with a group of clients in a community center, all over the age of 85. How should the nurse classify this group of clients? 1. Young-old 2. Middle-old 3. Old-old 4. Elite-old

3. Old-old

While caring for a client of a different culture, the nurse becomes disturbed when the clients spouse makes all the decisions about care and treatments. What behavior is this nurse demonstrating? 1. Inference 2. Judgment 3. Opinion 4. Evaluation

3. Opinion

The nurse is preparing to instruct a client about nutritional needs before and during pregnancy. What should the nurse encourage the patient to consume in order to meet the requirements for folic acid? 1. Meats, fish, and poultry 2. A mix of vegetables and fiber 3. Oranges and green leafy vegetables 4. Lowfat and highprotein foods

3. Oranges and green leafy vegetables

The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childs birth 2. Grandmother 3. Parents 4. Admitting physician

3. Parents

The manager of a small clinic has cross-trained the nurses to provide basic nursing care, and perform ECG testing, phlebotomy, and some respiratory therapy interventions. Which type of care delivery model has the manager implemented? 1. Managed care 2. Case management 3. Patient-focused care 4. Critical pathways

3. Patient-focused care

The nurse is providing assistance at a community health fair for middle-aged clients. Which information should the nurse use when working with this group of clients? 1. The middle-aged person has decreased intellectual and cognitive abilities as a result of the normal aging process. 2. Adults make the transition into this stage easily and without problems. 3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life. 4. Cognitive and intellectual abilities are somewhat decreased due to slower reaction time, loss of memory, and changes in perception and problem solving.

3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life.

The nurse is reviewing a clients chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

3. Plan of care

A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on self-administration. What is the best way for the nurse to assist this client? 1. Teach the spouse to draw up the medication, then the client can give the injection. 2. Make sure that the injection is scheduled during a visit, so the nurse can supervise. 3. Prefill syringes with the correct dose, so the client can use them for self-administration. 4. Schedule the clients clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic.

3. Prefill syringes with the correct dose, so the client can use them for self-administration.

The nurse is providing care within the total care context. What should the nurse consider when using this care approach? 1. The individualism of the client 2. Principles applicable to the client at this moment 3. Principles general to all clients of the same age and condition 4. The persons self-identity

3. Principles general to all clients of the same age and condition

A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus? 1. Competency 2. Structure 3. Process 4. Outcome

3. Process

A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily.

3. Provide ongoing assessment for skin breakdown every shift.

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed, but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed. 3. Recorder responded to clients call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

3. Recorder responded to clients call light, upon entering the room, found client on floor.

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. Confidentiality and privacy laws dont apply to students. 2. Most students review so many records and charts that they could not possibly remember details from any one of them. 3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence. 4. As long as the clinical instructor is in the area, accessing client records is part of the education process.

3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence.

A client asks the nurse about chiropractic medicine. What should the nurse explain as being among the goals of this type of health intervention? Select all that apply. 1. Improvement of blood and lymph flow through the body 2. Stimulation of specific points to help with pain relief, cures certain illnesses, and promote wellness 3. Reduce or eliminate pain 4. Correct spinal dysfunction 5. Preventive maintenance

3. Reduce or eliminate pain 4. Correct spinal dysfunction 5. Preventive maintenance

A hospital receives notice of being sued for an action performed by a nurse. The nurse realizes that which doctrine is being implemented in this case? 1. Contractual relationship 2. Stare decisis 3. Respondeat superior 4. Res ipsa loquitur

3. Respondeat superior

A nurse is helping to set up an elder social group at a local senior center where residents can come to play cards or participate in structured activities three times a week. In which community function is this nurse working? 1. Socialization 2. Social control 3. Social interparticipation 4. Mutual support

3. Social interparticipation

A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. Which professional value is the nurse demonstrating? 1. Human dignity 2. Altruism 3. Social justice 4. Integrity

3. Social justice

A nurse educator believes that teaching students without caring about them is an exercise in futility. This educator also believes that in meeting the students needs, educators must also work to take care of themselves and care for their own needs. From which stage of Gilligans theory is the educator approaching the teaching of students? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

3. Stage 3

A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this clients care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan

3. Standardized care plan

The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which role? 1. Facilitator 2. Advocate 3. Teacher 4. Coordinator of services

3. Teacher

The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this clients discharge was started by the nurse? Standard Text: Select all that apply. 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure. 3. The client does not have a scale to perform daily weights at home. 4. The clients spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control newly diagnosed health problem.

