Final- 2700

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4) While performing an endocrine assessment on a client suspected of having Cushing disease, the nurse asks the female client if she has experienced recent weight changes. Which endocrine systems is the nurse assessing? Select all that apply. A) Gonads B) Pituitary gland C) Thyroid gland D) Adrenal gland E) Parathyroid gland

B, C, D

2) The nurse is creating a four-column plan of care for a client. For which area(s) should the nurse prepare to document when creating this care plan? Select all that apply. A) Medications B) Nursing diagnosis C) Goals D) Interventions E) Evaluation

B, C, D, E

10) The nurse instructor is preparing a teaching session for staff nurses on intradisciplinary assessments. Which information should the instructor consider when preparing this presentation? Select all that apply. A) Utilization reviews B) Peer review C) Audits D) Performance appraisals E) Outcomes management

B, C, E

1) During a health history a client becomes upset because the nurse is asking many questions. What should the nurse respond to the client? A) "I use the answers you provide to determine what your current health needs are." B) "I am sorry the questions disturb you." C) "I will skip the questions that bother you." D) "I cannot help you if you do not answer me."

1) The mother of a preadolescent client diagnosed with an eating disorder believes it must be genetic because the client is adopted and the client's mother is very weight and exercise conscious. The nurse realizes which of the following? A) The mother is obsessed with weight and exercise, and the child learned the behavior. B) The child must have inherited a genetic predisposition to an eating disorder. C) The child must have a neurotransmitter abnormality. D) The mother is setting a good example with eating and exercise.

10) The nurse is caring for a client who is admitted to the Emergency Department with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. When the interpreter arrives, the staff should make sure that: A) They ask the interpreter to translate as closely as possible the same words used by the professional staff. B) The client's family is included in the process and exchange of information to ensure complete understanding. C) The staff addresses the questions to the interpreter, so nothing is missed. D) The interpreter uses a dialect the client is familiar with for the best understanding.

10) While assessing the cognitive status of a 7-year-old child, the nurse notes that the child was unable to perform division problems and unable to name several former presidents of the United States. Prior to determining that this client has cognitive issues, what should the nurse keep in mind? A) The child's developmental level B) The child's home environment C) The child's nutritional status D) The parent's participation in the child's cognitive development

14) The nurse is caring for a client who is prone to falls. Which nursing diagnosis would be most appropriate for this client? A) Risk for Injury B) Risk for Suffocation C) Deficient Knowledge D) Risk for Disuse Syndrome

16) A nurse educator is working with a group of nursing students in the lab on the application of personal protective equipment (PPE). The educator emphasizes the importance of appropriate technique when removing the face mask. Which response by the students indicates appropriate understanding? A) "I will touch the mask by the strings only." B) "I will bend the strip at the top of the mask." C) "I will tie the strings in a bow." D) "I will loop the ties over the ears."

17) The nurse is providing discharge teaching to a client with a diabetic wound. The nurse understands the importance of including what information? A) What the client learned about changing the dressing while in the hospital B) Teaching the client how to take blood sugars C) The client's ability to self-administer insulin D) The client's reaction to being a diabetic

18) The nurse asks the client to repeat the information taught during the discharge teaching session. The client states, "I have forgotten everything you just said." Which additional teaching would help the client retain the information? A) Writing down and repeating the information as the nurse teaches B) Having the client wait to ask questions until after the presentation C) Asking another nurse to provide the teaching for the client D) Asking the client to provide more information on learning strategies

2) A client tells the nurse, "My mother spent many years in a mental institution, and my father would abuse me when my mother was not around." The nurse realizes the client is at risk for developing which of the following? A) A personality disorder B) Poor relationships with the opposite sex C) An eating disorder D) Substance abuse

2) A home health nurse is working with a client who has chronic obstructive pulmonary disease. What nursing diagnosis will take the highest priority for implementing client education? A) Impaired Gas Exchange B) Ineffective Breathing Pattern C) Anxiety D) Activity Intolerance

2) The nurse is caring for a client who has been diagnosed with high cholesterol. When the nurse plans topics to teach, it is important to keep in mind that adult learners: A) Are more oriented to learning when the material is useful immediately. B) Are more likely to adhere to a regimen than are children. C) Usually can find information on their own. D) Do not need to be evaluated for understanding as children do.

2) The nurse provides an in-service to peers regarding situations that can affect the comfort level of the clients on the unit. Which client statement indicates that the client's sense of well-being is negatively impacted? A) "I feel like I have no energy today." B) "I don't feel any physical pain today." C) "I was able to sleep uninterrupted last night." D) "I am so glad that playing cards takes my mind off my worries."

21 Copyright © 2015 Pearson Education, Inc. 12) A home health nurse is admitting a new client to the agency. The client was discharged from the hospital with a diagnosis of pulmonary fibrosis. What does the nurse recognize as a priority for the client's initial follow-up care? A) The client will be able to set up and administer a nebulizer treatment by the end of the day. B) The client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. C) The client will have a positive attitude about the diagnosis by the end of the month. D) The client will have increased activity level by the end of the week.

3) A client admitted with a personality disorder is observed pulling another client's hair and pushing clients out of their chairs. Which of the following is a nursing priority for the client at this time? A) Removing the client from the room and addressing the behavior privately B) Establishing a therapeutic nurse-client relationship C) Placing the client in a jacket restraint D) Asking the client what purpose is served by disrupting others

3) A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After applying soft hand restraints to protect the client's airway, which action should the nurse take next? A) Notify the physician. B) Notify the family of the need for restraints. C) Reassess the need for the restraints in 8 hours. D) Document the application of restraints in the chart.

3) A goal of care for a client with congestive heart failure is for serum sodium levels to be within normal limits. What information should the nurse expect to see documented in the medical record? A) The client is experiencing dependent edema. B) The client experiences joint pain. C) The client is constipated. D) The client is experiencing wheezing respirations

3) A nurse educator for a medical-surgical unit is giving a demonstration of new equipment to the rest of the nursing unit and sets up her models in the front of the classroom after her initial efforts at having the class gather closely around the models was met with discomfort and inattention. Which level of proxemics would be appropriate for this situation? A) 4 to 12 feet B) 1-1/2 to 4 feet C) 12 to 15 feet D) Up to 1-1/2 feet

3) A nurse is preparing to teach a group of college students about organ donation. What should the teaching include to follow andragogic concepts? A) Directions about how to become an organ donor B) Past statistics about organ donors C) Information on how this group can influence their parents about organ donation D) Written pamphlets on organ donation

3) A nurse working on a medical-surgical unit has opted to return to school to earn a Bachelor of Science in Nursing (BSN) degree. After considering projected changes in health care and the population cared for in the community, the student might consider selecting which elective course? A) A course on medical Spanish B) A psychology course on young adults C) A personal finance class D) A class on the effect of illness on a young child

2) Which client is at the highest risk of being admitted to the Emergency Department with severe nausea and vomiting? Select all that apply. A) A 47-year-old with a 3-hour history of chest pressure B) A 61-year-old reporting sudden onset of vertigo C) A 72-year-old with an asthma exacerbation D) A 23-year-old who sustained a head injury in a fall E) A 19-year-old who is 6 weeks pregnant

A, D, E

3) An older client complains of periods of confusion and forgetfulness, but reports clear thought process at most times of the day. What is the an appropriate response of the nurse? A) "Are you having trouble hearing?" B) "You probably have nothing to worry about. It's most likely stress-related." C) "Everybody has a few problems with memory as they get older." D) "You should probably have an MRI of your brain."

