exam 5 exercise

Which statement by the nurse demonstrates a cultural bias?

"American healthcare is really so much better than that provided by any other country." A bias is based on the practice of applying one's own cultural beliefs and values when interpreting and judging the value of something. A prejudice is disapproving or negative attitude that is not rooted in fact or accurate information. Stereotyping involves a uniform image of one group that is believed by another group or a fixed, overgeneralized belief about a particular group.

Which questions may help the nurse assess his or her ability to relate to various groups in society? Select all that apply.

"Can I welcome this person sincerely?" "Can I genuinely try to help this person and be comfortable enough to listen?" "Do I have the experience to help this person?"

Which assessment notation describes a client's level of consciousness?

"Client was alert and cooperative during the assessment."

A nursing instructor is teaching about cultural awareness and sensitivity in client care. The student demonstrates understanding of the above when making which of the following statements?

"Cultural awareness happens first when the nurse obtains culturally specific information from the client's health history."

The nurse makes the following assessment: A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night even though the number of hours of sleep are unchanged, and continues to feel tired and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. The nurse further assesses by asking:

"Have you had any recent head injury?"

A nurse is taking care of a client who has a new, permanent colostomy. The nurse is talking with the client about the new appliance and asking how the client feels about managing it. Which client response indicates understanding of the relationship between self-concept and health?

"I am developing a set of realistic expectations to help me manage my overall health and quality of life." The statement indicating that the client is developing realistic expectations demonstrates understanding that self-concept is an integral part of overall health. Since self-concept is an important part of overall health, a client statement involving self-perception and self-concept should include an understanding of how the two are related. Spiritual beliefs, intellectual dimension, and physical dimension all are factors that influence a person's health-illness status. The client may be intelligent, but this is only a small component of self-concept. Having help at home is not a component of this client's self-concept. Likewise, realizing overall health is important, but keeping appointments is not a component of self-concept.

The nurse is educating a client and spouse about sudden jerking that occurs during sleep. What is the most appropriate nursing response?

"Sudden twitches that occur during the early phases of sleep are common." Nonrapid eye movement (NREM) is quiet sleep. NREM 1 sleep, which occurs at the onset of sleep and lasts about 10 minutes, is characterized as drowsiness and light sleep. Sudden twitches, called hypnogogic jerks, are common. During this early stage of sleep, a person may be aware of sounds and conversations, but avoids arousal. Sudden jerking movements do not indicate vivid dreams and do not occur during REM sleep. A decreased oxygen level does not cause hypnogogic jerks.

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States." A separate or different advance directive is not needed for each state; an advance directive can be used in any state, regardless of where it was created. The nurse should advise the client to take it when travelling out of state. The client should not assume that the family knows the client's wishes; the whole purpose of having an advance directive is to avoid the ambiguity and potential confusion that making such assumptions can cause. Other hospitals may not know who to contact to request a copy of the advance directive; therefore, it would be much safer for the client to take a copy of it while travelling.

A nursing student is studying depression in the elderly adult. Faculty members knows the student has mastered the information when she states which of the following?

"Treatment of depression includes counseling." Treatment of depression usually involves psychotherapy or counseling along with antidepressant medication. In an older adult, hopelessness rather than sadness is more often associated with suicidal intent. Depression usually does not resolve without treatment and is frequently underdiagnosed. There is usually a distinct change of behavior accompanied by other specific signs and symptoms of depression.

The nurse is working with the parents of an infant and has initiated a dialogue about immunizations. The infant's parent states, "We're not comfortable with immunizations because of the safety issue." What is the nurse's best response?

"What are some of the safety risks that most concern you?" The nurse should attempt the therapeutically engage with the clients' concerns in an attempt to have a productive dialogue. The nurse should avoid being condescending or confrontational. Categorical statements about the safety of immunizations may be true, but are likely to be met with resistance from parents who are reluctant.

Misdemeanor

(n.) a crime or offense that is less serious than a felony; any minor misbehavior or misconduct

The nurse attempts to notify a health care provider about a client's elevated temperature but does not get a response. Which statement, if documented by the nurse, would indicate that the nurse is following proper protocol for nursing documentation?

1300: Client temperature elevated. Telephoned health care provider's service 3 times without a response. Tepid sponge bath given and nursing supervisor notified. Documentation must have the correct, factual, and timely information. The nurse must document when the health care provider was called and response or lack of response; what nursing action was done, if any, and notification of appropriate personnel. The nurse cannot administer medication without an order. The nurse should be careful to not make incriminating statements, such as, "as usual, health care provider did not respond." The nurse should not wait until rounds are made to inform the supervisor.

The nurse is preparing to teach four clients. Which client will the nurse plan to teach using principles associated with gerogogy?

79-year-old who has slight cognitive changes Gerogogy is the unique techniques that enhance learning among older adults. Therefore, the nurse will use gerogogy with the 79-year-old client. Pedagogy is the science of teaching children or those with cognitive ability comparable to children, and would be appropriate for the 4-year-old client. Andragogy is the principles of teaching adult learners, and would be appropriate for the 31-year-old client and the 56-year-old client.

What immunizations are recommended for older adults? (Select all that apply.)

A one-time administration of pneumococcal vaccine at 65 years of age A tetanus-diphtheria (Td) booster every 10 years An annual influenza vaccine

What immunizations are recommended for older adults? (Select all that apply.)

A one-time administration of pneumococcal vaccine at 65 years of age An annual influenza vaccine A tetanus-diphtheria (Td) booster every 10 years

entrepreneur

A person who organizes, manages, and takes on the risks of a business.

The nurse is working in a clinic which is providing the annual influenza A vaccine for staff and residents of a large long-term care facility. Which client poses the greatest concern associated with being vaccinated?

A resident who received four units of packed red blood cells for a gastrointestinal bleed three weeks ago Recent blood transfusions contraindicate the use of vaccines because there is an associated risk of an unpredictable immune response. The influenza vaccine, like most vaccines, is not contraindicated during breastfeeding. Old age, COPD and recent hepatitis vaccinations are not contraindications.

Which statements best indicates the client understands recommended vaccines following the 65th birthday?

A tetanus-diphtheria booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age

A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?

A tort is a litigation in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. The lack of action on the nurse's part indicates unintentional tort. A misdemeanor or felony would be an offense under criminal law, and neither is applicable in this case. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property.

What is the priority assessment for the nurse when developing a plan of care for a client from a poverty culture?

Access to care Poverty has long been a barrier to adequate health care. If clients cannot access health care, it does not matter if they have affordable housing, health insurance, or the need for financial assistance. It is not possible to create a plan of care with client involvement without adequate support and access to care.

Which process evaluates and recognizes educational programs as having met certain standards?

Accreditation Accreditation is the process by which an educational program is evaluated and recognized as having met certain standards. Credentialing refers to ways in which professional competence is ensured and maintained. Licensure is the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession—and grants that person the license to do so. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area.

The nurse can best practice effective care by exhibiting which behavior during a cultural assessment?

Acknowledge own prejudices that might create barriers to care. Acknowledge that the nurse's own beliefs and prejudices might create barriers to providing culturally sensitive care. Leininger suggests that the attributes and behaviors of a nurse practicing effective care within the client's cultural context include the following: - Genuine interest in a client's culture and personal life experiences - Active listening and awareness of meanings behind the client's verbal communication (storytelling) - Nonverbal communication (body language, eye contact, facial expressions, interpersonal space, and preferences regarding touch) - Acknowledgement that the nurse's own beliefs and prejudices might create barriers to providing culturally sensitive care.

A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response?

Activates the receptors for the hormone melatonin Ramelteon is a selective melatonin receptor agonist prescribed to facilitate the onset of sleep; it is not intended for sleep maintenance. It may be used long-term and activates receptors for melatonin. Ramelteon does not cause a change in circadian rhythms, decrease impulses to the cerebral cortex, or stimulate the reticular activating system.

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?

Administer the medication if respiratory rate is > 9. The nurse can safely administer the new pain medication when the client's respiratory rate is greater than 9. Opioids can cause respiratory depression. Therefore, this is important to monitor before administering the opioid. Blood pressure and heart rate are slightly elevated due to the client experiencing pain. These vital signs are stable to administer the opioid.

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?

Administer the pain medication. Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It is important that the nurse understand that clients have different ways to manage their pain. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's health care provider needs to be notified at this time.

The nurse is concerned that a client is at risk for developing Alzheimer disease. Which assessment finding caused the nurse to have this concern? Select all that apply.

Age 70 Smokes cigarettes Treatment for hypertension Gained 10 kg over the last year Risk factors for the development of Alzheimer disease include over the age of 65, smoking history, treatment for a disease that can cause vascular complications such as hypertension, and not keeping body weight within recommended guidelines. Staying active does not predispose the client to developing Alzheimer disease.

A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for what?

Agnosia Agnosia is the failure to recognize or identify objects despite intact sensory function. Aphasia is alterations in language ability. Apraxia is the impaired ability to execute motor activities despite intact motor functioning. Executive functioning is the ability to think abstractly, plan, initiate, sequence, monitor, and stop complex behavior.

A client demonstrates nervousness and fear with a worsening loss of memory. Which nursing diagnosis should the nurse select to help guide this client's care?

Anxiety related to awareness of increasing memory loss The client is demonstrating signs of anxiety as evidenced by nervousness and fear. The most appropriate diagnosis would be Anxiety related to awareness of increasing memory loss. There is no evidence that the client has dementia. There is not enough information to determine if the client is disabled or has a hearing loss.

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?

Apple slices Carbohydrates promote sleep by making tryptophan available to the brain. Simple carbohydrates such as fruit slices or juice are effective. Chocolate provides high sugar content and possibly caffeine exposure which will promote wakefulness. Tuna salad and almonds are protein, not carbohydrates.

Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?

Apraxia Apraxia is the impaired ability to execute motor functions despite intact motor abilities. Aphasia is a deterioration of language function. Agnosia is the inability to recognize the name of objects. Executive functioning is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior.

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. The priority nursing intervention is to ask the client for the original bottle that the drug was dispensed into from the pharmacy. This will provide the most accurate identification of the medication. Other interventions can subsequently be implemented.

When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what?

Asking a family member to be present during the assessment

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care?

Asking only the client's parents to be present at the education session Peers are often more influential than parents, nurses, or teachers at this age. It is often appropriate to include a close friend in on the education session. The other answers are developmentally appropriate for a 15-year-old.Asking only the client's parents to be present at the education session

Which scenarios are examples of a culturally appropriate nursing intervention? Select all that apply.

