END OF CH26

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavioral changes. When using motivational interviewing, what outcomes does the nurse expect? (Select all that apply.) 1. Gaining an understanding of the patient's motivations 2. Directing the patient to avoid poor health choices 3. Recognizing the patient's strengths and supporting his or her efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors

. 1, 3, 5;

Which are examples of positive health habits that may prevent the development of chronic illness later in life? (Select all that apply.) 1. Routine screening and diagnostic tests 2. Unprotected sexual activity 3. Regular exercise 4. Consistent seat belt use 5. Excess alcohol consumption

.1, 3, 4;

A nurse newly hired at a community hospital learns about intentional hourly rounding during orientation. Which of the following are known evidence-based outcomes from intentional rounding? (Select all that apply.) 1. Reduction in nurse staffing requirements 2. Improved patient satisfaction 3. Reduction in patient falls 4. Increased costs 5. Reduction in patient call light use

.2, 3, 5.

Using the Transtheoretical Model of Change, order the steps that a patient goes through to make a lifestyle change related to physical activity. 1. The individual recognizes that he is out of shape when his daughter asks him to walk with her after school. 2. Eight months after beginning walking, the individual participates with his wife in a local 5K race. 3. The individual becomes angry when the physician tells him that he needs to increase his activity to lose 30 lb. 4. The individual walks 2 to 3 miles, 5 nights a week, with his wife. 5. The individual visits the local running store to purchase walking shoes and obtain advice on a walking plan.

.3, 1, 5, 4

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? 1. Caring touch 2. Protective touch 3. Task-oriented touch 4. Interpersonal touch

1

A nurse is caring for a man who is recently retired and who appears withdrawn. He says he is "bored with life." The nurse helps this individual find meaning in life by: 1. Encouraging him to reflect on his relationships with others. 2. Encouraging relocation to a new city. 3. Explaining the need to simplify life. 4. Encouraging him to adopt a new pet.

1

A nurse is caring for a patient newly diagnosed with testicular cancer. He asked the nurse to help him find the meaning of cancer by supporting beliefs about life. This is an example of: 1. Instilling hope and faith. 2. Forming a human-altruistic value system. 3. Cultural caring. 4. Being with.

1

A nurse is conducting a home visit with a new mom and her three children. While in the home the nurse weighs each family member and reviews their 3-day food diary. She checks the mom's blood pressure and encourages the mom to take the children for a 15- to 30-minute walk every day. The nurse is addressing which level of need, according to Maslow? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-actualization

1

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude? 1. Responsibility 2. Humility 3. Accurate 4. Fairness

1

A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care? 1. Patient will be able to walk 200 feet without shortness of breath. 2. Wound will heal without signs of infection. 3. Patient will express concerns related to return to home. 4. Patient will identify strategies to improve sleep habits.

1

A nurse is working with an older adult who recently moved to an assisted-living center because of declining physical capabilities associated with the normal aging process. Which nursing interventions are directed at promoting self-esteem in this patient? 1. Commending the patient's efforts at completing self-care tasks 2. Assuming that the patient's physical complaints are attention-seeking measures 3. Minimizing time discussing memories and past achievements spent with the patient 4. Limiting decision-making opportunities for the patient to reduce stress

1

A patient who is depressed is crying and verbalizes feelings of low self-esteem and self-worth, such as "I'm such a failure ... I can't do anything right." What is the nurse's best response? 1. Remain with the patient until he or she validates feeling more stable. 2. Tell the patient that is not true and that every person has a purpose in life. 3. Review recent behaviors or accomplishments that demonstrate skill ability. 4. Reassure the patient that you know how he or she is feeling and that things will get better.

1

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial 2. Conversion 3. Dissociation 4. Displacement

1

During a nursing assessment a patient displayed several behaviors. Which behavior suggests the patient may have a health literacy problem? 1. Patient has difficulty completing a registration form at a medical office 2. Patient asks for written information about a health topic 3. Patient speaks Spanish as primary language 4. Patient states unfamiliarity with a newly ordered medicine

1

During an EBP committee meeting, a nurse discussed two systematic integrative reviews related to the use of prepackaged bath kits versus the standard use of bath basins. What level of evidence is the nurse presenting? 1. Level I 2. Level II 3. Level IV 4. Level VI

1

Health care reform will bring changes in the emphasis of care. Which of these models is expected from health care reform? 1. Moving from an acute illness to a health promotion, illness prevention model 2. Moving from an illness prevention to a health promotion model 3. Moving from hospital-based to community-based care 4. Moving from an acute illness to a disease management model

1

Resolution of an ethical problem involves discussion with the patient, the patient's family, and participants from appropriate health care disciplines. Which statement best describes the role of the nurse in the resolution of ethical problems? 1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations 2. To study the literature on current research about the possible clinical interventions available for the patient in question 3. To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal views 4. To allow the patient and the physician private time to resolve the dilemma on the basis of ethical principles

1

The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient does the nurse need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

1

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? 1. Physical care technique 2. Activity of daily living 3. Indirect care measure 4. Lifesaving measure

1

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient

1

The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical elements of this case? 1. The health care team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources. 2. The patient should enroll in a clinical trial of a new technology that can do the work of the liver, similar to the way dialysis treats kidney disease. 3. The social worker should look into enrolling the patient in Medicaid, since many states offer expanded coverage. 4. A family meeting should take place in which the details of the patient's poor prognosis are made clear to his family so that they can adopt a palliative approach.

1

The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question demonstrates a nonjudgmental attitude? 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age?

1

The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3. "Most of the normal changes in function are related to alteration in circulation and hormone levels." 4. "Many medications can interfere with sexual function."

1

The nurse spends time with a patient and family reviewing a dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? 1. Educator 2. Advocate 3. Caregiver 4. Communicator

1

When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of: 1. Object permanence. 2. Sensorimotor play. 3. Schemata. 4. Magical thinking.

1

When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? 1. Holistic 2. Health belief 3. Transtheoretical 4. Health promotion

1

Which explanation provided by the nurse is the most accurate meaning for "providing culturally congruent care"? 1. It fits the patient's valued life patterns and set of meanings. 2. It is the same set of values as those of the health care team member providing daily care. 3. It holds one's own way of life as superior to those of others. 4. It redirects the patient to a more socially expected set of values.

1

Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need? 1. Patient obtains social support care related to caregiver stress 2. Fear related to open-heart surgery 3. Acute Pain related to splinting of incision 4. Impaired Family Coping related to insufficient caregiver support

1

Which statement made by a new graduate nurse about the teach-back technique requires intervention and further instruction by the nurse's preceptor? 1. "After teaching a patient how to use an inhaler, I need to use the teach-back technique to test my patient's technique." 2. "The teach-back technique is an ongoing process of asking patients for feedback." 3. "Using teach-back will help me identify explanations and communication strategies that my patients will most commonly understand." 4. "Using pictures, drawings, and models can enhance the effectiveness of the teach-back technique."

1

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? 1. Call the nursing supervisor to discuss the situation. 2. Discuss the problem with a colleague. 3. Leave the nursing unit and go home. 4. Say nothing and begin your work.

1

Which of the following statements correctly describe the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation involves the gathering of data for recognizing errors or omissions in care. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is done only when a patient's condition changes.