3. The client does not have a scale to perform daily weights at home. 4. The clients spouse has care needs that the client will not be able to complete going forward.

The spouse of a client diagnosed with Stage I/II Alzheimers disease must continue to work full-time. The spouse tells the occupational health nurse that the client has started to wander outside the house, forgets to turn off the stove after preparing food, and tries to drive the car if the keys are available. What should the nurse recommend for this family? 1. The client should be placed in long-term care. 2. The spouse should consider early retirement. 3. The client should be placed in an adult day-care environment. 4. An increase in the clients medications should be considered to slow the progress of the disease.

3. The client should be placed in an adult day-care environment.

A 30-year-old client who plans to travel extensively within the United States asks the nurse about appropriate immunizations. What should the nurse recommend to this client? 1. The client should have a tetanus booster if the client has not had one within the last 5 years. 2. The client should have the hepatitis B immunization series. 3. The client should receive a meningococcal vaccine if the client did not receive one as a teen. 4. The client should not worry about immunizations, as they are not recommended for this age group

3. The client should receive a meningococcal vaccine if the client did not receive one as a teen.

The nurse is performing a family risk assessment. Which factor should the nurse identify that indicates this family is at risk of developing health problems? 1. The family is an elderly couple who are active in their retirement community. 2. The family is a teenage mother and child. The mother is enrolled in parenting classes at the high school. 3. The family belongs to the local synagogue and has family members still living in Germany. 4. The family depends on two incomes with a limit on their health insurance spending.

3. The family belongs to the local synagogue and has family members still living in Germany.

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. 3. The goal is unrealistic. 4. The interventions are not clear enough.

3. The goal is unrealistic.

A nurse who has been a longtime employee of a hospital, providing bedside care to clients, was seriously injured and is paralyzed from the shoulders down, with limited use of the upper arms. Through rehabilitation, the nurse is able to mobilize with a wheelchair and has no cognitive or psychological deficits. The nurse wants to return to the same position held prior to the injury. Under the guidelines of the ADA, what should the hospital do? 1. The hospital is required to accommodate the nurse. 2. The hospital must find another job for the nurse. 3. The hospital should claim undue hardship to accommodate this nurse. 4. The hospital terminate the nurses employment.

3. The hospital should claim undue hardship to accommodate this nurse.

A nurse manager has the reputation of being an autocratic leader. Which of the following statements by this manager would support that reputation? 1. Id like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit. 2. Im putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit. 3. The new work schedule is posted for the next 6 weeks. 4. I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front.

3. The new work schedule is posted for the next 6 weeks.

A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. If you look better, you might feel better. 2. Taking a shower might wash away some of that gloom and doom. 3. This is a positive sign. Ill be right back with your supplies. 4. Your spouse will be glad to see that youre feeling better.

3. This is a positive sign. Ill be right back with your supplies.

The nurse is conducting an admission interview. Which response indicates that the nurse is attentively listening to the clients explanations? 1. Can you explain what your symptoms are like? 2. When was the last time you saw a doctor for this? 3. Uh-huh, while nodding the head 4. Im sorry, say that again?

3. Uh-huh, while nodding the head

During the admission interview, the culturally diverse client averts her eyes and refrains from answering questions for long periods of time. The culturally sensitive nurse should take which action? 1. Come back at a different time, when the client is feeling more communicative. 2. Have another nurse finish the interview, as there is something uncomfortable the client senses. 3. Understand that this may be completely appropriate and take cues accordingly. 4. Leave the room and come back after having learned more about this particular culture.