Asking the client's grandmother, who is the head of the family, to be involved in the plan of care Asking for cultural assistance from clergy at the client's request Allowing the client to eat food from home that is consistent with the client's dietary plan Asking sincerely for the client to explain religious rituals

The nurse is caring for a 5-year-old child on the pediatric unit. Which activities would promote the psychomotor skills of this child? Select all that apply.

Assembling blocks Building a house with popsicle sticks Removing the toys from the toy box Assembling blocks, building a house with popsicle sticks, and removing toys from the toy box are examples of activities that promote psychomotor skills. Labeling a diagram and identifying the caregiver promotes cognitive skills of a 5-year-old child. Watching television does not promote psychomotor skills because it is a stagnant activity.

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences. When the client is having difficulty learning, it may be possible that the client does not understand the language that the nurse speaks. In such a case, the nurse should take the necessary steps to break the cultural barrier and then proceed with the education. Written materials can enhance many clients' learning, but will not necessarily overcome many of the common barriers to understanding, including cultural and linguistic factors. The nurse should take action to overcome any barriers to the learning process before delegating to a colleague. The client's morale is not pertinent to the client's difficulty understanding the teaching.

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

Assess for medication prescription for breakthrough pain. Breakthrough pain is a temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock. It can occur before the next dose of analgesic is due (end of dose pain). It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis." Therefore, the nurse should check for a prescription for breakthrough pain medication. Telling the client that he or she has to wait is not a therapeutic action by the nurse. Administering the next dose of pain medication is a violation of nursing practice and does not follow the standard of care. The nurse needs to assess for the therapeutic effects of the pain medication and not opioid addiction.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem.

A 12-year-old black client has experienced significant blood loss and may require a blood transfusion. The client's mother, father, and sisters are currently present at the bedside in the emergency department. How should the nurse direct questions and education about the client's condition and treatment?

Assess who is the dominant member of the family and then address that person. Although black families can be matriarchal, this fact does not mean that the nurse should not assess the structure and roles of the family on an individual basis. This assessment is preferable to acting on a generalization, even if it is a generalization that may be accurate for many families who are culturally similar. The nurse should avoid directing questions to either the mother or the father without first assessing who is the dominant person, to avoid presuming, as this is culturally insensitive.

When completing a transcultural assessment of communication, which assessment by the nurse is most appropriate?

Assessment of eye contact, personal space, and social taboos Components of the transcultural assessment of communication are the cultural values associated with communication—eye contact, personal space, and social taboos. Religious assessment, racial identification, and income levels are not part of the transcultural assessment of communication.

A 79-year-old female is admitted to a long-term care facility. She is incontinent of urine and feces and has impaired cognition. What is the best nursing intervention to prevent skin breakdown for this resident?

Assist her to the toilet every 2 hours and after meals Implementing a toileting schedule will help prevent skin breakdown. Turning will not address the incontinence issue. Since the resident has poor cognition, asking her to notify the nurse for elimination needs is unrealistic. An indwelling catheter may increase her risk for infection and will not address the fecal incontinence.

Most older adults gradually modify activities or lifestyle to accommodate for declines in strength and health. The nurse recognizes the need for older adults to maintain activity and exercise in order to preserve all physiologic functions. When encouraging activity, it is important to consider which of the following? Select all that apply.

Assistive devices help to maintain mobility and safety. Chronic illness often accompanies aging. There is an increased risk of sleep disorders.

An older adult patient has been recently diagnosed with vascular dementia. Because the client lives alone and has poorly controlled hypertension, the client has begun to receive home healthcare. This new aspect of the client's care is characteristic of which stage of illness?

Assuming a dependent role The stage of assuming a dependent role often requires assistance in carrying out activities of daily living. As well, the patient often requires care, which may be provided in the home. Experiencing symptoms and assuming a sick role may precede (or accompany) this process. Recovery and rehabilitation are not evident in the patient's present circumstances.

An adult client being treated for breast cancer inquired about required vaccinations. What information should the nurse provide to this client?

Avoid all live vaccines. Clients with active malignant disease should not receive live vaccines. A tetanus-diphtheria-pertussis booster is not likely necessary, and there is no indication for a pneumococcal immunization. When possible, clients should have needed immunizations 2 weeks before or 3 months after immunosuppressive radiation or chemotherapy treatments.

Following the injection of a prescribed vaccination, a client has injected antibodies circulating through the body. The nurse explains the client's body will respond in what manner?

Be able to respond to the presence of antigens more quickly. The circulating antibodies act in the same manner as those produced from plasma cells, recognizing the foreign protein (antigen) and attaching to it, rendering it harmless. The immune system responds to antigens, not antibodies. Serum sickness is an atypical response involving antibodies against antibodies.

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client?

Begin the session with a reference to the client's actual experience. Beginning the session with a reference to the client's actual experience will help provide a link to which the new learning can connect. Although it may be appropriate to refer the client to online resources on proper bowel health, to encourage the client to join a support group, and to consult the client's family regarding the client's history, the nurse should first engage with the client to find out the client's experience and specific issues.

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the health care provider?

Benzodiazepines such as temazepam are often used to treat difficulty sleeping. Furosemide is a diuretic; amlodipine is a calcium channel blocker; simvastatin is a HMG CoA reductase inhibitor (statin) used to treat high cholesterol.

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?

Blocking 30 minutes of time for skill teaching Preschool age children (2 to 5 years) have short attention spans. Five- to ten-minute blocks of time are age appropriate. A 30-minute block is more appropriate for an older client. The other answers are developmentally appropriate for a 4-year-old.

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?

Burning, tingling The nurse should assess for neuropathic pain associated with diabetic neuropath. Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system (Staats, et al., 2004). Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. You should also be alert for the common terms that clients use to report neuropathic pain, such as burning, painful tingling, pins and needles, and painful numbness.

A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?

Check the client's vital signs and connect her to a cardiac monitor. Pain nociception has various locations. Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; clients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. An example is cardiac pain that a person experiences as indigestion, neck pain, or arm pain. Phantom pain is pain in an extremity or body part that is no longer there (e.g., a client who experiences pain in a leg with an amputation). The client is presenting with atypical chest pain and should be assessed for pain of a cardiac origin.

The nurse educator is teaching a class of community leaders about immunologic agents. To minimize the concern regarding adverse effects of vaccinations, the nurse should include which mild reactions in the teaching plan?

Chills and fever Chills and fever are mild adverse reactions observed after administration of vaccines. None of the other options are generally associated with mild adverse reactions to vaccines.

Why are health promotion and illness prevention a key responsibility of nurses?

Chronic illnesses are the leading health problem in the world.

A group of students are role-playing scenarios involving biological weapon exposure. Which medication would the students identify as using for a client with cutaneous anthrax?

Ciprofloxacin For cutaneous anthrax, ciprofloxacin or doxycycline would be used. Ribavirin would be used for hemorrhagic fever; streptomycin or gentamicin would be used for tularemia.

A client is scheduled to receive an immunization. In which client may the administration of a live vaccine be contraindicated?

Client taking steroid therapy Clients receiving a systemic corticosteroid in high doses (e.g., prednisone 20 mg or equivalent daily) or for longer than 2 weeks should wait at least 3 months before receiving a live-virus vaccine. No evidence supports withholding immunizations related to renal insufficiency or hepatic failure. Clients over the age of 65 should receive immunizations as needed to protect from infectious disease.

A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?

Clinical nurse specialist Clinical nurse specialists are nurses with an advanced degree who are considered experts in a specialized area of care. They also provide direct care, consultation, and education of clients, families, and staff. Nurse managers do not normally provide direct care. Nurse-midwives specialize in obstetrical care. Physician assistants are not nurses.

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?

Cognitive learning theory Cognitive learning theory is the result of people wanting to make sense of the world around them by assimilating and processing information to gain new understandings and insights. Developmental learning theory focuses on considering the patient's physical maturation and abilities, psychosocial development, and cognitive capacity when providing education. Behavioral learning theory focuses on how one learns and unlearns behaviors. Adaptive learning theory explains how learning is optimized when teaching is adapted to the particular learning style of the learner.

What intervention should a nurse implement to become culturally competent when assessing a client from another culture?

Collect relevant cultural data of client's health history The nurse should collect relevant cultural data of client's health history, as well as accurately perform a physical assessment. Self-cultural skills involve learning how to complete cultural assessments, culturally based physical assessments, and interpreting the data accurately. Engaging in intercultural encounters and acquiring cultural competence is known as cultural desire. The nurse should sincerely desire to acquire cultural knowledge and skills for effectively assessing the client. Becoming appreciative and sensitive to the values and beliefs of clients creates cultural awareness. The nurse needs to self-examine and explore in-depth his or her own cultural background. Seeking and obtaining a sound educational foundation concerning the worldviews of varied cultures enhances cultural knowledge.

Which are factors that impact how a client defines health? Select all that apply.

Community Culture Family Society

Which of the following nursing activities will be most effective to help achieve the Healthy People 2020 guideline to eliminate health disparities among clients?

Conducting blood pressure screenings in an underserved area

The nurse is caring for a client who is from another country, and states to the charge nurse, "I just don't know if the client really understands what I am saying, and I am not understanding the client either, even though he speaks English." What stage of cultural awareness is the nurse experiencing?

Conscious incompetence

A nurse is planning a health fair in the community to highlight promotion and prevention of the leading cause of death in the United States. Which disease process should the nurse address?

Coronary artery disease Heart disease is the leading cause of death in the United States. Lung cancer, emphysema, and cerebrovascular accidents are not the leading causes of death in the United States.

A 1-year-old child will receive a scheduled MMR vaccination shortly. The nurse should teach the child's parents that the child may develop what possible adverse effect related to the administration of this medication?

Cough and fever Adverse effects associated with MMR vaccine include fever and cough. Nausea and vomiting, pallor and listlessness, and serum sickness are not among the noted adverse effects of the MMR vaccine.

Which term describes the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture?

Cultural imposition Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Cultural blindness occurs when one ignores differences and proceeds as though they do not exist. Acculturation is the process by which members of a cultural group adapt to, or learn how to, take on the behaviors of another group. Cultural taboos are activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group.

A client is admitted with end-stage pancreatic cancer and is experiencing extreme pain. The client asks the nurse whether an acupuncturist can come to the hospital to help manage the pain. The nurse states, "You won't need acupuncture. We have pain medications." Which characteristic has the nurse displayed?