1, 2,

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples of these roles and responsibilities? (Select all that apply.) 1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion 5. Genetic counselor

1, 2, 3, 4

Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a person's roles and responsibilities during middle adulthood. When assessing the health-related knowledge base of both the middle-age patient with a chronic illness and his or her family, the assessment should include which of the following? (Select all that apply.) 1. Medical course of the illness 2. Prognosis for the patient 3. Coping mechanisms of the patient and family 4. Socioeconomic status 5. Need for community and social services.

1, 2, 3, 5

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure

1, 2, 3, 5

A 36-year-old patient newly diagnosed with type 1 diabetes shares with you that he is frustrated with the time it takes to prepare meals and monitor his exercise and blood sugar. He also is having trouble understanding his insulin schedule. Which of the following suggestions would be most appropriate? (Select all that apply.) 1. Provide patient education materials that are easy to read. 2. Refer this patient to a diabetes support group. 3. Refer the patient to his endocrinologist. 4. Suggest that the patient make an appointment with a registered dietitian. 5. Suggest ways to modify his schedule.

1, 2, 4, 5

A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.) 1. The review of patient data in the medical record 2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen 3. Reporting results of an ongoing assessment to a nurse working the next scheduled shift 4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration

1, 2, 4, 5

Health care organizations must provide which of the following based on federal civil rights laws? (Select all that apply.) 1. Provide language assistance services at all points of contact free of charge. 2. Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services. 3. Use patients' family members to interpret difficult topics. 4. Ensure that interpreters are competent in medical terminology. 5. Provide language assistance to all patients who speak limited English or are deaf.

1, 2, 4, 5

A nurse asks how a patient's condition from a serious infection changed since yesterday while receiving a hand-off report. The 280nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient's body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient's progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse's ability to perform evaluation? (Select all that apply.) 1. Checking the summary notes 2. Asking the leaving RN about the patient's condition. 3. Assigning the technician to measure intake and output 4. Comparing current outcomes with those set for the patient's goals 5. Reflecting on patient's progress

1, 2, 4, 5;

Which of the following should be included in health teaching for a pregnant patient? (Select all that apply.) 1. Exposure of the fetus to alcohol, drugs, or tobacco can cause abnormal development. 2. Nutritional needs increase during pregnancy, and eating healthy foods is important. 3. Complementary and alternative therapies should always be avoided during pregnancy. 4. Provide education on self-care to reduce common discomforts of pregnancy, such as nausea. 5. Recommend birthing classes to prepare the mother for the birthing process.

1, 2, 4, 5;

A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.) 1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the patient 4. Incorporates evidence-based interventions for stage II pressure injury 5. Provides for access to patient care information within the electronic health record

1, 2, 4.

A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Provide specific information in frequent, small amounts for older adult patients. 5. Speak quickly so that you do not take up much of the patient's time.

1, 2, 4;

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.) 1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 3. The nurse reviews the policy and procedure for the cold application. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. 5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.

1, 2, 4;

Which statements properly apply an ethical principle to justify access to health care? (Select all that apply.) 1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 3. Access to health care is a privilege in the United States, not a right. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

1, 2, 4;

Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (Select all that apply.) 1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 3. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified. 5. Whether a person has a job is an objective measure, but it does not play a role in understanding quality of life.

1, 2, 4;

The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

1, 2, 5

A nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate? (Select all that apply.) 1. Refer her to an ophthalmologist. 2. Suggest large-print books and playing cards. 3. Reassure her that this is part of normal aging. 4. Suggest lower-wattage light bulbs to decrease glare. 5. Assess her home environment for safety.

1, 2, 5;

Which of the following are examples of a nurse participating in primary care activities? (Select all that apply.) 1. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2. Assessing the nutritional status of older adults who come to the community center for lunch 3. Working with patients in a cardiac rehabilitation program 4. Providing home wound care to a patient 5. Teaching a class to parents at the local grade school about the importance of immunizations

1, 2, 5;

Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.) 1. Initiative in reading current evidence from the literature 2. Application of nursing theory 3. Reviewing a policy and procedure manual 4. Considering a colleague's view of a patient's needs 5. Previous time caring for a specific group of patients

1, 2.

A 45-year-old woman who is obese tells a nurse that she wants to lose weight. Which assessment findings may be contributing factors to the woman's obesity? (Select all that apply.) 1. The woman works in an executive position that is very demanding. 2. The woman says that she has little time to prepare meals at home and eats out at least four nights a week. 3. The woman works out at the corporate gym at 5 AM three mornings per week. 4. The woman says that she tries to eat "low-cholesterol" foods to help lose weight. 5. The woman says that she vacations annually to reduce stress.

1, 2;

A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse's ability to perform patient evaluation? (Select all that apply.) 1. Comparing patient response with previous response 2. Examining results of clinical data 3. Recognizing error 4. Self-reflection 5. Checking medical record for when IV was inserted.

1, 2;

The patient states, "I don't have confidence in my doctor. She looks so young." The nurse therapeutically responds: (Select all that apply.) 1. Tell me more about your concern. 2. You have nothing to worry about. Your doctor is perfectly competent. 3. You are worried about your care? 4. You can go online and see how others have rated your doctor. I do that. 5. You should ask your doctor to tell you her background.

1, 3

The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer user name and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged in to a computer to save time if you only need to step away to administer a medication

1, 3, 4

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip-read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

1, 3, 4

Intimate partner violence (IPV) is linked to which of the following factors? (Select all that apply.) 1. Alcohol abuse 2. Marriage 3. Pregnancy 4. Unemployment 5. Drug use

1, 3, 4,

One element of clinical decision making is knowing the patient. Which of the following activities affect a nurse's ability to know patients better? (Select all that apply.) 1. Caring for similar groups of patients over time 2. Reading the evidence-based practices appropriate to patients 3. Learning how patients typically respond to their clinical situations 4. Observing patients 5. Engaging with patients experiencing illness

1, 3, 4, 5;

Which of the following factors should be considered when choosing an intervention for a patient's plan of care? (Select all that apply.) 1. The specific patient outcome against which to judge effectiveness of interventions 2. The timing of care activities routinely conducted on the care unit 3. The scientific evidence available in support of an intervention 4. The amount of time required for implementation in consideration of patient's condition 5. The patient's values and beliefs regarding the intervention

1, 3, 4, 5;

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data.

1, 3, 4.

A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse's goal of care for this patient is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.) 1. Quality of life 2. Patient satisfaction 3. Clinic follow-up visits 4. Adherence to self-administration of insulin 5. Description of side effects of medications

1, 3, 4;

Which of the following are outcomes measurements? (Select all that apply.) 1. A nurse teaches a patient how to administer an injection and then observes the patient do a return demonstration. 2. A nurse implements a new pain-management protocol and checks patients' charts to confirm whether interventions are being provided. 3. A nursing unit adopts a set of strategies for reducing pressure injuries, and the UPC members use direct observation of the skin to measure incidence of pressure injuries. 4. A nursing unit implements a new fall-prevention protocol and checks the monthly performance data for incidence of falls on the unit. 5. A nursing unit implements a patient rounding program, and the charge nurse watches the assistive personnel to see whether hourly rounding is being done on patients.

1, 3, 4;

Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation involves reflection on the approach to care. 2. Evaluation involves determination of the completion of a nursing intervention. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is performed only when a patient's condition changes.

1, 3, 4;

A nurse is completing an assessment on a 27-year-old female patient. Which questions best assess the psychosocial aspects of this young woman's health? (Select all that apply.) 1. Do you feel safe in your home and at work? 2. How many fruits and vegetables do you typically eat every day? 3. Describe your relationship with your family. 4. Have you had the vaccine to prevent HPV? 5. What are your long-term career goals?