3) The nurse is assessing the vital signs of a client experiencing hypoparathyroidism. While monitoring the blood pressure, the nurse notes the client's hand begins to spasm. How should the nurse document this assessment finding? A) Trousseau sign B) Chvostek sign C) Turner's sign D) Cullen's sign

4) An older client recovering from prostate surgery is waking up frequently during the night. Which client statement supports the nursing diagnosis Disturbed Sleep Pattern for this client? A) "The pain in my hips is unbearable at times." B) "I walk for half an hour after I eat breakfast." C) "I take my Zoloft as soon as I get up in the morning." D) "I have one cup of regular coffee in the morning

4) The nurse conducting nursing audits to help increase efficiency and reduce costs wants to suggest a better contribution to quality care. What should the nurse suggest be performed instead? A) Conduct a wound care study to enhance client outcomes. B) Install cameras to detect abuse of the clients. C) Acquire new client care equipment. D) Decrease staffing on the unit

4) The nurse is caring for a client who has recently received a permanent colostomy. The client will be going home in several days and requires discharge teaching. What should the nurse do when organizing the teaching experience? A) Ask the client to tell the nurse what he or she knows about caring for the colostomy. B) Make sure the client's spouse is present before the teaching session begins. C) Start from the beginning and proceed through all steps required to perform colostomy care. D) Break the information into small sessions to enhance learning

4) The nurse manager on the neurology unit helps the other nurses on the unit become more involved with the local neurological association and providing healthcare in-services to the community. The nurses on the unit know that the nurse manager shows which type of commitment to the nursing profession? A) Affective commitment B) Normative commitment C) Obsessive commitment D) Continuance commitment

5) A child with injuries from a motor vehicle crash is crying, moaning, and thrashing about on the bed. The child's assessment reveals guarding of the abdomen. The nurse suspects that the child is in severe pain and anticipates which diagnostic test will be ordered for this client? A) Barium enema B) Electrolyte panel C) PET scan D) X-rays of the limbs

5) A client is with a history of GERD presents with metabolic alkalosis. Which medication do you suspect contributed to metabolic alkalosis? A) Aluminum hydroxide B) Omeprazole C) Ranitidine D) Metoclopramide

10) A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

12) A nursing instructor is teaching a group of student nurses about the different theories of cognition. Which cognitive development theory proposes that all children progress through the same stages of development? A) Piaget B) Vygotsky C) Information-processing D) Erickson

2) An older client tells the nurse about rarely going outdoors in the winter because of a lack of energy or desire. What might this client be experiencing? A) Seasonal affective disorder B) Side effect of medication C) Situational depression D) Anxiety

2) The nurse is teaching an in-service about metabolic disorders. Which person is at the greatest risk for malnutrition as a result of hypermetabolism? A) A client with chronic obstructive pulmonary disease B) A client with osteoporosis C) A client who is a vegetarian D) A client who has dysphagia

5) A community health nurse runs a clinic that provides health screening mainly to Mexican American and Filipino American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. What action should the nurse take to adjust their time orientation? A) Begin classes when a group of clients has gathered. B) Mail letters ahead of time to make sure clients are informed about the upcoming class. C) Make posters and place them in areas of the community frequented by these groups. D) Make sure that the classes are held at specific times.

4) The nurse is caring for a 1-year-old child in the postoperative period. Which pain assessment tool should the nurse use when assessing pain in this child? A) Faces Pain Rating Scale B) FLACC Behavioral Pain Assessment Scale C) Oucher Scale D) Poker Chip Tool

8) The nurse is caring for a client with a new tracheostomy. After completing a teaching session on tracheostomy care, what should the nurse include in the documentation? A) The language used for teaching B) The need for additional teaching C) The client's questions after the teaching session D) The supplies required for teaching

The Concept of Teaching and Learning 1) A nurse is preparing to discharge a client who has experienced a myocardial infarction. The client will have to make many lifestyle changes and the nurse is instructing the client on how to implement a heart-healthy lifestyle. The nurse knows that client education is a(n): A) Dependent function of nursing that needs a healthcare provider's order to implement. B) Important independent nursing function. C) Activity nurses learn on the job. D) Way to establish the client's dependence on the nurse.

3) What will the nurse assess in a client diagnosed with bulimia? Select all that apply. A) Increased urine output B) Hoarseness C) Poor skin turgor D) Low body temperature E) Elevated blood pressure

b, c

5) An older client is experiencing confusion, a temperature of 101.5°F, bruising to the arms and legs, and decreased urine output. The medical diagnosis is a urinary tract infection. What is the most appropriate nursing diagnosis for this client? A) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory

9) Which statement or statements accurately reflect the distinction between nursing diagnoses arrived at as part of the nursing process and medical diagnoses? Select all that apply. A) A nursing diagnosis is determined following an assessment and analysis of data gathered only by registered nurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D) A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care. E) A nursing diagnosis requires the nurses to consider standards and norms as well as cues from clients in discerning an appropriate nursing diagnostic label; a medical diagnosis uses standards and norms only. F) Both nursing diagnoses and medical diagnoses include a wellness diagnosis component.

b, c

The Concept of Immunity 1) The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection. The client asks the nurse what defenses the body has against infection. The nurse responds that which physiological barrier helps defend the body against microorganisms? Select all that apply. A) Moisturizing the skin B) Adequate urinary output C) Intact skin D) Occasional smoking E) A surgical incision

b, c

3) A client with a 2-month-old child is experiencing insomnia, mood swings, and crying. From what would this client most likely benefit? Select all that apply. A) Electroconvulsive therapy B) Psychosocial interventions C) Antidepressants D) Time management and exercise therapy E) Cognitive-behavioral therapy

b,c

4) The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the neurosurgeon during morning rounds. Which diagnostic test results should be on the medication record for the physician's review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Complete blood count of the cerebrospinal fluid

b,c,d,e

5) The nurse is reviewing the laboratory test results for a client with an endocrine disorder. For which tests should the nurse expect to have current values on the medical record? Select all that apply. A) Prothrombin time B) Albumin C) Ammonia level D) Liver functions studies E) Hemoglobin and hematocrit

b,d

8) A client who has just been diagnosed with diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statement or statements indicate that further teaching is required? Select all that apply. A) "I should talk to the doctor about an exercise program." B) "I don't need to watch my diet as long as I take my insulin." C) "I need to limit the amount of fat in my diet." D) "I should eat a candy bar when my energy is low." E) "I will test my blood sugar before meals and at bedtime."

b,d

13) The nurse is conducting a class for a group of pregnant women. Which topic should the nurse include in teaching this group with regard to safety of the fetus? A) Pedestrian accidents B) Suffocation in the crib C) Alcohol consumption D) Drowning

4 Copyright © 2015 Pearson Education, Inc. 4) The nurse detects an exaggerated concave curvature of the lumbar spine of a client. Which conclusion about this assessment is correct? A) Abnormal kyphosis is noted during range-of-motion assessment of a child. B) Normal scoliosis is observed during the joint assessment of an older man. C) Lordosis is commonly seen in the gait and posture assessment of a pregnant woman. D) Crepitus is commonly found during the assessment interview of a middle-aged woman.

6) A nurse has just received a shift report for a 12-hour shift. As the nurse is preparing to enter a client's room, the nurse overhears a coworker telling an offensive joke with a sexual undertone to the client. What is the best action for the nurse at this time? A) Tell the nurse, in private, that such conduct is offensive and not professional. B) Ignore the coworker and walk away. C) Report the incident to the nurse manager. D) Ask to be scheduled opposite this coworker.

6) An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. What should the nurse do? A) Allow the toddler to sit on the parent's lap and begin the assessment. B) Allow the toddler to stand on the floor until the crying stops. C) Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler's behavior. D) Instruct the parent to hold the toddler down tightly to complete the examination.