Cultural imposition The nurse has demonstrated cultural imposition by assuming that traditional pain relief measures are superior and the client should conform to the nurse's belief regarding pain control. This is not an example of cultural conflict because the nurse did not ridicule the request; it was simply dismissed. The nurse is not stereotyping, as no generalization is made about a group of people. The nurse is not demonstrating culture shock because the view of pain medications that the nurse expresses is consistent with the majority, Western culture.

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition?

Delirium

It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?

Delirium These are not signs of normal aging and seem to be of acute onset. This makes Alzheimer's disease unlikely. Stroke and meningitis could cause these symptoms as well, but the combination of the heat and a recent infection make delirium much more likely. Though she was prescribed an antibiotic, her condition may not have improved because of bacterial resistance, non-compliance due to cost, depression, or even an underlying mild dementia. Dementia should not result in an acute mental status change, although illness may cause a worsening of dementia.

What term is used to describe various disorders that progressively affect cognitive function?

Dementia Dementia describes various disorders that progressively affect cognitive function. Delirium is a temporary state of confusion that can last from hours to weeks and resolves with treatment. Ageism is a form of prejudice, like racism, in which older adults are stereotyped by characteristics found in a few members of their group. Reminiscence is the phenomenon of an older adult telling stories of the past.

A 35-year-old has chronic back pain. What condition would exacerbate this client's pain?

Depression Depression and anxiety often lead to increase in pain sensation.

The nurse is preparing a client who is Jehovah's Witness for surgery. The client states, "Please make sure I do not receive a blood transfusion." What policy should the nurse follow to best address the client's concern and needs?

Develop a plan of care with the client that addresses cultural practices regarding transfusions. Jehovah's Witnesses believe that blood is the source of a person's soul and cannot accept a transfusion since that blood has left someone's body. There are alternatives to blood transfusions that can be provided to the client. The policy that addresses the client's needs and cultural practices is found in The Essential Guide to Nursing Practice: Applying ANA's Scope and Standards in Practice and Education (White & O'Sullivan, 2012) which states "The registered nurse develops in partnership with the person, family and others an individualized plan considering the person's characteristics or situation, including but not limited to, values, beliefs, spiritual and health practices...:". Therefore, the provider, while integral to care, should also provide culturally competent care, and both nurse and provider should do this even in life-or-death situations.

ageism

Discrimination based on age

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate?

Distract the client with a familiar object or music. The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern?

Do you usually go to bed and wake up about the same time each day? The best interview question for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern would be to ask if the client usually goes to bed and wakes up about the same time each day. The other questions are possible to ask the client, but are not related to recent changes in the client's sleep-wakefulness pattern.

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident. It is imperative for nurses to carefully and accurately document assessment findings and the nursing care that they provide, especially when legal action is anticipated. This thorough and accurate assessment should precede consultation with the legal department, the state board of nursing, and colleagues.

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

During REM sleep, the client's temperature, pulse, blood pressure, and respirations increase. The client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations. During non-eye movement sleep, the client will exhibit a decrease in body temperature, pulse, blood pressure, and respirations.

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

During REM sleep, the client's temperature, pulse, blood pressure, and respirations increase. The client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations. During non-eye movement sleep, the client will exhibit a decrease in body temperature, pulse, blood pressure, and respirations.

An older adult client asks the nurse to explain the recommended schedule for influenza vaccination. Which statement should the nurse include in the response?

Each year a new vaccine is developed based on the strains most prevalent. Immune serums are the biologic products used for passive immunity. They act rapidly to provide temporary (for 1 to 3 months) immunity in people exposed to or experiencing a particular disease. The goal of therapy is to prevent or modify the disease process; to do this, the most prevalent strains must be identified on an annual basis. Annual influenza vaccination is recommended for all adults.

The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from 1 hour ago. The nurse assesses the stage of nonrapid eye movement (NREM) sleep, which the client exhibits as Stage:

Easy arousal from sleep and involuntary muscle jerking that may awaken the client are signs of Stage I NREM. In the other stages, the client becomes increasingly more difficult to arouse and does not exhibit involuntary muscle jerking. In Stage IV NREM, the client's pulse, respirations, and blood pressure decrease, and muscles are relaxed.

Which topics would the nurse be most likely to explore with a client with the aim of restoring health? Select all that apply.

Education of a client about living with a suprapubic catheter Postoperative teaching for the client after prostate surgery Orientation to treatment center and staff The medical and nursing regimens and how the client can participate in care

Which topics would the nurse be most likely to explore with a client with the aim of restoring health? Select all that apply.

Education of a client about living with a suprapubic catheter Postoperative teaching for the client after prostate surgery Orientation to treatment center and staff The medical and nursing regimens and how the client can participate in care The topics that the nurse would be most likely to explore with a client with the aim of restoring health would include the following: client and nurse's expectations of one another, orientation to treatment center and staff, and the medical and nursing regimens and how the client can participate in care. The nurse would not include informing a client about community resources or CPR teaching.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that certain measures, such as skin stimulation and relaxation techniques, release endorphins. Serotonin is an important chemical and neurotransmitter in the human body. It is believed that serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers.

A client is to undergo surgery for removal of the gallbladder. Which action related to the client's informed consent falls within the nurse's scope of practice? Select all that apply.

Ensuring the signed form is on the chart Acting as a witness to the client's signature on the form Answering questions about elements of the consent Obtaining informed consent is the responsibility of the person who will perform the diagnostic or treatment procedure or the research study. This person is responsible for explaining the procedure along with any risks and benefits associated with it. The nurse's role is to confirm that a signed consent form is present in the client's chart and to answer client questions about the elements of the consent. Unless the nurse is obtaining consent for a nurse-prescribed and nurse-initiated intervention, the nurse signs the consent form as a witness to having seen the client sign the form, not as having obtained the consent.

Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor?

Environmental risk factor Working and living environments may contribute to disease. Working with cancer-causing chemicals is an example of an environmental risk factor for illness. Physiologic risk factors are those relating to an individual's body or biology. Lifestyle risk factors are habits or behaviors people choose to engage in. A health habit risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury.

A nurse is administering a mumps vaccine to an adolescent. Which medication should be available when administering an immunization?

Epinephrine The administration of vaccines for immunization possesses the risk of an allergic reaction and anaphylaxis. The nurse should have aqueous epinephrine available in the event of an anaphylactic reaction. The administration of diphenhydramine or hydroxyzine will reduce the allergic reaction but will not be effective in the event of anaphylaxis. Physostigmine is not administered.

A client who was bitten by a pit viper is to receive antivenin. What is the nurse's best action?

Establish IV access Antivenin given to neutralize the venom of a pit viper is administered intravenously.

An elderly client is becoming progressively confused due to Alzheimer's disease. The family can no longer manage the client at home due to wandering. Which of the following living arrangements could the nurse recommend?

Extended-care facility If the older adult is cognitively impaired, family caregivers face the need for daily care giving, such as that which is provided in an extended-care facility. Respite care is temporary housing and NORCs enable the client to remain at home. Accessory apartments are separate apartments constructed, in part, out of an existing house and do not have any health care services.

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score?

Eye opening, and appropriateness of verbal and motor responses. The Glasgow Coma Scale rates responses to eye opening, verbal, and motor responses.

A nurse is caring for a 4-year-old client who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the client to point to the one that best represents the pain he is experiencing. This is an example of which of the following:

FACES scale The FACES scale is used for children who are 3 years or older. This tool allows the client to point to the picture of the face that best represents the pain he or she is feeling. The FLACC scale uses face, legs, activity, cry, and consolability to assess the pain. The visual analog scale uses a 100-mm line with "no pain" at one end and "worst pain" at the other. The numeric scale is the most commonly used scale--an example is an 11-point Likert scale with 0 meaning no pain and 10 meaning the worst pain ever.

The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.)

FLACC Scale Wong-Baker Faces Scale COMFORT scale When assessing the pain of a preschooler, the nurse could choose from the following pain scales: COMFORT, FLACC, and Wong-Baker Faces. The CRIES pain scale is for neonates, and the 0-10 Numeric scale is for adults and children over 9 years old.

The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the:

Face, Legs, Activity, Cry, Consolability Scale The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative client. This tool measures pain using observable behaviors as pain indicators. The FACES Pain Scale is appropriate for children age 3 and older, using six faces ranging from happy with a wide smile to sad with tears on the face. The other two scales are appropriate for use with older children and adults. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity.

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Faces Pain Scale The nurse should use the Faces Pain Scale (FPS) to rate the pain felt by the client. The FPS shows different facial expressions; the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best suited for cognitively impaired adults. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. It has been shown to be best for older adults with no cognitive impairment. The Visual Analog Scale (VAS) rates pain on a 10-cm continuum numbered from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?

Find a phone app that plays sounds of the city. Clients tend to adapt to the unique sounds where they live, such as traffic, trains, and the hum of appliance motors or furnaces. Unfamiliar sounds tend to interfere with the ability to fall or stay asleep. The nurse will recommend that the client find an app that plays sounds of the city, which mimics the sounds with which the client is most familiar. Ignoring the problem by telling the client to adapt to the new environment does not address the problem. Avoiding eating before bedtime could cause the client to wake up hungry in the middle of the night. The nurse does not recommend alcohol, a depressive drug, to clients.

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Flight of ideas

When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept?

Focus on what is possible.

The student nurse is aware that culturally competent care is described as which of the following?

Following five constructs of cultural awareness, knowledge, skill, encounters, and desire

What are the goals of performing a cultural assessment on a client from another culture? Select all that apply.

Gaining knowledge about the client's cultural beliefs and practices, including food and eating rituals, daily and nightly personal hygiene rituals, and sleeping habits Identifying similarities and differences among the cultural beliefs of the client, health care agency, and nurse Comparing culture-based care needs of the specific person with the general themes of those of similar cultural background Generating a holistic picture of the client's care needs, upon which a culturally congruent nursing care plan is developed and implemented

A client has a cerebrovascular accident (CVA), resulting in flaccidity of the right side with aphasia. For this client, which intervention constitutes tertiary prevention?

