Adult Exam 2
Which statement best describes the client most motivated to learn? A 29-year-old male; significant other insisting on education A 52-year-old male; hired to drive client home from clinic A 70-year-old female; learning care so spouse can come home A 25-year-old female; just completed a course of physical therapy
A 70-year-old female; learning care so spouse can come home
What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? Avoid stuffed animals and blankets in the crib. Educate about and be aware of signs of risky behaviors. Include safeguards to prevent falls in the home. Teach seat-belt safety.
Avoid stuffed animals and blanket in the crib
An administrative assistant of a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has what? A fracture of the hand Carpal tunnel syndrome A herniated cervical disc An infection in the bone
Carpal tunnel syndrome
The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her? "Car seats are only recommended until children are 3 years old." "At the age of 6 your child should be using a booster seat." "Car seats are recommended until children are at least 10 years old." "Your child will be safe in the car using the provided shoulder harness and lap belts."
"At the age of 6 your child should be using a booster seat."
The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response? "Clients with Alzheimer's disease often wander." "Consider the Alzheimer's Association 'Safe Return' program." "Adjust sleeping schedules so that you can monitor your loved one as they sleep." "I know, my parent has Alzheimer's disease and I worry about that too."
"Consider the Alzheimer's Association 'Safe Return' program."
A client who has recently been diagnosed with a chronic illness appears to be depressed. When the nurse asks if there is something wrong, the client states, "Nothing will ever be the same for me since I have this disease." Which of the following is the most appropriate response for the nurse? "You will never be able to care for yourself, but you can learn to live with that." "You will never be able to live the normal life you did before." "If you maintain a positive self-concept, you can live as normally as possible." "You do not have to worry, as other people will care for you."
"If you maintain a positive self-concept, you can live as normally as possible."
The nurse is assessing an adolescent with an annual physical. The mother reports that she has noticed a change in the child's behavior lately including mood swings, withdrawal from the family, and failing school grades. The mother does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." "Let's admit your child to an acute care facility so that we can run more tests." "These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial." "This is typical adolescent behavior. Ignore it and it will improve."
"These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial."
The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my parent understands what to do?" What is the appropriate nursing response? "After I demonstrate it once, your parent will be able to do it." "When 15 minutes have passed, I will ask your parent to show me how to instill the drops." "We can never be completely sure that your parent understands instructions." "I will have you bring your parent back next week to see how things are going."
"When 15 minutes have passed, I will ask your parent to show me how to instill the drops."
The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left him immobile. As the nurse enters the home, the client braces his hands on the arms of his chair to rise and uses crutches to walk across the room. What is the best response by the nurse? "Let me document that you can walk." "Those physical therapists work wonders. "You have made an amazing recovery." "Are you supposed to be out of the wheelchair?"
"You have made an amazing recovery."
The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed? 1 medium Banana handful of walnuts ½ cup of pineapples 3 ounces of chicken
1 medium banana
The nurse overhears an older client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? Ask to examine the client alone in order to speak to her privately. Document the observed behaviors in the client's chart. Nothing, as it is none of the nurse's concern. Report the suspicions to to the authorities.
Ask to examine the client alone in order to speak to her privately
A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide? Call 9-1-1. Induce vomiting. Administer laxative. Dilute with water or milk.
Dilute with water or milk
The nurse needs to understand the teaching-learning process when administering Physician-initiated interventions Educational interventions Technical interventions Psychosocial interventions
Educational interventions
As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse? Redirect client to learning about self-care and begin education Give written materials to the client and retrieve pain medication Have client rate the pain level and reschedule the teaching lesson Assess client understanding of self-care and administer medication
Have client rate the pain level and reschedule the teaching lesson
The nursing instructor is teaching the students about health and wellness and identifies which of the following as the best definition for health? Health is the absence of disease. Health is how people feel. Health is a state of complete well-being. Health is the lack of physical symptoms.
Health is a state of complete well-being
A female client has recently been diagnosed with early-stage Alzheimer's disease and her husband has asked the nurse to recommend Web sites that may supplement his learning about her diagnosis. How should the nurse respond to the husband's request? Identify and recommend some credible Web sites appropriate to his learning needs. Encourage the husband to avoid online resources due to the unregulated nature of the Internet. Direct the husband to online databases such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Provide the husband with print-based materials that are clearly referenced and reflect his learning style.