6) The client with diabetes mellitus reports having difficulty cutting his toenails because they are thick and ingrown. What should the nurse recommend to this client? A) Make an appointment with a podiatrist. B) Offer to file the tops of the nails to reduce thickness after cutting. C) Cut the nails straight across with a clipper after the bath. D) Make an appointment with a nail shop for a pedicure.

6) The nurse knows that communication among healthcare team members is essential during mass casualty events. Which factors are the most important for nurses in order to foster better communication? A) Concise, accurate, timely information B) Preparing for ethical challenges C) Documenting to prevent legal issues D) Coordinating care between management and clinicians Answer: A

6) The nurse observes the student nurse's behavior on the unit, and notes the student is always on time, neat in appearance, and caring toward clients. Which factor best indicates to the nurse the student level of professional commitment? A) A pattern of behaviors congruent with the nurses' professional code of ethics B) A strong belief in and acceptance of the company's goals, values, and mores C) A willingness to be able to exert control over personal behaviors D) A strong desire to be a part of a group

7) The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.

7) The mother of a preadolescent client is concerned because the child often reports non-specific "bone pain." What can the nurse respond to this mother? A) "Bone pain in children is caused from the pulling of muscles when bones grow quickly." B) "The child needs to rest more when the bones hurt." C) "Non-specific bone pain means there is a disease process somewhere else in the body." D) "It is a symptom that needs further investigation and will be reported to the physician."

7) The nurse is caring for a child with decreased level of consciousness secondary to increased intracranial pressure (IICP) from a head trauma. Which order from the healthcare provider should the nurse question? A) Passive range-of-motion exercises B) Elevating the head of the bed to 30° C) Vital signs and neuro checks every hour D) Administering oxygen at 2 L nasal cannula to keep saturation above 95%

7) The nurse understands that some factors affect health care delivery by creating new opportunities for the healthcare sector. Which of the following would affect healthcare delivery? A) Advances in technology requiring specialized personnel B) Healthcare literacy programs C) Changing demographics that increase the need for new jobs D) Managed care frameworks that coordinate clients and insurance plans

7) When speaking with a client newly diagnosed with chronic obstructive pulmonary disease (COPD), the nurse knows that therapeutic communication has been achieved when which action has occurred? A) The nurse asks appropriate questions about the client's medical history. B) The nurse closes the conversation with an anecdote about breathing. C) The nurse plans to tell the client about a COPD support group. D) The nurse bonds with the client by describing her life living with COPD.

7) When speaking with a nursing student about the nursing profession, the student states, "I'm so nervous about taking the NCLEX, but I'm excited also; your nurse manager asked if I wanted to work here!" The nurse knows that the student is in which stage of commitment development? A) The integrated stage B) The testing stage C) The passionate stage D) The exploratory stage

8) The nurse is giving discharge instructions on removing loose rugs in the home to a client with a total hip replacement. This is an example of which type of nursing intervention? A) Independent: injury prevention B) Independent: preservative functioning C) Collaborative: promotion of comfort D) Collaborative: family instruction

8) The nurse is planning care for a client with a head injury and increased intracranial pressure (IICP) from a motor vehicle crash. Which intervention is a priority for this client? A) Ensuring adequate oxygenation B) Maintaining a calm environment C) Monitoring for nausea and vomiting D) Controlling pain

8) The nurse is taking care of a client being discharged but will need home nursing care, physical therapy, and speech therapy. Which framework helps the client who has multiple care needs? A) Case management B) Client-focused care C) Managed care D) Multidisciplinary nursing teams

9) A concerned parent brings in her son, who is 13 years old, to see you. They both report that he doesn't go to sleep until late at night and then wakes up late in the morning. She doesn't know what to do. How might you respond? A) Inform her that adolescents experience changes in the body's internal clock associated with puberty. B) Recommend a polysomnography (PSG). C) Tell her to avoid giving her son any herbal preparations such as melatonin. D) Inform them that the son's sleep habits, such as bringing electronic devices to bed, have no effect on his sleep pattern.

9) The nurse is teaching the family of a client who has just been diagnosed with dementia. The family asks what treatments are available that will cure the client. What would be the nurse's best response to the family? A) "There are no treatments that will cure dementia." B) "Treatments to cure dementia include the use of vitamin E." C) "Treatments to cure dementia involve hormone replacement therapy." D) "Treatments to cure dementia include the daily use of ginkgo biloba."

9) The nurse knows that confrontation can be used to therapeutically communicate with clients. Which response by the nurse is an example of informational confrontation with a client diagnosed with hypertension? A) "I noticed you rubbing your head and your eyes, are you hurting? Let's take your blood pressure." B) "I heard raised voices when I was coming down the hall to your room. Are you upset?" C) "It is 3 p.m. and time to take your blood pressure before I give you your medication." D) "Is the blood pressure medication making your head hurt?"

Exemplar 41.1 Client/Consumer Education 1) A client who had outpatient surgery is given an instruction sheet in preparation for discharge. When the nurse asks if the instructions are clear, the client says, "I'll read them later when I have my glasses; besides, you told me everything I need to know." Based on these statements, what would the nurse suspect? A) The client may be unable to read the instructions. B) The client already knows the information. C) The client does not want the written information. D) The client is ready to learn

ICP 2) A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which interventions should the nurse prepare to implement? A) Assess airway, breathing, and circulation. B) Assess patency of the Foley catheter. C) Treat the client's pain. D) Get a complete history from the client. ( full alert: 15, lowest 3)

Module 51 Safety The Concept of Safety 1) The nurse is caring for a client who is prone to falls. Which nursing diagnosis would be most appropriate for this client? A) Risk for Injury B) Risk for Suffocation C) Deficient Knowledge D) Risk for Disuse Syndrome

The Concept of Digestion 1) A client presents with delayed wound healing. During the digestion assessment, which is the most likely nutrient deficit to be found in the client's diet? A) Protein B) Digestive enzymes C) Insulin D) Carbohydrates

The Concept of Mobility 1) During the assessment of a client, the nurse finds that the client's lower extremities are both warm, sensation is intact, and motion is unrestricted. What does this finding suggest to the nurse? A) Skeletal muscle attached to bones via tendons is performing correctly. B) Smooth muscle attached to bones via ligaments will require further assessment. C) Cartilage connecting bones has a good blood supply. D) Muscle connecting the axial skeleton is compromised.

The Concept of Quality Improvement 1) The nurse on a medical-surgical unit is asked to participate in data collection on skin care for the unit. What purpose will it serve for the nurse to cooperate with this request? A) Participate in the quality improvement process B) Advance the nurse's practice C) Prevent problems from arising in the unit D) Fulfill legal requirements

5) A nurse is planning a community health fair in a local community center. What goals are important for the client to understand about health promotion? Select all that apply. A) The ability to change and modify goals as health needs change B) The ability for clients to be able to assess and evaluate their health needs C) The ability for the client to promote health in other individuals D) The ability to promote cost-saving techniques to healthcare providers E) The ability to prevent disease by imitating nursing techniques

a,b

5) The nurse is planning the care for a client diagnosed with a personality disorder. Which goal or goals address the client's antisocial behavior? Select all that apply. A) The client will share meals with others in the community dining area. B) The client will interact socially with others. C) The client will engage in individual therapy without disruptions. D) The client will take all medications as prescribed. E) The client will refrain from violent behavior.

a,b

The Concept of Comfort 1) The nurse is preparing to assess pain level for several clients. What will the nurse assess, in addition to the client's physical experience of pain? Select all that apply. A) Religion B) Friendship C) Environment D) Psychospirituality E) Social interaction

C, D, E

11) The nurse manager at an acute care facility is educating her staff nurses on the definition of a sentinel event and providing examples. Which would be appropriate for the nurse manager to present to the staff nurses as examples of a sentinel event? Select all that apply. A) Delivery of radiation to the wrong body region B) Invasive surgical procedure at the wrong site C) Homicide of a staff member while at the facility D) Homicide of a patient while at the facility E) Administration of a compatible blood transfusion Answer: A, B, C, D

A, B, C, D

9) A student nurse is asked to recall questions included in the SCOFF questionnaire. The student nurse would identify which questions as a part of the SCOFF questionnaire? Select all that apply. A) Do you believe yourself to be fat when others say you are too thin? B) Would you say that food dominates your life? C) Do you worry you have lost control over how much you eat? D) Do you make yourself sick because you feel uncomfortably full? E) Have you recently lost more than 1 pound in a 3-month period?