Gait training and speech therapy Tertiary prevention occurs when a person already has been diagnosed with a long-term disease or disability and focuses on preventing further complications of the disease and restoring the client to an optimal level of functioning (i.e., rehabilitation). In this case, gait training and speech therapy are interventions aimed at restoring function to the client following a stroke. Assessment of blood pressure and of bleeding and coagulation times and education on the symptoms of a CVA represent secondary prevention measures.

Which statement about the sleep patterns of toddlers should the nurse incorporate into an education plan for parents?

Getting the child to sleep can be difficult. Getting the child to fall asleep is the most commonly reported problem, but frequent awakenings and occasional night terrors may also occur.

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

Guarding of the chest area A person's behavioral response to pain can be demonstrated by protecting or guarding the painful area, grimacing, crying, or moaning. Increased blood pressure and respiratory rate are typical physiologic (sympathetic) responses to moderate pain. Decreased heart rate is a typical physiologic (parasympathetic) response to severe pain.

A client complains of pain in several areas of the body. How should the nurse assess this client's pain?

Have the client rate each location separately. When assessing pain location, ask the client to point to the painful area. If more than one area is painful, have the client rate each one separately, and note which area is the most painful. Marking each site is not necessary practice for assessing pain. Pain is a subjective sensation for the client. Radiating pain is notable, because such radiation may affect treatment choices.

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have the client rate pain level, and reschedule the teaching session. The client is not ready or able to learn and is reporting a need that first must be met. Assessing the client's knowledge of self-care or redirecting the client to discuss self-care only delays the care that must be done before the client is able to learn. Although providing written materials is an excellent supplement to a teaching session, it does not replace teaching the client. It is best to address the physical needs before attempting to educate the client.

When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model?

Health belief model According to the health belief model, a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. According to the clinical model, health is defined narrowly as the absence of signs and symptoms of disease or injury. The holistic model views individuals as ever-changing systems of energy, and the interaction of a person's mind, body, and spirit within the environment. The high-level wellness model is the recognition of health as an ongoing process toward a person's highest potential of functioning.

Which definition of health is the best?

Health is a state of complete well-being. A classic definition of health is that health is a state of complete physical, mental, and social well-being, not merely the absence of disease or physical symptoms. Health encompasses a state of mind and not just how a client feels.

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area?

Health promotion Health promotion is the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability. Self-concept incorporates both how people feel about themselves (self-esteem) and the way they perceive their physical self (body image). Diagnosis of disease involves a medical aspect such that a disease is traditionally diagnosed—and treatment is prescribed—by a physician or advanced practice nurse, whereas nurses focus on the person with an illness.

The perinatal nurse recognizes that what vaccine can be safely given to a neonate?

Hepatitis B Hepatitis B is the only common vaccine that can be given to neonates.

Mrs. Jimenez, age 79, became a widow earlier this year and now resides alone in the house that she and her husband shared for 30 years. Her children have encouraged her to move, but she expresses a desire to remain in her home, despite some slight mobility challenges. The nurse who provides occasional home healthcare for Mrs. Jimenez should first propose which of the following?

Home modification Older adults typically express a desire to maintain their existing living relationships and this should be facilitated as long as it is safe. Consequently, the nurse should prioritize Mrs. Jimenez's wishes. Home modification may allow her to maximize her independence and maintain her current living situation in spite of some mobility challenges.

A 77-year-old woman is on the nurse's unit s/p left knee replacement. The client typically stools every morning but has not had a bowel movement in 3 days. The nurse knows that which medication places the client at increased risk for constipation?

Hydromorphone Hydromorphone is an opioid agent which is often constipating in older adults. Psyllium helps promote regular bowel elimination. Acetaminophen is not linked to constipation. Furosemide is used as a diuretic. It does not cause constipation.

The student nurse is assessing a severely disabled elderly patient hospitalized for infection. The patient's family ask the nurse why their loved one keeps getting infections. The student nurse explains to the family which of the following increases the risk of infection for this patient? Select all that apply.

Immobility Dysphagia Incontinence

A nurse is receiving post-exposure prophylaxis for hepatitis B. What would the nurse most likely receive?

Immune globulin Hepatitis B immune globulin would be used for post-exposure prophylaxis for hepatitis B. This vaccine would be used to prevent herpes zoster (shingles) in persons over the age of 60 years. Antivenin (crotalidae) would be used to neutralize the venom of pit vipers, rattlesnakes, and copperheads. BCG vaccine would be used to prevent tuberculosis in those with a high risk for exposure.

The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following?

Impaired memory Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide.

When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care?

Improvement of the client's health outcomes Consideration of clients' cultural background and incorporating health beliefs and practices in care plans contribute to enhanced client experiences with health care and improve health outcomes. Incorporating the client's health beliefs and practices will not enhance this client's social system or cultural connectiveness, nor will it improve communication with the family.

A nurse uses the Glasgow Coma Scale to assess a client's response to stimuli. The client receives a score of 10. Which of the following is the client's status?

In need of emergency attention The Glasgow Coma Scale is useful for rating one's response to stimuli. The client who scores 10 or lower needs emergency attention. The client with a score of 7 or lower is generally considered to be in a coma.

A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients?

Include the child in the education; ask questions of both the mother and the child. School-age children are able to make decisions and provide care for themselves. Focusing mainly or only on the mother fails to validate the child's abilities, and teaching the mother and the child separately does not make good use of time.

Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory?

Incorporating the client's request for complementary treatment therapy Leininger's theory of transcultural nursing includes assessing a cultural nature, accepting each client as an individual, having knowledge of health problems that affect particular cultural groups, and planning of care within the client's health belief system to achieve the best health outcomes. Therefore, incorporating the client's request for complementary treatment therapy is an example of this theory. The others do not support this theory.

The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention. Which activity performed by the nurse is classified as tertiary prevention?

Instructing a client on how to use crutches Tertiary prevention is used after an injury or sickness to help rehabilitate the client or to decrease potential risk and further damage, such as instructing the client on how to use crutches. Promoting safety in the home and counseling a client about a low-sodium diet are examples of primary prevention (preventing a disease from occurring in the first place). Assessing blood glucose level is an example of secondary prevention (screening to detect a disease early).

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?

It has a gradual onset and lasts for a long time. Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population.

When providing client teaching to parents regarding measles, mumps, and rubella vaccine administration, which is most important regarding the schedule for administration?

It is administered at 12 to 15 months. Measles, mumps, and rubella immunization is administered initially at 12 to 15 months of age. The vaccine is not administered under the age of 1 year.

A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?

It is the role of nursing to provide a caring relationship that facilitates health and healing. The American Nurses Association (ANA) defines nursing as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" (ANA, 2010). The ANA does not see nursing as dependent upon medicine. The ANA sees one of the roles of the nurse as assisting clients in understanding their health problems. The ANA does not address essential components of professional nursing care with terms such as strength, endurance, and cure.

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients. Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation.

A nurse is providing community education about the importance of getting enough sleep. Which information about REM sleep is most accurate?

It plays a role in memory. REM sleep is believed to play a role in learning, memory, and adaptation. It is more difficult to arouse a person during REM sleep than during NREM sleep. During REM sleep, the pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed.

Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions?

Mediterranean and Africa. Drug metabolism differences, lactose intolerance, and malaria-related conditions—such as sickle cell disease, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and Duffy blood group—are considered biochemical variations. The malaria-related conditions would obviously occur in populations living in or originating from mosquito-infested locales such as the Mediterranean and Africa.

Which of these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist?

Memantine Memantine is a NMDA receptor antagonist that has been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia. Galantamine, donepezil, and rivastigmine are cholinesterase inhibitors.

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?

Most sedative hypnotics lose their effect after 1 or 2 two weeks of administration. Although most sedative hypnotic drugs provide several nights of excellent sleep, the medication often loses its effects after 1 or 2 weeks. Alcohol and diphenhydramine should not be administered with a sedative hypnotic drug, as this can intensify the medication. Increased activity assists the client in sleeping. Carbohydrates have been shown to help a client sleep.

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

Naloxone Naloxone is an opioid antagonist that reverses the respiratory-depressant effect of an opioid. Diphenhydramine is an antihistamine mainly used to treat allergies. Atropine is a medication to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate and to decrease saliva production during surgery. It is typically given intravenously or by injection into a muscle. Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, and other options but not for opioids.

When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely:

Neuropathic Visceral pain originates from abdominal organs and is often described as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints. Referred pain originates from a specific site, but the client experiencing the pain feels it at another site along the innervating spinal nerve. Neuropathic pain is described as burning, painful numbness, or tingling.

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?

Newborns sleep 16 to 17 hours per day. Newborns sleep an average of 16 to 17 hours per 24 hours a day, divided into about seven sleep periods distributed fairly evenly throughout the day and night.

The nurse has a client who has been under stress due to a sick spouse. The client reports difficulty sleeping and a feeling of daytime sleepiness. Using the nursing process, place the following nursing steps in the correct order. Use all options.

Nurse states to client, "Tell me about your sleep problem." Nurse makes the diagnosis Disturbed Sleep Pattern. Nurse plans with the client an outcome of reporting adequate sleep in one week. Nurse teaches the client relaxation techniques. Nurse evaluates the client in 1 week for outcome achievement.

The student nurse is changing the bed linens of a hospitalized patient. While placing the contaminated materials into the laundry bag, the outside of the bag is touched by the material. What should the student nurse do next?

Obtain another laundry bag and place the contaminated bag inside while in the patient's room. If the outside of the bag becomes contaminated, place that bag in another bag (double-bagging).

The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client?

Offer client a small carbohydrate and protein snack before bedtime.

A nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use?

Opioids and opiates can cause sedation, nausea, and constipation. They also can cause respiratory depression, which is the main side effect to watch for with opioid use. Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

Opioids are not contraindicated in older adults but are rarely used in chronic pain prior to nonpharmacologic measures.

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?

Orientation to time is usually lost first and orientation to person is usually lost last.

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

Which guideline regarding pain should be included in the nurse's education plan for a group of parents with infants and toddlers?

Pain can be a source of fear and threat to the toddler's security.

Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture?

Pain must be endured to perform gender role duties, but response to it is very expressive. In the Hispanic culture pain response is often very expressive, though pain must be endured to perform gender role duties.

A nursing instructor is discussing the intended populations for various vaccines. Which groups might the instructor mention when discussing the hepatitis B vaccine?