3. Understand that this may be completely appropriate and take cues accordingly.

The administration of a hospital, along with nursing services, is planning to incorporate a struggling private clinic into the infrastructure of the hospital. Although relocating the clinic may cause transportation difficulty for some clients, keeping the clinic running will allow current employees as well as clients the continued benefit of the clinic. Which moral framework did the hospital leadership use to make this decision? 1. Teleological theory 2. Deontological theory 3. Utilitarianism 4. Caring theory

3. Utilitarianism

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis

3. Wellness diagnosis

During the first home care visit, the nurse determines that the client needs speech therapy, physical therapy, and custodial care several times a week. When should the nurse schedule the clients care to begin? 1. As soon as the nurse completes the initial assessment 2. As soon as the client agrees to the care 3. When the physician signs the plan of care the nurse develops 4. Within 48 hours of the nurses visit

3. When the physician signs the plan of care the nurse develops

A client asks the nurse to explain the difference between an HMO and a PPO. What should the nurse include when responding to the client? 1. Youll have good health care benefits, so dont worry. 2. Both the HMO and PPO are covered by your employer, so its really not your concern. 3. Your PPO offered you a choice in your health care provider as well as services. Now, you will choose a primary care provider who will evaluate your health and will coordinate all of your care. 4. You really should be happy about the HMO. Youll pay little, if any, out-of-pocket expense.

3. Your PPO offered you a choice in your health care provider as well as services. Now, you will choose a primary care provider who will evaluate your health and will coordinate all of your care.

The elderly client comes to the clinic reporting gastrointestinal problems, including frequent constipation and indigestion, but denies any recent weight loss. The nurse initially recognizes that these symptoms 1. indicate a concern and could be caused by cancer. 2. indicate the need for an upper and lower GI x-ray series. 3. could be related to normal changes in muscle tone and activity. 4. are probably indicative of a gastric ulcer or colitis.

3. could be related to normal changes in muscle tone and activity.

The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should 1. start from the beginning and proceed through all material. 2. break up sessions into shortened time periods. 3. discover what the learner knows before proceeding with further teaching. 4. make sure the clients spouse is present before the teaching session begins.

3. discover what the learner knows before proceeding with further teaching.

During a previous family assessment, the nurse realized that the mother did most of the talking and was quick to make decisions, which appeared to be acceptable to the father. When one of their children is hospitalized, the nurse should 1. make sure that both parents are involved in all decision making. 2. allow the mother to make the decisions. 3. include both parents in the decision making, but be accepting if the mother retains control. 4. make sure that the physician understands the family dynamics so parental consent comes from the mother.

3. include both parents in the decision making, but be accepting if the mother retains control

A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which cultural groups? 1. Latino American 2. Asian American 3. Native American 4. African American

4. African American

The nurse practitioner is working with a staff nurse to change the plan of care for a client with a terminal illness. In which areas of nursing practice are these nurses functioning? 1. Promoting health and wellness 2. Preventing illness 3. Restoring health 4. Caring for the dying

4. Caring for the dying

A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours

4. 24 hours

At birth a baby weighed 8 lb. What should the nurse expect this baby to weight at the age of 1? 1. 32 lb 2. 16 lb 3. 20 lb 4. 24 lb

4. 24 lb

The nurse is planning to explain the importance of culturally appropriate care to a new nursing assistant. What should the nurse include when explaining the term culture to this staff person? Select all that apply. 1. Culture involves groups who share biological markers. 2. Cultures seldom have diversity within them. 3. Male nurses are an example of a culture. 4. A culture is primarily exhibited through shared thoughts, actions, and beliefs. 5. A culture shapes its members view of the world.

4. A culture is primarily exhibited through shared thoughts, actions, and beliefs. 5. A culture shapes its members view of the world.

The nurse manager determines that a staff nurse demonstrates compassion when providing client care. What did the manager observe to come to this conclusion? 1. A nurse who has expert technical skills and has the most experience with critical care 2. A nurse who routinely gives back rubs to clients before they go to sleep 3. A nurse who has written procedures and policies in language that is both professional and realistic 4. A nurse who takes time to understand the spiritual needs of clients

4. A nurse who takes time to understand the spiritual needs of clients

A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. A STAT order 2. A one-time order 3. A prn order 4. A standing order

4. A standing order

A hospital was named in a lawsuit after a client had to undergo a second surgical procedure because an arthroscopy was performed on the wrong knee during surgery. The hospital settled out of court with the client for damages. This is an example of which principle of management? 1. Authority 2. Responsibility 3. Coordination 4. Accountability

4. Accountability

A student nurse accidentally left the call light outside the reach of an older client. Another nurse discovered the situation and was able to rectify the matter before something happened. The student apologizes and states the need to double check for call light placement before leaving a clients room. What behavior did the student demonstrate? 1. Justice 2. Fidelity 3. Responsibility 4. Accountability