A, B, C, D

The Concept of Metabolism 1) A client is experiencing health problems related to alterations in adrenal medulla function. On which areas should the nurse focus when assessing this client? Select all that apply. A) Heart rate B) Weight C) Respiratory rate D) Skin integrity E) Blood pressure

A, B, C, E

The nurse is designing a teaching plan for community members on ways to prevent chronic pain. Which information should the nurse include in this teaching plan? Select all that apply. A) Eating a healthy diet B) Obtaining adequate sleep C) Avoiding illicit drug use D) Limiting smoking before going to sleep E) Avoiding repetitive movements

A, B, C, E

2) The nurse is caring for a client recently diagnosed with schizophrenia. For what sleep issues is this client at risk because of this diagnosis? Select all that apply. A) Circadian cycle disruption B) Great difficulty getting to sleep C) REM rebound D) High nighttime levels of melatonin E) Reduced REM sleep

A, B, E

5) While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. What are appropriate interventions for the nurse to teach the family member? Select all that apply. A) The head of the bed should be elevated to 30 degrees. B) The client should remain in a supine position. C) The family should use slow, gentle movements when repositioning the client. D) The client should be repositioned as needed. E) Patients with ICP should remain in a stationary position.

A, C, D

5) A client with clinical depression asks the nurse for suggestions on how to improve the quality of sleep. After reviewing the client's history, which suggestion should the nurse make to this client? Select all that apply. A) Avoid the use of alcohol late in the evening. B) Consume a cup of tea before bed to relax. C) Adjust the temperature in the room to a comfortable level. D) Change the time of aerobic exercise to 1 hour prior to sleep. E) Avoid smoking before bedtime

A, C, E

3) The nursing instructor is evaluating a concept map created by a student for a client's plan of care. What characteristic or characteristics on the map indicate that the student created the map appropriately? Select all that apply. A) Legend created identifying nursing process phases and client information categories B) Lines drawn between assessment data and associated nursing diagnoses C) Different colors used to represent the phases of the nursing process D) A column entitled "evaluation" located on the outer edge of the document E) A checklist located at the bottom of the document

A,b,c

6) A nurse is providing a series of educational workshops for caregivers of clients enrolled in an Alzheimer's day treatment program. What would be appropriate topics? Select all that apply. A) Understanding dementia behaviors B) Caregiver stress relief C) Safety precautions D) Support service information E) Methods for curing the disease

A,b,c,d

5) The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. What actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Provide all care quickly at one time to provide periods of rest. E) Keep the room dark and quiet.

A,b,e

5) A nurse is preparing an educational program for clients in a long-term care facility regarding methods for coping with age-associated cognitive changes. Which information should the nurse include? Select all that apply. A) Becoming involved in activities such as reading that keep the mind active B) Playing board games C) Using assistive devices such as a pill box for medications D) Making lists, posting appointments on calendars, and writing notes to self E) Not relying on habits; challenging your mind to remember new things

A,c,d

12) The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which area(s) should the nurse focus when performing this reflection? Select all that apply. A) Things that could have been done differently B) Gut reactions to the situation C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available

A,c,d,e

6) The nurse is planning care for an older client with a head injury sustained from a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Reflexes are less intense in an older client. C) Impulse transmission and reactions to stimuli are slower. D) The plantar and Achilles reflexes are hyperactive in this age group. E) Impairment in vision and hearing should be taken into consideration.

A,c,e

10) A nurse enters a client's room to check on the client's response to IV pain medication she gave on request 20 minutes earlier. She finds the client on her side lying very still and not wanting to move, and asks the client about her current pain level. Which aspect(s) of the nursing process does this action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation Answer: A, D, E

A,d,e

6) A 57-year-old client was admitted to the hospital with chest pressure. After myocardial infarction was ruled out, he was diagnosed with erosive esophagitis through upper GI endoscopy. He owns and operates a bakery with his wife and adult son. His BMI is 39. He smokes 1 pack of cigarettes per day. The patient is now refusing all medications and states "I'm not getting hooked on any pills." What would the nurse recommend for the multidisciplinary collaborative plan? Select all that apply. A) Assess the client's readiness for change in smoking cessation and weight loss. B) Interview the client and his wife for a 24-hour recall of usual food content, intake, and meal times. C) Enlist the patient's son to elevate the foot of the client's bed at home 6 inches. D) Offer the client a surgical consult to reduce the necessity of medication. E) Omit the pharmacist notification of the Multidisciplinary Team meeting about the client.

a,b

8) The nurse doing an admission assessment and interview for client newly diagnosed with HIV knows that which response or responses convey to the client that the nurse is not interested? Select all that apply. A) "You know that you have to make better decisions in the future." B) "My brother went through the same thing last year." C) "When did your symptoms occur?" D) "After your mother left this afternoon, did your sister call?" E) "Does your family know you are gay?"

a,b

6) A client with a history of depression says that since taking yoga classes, the depressive episodes have decreased. What should the nurse explain about yoga? Select all that apply. A) Promotes alertness and enthusiasm B) Raises levels of endorphins C) Stimulates the production of serotonin D) Increases blood flow to the brain E) Improves physical energy

a,c

7) An older client, unable to tolerate most antidepressant medications because of adverse effects, is scheduled for electroconvulsive therapy. What should the nurse instruct this client? A) Participation in psychotherapy with some medication therapy often needs to be continued after the treatments. B) These treatments will cure the depression. C) Learn to write everything down, because repeated treatments can cause long-term memory loss. D) The treatments are known to help some but not all people with depression.

a,d

7) The instructor is evaluating a staff nurse's knowledge, skills, and attitudes when addressing safety issues with client care. What observations indicate the nurse is skilled when addressing safety concerns? Select all that apply. A) Documents care immediately after providing it B) Devises methods that enhance teamwork C) Participates in conflict resolution D) Recognizes deficiencies between current and best practice E) Participates in root cause analysis when appropriate

a,e

1) A 10-year-old loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 28 and irregular. What does this vital signs assessment indicate to the nurse? A) Typical for a sleeping child at this age B) A sign of increased intracranial pressure C) Normal for this child D) A sign that this child has a spinal cord injury

1) A client having difficulty sleeping asks the nurse what the complications of sleep deprivation might be. What should the nurse explain is a result of sleep deprivation? A) Fatigue occurring at night B) Auditory hallucinations C) Improved wound healing D) Development of Alzheimer's disease

1) A young client tells the nurse that she is going to fight recent charges of shoplifting since she was just taking what was rightfully hers. The nurse realizes the client is demonstrating which of the following? A) Lying B) Narcissism C) Projection D) Manipulation

10) A 34-year-old mother of three sustained a right distal radial fracture and a left tibia fracture. The nurse and physical therapist will teach the client to use which mobility aide(s)? A) Lofstrand crutches B) Platform crutches C) Walker D) Axillary crutches

11) A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." Because he also keeps saying "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work," the nurse also identifies "Anxiety" as another nursing diagnosis. Which diagnosis would receive priority for nursing intervention? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety

14) A student nurse is learning about the physiology of the nervous system and its relationship to cognition. What structure plays a role in memory formation? A) Neuron B) Hippocampus C) Cerebrum D) Neurotransmitter

2) A 70-year-old client is diagnosed with bone spurs of the vertebral column. The nurse should plan which priority action? A) Implement low-level exercise program. B) Assess pain management. C) Teach relaxation techniques. D) Refer to a dietitian.