Paramedics and emergency medical technicians Pre-exposure immunization against hepatitis B is recommended for people at high risk for exposure to the disease. This can include health care workers (e.g., paramedics and EMTs); patients with cancer, organ transplants, hemodialysis, immunosuppression drug therapy, or multiple infusions of blood products; sexually active gay and bisexual males; IV drug users; household contacts of HBV carriers; and residents and staff of institutions for people with intellectual disability.

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?

Patient advocate The nurse may assess the change in the client and will be the advocate and detective, determining when the change occurred and what was new in the treatment.

Rosenstock's Health Belief Model

People's decisions about health-related behaviors are guided by four main factors: 1. Perceiving a *personal threat* of developing a specific health problem Ex: Do you believe that you will get lung cancer from smoking? 2. Perceiving the *seriousness* of the illness and its consequences Ex: How serious do you think lung cancer is and what are the consequences? 3. *Believing* that changing a behavior will reduce the threat Ex: Will giving up smoking prevent you from getting lung cancer? 4. *Comparing perceived costs and benefits* of a health-related behavior change Ex: Will the reduced chance of getting cancer in the future be worth the loss of pleasure associated with not smoking now?

An older adult client develops delirium secondary to an infection. Which would be the most likely cause?

Pneumonia Delirium in the older adult is associated with medications, infections, fluid and electrolyte imbalance, metabolic disturbances, or hypoxia or ischemia. Infections of the respiratory tract such as pneumonia or urinary tract are among the most common infection-related causes. Appendicitis and cellulitis are not commonly associated with the development of delirium. Although low platelet count would render the older adult vulnerable to bleeding and easy bruising, it does not increase the risk of delirium.

A nurse is immunizing children against measles. This is an example of what level of preventive care?

Primary

The nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of?

Primary Primary health promotion and illness prevention is directed toward promoting good health and preventing the development of disease process or injury. Primary-level activities include immunization clinics, providing poison-control information, and education about seat belt and child-safety seat use. Secondary-level activities include screening programs and early identification of disease. Tertiary-level prevention is concerned with returning the client to the optimal function after diagnosis. Medical is not a level of health promotion or illness prevention.

The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention?

Provide the client with a tray, opening containers for the client.

In addition to pain intensity, what is another basic element of a pain assessment?

Quality Some prefer to use mnemonics to remember the elements of pain assessment. One of these is PQRST: O: Onset; P: Provocative or palliative; Q: Quality; R: Region and radiation; S: Severity; T: Timing.

A forest ranger arrives at a community clinic for prophylactic vaccination. Which vaccine would be most important to be administered to the ranger?

Rabies vaccine The ranger has to be administered the rabies vaccine as prophylaxis as he is at high risk for contracting the virus. The MMR vaccine is used in treating measles, mumps, and rubella. The varicella vaccine is used in chickenpox, and the rotavirus vaccine is used in preventing gastroenteritis caused by the rotavirus.

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred pain Referred pain originates from a specific site, but the person feels the pain at another site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigestion. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.

An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be?

Remind him of where he is and assess why he is having difficulty sleeping.

A nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about?

Respiratory depression Respiratory depression is always a major concern in an opioid-naïve patient.

A client has received a rubella immunization. The client was unaware that she was pregnant. What risk is associated with the administration of the rubella immunization in this client?

Risk of birth defects

Consultation and diagnostic tests are included in which level of health care?

Secondary care Consultation and diagnostic tests are included in the secondary level of health care. The first contact with a general physician is the primary care, and the referral to a highly specialized facility for desensitization is the tertiary care level. The secondary and tertiary care facilities are equipped to provide highly specialized care. Extended care is care provided to clients who no longer require acute hospital care.

The client is admitted with a gastrointestinal bleed. The physician ordered a colonoscopy. Which level of care encompasses this procedure?

Secondary care delivery is when primary caregivers refer clients for consultation and additional testing. Therefore, this scenario portrays secondary level of care. Primary care delivery is provided by the first healthcare provider or agency a person contacts. Quaternary care is an extension of tertiary care and includes experimental medicine and procedures and highly uncommon, specialized surgeries. Tertiary care is health services provided at hospitals or medical centers that have complex technology and specialists.

A mammogram represents which level of prevention?

Secondary prevention Secondary prevention includes screening for those at risk to develop illness, or those who could be diagnosed early in the process, and thus receive prompt treatment. Primary prevention refers to health promotion and illness prevention. Tertiary prevention refers to rehabilitation or prevention of complications after diagnosis with a disease. Medical is not a level of prevention.

A client develops fever and arthralgia 4 days after the administration of tetanus toxoid. What reaction to the vaccine is this?

Serum sickness

A 65-year-old male client lives in a long-term care facility. The infection control nurse identifies a cluster of clients on the unit diagnosed with shingles. What would the nurse expect the client's prescriber to order?

Shingles vaccine Vaccine to prevent shingles is available for adults aged 60 years and older.

A nurse may attempt to help a client solve a situational crisis during what type of counseling session?

Short-term counseling Short-term counseling would help a client solve a situational crisis. A client experiencing a developmental crisis, for example, might need long-term counseling. Motivational counseling is an evidence-based counseling approach that involves discussing feelings and incentives with the client. Professional counseling is a general term.

When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?

Show genuine interest in the client's culture and personal life experiences.

The nurse observes that a client responds better to health education when the nurse motivates him and assures him about the benefits of the teaching. In which of the following learning domains does the client's learning style fall?

Since the client responds better to health education when he is motivated and is assured about its benefits, the client's learning style falls into the affective domain. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values. This learning style would be suitable for this client. The cognitive domain is a style of processing information by listening to, or reading, facts and descriptions. The psychomotor domain is a style of processing that focuses on learning by doing. The interpersonal domain is a style of processing that focuses on learning through social relationships.

A nurse who comments to coworkers at lunch that a client with a sexually transmitted infection has been sexually active in the community may be guilty of what tort?

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

A nurse administrator is leading a seminar on cultural awareness in health care, beginning the seminar by defining culture. Which of the following elements should the nurse administrator include, based on the definition provided by Purnell and Paulanka (2008)? Select all that apply.

Socially transmitted Characteristic of a population or people Forms worldview Affects decision making Purnell and Paulanka provide the following useful definition of culture: "the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making." The particular culture defines values (learned beliefs about what is held to be good or bad) and norms (learned behaviors that are perceived to be appropriate or inappropriate). Culture is thus learned, shared, associated with adaptation to the environment, and is universal.

A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?

Somatic Somatic pain is caused by tissue damage, which would occur after abdominal surgery. Psychogenic pain relates to factors that influence the client's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system.

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?

Somatic pain Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.

The nurse enters an older client's room to assess for pain and discovers the client is hard of hearing. What is the nurse's best action?

Speak to the client face to face. When assessing the older client for pain, determine whether the client has any auditory impairment. If so, position your face in the client's view, speak in a slow, normal tone of voice, reduce extraneous noises, and provide written instructions. The FLACC scale is used primarily for infants. Hearing aids are expensive and suggesting to purchased one does not aid in the pain assessment at present.

An elderly farmer has sustained severe injuries after a serious accident involving a combine harvester. At the hospital, he tells the nurse that he thinks the pain he is feeling now is "payback" for living a "mean, selfish life." The nurse recognizes that this response by the man indicates which dimension of pain?

Spiritual dimension The spiritual dimension refers to the meaning and purpose that the person "attributes to the pain, self, others, and the divine." In this case, it seems that the man is interpreting his accident and subsequent pain as divine retribution for his past wrongdoings. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management." The sociocultural dimension concerns the influences of the client's social context and cultural background on the client's pain experience. The affective dimension concerns feelings, sentiments, and emotions related to the pain experience.

A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action?

Start with the lowest intensity and gradually increase it to the appropriate level. After applying the electrodes, the nurse should turn on the unit and adjust the intensity setting to the lowest intensity and determine if the client can feel a tingling, burning, or buzzing sensation. The nurse should then adjust the intensity to the prescribed amount or the setting most comfortable for the client. Skin should be clean before applying the electrodes, but it is unnecessary to use disinfectant. Analgesia may or may not be necessary before a TENS session.

A nurse is caring for an athlete who was injured during a practice session. There is visible skin impairment, and the client complains of throbbing pain in the leg. What level of pain does the nurse document for this client?

Subcutaneous level The nurse should document the client's pain as subcutaneous level pain, which is indicated by the throbbing pain. Pain at the epidermis level is a burning sensation. Pain at the dermis level is superficial and localized. Somatic pain develops from injury to muscles, tendons, and joints.

A 65-year-old client is being seen in the emergency department for exposure to rabies. The nurse checks the electronic health record and discovers the client has had no history of allergic reactions to immunization agents. The client's history guides the nurse to take which action?

Teach the client that the agent of choice is rabies immune globulin Exposure to rabies is treated with the immunization agent called rabies immune globulin. Administration is not contraindicated in senior citizens, and herbal remedies are not the recommended treatment of choice.

The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?

Teaching about adhering to a low-sodium diet Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate the client to a maximum level of functioning. Nursing activities on a tertiary level include teaching a client with heart failure the importance of adhering to a low-sodium diet. Primary prevention is directed toward promoting health and preventing the development of disease processes or injury. This client has a diagnosis. Secondary health promotion and illness prevention focus on screening for early detection of disease with prompt diagnosis and treatment of diseases found.

A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care?

Tertiary health promotion and illness prevention begin after an illness are diagnosed and treated, with the goal of reducing disability and helping rehabilitate clients to a maximum level of functioning. Referring an HIV-positive client to a local support group would be an example of tertiary preventive care. Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Secondary health promotion and illness prevention focus on screening for early detection of disease, with prompt diagnosis and treatment of any found. The term chronic is not related to health promotion.

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?

Tertiary prevention Tertiary prevention in health care deals with rehabilitation of the client. Teaching the client to walk with a walker is tertiary prevention. Primary prevention refers to health promotion or illness prevention. Secondary prevention refers to screening and early detection of disease.

What would the nurse identify as a vaccine that is a toxoid?

Tetanus The vaccine for tetanus is a toxoid. The vaccines for haemophilus influenza B and pneumococcal polyvalent are bacterial vaccines. Hepatitis A is a viral vaccine.

The nurse is providing wellness information to a 50-year-old client who is employed as a paramedic. The client asks what, if any, vaccines the client should get. What is the nurse's best response?