Identify and recommend some credible Web sites appropriate to his learning needs
When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized? Have the clients read material after client education. Be sure that clients are formally engaged. Include educational strategies that encourage clients to be active participants. Administer tests to evaluate learning.
Include educational strategies that encourage clients to be active participants.
A nurse is preparing to teach a 6-year-old with a broken arm and her mother about caring for the child's cast. Which statement reflects the best education plan for these clients? Include the child in the education; ask questions of both mother and child. Focus mainly on the mother; ask the child a couple simple questions. Provide the mother with written materials; teach the child about keeping cast dry. Separate the mother and child; teach the mother and let her teach the child.
Include the child in the education; ask questions of both mother and child.
An older adult female client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. She is tearful and verbalizes that she feels lonely and abandoned in the hospital unit. The nurse noticed that family visits daily and that there are flowers and cards in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client? Ineffective Coping; verbalizes support systems. Impaired Walking; unilateral neglect. Altered Mobility; able to tie shoes. Dysfunctional Family Processes; family contact daily.
Ineffective Coping; verbalizes support systems.
The unlicensed personnel tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Contact the physician for a restraint order. Administer the client's sedative as ordered. Put up all four siderails on the bed. Initiate use of a bed alarm.
Initiate use of a bed alarm
Which developmental consideration is a nurse assessing when determining that an 8-year-old boy is not equipped to understand the scientific explanation of his disease? Intellectual development Motor development Emotional maturity Psychosocial development
Intellectual development
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? Obtain a three-prong grounded plug adapter. Use an extension cord to provide freedom of movement. Tape the electrical cord of the pump to the floor. Run the electrical cord of the pump under the carpet.
Obtain a three-prong grounded plug adapter
An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in the bilateral knees. The nurse knows this client does not want to be a burden on his family, and he remains stoic even though he reports the pain as severe. He avoids the topic of surgery and attends church weekly. His family is supportive of any decisions he makes regarding his health. Which of the assessment data are most important to forming an individualized education plan for this client concerning treatment for his osteoarthritis? Orthopedic surgical history Personal perception of health and aging Flooring plan of the client's dwelling Formal religious beliefs
Personal perception of health and aging
The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which of the following dimensions is the nurse referring to? Physical dimension Emotional dimension Intellectual dimension Environmental dimension
Physical dimension
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client? Placing the client in a bed with a bed alarm Providing a bed that is elevated from the floor Raising all the side rails of the bed Using restraints on the client to prevent a fall
Placing the client in a bed with a bed alarm
A school nurse is discussing bike and outdoor safety measures with a group of Boy Scouts. What type of health education and counseling is the nurse providing to this group of children? Preventing illness Promoting health Restoring health Facilitating coping
Preventing illness
A nurse is immunizing children against measles. This is an example of what level of preventive care? Primary Secondary Tertiary
Primary
Which is an example of tertiary health promotion? Family counseling Water treatment Pap tests Rehabilitation
Rehabilitation Tertiary health promotion and disease prevention begin after an illness is diagnosed and treated to reduce disability and to help rehabilitate clients to a maximum level of functioning.
A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? Lock all cabinets that contain cleaning supplies. Keep all pots and pans in lower cabinets. Give warm bottles of formula to the baby. Restrain the baby in a car seat.
Restrain baby in a car seat
A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client? Written test Oral test Return demonstration Stimulation
Return Demonstration
Nurses promote the needs of clients as an integral part of each person's human dimension. Which needs are being met when a nurse recommends a senior citizen community centre for an older client who is living alone? Spiritual needs Sociocultural needs Intellectual needs Emotional needs
Sociocultural needs
The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient? Sedate her with sleeping pills and leave the restraints on. Take the restraints off, stay with her, and talk gently to her. Leave the restraints on and talk with her, explaining that she must calm down. Talk with the patient's family about taking her home because she is out of control.
Take the restraints off, stay with her, and talk gently to her
When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way? Request family members to serve as translators. Provide less health teaching because of the language barrier. Elongate the teaching session to be sure the client understands. Talk with animation and vocal inflection, to stimulate the client aurally.
Talk with animation and vocal inflection, to stimulate the client aurally.