1, 3, 5;

A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this woman's health? (Select all that apply.) 1. Medicaid insurance 2. Annual screening 3. Mother's history of breast cancer 4. Lack of transportation 5. Woman's age

1, 4, 5

A nurse demonstrates caring by helping family members to: (Select all that apply.) 1. Become active participants in care. 2. Remove themselves from personal care. 3. Make health care decisions for the patient. 4. Plan uninterrupted time for family and patient to be together. 5. Discuss their concerns.

1, 4, 5

A 71-year-old patient enters the emergency department after falling down stairs at church. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1, 4, 5.

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination on whether the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1, 4;

Which of the following best describe a collaborative health problem? (Select all that apply.) 1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status 2. The language medical practitioners use to communicate a patient's health problem and associated treatments and response 3. A diagnostic label that classifies a patient's response to illness so that all nurses can be familiar with a specific patient's health care needs 4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals

1, 4;

Sequence the skills in the expected order of gross-motor development in an infant, beginning with the earliest skill. 1. Can lift head 45 degrees off table, when prone 2. Pulls self to standing position 3. Sits upright without support 4. Rolls from back to abdomen 5. Rolls from abdomen to back

1, 5, 4, 3, 2;

A 20-year-old patient diagnosed with an eating disorder has a nursing diagnosis of Situational Low Self-Esteem. Which of the following nursing interventions are appropriate to address self-esteem? (Select all that apply.) 1. Offer independent decision-making opportunities. 2. Review previously successful coping strategies. 3. Provide a quiet environment with minimal stimuli. 4. Support a dependent role throughout treatment. 5. Increase calorie intake to promote weight stabilization.

1,2

Which of the following are common barriers to effective discharge planning? (Select all that apply.) 1. Ineffective communication among providers 2. Lack of role clarity among health care team members 3. Sufficient number of hospital beds to manage patient volume 4. Patients' long-term disabilities 5. The patient's cultural background

1,2

Which of the following are examples of the conventional reasoning form of cognitive development? (Select all that apply.) 1. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. 2. A young father is considering whether or not to return to school for a graduate degree. He considers the impact the time commitment may have on the needs of his wife and infant son. 3. A teenage girl is encouraged by her peers to engage in shoplifting. She decides not to join her peers in this activity because she is afraid of getting caught in the act. 4. A single mother of two children is unhappy with her employer. She has been unable to secure alternate employment but decides to quit her current job. 5. A young man drives over the speed limit regularly because he thinks he is an excellent driver and will not get into a car accident.

1,2

The nurse can increase a patient's self-awareness and self-concept through which of the following actions? (Select all that apply.) 1. Helping the patient define personal problems clearly 2. Allowing the patient to openly explore thoughts and feelings 3. Reframing the patient's thoughts and feelings in a more positive way 4. Having family members assume more responsibility during times of stress 5. Recommending self-help reading materials

1,2,3

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

1,2,3

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." 5. "I will go back to school as soon as I finish orientation."

1,2,3

A 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over 10 lb. She is started on intravenous antibiotics, high-protein shakes, and 2 L O2 via nasal cannula. Her most recent vital signs are HR 112, BP 138/82, RR 22, tympanic temperature 37.9°C (100.2° F), and oxygen saturation 94%. Which vital signs reflect a positive outcome of the treatment interventions? (Select all that apply.) 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 98 3. Respiratory rate: 18 4. Oxygen saturation: 96% 5. Blood pressure: 134/78

1,2,3,4

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

1,2,3,4

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain.

1,2,4

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

1,2,4,5

Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. A patient admitted with hypothermia 4. Postoperative patient waking from general anesthesia 5. Three-pack-per-day smoker with pneumonia

1,2,5

While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. Tell me what your husband was like. 4. I know this must be hard for you. Let me tell you what might help. 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

1,2,5

Before implementing touch, what does a nurse need to know about touch? (Select all that apply.) 1. Some cultures may have specific restrictions about non-skill-based touch. 2. Touch is a type of verbal communication. 3. Touch can successfully influence a patient's level of comfort. 4. There is never a problem with using touch at any time. 5. Touch only reduces physical pain.

1,3

Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.) 1. Priority setting establishes a preferential order for nursing interventions. 2. In most cases wellness problems take priority over problem-focused problems. 3. Recognition of symptom patterns helps in understanding when to plan interventions. 4. Longer-term chronic needs require priority over short-term problems. 5. Priority setting involves creating a list of care tasks.

1,3

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.

1,3

When assessing a patient's adjustment to the role changes brought about by a medical condition such as a stroke, the nurse asks about which of the following? (Select all that apply.) 1. What are your thoughts about returning to work? 2. What questions do you have about your medications? 3. How has your health affected your relationship with your partner? 4. What level of physical activity are you able to perform? 5. What concerns do you have about another stroke?

1,3

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

1,3

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1,3,4

An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (WHNP) informs the patient that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." Which responses by the WHNP would be appropriate? (Select all that apply.) 1. "Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women." 2. "Bacterial STIs don't usually cause symptoms, or you could have an asymptomatic viral STI." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 are often asymptomatic and have the highest incidence of STIs." 5. "There is no need to screen for infection since you aren't having any problems or symptoms."

1,3,4

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (Select all that apply.) 1. Ethics of care pays attention to the context in which caring occurs. 2. Ethics of care is used only by nurses because it is part of the Nursing Code of Ethics. 3. Ethics of care requires understanding the relationships between involved parties. 4. Ethics of care considers the decision maker's relationships with other involved parties. 5. Ethics of care is an approach that suggests a greater commitment to patient care. 6. Ethic of care considers the decision maker to be in a detached position outside the ethical problem.

1,3,4

The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this age-group. 3. Lesbian, gay, bisexual, and transgender (LGBTQ+) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance.

1,3,4

The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) 1. "I don't need to use condoms since there is no risk for pregnancy." 2. "I should be screened for an STI each time I'm with a new partner." 3. "I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year, so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

1,3,4,5

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

1,3,4,5

Which of the following describe characteristics of an integrated health care system? (Select all that apply.) 1. The focus is holistic. 2. Participating hospitals follow the same model of health care delivery. 3. The system coordinates a continuum of services. 4. The focus of health care providers is finding a cure for patients. 5. Members of the health care team link electronically to use the EMR to share the patient's health care record.

1,3,5

A 9-year-old child has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, failure at this stage of development results in: (Select all that apply.) 1. Feelings of inadequacy. 2. A sense of guilt. 3. A poor sense of self. 4. Feelings of inferiority. 5. Mistrust.

1,4

At a well-child examination, the mother comments that her toddler eats little at mealtime, will sit only briefly at the table, and wants snacks all the time. Which of the following should the nurse recommend? (Select all the apply.) 1. Provide nutritious snacks for a healthy diet. 2. Offer rewards for eating at mealtimes. 3. Avoid snacks so she is hungry at mealtime. 4. Offer finger foods so she can eat as she walks. 5. Explain to her why eating at mealtime is important.