Tetanus-diphtheria-pertussis; hepatitis B vaccine once; influenza vaccine annually Middle-aged adults should maintain immunizations against tetanus-diphtheria-pertussis. Health care providers should receive hepatitis B vaccine once (if not previously taken). The influenza vaccine is recommended annually for everyone over the age of 6 months. An additional vaccine to prevent zoster infections (shingles) is available for adults aged 60 years and older. Middle-aged adults born after 1956 should get at least one dose of measles-mumps-rubella (MMR) vaccine unless they have had either the vaccine or each of the three diseases.

The nurse is providing wellness information to a 50-year-old client who is employed as a paramedic. The client asks what, if any, vaccines the client should get. What is the nurse's best response?

Tetanus-diphtheria-pertussis; hepatitis B vaccine once; influenza vaccine annually Middle-aged adults should maintain immunizations against tetanus-diphtheria-pertussis. Health care providers should receive hepatitis B vaccine once (if not previously taken). The influenza vaccine is recommended annually for everyone over the age of 6 months. An additional vaccine to prevent zoster infections (shingles) is available for adults aged 60 years and older. Middle-aged adults born after 1956 should get at least one dose of measles-mumps-rubella (MMR) vaccine unless they have had either the vaccine or each of the three diseases.

Which model is most useful in examining the cause of disease in an individual and is based upon external factors?

The AgentHostEnvironment Model is useful for examining the cause of disease in an individual. The agent, host, and environment interact in ways that create risk factors.The HealthIllness Continuum is a way to measure a person's level of health. The High-Level Wellness Model is characterized by functioning to one's maximum potential while maintaining balance and purposeful direction in the environment. The Health Belief Model is used to describe health behaviors.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

The CRIES scale is appropriate for neonates (0 to 6 months). The Wong-Baker Faces Pain Rating scale requires children to be at least 3 years old. The FLACC scale is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify pain severity; and the PAINAD scale is specific to the needs of clients with dementia.

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case?

The Good Samaritan law will provide legal immunity to the nurse.

The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?

The Health Belief Model focuses on what people perceive or believe to be true about themselves in relation to their health. The Health Promotion Model focuses on how people interact with their environments, as they pursue health. The Health-Illness Continuum Model focuses on health as a constantly changing state, whereas The Agent-Host-Environment Model explains how certain factors place a person at risk for an infectious disease.

The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?

The RN coordinates care delivery. There are 12 Standards of Practice: assessment, diagnosis, outcomes identification, planning, implementation, evaluation, ethics, culturally congruent practice, communication, collaboration, leadership, and education. The standard exemplified by the nurse is 5a, implementation via coordination of care in which the RN coordinates care delivery. Standard 5b is health teaching and health promotion in which the registered nurse employs strategies to promote health and a safe environment. Standard 3 is outcomes identification, in which the registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation. Standard 2, diagnosis, is when the registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues. Standard 1 is assessment, in which the registered nurse collects pertinent data and information relative to the health care consumer's health or the situation.

What governing body has the authority to revoke or suspend a nurse's license?

The State Board of Nurse Examiners The State Board of Nurse Examiners in the United States may revoke or suspend a nurse's license or registration. The employing health care institution may have submitted the paperwork regarding the allegation of the issue but does not suspend or revoke the nurse's license. The National League for Nursing is a national organization for faculty nurses and leaders in nurse education. The Supreme Court is the highest judicial court in a country or state. The Supreme Court does not rule on a nurse's license.

Acculturation

The adoption of cultural traits, such as language, by one group under the influence of another. 문화적 적응, 사회화

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache. No other medications should be administered; a peripheral IV line should already be in place. Resistance should not be felt when removing an epidural catheter.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?

The client and the nurse are equal participants. Effective learning occurs when clients and health care professionals are equal participants in the teaching-learning process, not when the nurse is viewed as the expert. Although it is important for the nurse to be able to handle criticism and to understand and apply psychomotor concepts when teaching, these are not as important as viewing the client and nurse as equal participants.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?

The client describes signs and symptoms of hypoglycemia. The client's ability to describe the signs and symptoms of hypoglycemia demonstrates cognitive learning (the storing and recalling of new knowledge in the brain). Demonstrating a skill, such as insulin injection, is an example of psychomotor learning. Affective learning includes changes in attitudes, values, and feelings (e.g., desire to lose weight).

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

The client needs further instruction when they say they can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician. The TENS unit will decrease the amount of the pain medication used by the client as it increases the blood supply to the injured area and will not interfere with the activities of daily living.

A client has come to the clinic requesting a hepatitis A and B vaccination before leaving on a tropical vacation. After assessing the client, the nurse should prioritize what finding to communicate to the provider?

The client takes corticosteroids to treat rheumatoid arthritis Corticosteroids decrease the normal immune response and could interfere with the intended stimulation of B cells. Recent influenza vaccination does not contraindicate the hepatitis vaccine, nor does type 2 diabetes. Occasional marijuana use would not contraindicate a hepatitis vaccination.

A nurse on the night shift checks on a client and suspects that the client is in REM sleep. Which client cue is indicative of this stage of sleep?

The client's eyes dart back and forth quickly The nurse would find the client's eyes dart back and forth quickly during REM sleep. The client would have a rapid or irregular pulse. The client's metabolism and body temperature would increase. The client's blood pressure would increase.

What is Rosenstock's health belief model based on?

The client's perceptions of susceptibility to and seriousness of a disease and the benefits of action are the focus. Rosenstock's health belief model focuses on the client's perception of susceptibility to and seriousness of a disease and the benefits of action. Modifying factors, including demographic variables such as age and gender and sociocultural variables such as personality and peer pressure, also affect the client's perception. Sociocultural variables are not the most important variables. A modifying factor is cues to action, such as mass-media campaigns.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset. PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.

In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?

The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use.

The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?

The new mother may believe buying infant clothing before the delivery is bad luck. The nurse may suspect the new mother is from a culture that may believe buying infant clothing before the delivery is bad luck. There is no information to support that the mother is from a lower socioeconomic level or lacks knowledge of how to prepare for the new baby or that the baby is unwanted.

Which best exemplifies malpractice?

The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest. All elements of liability are in place for the scenario involving a nurse administering amoxicillin to a client with documented allergies to penicillin: the nurse had a duty and breached it by giving the medication (amoxicillin), which caused the client harm (seizures and respiratory arrest). The nurse is negligent when applying an ice pack without an order. The nurse assisting the client into bed used proper body mechanics, so the client fall is an accident even though harm occurred. Giving the wrong medication could be cause for malpractice, but in this case, the client was not harmed.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?

The nurse documents a complete description of the happenings in the client's records.

A nurse is meeting for the first time a 42-year-old client whose visit to the clinic has been prompted by her chief complaint of ongoing lower back pain. Which of the following approaches to pain assessment should the nurse use when assessing the client's pain?

The nurse should use a pain assessment tool that is simple but still addresses the major parameters of pain.

A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care?

The nurse withholds the medication and notifies the health care practitioner.

A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation. What would be the sedation score for this client?

The sedation score for this client is 3. A score of 1 is given to a client who is awake and alert, 2 is given to a client who is slightly drowsy but easily aroused, and 4 describes a client who is somnolent, with minimal or no response to physical stimulation.

A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client?

The student nurse, the nurse instructor, and the hospital

perseveration

The tendency to persevere in, or stick to, one thought or action for a long time. 고집

A nursing instructor is teaching students about communication in different cultures. When discussing the meaning of hand gestures and body language in different cultures, the nurse realizes that further instruction is necessary when a student makes which statement?

There are many different elements of body language and hand gestures among different cultures. Using the hand to indicate height is a common gesture of Americans and Latins. Making a circle with the thumb and forefinger can mean OK for Americans but can be a definite and serious insult in many cultures. Therefore, if any hand gesture is used, the nurse should always clarify if there seems to be a strange or unexpected outcome on the other person's part.

A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently?

To assess for fluctuation in the client's capabilities Clients with organic diseases like delirium tend to have fluctuations in their ability to carry out activities of daily living. Thus, the nurse should assess these daily. Although the nurse should encourage the client to make decisions about treatment and assist the client in establishing a daily routine, these actions do not require daily assessment. Assess the prognosis of the client after therapy also is not required daily.

What have the models of health promotion and illness prevention been used for?

To help health care providers understand health-related behaviors. Several models of health promotion and illness prevention have been used to help health care providers understand health-related behaviors and adapt care to people from diverse economic and cultural backgrounds. The models include the health belief model, the health promotion model, the health-illness continuum model, and the agent-host-environment model. These models do not define a medical framework in the care of the disabled; these models do not create a forum for improving rehabilitative care; and these models do not formulate care plans for use with the disabled.

After teaching a group of students about the standard childhood immunizations given today, the instructor determines that the students need additional teaching when they identify which as a common disease for which immunizations are given?

Tuberculosis Immunization for tuberculosis occurs worldwide, but it is not routinely used in the United States.

A nurse is preparing to give a client a massage. What action should the nurse perform during this intervention?

Using a light, gliding stroke, apply lotion to the client's shoulders, back, and sacral area. Lotion should be applied using light, gliding strokes (effleurage). The massage should begin at the base of the client's spine and work up and down the back using circular stroking motions.

To prevent meningococcal infections, the nurse would administer:

Vaccine Meningococcal infections would be prevented by a vaccine. A toxoid is a type of vaccine made from the toxins produced by the organism. Immune globulins and antivenin are examples of immune sera.

The nurse has completed teaching. Which client behaviors demonstrate understanding within the cognitive domain? Select all that apply.

Verbalizes key points of a brochure about diabetes that was read Provides a description of what appropriate wound healing should look like The cognitive domain is a style of processing information by listening or reading facts and descriptions. In this scenario, the client has shown learning in the cognitive domain by reading a brochure and articulating key points and by providing a description of what appropriate wound healing should look like. Providing return demonstration of how to use the inhaler demonstrates learning in the psychomotor domain. Expressing comfort with the walker and expressing a belief system demonstrate learning in the affective domain.

Which type of hallucination is most commonly seen in clients diagnosed with delirium?

Visual Visual hallucinations are the most common type seen in clients diagnosed with delirium.

Which population group should the nurse routinely screen for heart disease?

White Whites (Caucasians) have a high incidence of heart disease and should be screened based on race and age parameters.

The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study?

Witchcraft "Unnatural illnesses" are thought to be punishments for failing to follow a god's rules, resulting in evil forces or witchcraft causing physical or mental health problems. "Natural illnesses" are thought to be caused by dangerous agents such as cold air or impurities in the air, water, or food.