The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? The 2-year-old leaning against the screen of a window in a classroom. The 2-year-old and 6-year-old each holding the mother's hand. The 2-year-old helping mom to open the front door of the school. The 6-year-old riding a bike on the playground with his friend.
The 2-year-old leaning against the screen of a window in the classroom
Which model is most useful in examining the cause of disease in an individual, based upon external factors? The Agent-Host-Environment Model The Health-Illness Continuum The High-Level Wellness Model The Health Belief Model
The Agent-Host-Environment Model
The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, what best represents that the client has learned a new skill? The client states understanding and passes a written test. The client organizes materials needed and gives return demonstration. The client verbalizes items needed and how to perform skill. The client nods when asked about process and assists with clean up.
The client organizes materials needed and gives return demonstration.
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure ulcer on his coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? The hospital must bear any costs incurred for treating the client's ulcer. The hospital will be fined by CMS because the client developed a pressure ulcer. CMS will bear the hospital's costs if the client chooses to sue the hospital. CMS may choose to divert clients to other health care facilities in the future.
The hospital must bear any costs incurred for treating the client's ulcer
A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives? The nurse writes one or two broad objectives rather than several specific objectives. The nurse writes general statements for learner objectives that could be accomplished in any amount of time. The nurse plans learner objectives with another nurse before obtaining input from the client and family. The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.
The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.
A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives? The nurse writes one or two broad objectives rather than several specific objectives. The nurse writes general statements for learner objectives that could be accomplished in any amount of time. The nurse plans learner objectives with another nurse before obtaining input from the client and family. The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.
The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.
A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which of the following as a characteristic of an adult learner? Their readiness to learn is often related to a developmental task or social role. Peer group acceptance is a critical issue for this age group. The material presented should focus on future application. Previous experiences have little impact on learning.
Their readiness to learn is often r/t a developmental task or social role
Which client would be the best candidate for a nurse to use motivational interviewing? a 38-year-old male training to walk a half-marathon a 44-year-old female who brought a food log to weight loss counseling a 66-year-old male who is showing improvement in range of motion a 28-year-old female with elevated blood glucose for 8 months
a 28-year-old female with elevated blood glucose for 8 months
A nurse caring for clients in a skilled nursing facility assesses client motivation to participate in care. Based on the health belief model, which clients would be most motivated? Select all that apply. a client who does not view themself as susceptible to the disease a client who views a disease as a serious threat a client who believes there are actions that will reduce the probability of contracting the disease a client who believes that the threat of taking actions against a disease is not as great as the disease itself a client who believes that noncompliance is not an option A client who believes that doing nothing is preferable to painful treatments
a client who views a disease as a serious threat a client who believes there are actions that will reduce the probability of contracting the disease a client who believes that the threat of taking actions against a disease is not as great as the disease itself
The nurse must instruct a 35-year-old client with Down syndrome about use of an albuterol rescue inhaler. Which of the following demonstrates individualization of the education plan for this client? lesson focused for client of school-age developmental level, authoritarian style, client taught at meal time developmental stage is adult at age 35, information given in short sentences, motor skills not assessed client's understanding of health assessed, questions answered on age-appropriate level, television on in room client understanding of illness, motor skills and developmental stage assessed, clarification provided
client understanding of illness, motor skills and developmental stage assessed, clarification provided
An woman 80 years of age has had a cerebrovascular accident. She has flaccidity of her right side with aphasia. For this client, which of the following activities constitutes tertiary prevention? assessment of her blood pressure daily bleeding and clotting times gait training and speech therapy education on the symptoms of a CVA
gait training and speech therapy
Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers? telling the mothers to avoid taking over the counter drugs while breast feeding showing charts to the mothers that illustrate the types of breast milk observing a mother expressing the breast milk advising the mothers to drink plenty of water
observing a mother expressing the breast milk
The nurse has completed teaching. Which client behavior demonstrates understanding within the psychomotor domain? provides return demonstration of use of inhaler states, "I feel comfortable using my walker." verbalizes key points of a brochure about diabetes that was read provides a description of what appropriate wound healing should look like
provides return demonstration of use of inhaler
Chronic illness may be characterized by periods of remission. Remission is best defined as: the presence of a disease with the absence of symptoms. the reappearance of symptoms of a disease. the response of a person to a disease. a pathologic change in the structure of function of the body or mind.
the presence of a disease with the absence of symptoms.