1,4

Which of the following actions, if performed by a registered nurse, could result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) 1. Reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written order 5. Completing an occurrence report on the unit

1,4

A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements

1,5

A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) 1. Difficulty paying his bills 2. Praying daily 3. Age of patient (46 years) 4. Stress from the divorce and the loss of a job 5. Family practice of not routinely seeing a health care provider

1,5

A patient is in skeletal traction and has a plaster cast due to a fractured femur. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to provide patient education about cast care. 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

1,5

Match the advanced practice nurse specialty with the statement about the role. 1. Clinical nurse specialist 2. Nurse anesthetist 3. Nurse practitioner 4. Nurse-midwife

1.b. Expert clinician in a specialized area of practice such as adult diabetes care 2.d. Provides care and services under the supervision of an anesthesiologist 3.c. Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or have chronic conditions 4.a. Provides independent care, including pregnancy and gynecological services

Match the following caring behaviors with their definitions. 1. Knowing 2. Being with 3. Doing for 4. Maintaining belief

1.b. Striving to understand an event as it has meaning in the life of the other 2.c. Being emotionally present to the other 3.d. Doing for the other as he or she would do for self if it were at all possible 4.a. Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning

From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O). 1. _____ Will achieve pain relief 2. _____ Ambulates 10 feet down hallway 3. _____ Will remain free of infection 4. _____ Will be afebrile 5. _____ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10 6. _____ Will gain improved mobility

1G, 2O, 3G, 4G, 5O, 6G;

The nurse is caring for a patient who is very depressed and decides to complete a spiritual assessment using the FICA tool. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question on the right. 1. F—Faith ___ 2. I—Importance of spirituality ___ 3. C—Community ___ 4. A—Interventions to address spiritual needs ___

1a. Tell me if you have a higher power or authority that helps you act on your beliefs 4b. Describe which activities give you comfort spiritually 3c. To whom do you go for support in times of difficulty? 2d. Your illness has kept you from attending church. Is that a problem for you?

A critical care nurse is using a new research-based intervention to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Evidence-based practice 3. Teamwork and collaboration 4. Quality improvement

2

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Anxiety.

2

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. The patient is very thin and unkempt, has a stage 3 pressure injury on her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step? 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so that she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess the patient's cognitive status.

2

A nurse is assigned to care for an 82-year-old patient who will be transferred from the hospital to a rehabilitation center. The patient and her husband have selected the rehabilitation center closest to their home. The nurse learns that the patient will be discharged in 3 days and decides to make the referral on the day of discharge. The nurse reviews the recommendations for physical therapy and applies the information to fall prevention strategies in the hospital. What discharge planning action by the nurse has not been addressed correctly? 1. Patient and family involvement in referral 2. Timing of referral 3. Incorporation of referral discipline recommendations into plan of care 4. Determination of discharge date

2

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: 1. Educator. 2. Advocate. 3. Caregiver. 4. Communicator.

2

A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Normal aging. 2. Delirium. 3. Depression. 4. Worsening dementia.

2

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? 1. Family member 2. Surgeon 3. Nurse 4. Nurse manager

2

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Reflection. 2. Clinical inference. 3. Cue. 4. Validation.

2

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? 1. Incorrect clustering of data 2. Wrong diagnosis 3. Condition is a collaborative problem 4. Premature ending assessment

2

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

2

A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient's airways. When the nurse asks how the patient feels, he responds by saying, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient's condition? 1. Counting respirations per minute 2. Asking the patient to describe how his breathing feels 3. Observing breathing pattern 4. Auscultating lung sounds

2

A patient in the intensive care unit experiences a sentinel event related to central-line catheter care that resulted in serious injury. What performance improvement model should the unit use to identify errors that led to the sentinel event? 1. Six Sigma 2. Root cause analysis 3. PDSA 4. Balanced scorecard

2

A patient suddenly experiences a severe headache with numbness and decreased movement in the left arm. The emergency room physician suspects a stroke and is going to have the patient undergo an emergent angiogram to remove the clot. Which teaching approach is most appropriate? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach

2

As part of a faith community nursing program in her church, a nurse is developing a health promotion program on breast self-examination for the women's group. Which statement made by one of the participants is related to the individual's accurate perception of susceptibility to an illness? 1. "I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly." 2. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer." 3. "Since I am only 25 years of age, the risk of breast cancer for me is very low." 4. "I participate every year in our local walk/run to raise money for breast cancer research."

2

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2

The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data interpretation 4. Termination

2

The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? 1. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. 3. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours.

2

The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity.

2

The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erikson's stages of development? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Autonomy versus sense of shame and doubt

2

What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

2

When designing a plan for pain management for a patient following surgery, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. If the nurse's actions are driven by respect for autonomy, what aspect of this scenario best demonstrates that? 1. Assessing the patient's pain on a numeric scale every 2 hours 2. Asking the patient to establish the goal for pain control 3. Using alternative measures such as distraction or repositioning to relieve the pain 4. Monitoring the patient for oversedation as a side effect of his pain medication

2

When nurses are communicating with adolescents, they should: 1. Ask closed-ended questions to get straight answers. 2. Ask the adolescent to collaborate on plan of care. 3. Avoid looking for meaning behind adolescents' words or actions. 4. Avoid discussing sensitive issues such as sex and drugs.

2

You are caring for a 4-year-old child who is hospitalized for an infection. He tells you that he is sick because he was "bad." Which is the most correct interpretation of his comment? 1. Indicative of maladaptive stress response 2. Representative of his cognitive development 3. Suggestive of excessive discipline at home 4. Indicative of his developing sense of inferiority

2

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity.

2, 3

A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Goal setting

2, 3, 4

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. To improve the nurse's status with the health team members 2. To reduce the risk of errors to the patient 3. To provide an optimum level of patient care 4. To improve patient outcomes 5. To prevent issues that need to be reported to outside agencies

2, 3, 4

The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) 1. Matching the rate of speech to be the same as that of the patient 2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient 5. Assuring the patient that all will be well

2, 3, 4

Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select all that apply.) 1. Regular participation in a book club 2. Lack of interest in exercise 3. Difficulty falling asleep 4. Lack of desire to go to work 5. Anxiety while working

2, 3, 4, 5

A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply.) 1. State goals of the session for the patient. 2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 5. Use a standard question list for the chosen topic.

2, 3, 4;

A nurse is teaching the mother of a young infant about prevention of sudden infant death syndrome (SIDS). Which of the following statements indicates that the teaching has been effective? (Select all that apply.) 1. "I'll let the baby sleep in bed with me so I can watch her." 2. "I'll remove stuffed animals and pillows from the crib." 3. "I'll place my baby on her back for sleep." 4. "I'll be sure to keep my baby's room cool." 5. "I'll keep a crib bumper in the bed to prevent drafts."

2, 3, 4;

Which of the following are strategies for creating work environments that support nurse caring interventions? (Select all that apply.) 1. Increasing technological support 2. Improving flexibility for scheduling 3. Providing opportunities to discuss care 4. Promoting autonomy of practice

2, 3, 4;

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

2, 3, 5

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2, 3, 5

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment data, noting objective and subjective clinical information. 3. Cluster clinical data elements that form a pattern. 4. Identify appropriate assessment findings for diagnosis. 5. Identify a nursing diagnosis.

2, 3, 5, 1, 4;

A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient's airways. The patient tells the nurse after the first medication infusion, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.) 1. Asking patient to breathe deeply during auscultation 2. Counting respirations per minute 3. Asking the patient to describe how his breathing feels 4. Starting the intravenous infusion 5. Auscultating lung sounds

2, 3, 5;

A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse's unit environment will affect the ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. Type of hospital unit 5. Competency of patient care technician

2, 3, 5;

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) 1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure. 2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.