A 70-year-old client is seen in the family practice clinic. Which vaccine should be administered to prevent herpes zoster?

Zoster vaccine Zoster vaccine is administered to adults 60 years and older to prevent herpes zoster (shingles). The Haemophilus influenzae type B is not administered to prevent herpes zoster. HPV and pneumococcal vaccine do not address the risk factors for shingles.

SLUMS tool

a clinician administered examination used to identify persons who have dementia or Mild Neurocognitive Impairment.

Felony

a crime, typically one involving violence, regarded as more serious than a misdemeanor, and usually punishable by imprisonment for more than one year or by death.

Surrogate decision maker

a person designated by a patient to make health care decisions as the patient would want when the patient becomes incapable of making decisions

The nurse is educating an older adult client on routine vaccines. Which statement best describes the recommended vaccination schedule for an older adult client?

a tetanus-diphtheria booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age Recommended immunizations for older adults have usually consisted of a tetanus-diphtheria (Td) booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age. A second dose of pneumococcal vaccine may be given at 65 years if the first dose was given 5 years previously. None of the other options present accurate information concerning currently recommended vaccination scheduling for older clients.

Tort

a wrongful act or an infringement of a right (other than under contract) leading to civil legal liability.

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as:

abandonment. The client is alone and without any support or caregivers. Therefore, abandonment, which is the desertion or a vulnerable older adult by anyone who has assumed responsibility for that adult's care, would apply. Exploitation involves illegally taking or misusing funds, property, or assets of a vulnerable older adult. Neglect involves refusal or failure by those responsible to provide food, shelter, protection, or health care for a vulnerable older adult. Emotional abuse involves verbally or nonverbally causing mental pain, anguish or distress on the older adult.

tertiary prevention

actions taken to contain damage once a disease or disability has progressed beyond its early stages

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should:

actively solicit information about the client's pain level. Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments.

When admitting an adolescent to the hospital, the nurse anticipates that the client will respond to questions about the client's health beliefs based primarily on the client's:

age and developmental stage.

The charge nurse overhears two new graduate nurses talking in the break-room. One graduate nurse states, "I hate getting reports from the older nurses; they are just too slow." The charge nurse understands that the nurse is demonstrating what?

ageism Ageism is a negative belief that older adults are physically and cognitively impaired. Therefore, the statement about the older nurses demonstrates ageism. Stereotyping is a fixed attitude about people who share common characteristics. Cultural shock is bewilderment over behavior that is culturally atypical. Ethnocentrism is the belief that one's cultural is better than other cultures.

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:

anticipate sleeping overnight at a health care center. Polysomnography is a sleep study. The client will be scheduled for the study at a health care center and sleep overnight as part of the study. The client should avoid sedatives, as this will aggravate OSA. Interventions for OSA include inserting an oral appliance or applying a facial mask for continuous positive airway pressure.

A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state?

applying for a reciprocal license in the new state

The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

art of nursing In this example, the nurse is utilizing a holistic approach to the provision of nursing care based on the knowledge of providing psychosocial interventions, such as allowing the client to verbalize feelings/fears. This application of knowledge is the art of nursing. The science of nursing is the knowledge base for the provision of care. Evidence-based practice and application of research are using research to make decisions on how to care for clients.

When assessing the client for pain, the nurse should

believe the client when he or she claims to be in pain. "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

confabulation

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

cutaneous stimulation Acupressure, a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care.

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?

decreased REM sleep

habituation

decreasing responsiveness with repeated stimulation. As infants gain familiarity with repeated exposure to a visual stimulus, their interest wanes and they look away sooner. 습관(작용)화, 상용벽

The nurse spends a day off in a part of a non-English speaking community in order to learn more about the culture to improve interactions when providing client care. What cultural activity is this nurse demonstrating?

desire

A client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. The remission state is characterized by:

disappearance of signs and symptoms associated with the disease. Remission is a temporary state of disappearance of the signs and symptoms related to a particular disease. It is of short duration, but the duration is unpredictable. It is a condition opposite to exacerbation, which is characterized by reactivation of symptoms. Remission is not permanent, but is rather a temporary relief from signs and symptoms. Exacerbation is the periodic occurrence of disease in clients with chronic diseases.

Diagnostician

doctor who is an expert at recognizing the nature of a disease or condition

A nurse is preparing a presentation for a group of families who are providing care to their older adult parents. One of the family members asks the nurse, "How common is Alzheimer's disease?" The nurse responds by telling the group that after age 65, the prevalence of Alzheimer's disease:

doubles every 5 years. According to the Alzheimer's Association, the prevalence of Alzheimer's disease doubles every 5 years beyond age 65.

The nurse is caring for two clients with the same ethnic background. The nurse notices some differences between the two in the religious practices and the slang used for communicating. What is most likely the etiology of these differences?

ethnicity Ethnicity or ethnic identity refers to the differences among a group who share the same cultural and/or ancestral heritage. Cultural norms are the actions that are expected by others within the culture. Cultural relativity refers to the differences between cultures in the meaning of various behaviors. Ethnocentrism is the belief that one's own practices are the only correct practices.

Within a culture, the world becomes predictable and coherent for its inhabitants. This predictability has been defined as:

habituation Culture is habituated; it reflects a usual way of doing things that people learn through socialization as they may mature and become deeply involved in different subcultures. Cultural habituation is advantageous. Any behavior or situation can be normalized, for short or long durations or when it should not be accepted as such. Stereotypical behaviors are not consistent among people or situations. Desensitization is a term used to reduce response to a behavior or situation and does not apply here.

The action of ibuprofen is to:

have an antiprostaglandin effect on the CNS. NSAIDs are generally effective for pain-related tissue damage. The analgesic action of these drugs has antiprostaglandin effects in both the peripheral and central nervous systems.

Competence

having enough skills to do something 능숙함, 능숙도

Nurses are socialized into the:

healthcare culture.

The recognition of health as an ongoing process toward a person's highest potential of functioning is defined as:

high-level wellness. High-level wellness is defined as recognizing health as an ongoing process toward a person's highest potential of functioning. The Health Belief Model focuses on how the client's beliefs about health influence the client's health and response to health and health care. Illness is a person's response to disease. the Agent-Host-Environment model explores the factors that contribute to infection in a client.

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

When the nurse informs a client's employer of the client's autoimmune deficiency disease, the nurse is committing the tort of:

invasion of privacy.

In the role of entrepreneur, the nurse's primary responsibility is:

managing a health-related business. A nurse entrepreneur is primarily concerned with organizing, developing, and managing a clinic or health-related business. Although a nurse entrepreneur may also administer resources, manage personnel, and teach, the primary responsibility of this role is managing a health-related business. A nurse administrator is primarily concerned with administering resources and managing personnel. A nurse educator is primarily concerned with teaching in a clinical setting.

A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the:

media Ethnocentrism is a way of looking at the world through a personal lens that has been influenced by personality, genetics, family/relationships, and media. None of the remaining options play a role in the client's comment to the nurse.

The nurse is assessing a client for sleep disorders. The initial step in sleep assessment is:

observe the client's hours of sleep and review the client's sleep diary. Observing the sleeping patterns and checking the client's sleep diary can lead the nurse to clues about the quality of the client's sleep. Neck circumference can be a factor in obstructive sleep apnea, but it is not routinely measured during assessment. Being overweight is a common finding in sleep disorder clients, but visual acuity issues are not. Auscultation of the lungs and abdomen are not pertinent to the potential disorder.

A client of a different culture than the nurse is enjoying the afternoon in the park playing with her daughter. She later arrives 30 minutes late to her doctor's appointment and does not understand the problem when the receptionist tells the client that she will have to reschedule. This client views time in which context?

present Different cultures tend to value time in the past, present, or future. Those focused on the past value practices unchanged from ancestors and are often resistant to new ways. Those focused on the present put what is going on today above what will occur tomorrow. Those who are future oriented place value on deferring pleasures for later gain.

A toddler has been brought to the community clinic and will be administered the ProQuad vaccine. When educating the child's parents about this vaccine, the nurse should explain what benefits? Select all that apply.

protection against mumps and rubella protection against measles and varicella

In Stage 4 sleep, the:

pulse rate is slow During slow-wave sleep, the muscles are relaxed, but muscle tone is maintained; respirations are even; and blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle all decrease.

Which factor necessitates the need for more sleep in the adolescent population?

rapid growth The growth spurt that occurs during adolescence may necessitate the need for more sleep. However, the stresses of school, activities, and part-time employment may cause adolescents to have restless sleep, and many adolescents do not get enough sleep.

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain Pain from the abdominal, pelvic, or back region may be referred to as areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

The nurse is caring for an older adult client post surgery in the critical care unit. The nurse finds that the client is acutely confused and trying to get out of bed. Which is the priority nursing intervention?

review with the client that he or she is in the hospital Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. The nurse can use reality orientation, which involves interventions to redirect the client's attention to what is real in the environment. Benzodiazepines are usually avoided because they may increase confusion and cause oversedation. Insertion of an indwelling urinary catheter can trigger a series of downward events that are referred to as cascade iatrogenesis. Delirium may be managed by incorporating a bundle of strategies in routine care, one of which is early progressive mobility, not bed rest.

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

reviewing and revising the pain management treatment plan

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

reviewing and revising the pain management treatment plan The nurse's focal point should be on reviewing and revising the pain management treatment plan presently in place. The client is status-post bowel resection, so administering a placebo is not the correction option, and could be ethically wrong. The nurse would possibly do a depression assessment, but if the client is reporting constant pain, the pain management plan must be reviewed and revised. The question does not address if the client is taking pain medications, so the option addressing beginning pain medications before the pain is too severe is not correct.

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is:

reviewing the client's sleep diary for the past 2 weeks. A sleep diary kept for 2 weeks will provide a more detailed history of the client's sleep-wakefulness pattern than having the client identify foods that impact sleep, or having the client recall the number of hours of sleep each day for the past week. Client recall may be inaccurate. The client should describe the sleep problem, not the client's bed partner.

The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated?

science of nursing The science of nursing is the knowledge base for the care provided by the nurse. In this example, the nurse is using this knowledge base to decide how best to care for the client by giving or not giving the blood pressure medication. The art of nursing is the application of the knowledge. In this example, it would be demonstrated by the nurse actually giving or holding the medication. Quality improvement activities and the conduction of research influence the science and the art of nursing by helping build the body of knowledge that is the science of nursing.