2) A nurse educator is teaching a group of students about therapeutic touch. In which of the following situations should the student use therapeutic touch as a means of communication? A) Touch is appropriate when a family member is making inappropriate comments to the nurse. B) Touch is appropriate when an upset spouse is alone and the client has just expired. C) Touch is never appropriate in the nursing profession. D) Touch is appropriate when a young male client asks a young student nurse for a hug.

2) During a routine physical examination, a preadolescent tells the nurse, "I am too fat and I'm going to do whatever I can to look like the girls on the cover of fashion magazines." Which risk factor does the nurse realize the client is exhibiting? A) A desire for a long-term profession B) Societal influences on body weight for girls C) Unrealistic expectations D) Family influences on body weight

2) The nurse is caring for a client in the neurological ICU with head trauma. The client is being monitored for increased intracranial pressure (IICP). Using the Monroe-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "There is nothing that can be done." B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." C) "The pressure in the brain is increasing because the brain is shrinking." D) "Because there is more pressure in the brain, the blood flow is also increasing."

2) The quality assurance officer notes that one particular nursing unit has received a higher-than-usual number of negative client responses about aspects of the nursing care during the previous quarter. To which component of care should the quality assurance officer pay particular attention when benchmarking this issue? A) Structure B) Process C) Outcome D) Competency

2) Which of the following clients are at high risk of developing GERD? A) A client who is 6 weeks pregnant B) A client who is morbidly obese C) A client who follows a strict vegetarian diet D) A client who drinks one glass of wine monthly

3) A preadolescent patient who fell from a balance beam in Physical Education class reports ankle pain. The nurse assesses edema and ecchymosis. What initial cause and intervention will be anticipated? A) Neurological evaluation for Parkinson's disease B) Rest, ice, compression and elevation (RICE) for ankle sprain. C) Brace fitting for scoliosis D) Colchicine for gout

3) The nurse anticipates that which condition requires surgery? A) Hepatitis B) Pancreatitis C) Pyloric stenosis D) Fecal impaction

3) The nurse is caring for an 8-year-old child who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for IICP. The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child develops sunset eyes, it will be important to call the doctor."

4) A client admitted with an eating disorder tells the nurse, "No matter what I do, I continue to be fat." What is the appropriate nursing diagnosis for this client? A) Ineffective Coping B) Disturbed Body Image C) Impaired Tissue Integrity D) Deficient Knowledge

4) The nurse identifies the diagnosis of Interrupted Family Processes for a child who sustained a brain injury during an automobile accident. Which intervention would support this diagnosis? A) Teach the family the importance of using seat belts. B) Encourage the family to express feelings. C) Refer the family to support services in the community. D) Explain rules for visiting in the Intensive Care Unit

4) The nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." The nurse is displaying which skill that is often associated with the working phase of the nurse-client relationship? A) Confronting B) Respect C) Concreteness D) Genuineness

5) A client is scheduled for a diagnostic test to determine digestion status. Which test does not require fasting or other preparation? A) Barium swallow B) Amylase C) Endoscopy D) Lipid panel n

5) Several nurses are discussing the Joint Commission's 2013 National Patient Safety Goals during a staff meeting. Which goal improves the effectiveness of communication among caregivers? A) Conduct a verification process to confirm the correct procedure. B) Transmit test results in a timely manner to the appropriate staff member. C) Review a list of look-alike/sound-alike drugs used in the organization. D) Use the client's room number as an identifier.

6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

6) A female nurse is caring for a 21-year-old male client with a questionable gastrointestinal blockage. The physician has ordered an enema. The nurse is planning care and anticipates which of the following reactions by the client? A) "May I have a visitor as support in the room?" B) "I would rather have my doctor perform this procedure." C) "I have never had an enema before." D) "I am afraid of having an enema."

6) The nurse is assessing an older adult client and observes that the client is having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms with the family that the client's symptoms developed over a several-year period. Which health problem is the client most likely experiencing? A) Depression B) Dementia C) Intellectual disability D) Delirium

6) The nurse is caring for a client in an allergy clinic. The nurse believes the client is having a reaction to a specific antigen. Which lab test would the nurse assess in order to determine the possibility of a hypersensitivity reaction? A) Indirect Coombs' showing no agglutination B) Patch test with a 1-inch area of erythema C) 2% eosinophils in the WBC count D) Rh antigen with negative results

7) A 70-year-old client comes into the clinic for his pneumonia vaccine. During the client interview, he seems to have mild difficulty with several words and has problems remembering the nurse's name. He is alert and oriented to time, person, and place. His responses seem appropriate. How should the nurse describe this client's cognitive changes? A) Memory impairment that may be related to cerebral ischemia B) Normal signs of aging C) Indicators of depression in the elderly D) Early symptoms of dementia

7) A nurse educator is discussing the use of the internet in nursing care. The educator is preparing to teach a group of nursing students how to navigate the internet for researching healthcare information. What does the educator plan to include during lecture? A) A directory of campus internet sites of interest B) How to search for and evaluate health information C) A directory of libraries D) Information technology instruction

7) The nurse is assigned to care for a client who will be going home on multiple new medications. The nurse has just completed teaching the client regarding medication administration. What statement by the client best illustrates compliance with the medication plan? A) "I think you should have waited until I was ready to go home. Maybe I'd remember better." B) "I'm glad to know about my new medications. It makes taking them all a lot easier." C) "If I take my medications as prescribed, I'll feel better." D) "I already knew most of what you told me."

7) The nurse is caring for a postoperative client on a medical-surgical unit. An analgesic is ordered to be given every 3-4 hours. What can occur if the nurse delays providing the client with the medication? A) Increase in the client's pain tolerance B) Increase in the chance of breakthrough pain C) Decrease in the chance of withdrawal symptoms D) Decrease in the chance of addiction

7) The nurse is teaching a group of young parents at the local elementary school health fair about immunity and the importance of vaccination. The nurse is giving the group an example of how active immunity is acquired. Which scenario would provide a client with active immunity? A) Receiving a rabies shot after being bitten by a rabid dog B) Having measles C) Receiving an injection of gamma globulin D) Becoming ill with tetanus and receiving tetanus toxoid

8) A client is admitted with signs and symptoms of early Alzheimer disease. What would be used to confirm this client's diagnosis? A) Abnormal CT scan findings of neuritic plaques and tangles in the brain B) Client history and physical examination C) Positive blood tests for beta-amyloid and tau proteins D) Blood test for amyloid plaques and neurofibrillary tangles

8) A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that the wound is showing signs and symptoms of infection. The client's spouse asks the new nurse how the wound looks. The new nurse responds by stating, "It looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse the preceptor should note that work is needed on which aspect of communication? A) Credibility B) Adaptability C) Timing and relevance D) Clarity and brevity

8) The nurse is assessing a client's sleep patterns. Which behavior assessment should the nurse use to make this assessment? A) Videotaping client movement during sleep B) Observing client alertness during sedentary, repetitive activities C) Noting the ability of the to fall asleep within 1 hour D) Noting the client's final awakening at the habitual sleeping time

8) The nurse is caring for a client who is taking an immunosuppressant agent for the treatment of an autoimmune disorder. Which client statement shows that teaching has not been effective? A) "I should drink plenty of water to keep from getting dehydrated." B) "I should drink a lot of grapefruit juice while on these medications." C) "If I experience any joint pain, I should take ibuprofen for the pain as needed every 4 hours." D) "I know to call the physician if I start experiencing a lot of bruising."