2, 3, 5;

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse asks about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2, 3, 5;

A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient's intravenous (IV) port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.) 1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient. 2. Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 4. Tell the IV nurse the problem is probably related to the physician who inserted the port. 5. Describe to the IV nurse the type and condition of the port currently in use.

2, 3, 5;

The school nurse has been following a 9-year-old student who has shown behavioral problems in class. The student acts out and does not follow teacher instructions. The nurse plans to meet with the student's family to learn more about social determinants of health that might be affecting the student. Which of the following factors would be appropriate for this type of assessment? (Select all that apply.) 1. The student's seating placement in the classroom 2. The level of support parents offer when the student completes homework 3. The level of violence in the family's neighborhood 4. The age at which the child first began having behavioral problems 5. The cultural values about education held by family

2, 3, 5;

Which of the following is an example of a patient with a health disparity? (Select all that apply.) 1. A patient who has a homosexual sexual preference 2. A patient unable to access primary care services 3. A patient living with a chronic disease 4. A family who relies on public transportation 5. A patient who has had a history of smoking for 10 years

2, 3, 5;

A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse's statements in order according to these phases. 1. The nurse states, "Let's work on learning injection techniques." 2. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency. 3. The nurse summarizes progress made during the nursing relationship. 4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship.

2, 4, 1, 3;

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the past month." 2. "My name is Terry. I'll be the nurse taking care of you today." 3. "I have no further questions. Is there anything else you wish to ask me?" 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite has been poor—correct?"

2, 4, 1, 5, 3;

A nurse enters a patient's room at the beginning of a shift to conduct an assessment of his condition following a blood transfusion. The nurse cared for the patient on the previous day as well. The patient has a number of issues he wishes to share with the nurse, who takes time to explore each issue. The nurse also assesses the patient and finds no signs or symptoms of a reaction to the blood product. The 209nurse observed the patient the prior day and sees a change in his behavior, a reluctance to get out of bed and ambulate. Which of the following actions improve the nurse's ability to make clinical decisions about this patient? (Select all that apply.) 1. Working the same shift each day 2. Spending time during the patient assessment 3. Knowing the early mobility protocol guidelines 4. Caring for the patient on consecutive days. 5. Knowing the pattern of patient behavior about ambulation

2, 4, 5;

The nurse is using the QSEN competency of EBP when working with the unit council to initiate a change related to pain management. Which behaviors demonstrate the nurse practicing behaviors associated with EBP? (Select all that apply.) 1. Initiating plan for self-development as a team member 2. Reading original research related to pain management 3. Demonstrating effective use of strategies to reduce risk of harm to self or others 4. Valuing EBP as critical to the development of pain management guidelines for the unit 5. Describing to the unit council reliable sources for locating clinical guidelines 6. Applying technology and information management tools to support safe processes of care

2, 4, 5;

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.) 1. Age 42 2. Dysuria 3. Difficulty performing perineal hygiene 4. Nocturia 5. Episode of diarrhea

2, 4;

A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) 1. Reviewing the family caregiver's availability during medication administration times 2. Determining the value the patient places on taking medications 3. Reviewing the number of medications and time each is to be taken 4. Determining all consequences associated with the patient missing specific medicines 5. Reviewing the therapeutic actions of the medications

2, 4;

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Offer frequent skin care because of Impaired Skin Integrity 2. Risk of Infection 238 3. Chronic Pain related to osteoarthritis 4. Activity Intolerance related to physical deconditioning 5. Lack of Knowledge related to laser surgery

2, 4;

A patient presents in the clinic with dizziness and fatigue. The assistive personnel (AP) reports a slow but regular radial pulse of 44. Place the following care activities in priority order. 1. Direct the AP to obtain a blood pressure. 2. Request that the patient lie on the clinical stretcher. 3. Assess the patient's apical pulse for a full minute. 4. Prepare to administer cardiac-stimulating medications.

2,1,3,4

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church."

2,3

A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What should the oncoming nurse do? (Select all that apply). 1. Add this information to the board hanging at the patient's bedside. 2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. 4. Forward the text to the charge nurse. 5. Thank the nurse for sending the information.

2,3

The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse's silence? (Select all that apply.) 1. Allows the nurse time to focus and avoid saying the wrong thing 2. Prompts the patient to talk when he or she is ready 3. Allows the patient time to think and gain insight 4. Allows time for the patient to drift off to sleep 5. Determines whether the patient would prefer to talk with another staff member

2,3

Which of the following assessment findings suggest an altered self-concept? (Select all that apply.) 1. Uneven gait 2. Slumped posture and poor personal hygiene 3. Avoidance of eye contact when answering a question 4. Requests for visits from the chaplain 5. Frequent use of the call light

2,3

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply.) 1. Loss of autonomy caused by health problems 2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

2,3,4,5

A nurse is caring for a 40-year-old male diagnosed with Crohn's disease several years ago, resulting in numerous hospitalizations each year for the past 3 years. Which of the following behaviors interfere with the developmental tasks of middle adulthood? (Select all that apply.) 1. Sends birthday cards to friends and family 2. Refuses visitors while hospitalized 3. Self-absorbed in physical and psychological issues 4. Performs self-care activities 5. Communicates feelings of inadequacy

2,3,5

The nurse assesses the risk factors for coronary artery disease (CAD) in a female patient. Which of these factors are classified as genetic and physiological? (Select all that apply.) 1. Sedentary lifestyle 2. Mother died from CAD at age 48 3. History of hypertension 4. Eats diet high in sodium 5. Elevated cholesterol level

2,3,5

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry.

2,3,5

A nurse is assigned to care for a woman who is expecting her first child. The nurse organizes herself and plans to gather data about the patient by applying Pender's health promotion model, including the patient's characteristics and experiences and situational influences. She plans to observe patient behavior and consider the patient's psychosocial issues. Such data will offer a clear understanding to help the nurse identify the patient's needs. This is an example of which of the following concepts? (Select all that apply.) 1. Diagnostic reasoning 2. Deductive reasoning 3. Inductive reasoning 4. Assessment 5. Problem solving

2,4

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

2,4

The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) 1. Nurses are not expected to discuss sexual issues with male patients and the physician should address this. 2. Sexual function can be affected by some medications. 3. Sexually transmitted infections (STIs) can cause complications such as erectile dysfunction and screening should be done. 4. Some men with health issues experience erectile dysfunction. 5. Medications used to treat hypertension and depression seldom interfere with sexual function.

2,4

Which of the following scenarios demonstrate that learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors.

2,4

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents. 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her."

2,4,3,1

A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) 1. Sexual issues are expected in a woman this age. 2. Women experience sexual dysfunction more frequently than men. 3. Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. 4. Medical conditions such as cancer often contribute to HSDD. 5. Disturbances in self-concept affect sexual functioning.

2,4,5

A nurse working on a medical patient care unit states, "I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can't wait for my shift to be over. I wish I felt happy again." What are the best responses from the nurse manager? (Select all that apply.) 1. "I'm sure this is just a phase you are going through. Hang in there. You'll feel better soon." 2. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" 3. "You can take diphenhydramine over the counter to help you sleep at night." 4. "Describe for me what you do with your time when you are not working." 5. "The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-mail the schedule to you?"