4. Accountability

A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change? 1. Termination stage 2. Maintenance stage 3. Contemplation stage 4. Action stage

4. Action stage

The nurse is reviewing interventions written for a clients plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain

4. Administering medications for pain

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the clients problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors

4. Alteration in thought processes, related to complex factors

A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make sure that these observances can be met if possible. Which value is the manager practicing? 1. Human dignity 2. Social justice 3. Autonomy 4. Altruism

4. Altruism

An unlicensed assistive person (UAP) is working on a rehabilitation unit. Which task would be appropriate for this person to delegate? 1. Taking and recording vital signs 2. Assisting with bathing 3. Making a bed 4. An unlicensed assistive person may not delegate tasks.

4. An unlicensed assistive person may not delegate tasks.

The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care

4. Appropriately supervising care

A new graduate nurse is moving from a small rural college town to a metropolitan area to begin work in a county hospital. The nurse has had limited prior experience with the various cultural groups that are served by the hospital. What might be this nurses greatest challenge? 1. Prejudice 2. Stereotyping 3. Discrimination 4. Assimilation

4. Assimilation

The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning? 1. Thorndikes behaviorism 2. Skinners positive reinforcement 3. Pavlovs conditioning response 4. Banduras imitation

4. Banduras imitation

After having a difficult time saying no when asked to work yet another overtime shift, the nurse begins to feel overwhelmed and irritable. As a method to most effectively promote self-healing, what should this nurse do? 1. Clarify values and beliefs. 2. Set realistic goals. 3. Learn to manage stress. 4. Challenge the belief that others always come first.

4. Challenge the belief that others always come first.

The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception

4. Charting by exception

The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours.

4. Client will have intake of at least 1000 mL within 24 hours.

Nursing students have been assigned to develop their own theory of nursing. What should they include in their theory, often referred to as the metaparadigm for nursing? 1. Society, medicine, nursing, and biology 2. Patient, facility, health, and nursing 3. Organization, discipline, nursing, and client 4. Client, environment, health, and nursing

4. Client, environment, health, and nursing

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive

4. Cognitive

A client with a sexually transmitted illness (STI) asks the nurse to not tell anyone about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, what must the nurse do? 1. Honor the clients wishes. 2. Not disclose any information to anyone. 3. Respect the clients privacy and confidentiality. 4. Communicate only necessary information.

4. Communicate only necessary information.

The nurse is working in a busy intensive care unit. A client is admitted with extensive medical problems and requires a ventilator. Because the nurse already has two other clients assigned to his care, he requests that the nurse manager change assignments so that appropriate attention can be given to this new admission. According to Roachs six Cs of caring, which one is the nurse emulating? 1. Compassion 2. Confidence 3. Commitment 4. Conscience

4. Conscience

An older client has no family in the same community, lives alone in a small house, and is having greater difficulty with mobility due to advanced osteoarthritis. Cognitively, this client is alert, is able to manage her own business matters, and does her own cooking, but does not enjoy cooking for one. The home health nurse who visits has noticed that the client is losing weight and does not have as much energy or interest in activities as on previous visits. What should the nurse recommend for this client? 1. See a psychiatrist because the client appears to be depressed. 2. Check out joint replacement options for the osteoarthritis. 3. Start thinking about long-term care. 4. Consider moving to an assisted living facility.

4. Consider moving to an assisted living facility.

The nurse accesses previous hospitalization information to learn more about the clients previous health history. In what way is the availability of the clients health information assisting with the planning to address new care needs? 1. Ability to monitor quality 2. Access warehoused data (stored data) 3. Client sharing of knowledge that influences health 4. Constant availability of client health information

4. Constant availability of client health information

A nurse is working in collaboration with a group of health care providers in a community clinic setting. They have defined a problem and now are focusing on objectives and considering various viewpoints presented by the group. Which collaboration competency is this nurse demonstrating? 1. Mutual respect 2. Trust 3. Communication 4. Decision making

4. Decision making

A client with a PhD in epidemiology has been to numerous physicians and has had numerous laboratory tests, all of which were abnormal, and exploratory surgery, but no one is able to explain the etiology of his problem. The client also states that he has a rare form of a neurological disorder. Which statement should the nurse make that demonstrates critical thinking? 1. Why dont you just tell your physician what you think you have? 2. Did you bring your prior tests and results with you, so we dont repeat anything? 3. If you know what you have, what do you want from us? 4. Describe what tests youve had and explain the symptoms of this disorder.