5) A nurse supervisor in a hospital that is about to vote on unionizing nurses has been told by the hospital CFO to schedule union organizers during times that have been arranged for union organizational meetings. How might this nurse respond professionally? Select all that apply. A) Schedule the organizers during union meeting times. B) Schedule the organizers according to clinical staffing needs. C) Reprimand nurses for attempts to unionize. D) Continue to implement the usual staffing procedures. E) Discuss the need for professional nursing integrity with the CFO.

b, d, e

4) The manager of a small clinic has cross-trained the nurses to perform electrocardiogram (ECG) testing, phlebotomy, and some respiratory therapy interventions. This clinic is providing client-focused care. Which of the following are the benefits of this delivery model? Select all that apply. A) Collaboration among many disciplines in providing client care B) Decreased steps to provide client care C) Decreased personnel required to provide client care D) Ease in tracking client progress E) Cost-effective care resulting in improved outcomes

b,c

6) After completing an assessment, the nurse determines a client is at risk for safety issues. What did the nurse assess in this client? Select all that apply. A) Lives with adult married daughter and family B) Occasional dizziness with walking C) Prescribed antihypertensive and pain medication D) Ingests three meals a day and two snacks E) Receives an annual ophthalmologic examination

b,c

5) An older client is demonstrating signs of osteoporosis. The nurse should instruct the client on which tests to aid in the diagnosis of this disorder? Select all that apply. A) Magnetic resonance imaging B) Dual energy x-ray absorptiometry C) Bone mineral density D) Quantitative ultrasound E) Computed tomography

b,c,d

8) The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care? Select all that apply. A) Apply physical restraints if the client gets out of bed. B) Assess the client's vision and make sure he is utilizing any prescribed eyewear. C) Utilize side rails on client beds. D) Keep frequently used items within easy reach.

b,c,d

The Concept of Cognition 1) The family of an 82-year-old client is concerned about the changes in the client's behavior. The client used to be a wonderful cook but now cannot even remember how to use a blender. For which causes of impaired cognitive function should the nurse assess the client? Select all that apply. A) Obesity B) Nutritional deficiencies C) Medication reactions D) Stroke E) Snoring

b,c,d

11) The nurse contacts the provider to question an order to administer 1,000 mg aspirin to which clients? Select all that apply. A) 68-year-old client for hand pain who has rheumatoid arthritis B) 5-year-old client for ankle pain after a fall from a horse C) 38-year-old client for headache pain after a skiing accident D) 70-year-old client for back pain after laminectomy E) 22-year-old client for knee pain who is allergic to naproxen

b,c,d,e

13) A nurse is caring for an older adult who displays symptoms of cognitive decline. What is true regarding the aging process and cognition? Select all that apply. A) Generally, older adults' short-term memory changes significantly. B) Generally, many older adults have increased difficulty finding and rapidly listing words. C) The ability to use and understand word combinations declines steadily with age. D) The ability to acquire practical information declines steadily with age. E) The ability to engage in abstract thought declines slightly

b,e

4) The nurse is working with a group of parents of children with intellectual disabilities. What should the nurse recommend to support environmental safety for these children? Select all that apply. A) Have parents maintain a regular schedule for activities. B) Teach emotional safety. C) Use medications to decrease agitation. D) Provide aids to assist with orientation. E) Turn the temperature down on the hot water heater.

b,e

1) A new graduate nurse has been hired to work in a busy cardiac intensive care unit at the local hospital. The nurse will spend 12 weeks in orientation to the unit. How does the new nurse demonstrate commitment? A) Joining the ANA B) Questioning the preceptor during all procedures C) Attending every shift on time D) Exhibiting clinical competence Answer: C

1) The nurse is caring for an elderly client in a long-term care facility. The nurse has just attended an in-service regarding therapeutic communication. This nurse is conveying respect and an attitude that shows the nurse takes the client's opinions seriously by which of the following behaviors? A) Facilitating and taking action when needed B) Maintaining a proper social distance when speaking with the client C) Leaning toward the client during conversation D) Being concrete about actions that need to be taken during client care

1) The nurse is explaining the alteration in normal function to a client recently diagnosed with gastrointestinal reflux disease (GERD). Which of the following etiologies contribute to GERD? A) Transient constriction of the lower esophageal sphincter B) Decreased pressure within the stomach C) Incompetent lower esophageal sphincter D) Prolonged constriction of the upper esophageal sphincter

10) A 55-year-old client diagnosed with sleep apnea has been prescribed a CPAP machine as treatment. The nurse is instructing the client on how to use the machine. What instruction should the nurse include? A) Any size mask will work. B) Straps can be loose, if that feels more comfortable. C) Use relaxation exercises to reduce uncomfortable feelings from the mask. D) Do not use a humidifier at the same time.

10) A behavioral health nurse is preparing an educational program on eating disorders. When identifying clients at risk, the nurse is aware that which client is at a higher risk for anorexia nervosa? A) A 16-year-old Hispanic female client B) A 21-year-old Hispanic female client C) A 16-year-old male Caucasian client D) A 22-year-old male Caucasian client

10) A nurse is caring for a client with leukocytosis. Which action by the nurse is most appropriate when caring for this client? A) Instruct the client on the use of an electric razor and soft toothbrush. B) Assess for bleeding and bruising. C) Assess for source of infection. D) Place the patient in reverse isolation precautions.

11) A graduate nurse is planning care for an older client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking? A) Discuss the plan with the physician. B) Request that the client review the plan. C) Request a review of the plan with the nurse's preceptor. D) Place the plan on the client's chart

11) The nurse is providing care for a client who is about to be discharged. The nurse is discussing medical interventions that have been prescribed for this client with the primary care provider. Which nurse statement is the best example of appropriate assertive communication? A) "Can we talk about this client prior to discharge?" B) "That new medication you prescribed for the client is ineffective." C) "I am worried about the client's blood pressure. It remains high even with the new medication." D) "Excuse me, Doctor, I think you need to do something about the client's blood pressure."

11) The nurse is teaching a client how to properly administer a new medication. The client goal for this teaching is compliance with the medication regimen. What client statement best illustrates compliance? A) "I already knew most of what you told me." B) "If I take my medications as prescribed, I'll feel better." C) "Knowing how to take a new medication properly makes the process much easier." D) "I think you should have waited until I was ready to go home. Maybe I'd remember better

12) A 13-year-old child is in the hospital preparing for major surgery for the removal of a tumor on the kidney. The mother of the child tells the nurse that she doesn't want the child to receive narcotics for pain postoperatively. Which is the best response by the nurse? A) "Okay, I'll tell the doctor not to order any. Are you sure you want to do this?" B) "The pain will be severe. Why don't we ask your child about this?" C) "The pain for your child will be severe after surgery. Can you tell me why you feel this way?" D) "You do not have a choice of medication. Decisions involving pain relief are up to the healthcare providers."

12) A newly licensed nurse is passing medications with a nurse preceptor. Which action taken by the newly licensed nurse would be inappropriate and require the nurse preceptor to intervene? A) The newly licensed nurse verifies tube placement prior to administering medications. B) The newly licensed nurse checks for known allergies prior to administering medication. C) The newly licensed nurse combines medications with the same active ingredient. D) The newly licensed nurse has a second nurse check the medication order.