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns?

sleep paralysis and automatic behavior Sleep paralysis occurs when the person cannot move for a few minutes just before falling asleep or awakening. Cataplexy occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger. Hypnogogic hallucinations are dream-like auditory or visual experiences while dozing or falling asleep. Automatic behavior is the performance of routine tasks without full awareness, or later memory, of having done them. This client experiences sleep paralysis and automatic behavior.

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.

smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism

The nurse is caring for a client who has had unrelieved back pain for 3 years. How will the nurse document this type of pain? Select all that apply.

somatic chronic

The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is

spend time with a variety of individuals of that ethnic group. Repeated face-to-face encounters help to refine or modify the nurse's knowledge of the culture. The nurse must seek out many such encounters with the desire to understand more about the culture.

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake The most common side effect of opioid use is constipation. Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.

Based on an understanding of the cognitive changes that normally occur with aging, what might the nurse expect a newly hospitalized older adult to do?

take longer to respond and react The nurse would expect a newly hospitalized older adult to take longer to respond and react. It is normal for an older adult to take longer to respond and react, particularly in new or unfamiliar surroundings. Knowing this, the nurse should slow the pace of care and allow older clients extra time to ask questions or complete activities.

normalization

the belief that people with disabilities should be physically and socially integrated into the mainstream of society regardless of the degree or type of disability

Which factor has the most influence on an individual's sleep-wake patterns?

the inner biologic clock

automatic behavior

the performance of routine tasks without full awareness or later memory of having done them

pervasiveness

the quality of spreading widely or being present throughout an area or a group of people. 충만함 , 침투성.

derailment

the shifting from one subject to another, without following any one line of thought to conclusion 탈선

desensitization

the tendency over time to show weaker emotional responses to emotional stimuli 생약학, 약리학,

confabulation

the unintended false recollection of episodic memories 작화(증) (마음속으로 이야기를 지어내는 행위 또는 그런 이야기)

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:

they may be disoriented on awakening.

A client being vaccinated for measles asks the nurse about the contents of the vaccine. During the explanation, the nurse mentions a poisonous substance produced by some bacteria that is capable of stimulating antitoxin production. Which is the nurse referring to in the explanation?

toxin A toxin is a substance that is capable of stimulating the body to produce antitoxins, which act in the same manner as antibodies. Toxins are powerful substances, and they can be attenuated and used as toxoids to produce antitoxins. Toxoids are attenuated toxins, which are capable of stimulating antibody production and creating immunity. Vaccines are attenuated or killed antigens, which are capable of stimulating antibody production and creating immunity. Immune globulins are antibodies containing solutions formed to specific antigens and are obtained from human or animal blood.

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:

use caution when driving an automobile. The client is describing hypersomnia and is at increased risk for a motor vehicle accident when drowsy while driving an automobile. The client is to avoid alcohol, caffeine, and late-night activities.

Besides controlling pain of the postabdominal surgery client with opioids, the nurse suggests to the client that he:

use distraction. Distraction is useful when clients are undergoing brief periods of sharp, intense pain, such as dressing changes, wound debridement, biopsy, or incident pain from shifting positions.

The nurse is caring for a client who reports nausea and vomiting for 1 week. How will the nurse document this type of pain? Select all that apply.

visceral acute Visceral pain is associated with disease or injury. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse in the scenario documents the client's pain as visceral and acute. Cutaneous, somatic, referred, neuropathic, and chronic pain are not represented in this scenario.

The nurse is caring for a client who has come to the emergency department reporting chest pain rated at 9 on a scale of 1 to 10. The pain shoots down the left arm and started 45 minutes ago. How will the nurse document this pain in the electronic health record? Select all that apply.

visceral referred acute Visceral pain (discomfort arising from internal organs) is associated with disease or injury. It is sometimes referred or poorly localized. Referred pain (discomfort perceived in a general area of the body, usually away from the site of stimulation) is not experienced in the exact site where an organ is located. Acute pain (discomfort that has a short duration) lasts for a few seconds to less than 6 months.

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

visceral pain. The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

A client describes difficulty falling asleep and difficulty maintaining sleep, and reports daytime fatigue and inability to concentrate. The nurse suggests which noninvasive techniques that may help promote restful sleep? Select all that apply.

waking at the same time every morning removing bedtime distractions such as watching television in bed practicing relaxation techniques Maintaining a sleep/wake routine is essential to restful sleep. Promoting it by removing distractions and learning relaxation techniques can be beneficial. Exercising right before bed may promote wakefulness. Research has shown that melatonin and valerian do not help with insomnia.

What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.

whether there are any existing language barriers nutritional or dietary considerations alternative medicine practices Aspects of culture relevance to a health assessment include communication and language, nutrition, and health care beliefs and practices. The remaining questions relate to the social aspects of a cultural assessment.

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality."

Which statement by the nurse demonstrates an understanding of the importance that a client's culture plays in the client's health and wellness?

"I need to understand the client's cultural background to best interpret the client's needs."

A nurse is conducting an assessment of a middle-aged client who reports difficulties with sleeping at night. Which information would the nurse correlate with the client's sleep-wakefulness pattern? Select all that apply.

"I usually go to bed around 9 and get up at about 7." "I usually get up two to three times a night to urinate."

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary?

"I will record the time I go to bed and how long it takes me to fall asleep."

The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?

"My boys love to roughhouse in their room right before bedtime." Bedtime rituals such as reading stories, having a healthy carbohydrate snack, holding a favorite stuffed toy, and use of a night light promote a healthy sleep routine for children. Most studies show that exercise right before going to bed impedes the person's ability to fall asleep quickly.

A client asks an RN to prescribe a medication for pain. What is the best answer by the nurse?

"Only advanced practice registered nurses have prescriptive authority." The best answer by the nurse is that only advanced practice registered nurses have prescriptive authority. The registered nurse who is not an advanced practice nurse should not prescribe medications, even over-the-counter medications such as ibuprofen and acetaminophen.

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?

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

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed with safeguards to limit the possibility overmedication." The parameters programmed into the PCA pump prevent accidental overdose. Addiction is not a realistic risk for most clients. Care related to a PCA is not delegated to unlicensed care providers. The button should be pushed only by the client.

Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?

"There's a very minimal risk of addiction, and controlling his pain is our first concern." Concerns about addiction are normally unfounded. Nonetheless, it is inaccurate to characterize the possibility of addiction as a myth, on one hand, or a very real risk, on the other. Tolerance would not necessitate discontinuation.

A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds:

"What precipitates the outbursts?" A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both.

An adult client is scheduled to receive the inactivated hepatitis A vaccine. The nurse should provide what education to the client?

"You'll need another dose of the vaccine in six to 12 months from now." Hepatitis A vaccine requires a repeat dose in six to twelve months. There is no prohibition against drinking alcohol after receiving the vaccine. B cells take more than 48 hours to create the necessary immunoglobulins for conferring immunity. The hepatitis A vaccine does not require an annual booster.

A mother brings her 18-month-old into the clinic for a well-baby check-up. A nurse will administer measles, mumps, and rubella vaccine (MMR) to the 18-month-old. What dosage will the nurse administer?

0.5 mL The nurse will administer 0.5 mL. This is the recommended dose for adults and children older than 15 months of age.

Which nursing student would most likely be held liable for negligence?

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home. The nursing student who administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home is performing a task outside the scope of the job responsibilities of a UAP. The other options demonstrate legally defensible actions by the nursing student.

Which are characteristics of chronic conditions? (Select all that apply.)

Are rarely curable Require lifelong management Have a prolonged course

When preparing client teaching materials, how does the nurse best assess a client's preferred learning style?

Ask the client, "Do you learn best by observing, valuing, or doing?"

Antivenins are used for passive, transient protection from which bites? (Select all that apply.)

Black widow Rattlesnake Copperhead Antivenins are used for passive, transient protection from the toxic effects of bites by black widows, rattlesnakes, copperheads, cottonmouth, and coral snakes.

Which is a metabolic cause of delirium?

Hypoglycemia Hypoglycemia is a metabolic cause of delirium. Meningitis and encephalitis are infection-related causes. Alcohol intoxication is a drug related cause of delirium.

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention?

Low-flow oxygen The pattern of frequent arousals seen in people with chronic obstructive pulmonary disease may result from the body's adaptation to maintain adequate oxygenation. Usually, these clients require low doses of oxygen at night.

The nurse is managing the environment for clients on a busy hospital unit. Which interventions would the nurse perform to facilitate a more restful environment? Select all that apply.

Maintain a brighter room during daylight hours and dim lights in the evening. Decrease the volume on alarms, pages, telephones, and staff conversations. Medicate for pain if needed.

A nurse caring for older adults in a long-term care facility is teaching a novice nurse characteristic behaviors of older adults. Which statement is not considered ageism?

Personality is not changed by chronologic aging.

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?

The nurse should ensure that naloxone is readily available on the unit, as it can reverse the respiratory depressant effects of opioids. Naloxone is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids. Furosemide is a loop diuretic and used to treat hypertension (high blood pressure) and edema. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor used for treating high blood pressure, heart failure and for preventing kidney failure due to high blood pressure and diabetes. Digoxin is used to treat congestive heart failure.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care

Below are the four physiological processes involved in pain perception. Put them in the correct order.

Transduction Transmission Perception Modulation

To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what?

Use of disposable, adult diapers Urinary incontinence can be managed with the use of disposable, adult-size diapers that must be checked regularly and changed expeditiously when soiled. Indwelling catheters foster the development of urinary tract infections and may compromise the client's dignity and comfort. Use of intermittent catheterization and condom catheters would not be the best options, either.

A popular pain assessment scale for children is:

Visual Analog Scale.

Cultural imposition

When one person imposes his or her beliefs, values, and practices on another because he or she believe his or her ideals are superior

imposition

an unwelcome demand; a burden 부담

negligence

careless neglect, often resulting in injury

stereotypical

having an idea of what a person is like before knowing them, usually a simple judgement 진부한, 틀에 박힌.

Remission

improvement or absence of signs of disease

Health Belief Model

model for explaining how beliefs may influence behaviors

A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms:

require an individualized approach by the nurse.

Stages of sleep cycle

stage 1- light level, stage 2- sound sleep, stage 3- deep sleep, stage 4- deepest stage of sleep

cataplexy

sudden loss of muscle control

Fraud

wrongful or criminal deception intended to result in financial or personal gain