4. Describe what tests youve had and explain the symptoms of this disorder.

The nurse has two older parents who were recently hospitalized at the same time and are being discharged home on the same day. What should the nurse do to ensure these family members receive the highest quality of care in the home? Select all that apply. 1. Call off from work to provide care to both parents. 2. Adjust his or her personal schedule to provide care to the parents. 3. Move in with the parents until conditions are stabilized. 4. Determine if custodial support is needed for the parents. 5. Find out when the home care nurse is scheduled to arrive.

4. Determine if custodial support is needed for the parents. 5. Find out when the home care nurse is scheduled to arrive.

A school nurse is implementing a program to promote psychosocial development among adolescent teens at a high school. Which activity should the nurse include? 1. Career planning 2. Establishing peer groups 3. Playing musical instruments 4. Determining a value system

4. Determining a value system

While assessing a clients environment for safety concerns, the nurse finds that most of the rooms in the house have only one outlet with various cords entering the outlet. When this concern is shared with the client and spouse, they state that this is the way weve lived for years. What should the nurse do? 1. Provide telephone numbers for local electricians. 2. Continue to persuade the client to have the home rewired. 3. Not bring the subject up again. 4. Document the findings and the client and spouses response to the concern.

4. Document the findings and the client and spouses response to the concern.

The nurse would like to admit a client to home health care, but is worried about insurance reimbursement. What client action is causing the nurse to question if home care can be prescribed for this client? 1. Lives with a spouse 2. Needs skilled care 3. Needs intermittent care 4. Drives a car for trips to the barber

4. Drives a car for trips to the barber

A client comes to the womens clinic, stating she has had a positive home pregnancy test. The client states that her last menstrual cycle was 2 months ago. According to this time frame, the nurse determines that the client is in which stage of pregnancy? 1. Fetal phase 2. Second trimester 3. Third trimester 4. Embryonic phase

4. Embryonic phase

The nurse is working in the school system with a group of students who are struggling with the death of a classmate. The nurse encourages the students to talk about their friend, bring pictures, and share memories with each other. The nurse also invites the deceaseds family members to come to the school and visit with their childs classmates. This nurse is working in which of Swansons processes? 1. Knowing 2. Being with 3. Doing for 4. Enabling

4. Enabling

A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the clients motivation to learn? 1. Demonstrating the finger stick on the nurse 2. Offering to do the procedure for the client each time it is scheduled 3. Teaching the clients support system how to perform the procedure 4. Encouraging the clients participation each time the procedure is performed

4. Encouraging the clients participation each time the procedure is performed

The student nurse is following a preceptor on the assigned clinical shift. Which behavior of the nurse should the student interpret as caring? 1. Making sure that all medications and treatments are done on time 2. Using aseptic technique when performing a dressing change 3. Advising the physician that the client wants to speak to him or her prior to a procedure 4. Explaining an invasive procedure to the client, then asking if it is all right to begin the procedure

4. Explaining an invasive procedure to the client, then asking if it is all right to begin the procedure

A parish health nurse is working with a particular congregation in setting up a support program for shut-ins within the congregation who are not able to come to regular prayer services. In which role is this nurse functioning? 1. Counselor 2. Educator 3. Referral source 4. Facilitator

4. Facilitator

The nurse is reviewing public health and health promotion roles for available for nurses. To which leader should the nurse attribute the development of these roles? 1. Clara Barton 2. Lillian Wald 3. Mary Brewster 4. Florence Nightingale

4. Florence Nightingale

A school nurse is working with teachers in helping them address the developmental needs of grade school students, according to Eriksons theory of industry versus inferiority. Which activities should the nurse suggest? 1. Providing time for running and playing sports, such as basketball, to increase gross motor skills 2. Allowing pretend time during their classes, such as for dress-up or role-playing activities 3. Presenting diversity in culture and practices as part of classroom study 4. Helping them develop skills needed in the adult world, such as allowance budgeting

4. Helping them develop skills needed in the adult world, such as allowance budgeting

A colleague is telling the community health nurse that his adult child has just moved back in with him and his wife. They are finding this situation somewhat difficult to adjust to. The nurse offers support and listens, while understanding that which factor is least likely contributing to this particular trend? 1. Maladaptive behavior 2. High unemployment rate 3. High housing costs 4. High incidence of chronic disease