13) The nurse is caring for a client who is having difficulty understanding the wound care dressing changes that need to be completed in the home after discharge. The client asks the nurse to demonstrate the procedure again and allow the client's spouse to perform the procedure while the nurse watches. This assertive request will result in: A) A slightly increased chance that the wound will become infected due to exposure during dressing changes. B) Less compassionate care for the client due to the spouse's irritation by the request. C) A greater likelihood that the wound will heal appropriately. D) A guarantee that the spouse will change the dressings correctly.

13) The nursing instructor is speaking to a group of nursing students about standards of care. Which comment made by the nursing student indicates the need for further education about the standards of care? A) "Standards of care are based on models of high-quality performance." B) "Process standards focus on the steps used to lead to a particular outcome." C) "Process standards focus on human resources, and general organizational structure." D) "Outcome standards focus on the performance of a process."

2) A student nurse is caring for an elderly client with dementia who is confused, agitated, and forgetful. The student leaves for a break and forgets to put the call light within reach of the client. When checking on the student's clients, the instructor discovers the student's negligence and determines which of the following? A) The student is appropriately taking care of self. B) The student's workload is too difficult. C) The student is demonstrating inappropriate safety measures for the client. D) The student is demonstrating appropriate comfort measures for the client.

2) An older client with no history of cognitive impairment is showing signs of increased confusion. Which health problem should the nurse suspect is causing this client's confusion? A) Cataracts B) Hypertension C) Urinary tract infection D) Lower back strain

3) A client is experiencing severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Which type of pain should the nurse suspect the client is experiencing? A) Somatic pain B) Referred pain C) Visceral pain D) Chronic pain

3) A college student tells the nurse about being "out of control" with eating. She is trying to keep her body weight down so her mother does not call her fat, and she does this by making herself throw up. The nurse realizes the client is experiencing which of the following? A) Binge-eating B) Anorexia nervosa C) Bulimia D) Purging disorder

3) A pediatric client has GERD. The nurse is observing a return demonstration of the mother preparing and feeding the infant formula. Which of the following observations demonstrates correct procedure for preventing GERD symptoms? A) Burping the infant after 4 ounces of formula are taken B) Thinning the formula with water prior to feeding C) Positioning the infant upright for a minimum of 30 minutes D) Warming the formula prior to feeding

4) A client presents at the Emergency Department reporting 7/10 chest burning. GERD secondary to hiatal hernia is diagnosed. Based on your assessment, which of the following is the priority nursing diagnosis? A) Dysfunctional Gastrointestinal Motility B) Anxiety C) Acute Pain D) Ineffective Health Maintenance

4) A nurse is working in a neonatal intensive care unit. The nurse wants to teach a mother of a premature baby how to give her baby a bath. Which statement by the mother reflects a readiness to learn? A) "You'll give us written instructions before we go home, correct?" B) "When my baby is just a little bigger, I'll feel more comfortable giving him a bath." C) "I want to make sure my husband is here, in case I don't hear everything that's said." D) "I'm so afraid I'll hurt my baby with all these tubes and wires."

4) The nurse is planning to assess a client demonstrating signs of depression. What should the nurse use to assess this client? A) More time talking with the client B) The client's family members, for answering the assessment questions C) Beck Depression Inventory D) Glasgow Coma Scale

5) A client is experiencing symptoms of depression. Which laboratory or diagnostic test would be used to determine if depression is being caused by another health problem? A) Electrocardiogram B) MRI of the brain C) Thyroid function tests D) Cerebral angiogram

5) A client tells the nurse that the thought of eating makes her anxious and nervous, and she just avoids it altogether. What is the appropriate plan for this client? A) Instruction on the role of nutrition in normal menstruation B) Instruction on the importance of nutrition for vital signs and muscle tone C) Interventions to address anxiety and feelings of being in control D) Instruction on nutrition

5) A new graduate nurse is working with a client who has been admitted to a medical-surgical unit. The nurse is working on establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid, if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, as my mother has the same illness."

6) A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn? A) A client who has been there the longest and is a great "coach" for newcomers B) A client who has been struggling with following nursing directives regarding discharge goals C) A client who is excited to learn ambulation techniques D) The client who has just moved in and is already eager for discharge

6) What statement made by the client would indicate understanding of discharge teaching for self-care after hospitalization for acute pancreatitis? A) "I will avoid onions, caffeine, and spices." B) "I will take the antibiotics for 2 weeks." C) "I will avoid alcoholic beverages." D) "I will get immunized prior to my vacation."

7) A client with a history of insomnia is scheduled for a polysomnogram that requires an overnight stay in a sleep laboratory. What additional information about this test should the nurse provide to the client? A) The test occurs 2 hours after awakening from the overnight sleep study. B) The test requires a 24-hour interval of sleep deprivation. C) The test records the biophysical changes the client experiences during sleep. D) The test consists of five 20-minute nap trials

7) The nurse has implemented a care plan for a 22-year-old client with GERD. On the next clinic visit, which of the following statements by the client indicate adherence to the plan of care? Select all that apply. A) "Spandex camisoles are worth heartburn." B) "I have switched from margaritas to wine." C) "I've lost 6 pounds because I eat every 3 hours and never before bed." D) "I take a TUMS with the ranitidine to make it work better." E) "I haven't had any heartburn for 3 weeks

7) Which intervention would best improve diet adherence of a 75-year-old Hispanic male immigrant recently diagnosed with GERD? A) Scheduling low-fat meal deliveries to the home B) Providing printed diet information in Spanish C) Interviewing the client to assess his current diet D) Giving a list of foods to avoid to the client's wife

8) The nurse is caring for a female client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A) Notify the physician of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.

9) A 68-year-old client has decreased bone density. Which diagnostic test results will alert you to the need for dietary education? A) High calcitonin levels B) High creatine kinase (CK) levels C) Low phosphorus (P) levels D) High growth hormone (GH) levels

9) The nurse is caring for a 10-year-old client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client

The Concept of Self 1) A client explains that before leaving for work, the children need to be taken to daycare and dinner prepared. The nurse realizes this client might be experiencing which of the following? A) Self-esteem B) Role mastery C) Role conflict D) Role ambiguity

11) A nurse is educating a group of pregnant clients regarding infant immunity. Which statements will the nurse include in the teaching? Select all that apply. A) IgM is the only immunoglobulin that crosses the placental barrier. B) IgA and IgE are present at birth. C) In the infant, maternal IgG disappears by 6-8 months. D) Infants and children have differing amounts of some immunoglobulins. E) A newborn's levels of IgG differ widely from those of the mother

c, d

5) A client who has read several articles about the need to contain healthcare costs asks how a quality improvement program can contain cost of care. What should the nurse respond to this client's question? Select all that apply. A) "Promoting safety increases the cost of care." B) "Medication errors decrease the cost of care." C) "High nurse-to-client ratios result in decreased length of stay." D) "Increased nursing staff has been linked to decreased infection rates." E) "Use of computers increases the number of lawsuits

c,d

6) The nurse is providing care to prevent a client recovering from a head injury from developing increased intracranial pressure (IICP). Which assessment information suggests that nursing care has been successful? Select all that apply. A) Body temperature elevated 1 degree in 4 hours B) Absent gag reflex C) Pupils equal and reactive to light D) Oxygen saturation 93% via pulse oximetry E) Sluggish response to verbal stimuli

c,d

10) The nurse is caring for a client who has been diagnosed with diabetes mellitus. The client must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client says, "I already know what you are attempting to teach because I looked everything up on the internet." What is the best action by the nurse? A) Document that the client understands teaching. B) Teach the client's support system how to perform the procedure. C) Give the client printed learning materials. D) Watch the client perform a return demonstration of the skill.