2,4,5

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The assistive personnel reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4°C (99.3°F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%

2,4,5

According to Piaget's cognitive theory, a 12-year-old child is most likely to engage in which of the following activities? (Select all that apply.) 1. Using building blocks to determine how houses are constructed 2. Writing a story about a clown who wants to leave the circus 3. Drawing pictures of a family using stick figures 4. Writing an essay about patriotism 5. Hanging out with a best friend

2,5

During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately. 2. Repeat the measurements on both arms using a stethoscope. 3. Ask the patient if she has taken her blood pressure medications recently. 4. Obtain blood pressure measurements on lower extremities. 5. Verify that the correct cuff size was used during the measurements. 6. Review the patient's record for her baseline vital signs. 7. Compare right and left radial pulses for strength.

2,6

4. The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time:

2000

Match the cultural concepts on the left with the correct definitions on the right. 1. Etic world view 2. World view 3. Cultural desire 4. Intersectionality 5. Emic world view

2a. Factor that shapes how people perceive others and how they relate to reality 5b. Insider's perspective in an intercultural encounter 4c. A policy model that describes factors and power structures that shape and influence life 1d. An outsider's perspective in an intercultural encounter 3e. The motivation of a healthcare professional to "want to" engage in cultural competency

1. A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: 1. "Latex condoms are the most effective way to eliminate the risk of HPV transmission." 2. "Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity." 3. "The HPV 9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts." 4. "You are past the recommended age to receive the vaccine."

3

A 15-year-old patient tells the nurse that she is sexually active. What is the best action by the nurse? 1. Contact her parents to alert them of her need for birth control. 2. Explain that having sex is not appropriate for her age-group. 3. Counsel her on safe sex practices and on minimizing health risks. 4. Ask her to have her partner come to the clinic for STI testing.

3

A 50-year-old woman has elevated serum cholesterol levels that increase her risk for cardiovascular disease. One method to control this risk factor is to identify the patient's current diet trends and describe dietary changes to reduce the risk. This nursing activity is a form of: 1. Referral. 2. Counseling. 3. Health education. 4. Stress-management techniques.

3

A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregivers

3

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? 1. Document her findings and treat the patient. 2. Instruct the mother on safe handling of a 2-year-old child. 3. Contact a child abuse hotline. 4. Discuss this story with a colleague.

3

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."

3

A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing

3

A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works.

3

A nurse is reading a research article discussing a new practice to decrease the incidence of catheter-associated urinary tract infections. One section of the article describes who was studied and how the data were collected to answer the research questions and hypotheses. What section of the research article is currently being read? 1. The literature review 2. The data analysis 3. The methods 4. The implications for practice

3

A nurse meets with the registered dietitian and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Quality improvement

3

A nurse received bedside report at the change of shift with the night-shift nurse and the patient. The nursing student assigned to the patient asks to review the patient's medical record. The nurse lists patients' medical diagnoses on the message boards in the patients' rooms. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? 1. Discussing patient conditions at the bedside at the change of shift 2. Allowing the nursing student to review the assigned patient's chart before providing care during the clinical experience 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

3

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

3

A nurse working in a large occupational health clinic knows that many of the workers at her company are marginalized and at risk for poor health outcomes. Which of the following individuals are most likely to be marginalized? 1. Wives of the employees 2. The head supervisors of the company 3. Workers who have a high school education 4. Workers employed for less than a year at the company

3

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray

3

A nursing student is providing a hand-off report to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated walking to end of hall each time and back with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS. Which intervention is a dependent intervention? 1. Providing hand-off report at change of shift 2. Enhancing the patient's sleep hygiene 3. Administering IV fluids 4. Taking vital signs

3

A parent has brought her 6-month-old infant in for a well-child check. Which of her statements indicates a need for further teaching? 1. "I can start giving her whole milk at about 12 months." 2. "I can continue to breastfeed for another 6 months." 3. "I can give her plenty of fruit juice to increase her vitamin intake." 4. "I can start giving her solid food now, introducing one food at a time."

3

A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Transtheoretical prevention

3

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) at 0400, 36.6°C (97.9°F) at 0800, 36.9°C (98.4°F) at 1200, 37.6°C (99.6°F) at 1600, and 38.3°C (100.9°F) at 2000. How would the nurse describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern

3

A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. Cloze test

3

A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient's cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, "Let me get through these questions first." Which action interferes with the nurse's ability to use connection as a communication skill. 1. Introducing self to patient 2. Using the computer as a prompt for questions 3. Making the nurse's questions a priority 4. Assuring the patient all information is confidential

3

A young woman comes to a clinic for the first time for a gynecological examination. Which nursing behavior applies Swanson's caring process of "knowing" the patient? 1. Sharing feelings about the importance of having regular gynecological examinations 2. Explaining risk factors for cervical cancer 3. Recognizing that the patient is modest and maintaining her privacy during the examination 4. Asking the patient what it means to have a vaginal examination

3

Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: "Me, stop smoking? I've been smoking since I was 16!" 1. "That's fine. Some people who smoke live a long life." 2. "OK. I want you to decrease the number of cigarettes you smoke by one each day, and I'll see you in 1 month." 3. "What do you think is the greatest reason why stopping smoking would be challenging for you?" 4. "I'd like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed."

3

Nurses in a community clinic are conducting an EBP project focused on improving the outcomes of children with asthma. The PICO question asked by the nurses is "In school-aged children, does the use of an electronic gaming education module versus educational book improve the usage of inhalers?" In the question, what is the "O"? 1. School-aged children 2. Educational book 3. Use of inhalers 4. Electronic gaming education

3

The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology? 1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action. 2. The single focus on power imbalances does not apply to all situations in which ethical problems occur. 3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. 4. The focus on consequences rather than on the "goodness" of an action makes decision makers uncomfortable.

3

The examination for registered nurse (RN) licensure is the same in every state in the United States. This examination: 1. Guarantees safe nursing care for all patients. 2. Ensures standard nursing care for all patients. 3. Provides a minimal standard of knowledge for an RN in practice. 4. Guarantees standardized education across all prelicensure programs.

3

The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)

3

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3

When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation

3

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

3

Which factor affects a middle-age adult's adherence to a treatment plan? 1. Gender 2. Lifestyle 3. Motivation 4. Family history

3

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? 1. Knowing the source of the guideline 2. Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4. Explaining to a patient the purpose of the guideline

3

The REFLECT model can improve learning after providing patient care. Place the steps of this model in the correct order: 1. Think about your thoughts and actions at the time of a situation. 2. Review the knowledge you gained from the experience. 3. Review the facts of the situation. 4. Set a schedule for completing your plan of action. 5. Consider options for handling a similar situation in the future. 6. Recall any feelings you had at the time of the situation. 7. Create a plan for future situations.

3, 1, 6, 2, 5, 7, 4;

A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude.

3, 4, 5

A nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his family history is not significant for chronic illnesses, and his physical and laboratory findings are within normal limits. Because of these findings, nursing interventions are directed toward activities related to: (Select all that apply.) 1. Instructing him to return in 2 years. 2. Instructing him in secondary prevention. 3. Instructing him in health promotion activities. 4. Instructing him about routine screenings. 5. Instructing him about proper vaccinations.

3, 4, 5.

A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming her patient's care at the end of the clinical day. The student states, "The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated walking to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after exercise. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints. For the goal of improving the patient's activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses walker to walk 3. Walked to visitors lounge 4. No shortness of breath 5. Tolerated dinner meal

3, 4;

Place the following steps of the assessment process in the correct order. 1. Compare data with another source to determine data accuracy. 2. As a pattern forms, probe and frame further questions. 3. Interview a patient, observe behavior, and gather physical assessment findings. 4. Cluster cues that relate together, make inferences, and identify emerging patterns. 5. Differentiate important data from the total data you collect.