4. High incidence of chronic disease

A nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet, and has supportive, sound relationships with her spouse and children. According to Dunns high-level wellness grid, this client would exemplify which health characteristic? 1. Emergent high-level wellness in a favorable environment 2. Emergent high-level wellness in an unfavorable environment 3. Protected health in a favorable environment 4. High-level wellness in a favorable environment

4. High-level wellness in a favorable environment

The nurse needs to communicate information about a clients status to a physician. Which approach demonstrates assertive communication by the nurse? 1. You need to check the laboratory results of the client in room 423. 2. You should visit with the clients family about the upcoming procedure. 3. We need to be more aware of the situation among the client and the clients family. 4. I am concerned that the client does not have adequate pain management.

4. I am concerned that the client does not have adequate pain management.

A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make? 1. Just sign the form, and Ill make sure your physician talks to you before he begins the procedure. 2. Ill explain whatever you dont understand. 3. You should have asked your physician when he was in here. 4. Ill call your physician back in the room to answer your questions.

4. Ill call your physician back in the room to answer your questions.

During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using? 1. Adapt activities to the individual client. 2. Encourage clients to participate actively in implementing nursing interventions. 3. Base nursing interventions on scientific knowledge, research, and standards of care. 4. Implement safe care.

4. Implement safe care.

The nurse is preparing information for a community health education seminar. Which statement should the nurse include regarding disease for the middle-aged adult? 1. Cancer is the leading cause of death in the age group from 25 to 64 years. 2. Coronary heart disease is the leading cause of death. 3. Leading causes of death include suicide and motor vehicle crashes. 4. Injuries and chronic disease are the leading causes of death in this age group.

4. Injuries and chronic disease are the leading causes of death in this age group.

The nurse observes a client working to include the spouse in the treatment and recovery process of an illness. Which of Roys modes should the nurse recognize that this client is demonstrating? 1. Physiologic 2. Self-concept 3. Role function 4. Interdependence

4. Interdependence

A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program? 1. Situational influences 2. Perceived benefits of action 3. Perceived barriers to action 4. Interpersonal influences

4. Interpersonal influences

A client tells the nurse about researching on the Internet for information about a newly prescribed medication. What should the nurse respond to the client? 1. Im glad youre interested in your therapy. 2. Information on the Internet cannot be trusted. You should check with your pharmacist. 3. Your physician is the one you should be asking these kinds of questions. 4. Lets look at some of the sites youve been visiting.

4. Lets look at some of the sites youve been visiting.

A parent is concerned that her child is unable to sit alone. The nurse explains that development is based on in-born timetables and the child will be most likely able to meet this milestone at a specific time. Upon which theory did the nurse base the response to the client? 1. Havighursts theory 2. Task theory 3. Psychosocial theory 4. Maturational theory

4. Maturational theory

A client comes to the family planning clinic for follow-up and is currently taking an oral contraceptive. During the interview assessment, the client states she has been using some natural medicines. Which herbal preparation should alert the nurse to a possible interaction with oral contraceptives? 1. Valerian 2. Echinacea 3. Garlic 4. Milk thistle

4. Milk thistle

The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing

4. Observing

The nurse is hired to provide home care through a community agency that is operated by the state health department and financed by taxes. In which type of agency is this nurse employed? 1. Institution based 2. Private 3. Not-for-profit 4. Official

4. Official

A client has agreed to participate in a research study. Which action would constitute risk of harm to this client? 1. Withholding information about the study 2. Suggesting that participation would greatly benefit the clients financial situation 3. Giving the client false information about his or her participation 4. Providing the clients name as a participant in the study

4. Providing the clients name as a participant in the study

A client who has a long-standing history of depression has been on a prescribed antidepressant for several months and states that he has also been trying St. Johns wort. Which vital sign should the nurse assess for possible adverse effects? 1. Temperature 2. Respiratory rate 3. Oxygen saturation 4. Pulse rate

4. Pulse rate

An RN delegates the task of taking a newly admitted clients vital signs to a nurses aide. The clients blood pressure was 182/98, but did not get reported to the physician for several hours. Who is responsible for the lapse in time between discovery and action? 1. Nurse manager 2. Aide 3. Client 4. RN