15) A nurse conducted a safety class for a group of elderly clients in the community on fall prevention. The nurse determines that the clients understood safety teaching for the home when the nurse visits and finds that a client has: A) Placed all meat in the freezer. B) Changed the locks on the doors. C) Placed scatter rugs in the kitchen. D) Installed safety strips in the shower.

2) A client with congestive heart failure is having difficulty breathing. Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority-setting C) Conflict resolution D) Critical thinking

2) A nurse manager is assessing the hospital environment in order to decrease the risk for client falls. Which is the best intervention to decrease the risk of client falls? A) Keep the call button within reach at all times. B) Read label directions. C) Keep electrical cords under the bed. D) Clean the environment of clutter.

2) The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. Upon completion of the class, what should the nurse expect the participants to do? A) Set goals for the next class session. B) Pass a written test on how to bathe a newborn infant. C) Review the major points of the class. D) Provide a return demonstration of a bath on a newborn doll.

3) A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) A response to a change in the client's condition

3) An older client is talking with the nurse about sleep problems. What fact regarding sleep should the nurse teach this older client? A) All elderly individuals experience disrupted sleep and depression. B) The need for sleep decreases with age. C) Normally, a person should not awaken more than once during the night. D) The elderly do not experience as much deep sleep as a younger person

3) The nurse manager is planning to implement the Lean Six Sigma system on the care area to improve the quality of care. When following this model, what should the manager implement? A) Shortening break time B) Ordering more supplies than needed on the unit to ensure they never run out C) Replacing a licensed staff member with unlicensed assistive personnel D) Decreasing staff when the census is low

3) The nursing student is planning an educational program for a senior project. The program is focusing on cancer detection education for a community group. What should the nursing student plan to include in order to address the various learning styles of the target group? A) A lecture using many examples for each learning need B) Multicolored brochures with bright colors C) A game board, with client matching terms D) Audiovisuals, examples, group discussions, and activities

3) The student nurse is attending a lecture about commitment to the profession of nursing. The instructor is grading the student's commitment to nursing during this rotation. The instructor knows the student is committed to the nursing profession when the student does which of the following? A) Calls in sick for clinical to study for a class exam B) Declines to observe a new procedure to give a necessary bath C) Misses class to attend a political rally D) Calls in sick for clinical because of a respiratory infection

4) A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. What should the nurse respond to this client? A) "We want the public to know we are trying to be safe." B) "Clinic staff members require frequent reminders about client safety." C) "National safety goals focus on the individual making the error." D) "National safety goals seek prevention of injury."

4) The nurse is assigned to a 4-month-old client with vomiting and diarrhea brought to the pediatric clinic by his mother. Temperature: 37° C, apical HR: 130, R: 40/min. Your abdominal assessment reveals a soft, concave abdomen, 10 gurgles auscultated in 1 minute in all four quadrants, and tympani to percussion. Which collaborative care action does the nurse anticipate? A) Check the surgical call schedule and reserve an operating suite. B) Place the infant NPO for a barium swallow. C) Prepare a milk-based infant formula to replace fluids. D) Complete a thorough digestion assessment interview with the mother.

4) The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A) "Your eyelid is red and swollen." B) "Your skin appears to be dry and irritated." C) "I see that you have bruises on your legs." D) "Tell me why you have difficulty sleeping."

5) The nurse is caring for a client being seen at an urgent care clinic because of an infected arm. The client tells the nurse he was bitten by a raccoon on a recent camping trip. The nurse expects treatment for this client to include which of the following? A) An injection of immunoglobulin B) A tetanus toxoid injection C) Mother's breast milk with antibodies in it D) An immunization for rabies

6) A resident in an assisted-living facility is restless most nights and sits in the lounge area reading. When questioned, the resident reports suffering from insomnia. What should the nurse expect as an outcome if the resident continues with this pattern of sleep? A) Safety issues with an unsupervised resident in the lounge area B) Onset of cardiac dysfunction C) Onset of new underdiagnosed health problems D) The ability to function during the day may be hindered by these episodes

6) An older client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A) Complete all nursing care at the end of the shift. B) Delegate care for the client to an aide. C) Complete all nursing care in the morning. D) Pace nursing care throughout the shift.

6) The nurse is caring for a 9-year-old client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which of the following responses by the nurse is most therapeutic? A) "Would you like some toys from the playroom?" B) "I'm going to go get the doctor." C) "You shouldn't cry. You are not in pain." D) "It is okay to cry. I know this is scary."

7) A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain

7) The nurse provides medication to a client at the wrong time. No harm came to the client as a result of the nurse's error and the nurse files a report about the medication error. What should the risk management team do? A) Discipline the nurse appropriately. B) Report the nurse to the board of nursing. C) Monitor all nurses on the unit to ensure this does not occur again. D) Attempt to implement policy changes to prevent future errors.

8) The nurse is considering nutritional support for a client experiencing severe side effects of chemotherapy. Which independent and collaborative interventions will best limit the adverse digestive and nutritional effects of chemotherapy? A) Encourage client to drink 350 ml of clear liquids within 1 hour prior to meals. B) Position the client flat during intermittent enteral nutrition feedings. C) Verify that enteral nutrition and total parenteral nutrition (TPN) are never used concurrently. D) Offer the client music therapy in addition to IV ondansetron

8) While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a "time out" procedure before the surgery begins. What sentinel event should the "time out" procedure prevent? A) Ineffective control of the client's pain B) The lack of healing of the stump C) The client being mildly over-sedated D) The removal of the wrong arm

9) A nurse is caring for a child who is hospitalized with asthma. The nurse is preparing discharge teaching, as the client will be going home on nebulizer treatments and an inhaler. The family members speak little English. In addition to enlisting an interpreter to help with the language barrier, what should be a priority for the nurse? A) Provide written instructions before discharge. B) Make sure the parents can set up the treatments for their child. C) Make sure the child comes back for the follow-up appointment. D) Address any healing beliefs the family has

9) The nurse educator in the hospital is educating a newly licensed nurse on National Patient Safety Goals. When discussing the goal of safe medicine use, the nurse educator is aware that which is of the following is not a solution to safe medicine use? A) Labeling all medicines that will be administered to the client appropriately B) Using extra caution with blood thinners C) Taking care when recording client medicine information D) Allowing the client to keep home meds at the bedside for use while in the hospital

Module 38. 2) A nurse is teaching a client about a dressing change that should be done three times a day, and the client is from a culture that is "present oriented." The nurse should instruct the client to perform the dressing change at which of the following times? A) At times that the client selects, as long as they are 8 hours apart B) At 9 a.m., 3 p.m., and 9 p.m. C) Whenever the client chooses, as long as it gets done three times daily D) After breakfast, lunch, and dinner

Module 46 Healthcare Systems The Concept of Healthcare Systems 1) The nurse is caring for a client who sustained multiple injuries in an automobile accident. As a part of secondary prevention for this client, the nurse plans to do which of the following? A) Promote wellness. B) Detect early disease. C) Restore the client to previous functioning. D) Prevent the progression of more symptoms

The Concept of Mood and Affect 1) The nurse overhears a client apologize to the spouse about being ill and leaving tasks at home uncompleted. In addition to this client's reason for hospitalization, the nurse realizes this client is at risk for developing which of the following? A) Musculoskeletal disorder B) Heart disease C) Diabetes D) Depression

5) A nursing student has been assigned to present a teaching project to the class, using each of Bloom's domains. The student has planned several activities to include when presenting the project to the class. Which activity or activities are within the affective domain? Select all that apply. A) Class members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. B) Class members must list the technical skills they have learned. C) Class members must demonstrate a favorite nursing skill for the class. D) Class members must reflect on how they felt the first time they provided direct client care. E) Class members must identify two attitudinal changes that have occurred in their lives since beginning their nursing education

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