3, 5, 4, 2, 1

A 30-year-old patient diagnosed with major depressive disorder has a nursing diagnosis of Situational Low Self-Esteem related to negative view of self. Which of the following are appropriate interventions by the nurse? (Select all that apply.) 1. Encourage reconnecting with high school friends. 2. Role-play to increase assertiveness skills. 3. Focus on identifying strengths and accomplishments. 4. Provide time for journaling to explore underlying thoughts and feelings. 5. Explore new job opportunities.

3,4

A nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but feels uncomfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) 721 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge. 2. Avoid discussing the topic unless the patient brings it up. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. 5. Encourage the patient to discuss any personal concerns with the cardiologist.

3,4

A nurse has been caring for a patient with a chronic wound that has not been healing. The nurse talks with a nurse specialist in wound care to find alternative approaches from what the health care provider ordered for dressing the wound. The two decide that because of the patient's allergy to tape a nonallergenic dressing will be used. The nurse obtains an order from the health care provider for the new dressing. After two days there is improvement in the wound. This is an example of which critical thinking standards? (Select all that apply.) 1. Clear 2. Broad 3. Relevant 4. Risk taking 5. Creativity

3,4,5

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

3,4,5

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, "It is hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) 1. Heart rate of 20 per minute and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 per minute 5. Patient report of sore throat and hoarseness

3,5

A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain

3,5

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) 1. "I'm going to learn to drive a car, so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3,5

Match the components of PICO using the question "Does the use of guided imagery compared with standard care decrease the postoperative pain in hospitalized adolescents?" (P) Patient/population (I) Intervention C) Comparison (O) Outcome

3A. Adolescents receiving standard care 4B. Decreased postoperative pain 1C. Hospitalized adolescents 2D. Guided imagery

Match the concepts for a critical thinker on the right with the application of the term on the left. 1. Truth seeking 2.Open-mindedness 3.Analyticity 4.Systematicity

3a. Anticipate how a patient might respond to a treatment 4b. Organize assessment on the basis of patient priorities. 1c. Be objective in asking questions of a patient. 2d. Be tolerant of the patient's views and beliefs.

Match the elements for correct identification of outcome statements with the SMART acronym terms below. 1. Specific 2. Measurable 3. Attainable 4. Realistic 5. Timed

3a. Mutually set an outcome that a patient agrees to meet. 4b. Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources. 1c. Be sure an outcome addresses only one patient behavior or response. 5d. Include when an outcome is to be met. 2e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status.

A nurse desires to communicate with a young woman who is Serbian and who has limited experience with being in a hospital. The nurse has 10 years of experience caring for Serbian women. The patient was admitted for a serious pregnancy complication. Apply the LEARN model and match the nurse's behaviors with each step of the model. 1. L, 2.E, 3.A, 4.R, 5.N

3a. The nurse notes that she has learned that fathers can visit mothers at any time in both Serbia and the United States. 2b. The nurse shares her perception of the woman's experiences as a patient. 5c. The nurse asks the patient how she can maintain bed rest when she returns home. 1d. The nurse attends to the patient and listens to her story about hospitals in Serbia. 4e. The nurse involves the patient in a discussion of the treatment options for her condition.

A 34-year-old female executive has a job with frequent deadlines. She notes that when the deadlines appear, she tends to eat high-fat, high-carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. After receiving health education from the nurse, the executive decides to try yoga. In this scenario yoga is used as a(n): 1. Outpatient referral. 2. Counseling technique. 3. Health promotion activity. 4. Stress-management technique.

4

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer."

4

A 50-year-old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? 1. "What's the special occasion?" 2. "You must be feeling better today." 3. "This is the first time I've seen you look this good." 4. "I see that you've combed your hair and put on makeup."

4

A 55-year-old adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn

4

A man who is homeless enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the city hospital for care before assessing the patient. This action is most likely a violation of which of the following laws? 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA)

4

A mother is concerned about her child's flulike symptoms. You learn from the health assessment that the mother practices use of "hot" and "cold" foods to treat ailments. Which of the following foods do you expect the mother to use to treat her child? 1. Chicken 2. Yogurt 3. Fresh fruits 4. Eggs

4

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the past 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal formed stool within 48 hours. 3. Patient's ability to turn self in bed improves. 4. Erythema of skin will be mild to none within 48 hours.

4

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: 1. Creativity. 2. Fairness. 3. Clinical reasoning. 4. Applying ethical criteria.

4

A nurse implements an EBP change that teaches patients the importance of taking their diabetes medications correctly and regularly on time using videos streamed on the Internet. The nurse measures the patients' behavioral outcome from the practice change using which type of measurement? 1. Measuring the patient's weight 2. Chart auditing teaching sessions 3. Observing patients viewing the videos 4. Checking patients' blood sugars

4

A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient's heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient's situation? 1. The patient is recovering normally. 2. The symptoms reflecting restlessness 3. The patient's blood pressure trend 4. The delay in administration of the analgesic

4

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.

4

A nurse is caring for a patient who has poor pain control. The patient has a history of opioid abuse. During the day the patient made frequent requests for a pain medication. In order to make an effective clinical decision about this patient, the nurse needs to ask questions about the data available on the patient to make a thorough and thoughtful decision. The nurse asks herself, "How does my view about the patient's pain tolerance compare with the patient's, and does that pose a problem?" This is an example of: 1. A question about assumptions. 2. A question about evidence. 3. A question about procedure. 4. A question about perspective.

4

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: 1. "You're correct; spiritual care should be left to a pastoral care professional." 2. "You're correct; religion is a personal decision." 3. "Nurses should explain their own religious beliefs to patients." 4. "Spiritual, mind, and body connections can affect health."

4

A woman has severe life-threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The health care provider ordered two units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? 1. Obtain a court order to give the blood. 2. Convince the husband to allow the nurse to give the blood. 3. Call security and have the husband removed from the hospital. 4. Gather more information about the wife's preferences and determine whether the husband is her power of attorney for health care.

4

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: 1. Making health care decisions for patients. 2. Having family members provide a patient's total personal hygiene. 3. Injecting the nurse's perceptions about the level of care provided. 4. Asking permission before performing a procedure on a patient.

4

An experienced nurse is explaining the use of touch from a caring perspective. What information does the nurse include in the discussion with the student about touch? 1. Nurses touch patients only while performing procedures or doing assessments. 2. Touch is a type of verbal communication. 3. Nurses use touch only when a patient is in pain. 4. Touch forms a connection between nurse and patient.

4

Dave reports being happy and satisfied with his life. What do we know about him? 1. He is in one of the later developmental periods, concerned with reviewing his life. 2. He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives. 3. He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships. 4. It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages.

4

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent: 1. Imaginary audience. 2. False-belief syndrome. 3. Personal fable. 4. Sense of invulnerability.

4

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Medication side effects often impact sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

4

Parents are concerned about their toddler's negativism. To avoid a negative response, which of the following is the best way for a nurse to demonstrate asking the toddler to eat lunch? 1. Would you like to eat your lunch now? 2. Would you like to sit at the big table to eat? 3. When would you like to eat your lunch with your friends? 4. Would you like apple slices or applesauce with your sandwich?