4. RN

A researcher is conducting a study with single-parent families within a school system. What sample is the researcher using? 1. The school system 2. Children 3. Parents 4. Single-parent families

4. Single-parent families

A nurse has been asked to be a member of a hospitals internal review board and evaluate research studies. Which characteristic does this nurse most likely possess? 1. Sound empirical knowledge 2. Sound personal knowledge 3. Sound aesthetic knowledge 4. Sound ethical knowledge

4. Sound ethical knowledge

A school nurse is bringing a group of students to a nursing home for a social exchange project. Before the students arrive, the nurse reminds them to do what when speaking to the residents? 1. Speak as loud as they can. 2. Speak into the residents ears. 3. Write out what they want to say on a piece of paper. 4. Speak distinctly, while facing the residents

4. Speak distinctly, while facing the residents

During a midterm evaluation, the nurse educator tells the students they need to work on improving their aesthetic knowledge. How should the students plan to accomplish this recommendation? 1. Study harder. 2. Take better notes. 3. Read about the same topic from a variety of sources. 4. Spend time in the clinical area with seasoned nurses.

4. Spend time in the clinical area with seasoned nurses.

A home health nurse is working with a client who has had to quit his job after a serious injury and whose future employability is uncertain. The client states that his life has no meaning or purpose anymore and that he feels lonely and abandoned. What is an appropriate nursing diagnosis for this client? 1. Body Image Disturbance 2. Health-Seeking Behavior 3. Altered Family Processes 4. Spiritual Distress

4. Spiritual Distress

The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the clients life. What action is the nurse assisting the client to complete? 1. Lifestyle assessment 2. Social support systems review 3. Health beliefs review 4. Spiritual health assessment

4. Spiritual health assessment

A client was given the wrong dose of medication and died. The case is being tried in court and similar cases are used by the court in comparison to arrive at a decision. Which doctrine should the nurses attorney explain is applied to this situation? 1. Common law 2. Public law 3. Administrative law 4. Stare decisis

4. Stare decisis

A nurse practitioner emphasizes the importance of the staff engaging in activities that help restore peace and balance between the mind and body. Which might be an appropriate therapy for this? 1. Bike riding 2. Cake decorating 3. Reading 4. Storytelling

4. Storytelling

The new community health nurse is compiling information about the community and wants to understand more about services to maintain and promote health. What entity should the nurse access to learn this information? 1. Chamber of commerce 2. Public and university libraries 3. Recreational directors 4. Teachers and school nurses

4. Teachers and school nurses

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used.

4. The difference is in how the data are used.

A home health client participates in cultural health practices that the nurse feels may be detrimental to his health. In order to remain attentive to cultural sensitivity and provide appropriate cultural nursing care, the nurse should take which action? 1. Explain the right and wrong of the clients treatment and try to persuade him to follow the scientific perspective. 2. Have the clients physician explain the care to the client in a firm but gentle manner. 3. Validate the clients practices and understand that for this client, it may be beneficial to continue with his preferences. 4. Try to negotiate with the client by exploring his views and then provide relevant scientific information.

4. Try to negotiate with the client by exploring his views and then provide relevant scientific information.

During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern

4. Value/belief pattern

A Department of Nursing within a medical center is adopting the theory that is founded on 14 fundamental needs of individuals. Which nurse theorist is this department using to guide client care? 1. Dorothea Orem 2. Florence Nightingale 3. Martha Rogers 4. Virginia Henderson

4. Virginia Henderson

The nurse enters a clients room and finds that the telephone is lying in the clients lap, tissues are wadded up on the bed, and the clients eyes are red and watery. What is the best response by the nurse? 1. Can I hang that phone up for you? 2. Well, it's a beautiful day outside. Let's open the blinds. 3. Has your doctor been in to talk to you yet? 4. You look upset. Is there anything you'd like to talk about?

4. You look upset. Is there anything you'd like to talk about?

The nurse is providing education regarding early detection of breast cancer to a group of women between the ages of 30 and 40. According to recommendations from the American Cancer Society, the nurse should explain that it is important for these women to 1. do monthly breast self-exams. 2. have a yearly mammogram. 3. see a physician if there is a strong family history of breast cancer. 4. have an annual breast exam performed by a health care provider.

4. have an annual breast exam performed by a health care provider.