4

The home health nurse is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks' post right hip replacement. He ambulates with difficulty with a walker. He comments that he is saddened now that his wife has to do more for him and he is doing less for her. Which of the following is the priority nursing diagnosis? 1. Impaired Self Toileting 2. Lack of Knowledge Regarding Resources for the Visually Impaired 3. Disturbed Body Image 4. Risk for Situational Low Self-Esteem

4

The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of: 1. Logical reasoning. 2. Egocentrism. 3. Concrete thinking. 4. Animism.

4

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

4

The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. 4. CPOE improves patient safety by reducing transcription errors.

4

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

4

The nurses on a medical unit have seen an increase in the number of pressure injuries developing in their patients. The nurses decide to initiate a performance improvement project using the PDSA model. Which of the following is an example of "Plan" from that model? 1. Orienting patients to the unit's practice of hourly rounding on patients 2. Reviewing the incidence of pressure injuries on patients cared for using the protocol 3. Based on findings from patients who developed injuries, implementing an evidence-based skin care protocol on all units 4. Meeting with all disciplines to develop a multidisciplinary approach for reducing pressure injuries

4

The nurses on an acute care medical floor notice an increase in pressure injury formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure injury risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career? 1. Clinical nurse specialist 2. Nurse administrator 3. Nurse educator 4. Nurse researcher

4

What is the best response for the nurse to give if a patient asks the nurse to send a photo of an x-ray to him via a messaging tool in a social media site? 1. Yes, if you remove all patient identifiers before sending 2. No, because the patient's x-ray results should be discussed with a provider 3. Yes, because respect for autonomy means honoring this patient's request 4. No, because health information of any kind should not be shared on social media

4

When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use? 1. Allowing the child to watch another child undergoing the same procedure 2. Showing the child pictures of what he or she will experience 3. Talking to the child in simple terms about what will happen 4. Preparing the child through play with a doll and toy medical equipment 142

4

Which activity performed by a nurse is related to maintaining competency in nursing practice? 1. Asking another nurse about how to change the settings on a medication pump 2. Regularly attending unit staff meetings 3. Participating as a member of the professional nursing council 4. Attending a review course in preparation for a certification examination

4

Which of the following statements is true regarding Magnet® status recognition for a hospital? 1. Nursing is run by a Magnet manager who makes decisions for the nursing units. 2. Nurses in Magnet hospitals make all of the decisions on the clinical units. 3. Magnet is a term that is used to describe hospitals that are able to hire the nurses they need. 4. Magnet is a special designation for hospitals that achieve excellence in nursing practice.

4

Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? 1. "My pain medicine helps me feel better." 2. "I know I will get better if I just keep trying." 738 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I feel so much closer to God after I read my Bible and pray."

4

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which statement best describes this code? 1. Improves self-health care 2. Protects the patient's confidentiality 3. Ensures identical care to all patients 4. Defines the principles of right and wrong to provide patient care

4

The assistive personnel (AP) informs the nurse that the electronic blood pressure machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place the care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.

4, 1, 3, 2, 5

The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) 1. Validate health care needs through verbal discussion with the patient. 2. Compare actual and expected patient care outcomes with the patient. 3. Provide support through therapeutic communication techniques. 4. Complete a nursing history using verbal communication techniques.

4, 1, 3, 2;

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 PM yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days." 2. "The patient reported feeling very nauseated after her dose of levofloxacin an hour ago." 340 3. "Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started to complain of nausea yesterday evening and has vomited several times during the night."

4S, 1B, 2A, 3R;

Match the category of direct care on the left with the specific direct care activity on the right. 1. Counseling ___ 2. Lifesaving measure ____ 3. Physical care technique ___ 4. Activity of daily living ____

4a. Assisting patient with oral care 1b. Discussing a patient's options in choosing palliative care 2c. Protecting a violent patient from injury 3d. Using safe patient handling during positioning of a patient

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?226 1. Current medications 2. Patient expectations of planned surgery 3. Review of patient's family support system 4. History of allergies 5. Patient's explanation for what might be the cause of symptoms that require surgery

5

Place the steps of the EBP process in the appropriate order. 1. Critically appraise the evidence you gather. 2. Ask the clinical question in PICOT format. 3. Evaluate the outcomes of the practice decision or change. 4. Search for the most relevant and best evidence. 5. Cultivate a spirit of inquiry. 6. Integrate the evidence. 7. Communicate the outcomes of the EBP change.

5, 2, 4, 1, 6, 3, 7;

The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution? 1. List all the possible actions that could be taken to resolve the problem. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 3. Develop and implement a plan to address the problem. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 6. Recognize that the problem requires ethics.

6, 4, 5, 2, 1, 3

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

6, 9, 2, 5, 7, 3, 1, 4, 8 -Ensure that the request for organ/tissue donation and/or autopsy was completed. -Elevate the head of the bed. -Collect any needed specimens. -Speak to the family members about their possible participation. -Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. -Remove all tubes and indwelling lines. -Bathe the body of the deceased. -Position the body for family viewing. -Accurately tag the body, including the identity of the deceased and safety issues regarding infection control.

Match the assessment activity on the left with the type of assessment on the right. A. Problem focused B. Comprehensive

A1. Assessment conducted at beginning of a nurse's shift A2. Review of a patient's chief complaint B3. Completion of admitting history at time of patient admission to a hospital B4. Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home

A nurse on a hospital unit is preparing to hand off care of a patient being discharged to a home health nurse. Match the activities on the left with the hand-off report categories on the right. A. Strategy for Effective Hand-off B. Strategy for Ineffective Hand-off

A1. Use a standard checklist for the report. A2. Encourage questions and clarification. A3. Offer specific information on how to reduce patient's risks. B4. Give report at time when shift has ended and other nurses are requesting information. B5. Explain how patient's discharge was delayed by insufficient numbers of staff. A6. Organize time by preparing in advance what to report.

A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. ACCESS model component: 1. Assessment 2. Communication 3. Cultural 4. Establishment 5. Sensitivity 6. Safety

Nursing approach: 6A. Help patients feel culturally secure and able to maintain their cultural identity. 2B. Remain aware of verbal and nonverbal responses. 5C. Be aware of how patients from diverse backgrounds perceive their care needs. 3D. Become aware of your patient's culture and your own cultural biases. 1E. Learn about the patient's health beliefs and practices. 4F. Show respect by creating a caring rapport.

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2019 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage 7. Rates pain 7/10 at location of surgical incision.

O: 1, 2, 3, 5, 6, 7. S: 4;

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. GOALS: 1. _____ Patient will ambulate independently in 3 days. 2. _____ Patient will be injury free for 1 month. 3. _____ Patient will achieve 5-pound weight gain in 1 month. 4. _____ Patient will achieve pain relief by discharge.

OUTCOMES: 4a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. 3b. Patient increases caloric intake to 2500 calories daily. 1c. Patient walks 20 feet using a walker in 24 hours. 2d. Patient identifies barriers to remove in the home within 1 week.

When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

Post-traumatic stress disorder (PTSD)

A(n)__________________________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.

Risk diagnosis.

Match the following actions (1 through 4) with the terms (a through d) listed below: a. Advocacy b. Responsibility c. Accountability d. Confidentiality

d1. You see an open medical record on the computer and close it so that no one else can read the record without proper access. c2. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the provider and your head nurse and follow agency procedure. a3. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request. b4. You tell your patient that you will return in 30 minutes to give him his next pain medication.