FINAL

An 8-year-old client whose grandmother died a week ago asks the parents about the grandmother's absence. Which statement by the parents could lead to a negative self-concept in the client? Select all that apply.

"Did you do something wrong to your grandmother?" "You are not supposed to ask such questions." "Your grandmother will come back in a week."

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains?

A Penrose drain promotes drainage passively into a dressing.

Which situation is most likely to warrant an autopsy?

A client's death involves an allegation of a medical error.

A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply

Bathing can improve appearance and self-image. Bathing can stimulate circulation. Bathing removes organisms from the skin, reducing infection.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document?

Black classification

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites.

A nurse is providing care to a client who has undergone skin grafting to her face due to a burn injury. The client states, "I know it could have been worse, but my face will never be the same as it was. I haven't been able to look at myself in the mirror because of what I might see." The nurse interprets this statement as most likely reflecting which pattern?

Body image

The nurse is differentiating beliefs of atheists from agnostics. Which statement is accurate?

Both are guided by a philosophy of living that does not include a religious faith.

After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat?

Bouillon, apple juice, and gelatin

The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care

Check the nursing care plan for hygiene directives.

A nurse is assessing a client's self-perception. Which dimension is reflected by the client's statement, "I want to use my skills to become the best artist I can be"?

Self-expectation

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. The nurse informs the parents that the development of a child's spirituality is best accomplished by:

educating through parental behaviors.

Which laboratory test is the best indicator of a client in need of TPN?

serum albumin

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.

"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin." "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums."

When asked about his religious preference, the client becomes very upset with the nurse. Which response is appropriate for this situation?

"I can see that this question upsets you. Do you have any questions about this?"

A nurse is reviewing the health history of a client. Which statement documented in the history would lead the nurse to suspect that the client has a negative self-concept? Select all that apply.

"I feel like I'm so ugly." "I'm such a horrible person." "Who would want to marry me now the way I look?" "What good am I?"

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair."

A client is requesting that the nurse speak with the physician regarding alternate treatment options. What comment by the nurse would be most appropriate to help the client identify and use her personal strength?

"I wonder why you want me to talk with the doctor? If you talk with them, you could hear all the treatment options firsthand. I will gladly stay with you while you talk to the doctor." Correct response:

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

The nurse is caring for a client who has just died after a long diagnosis of dementia. Which nursing assessment is the priority for documentation?

"No breathing and no pulse at 0840."

The nurse is caring for Mrs. Grace, a 26-year-old woman who has just delivered a healthy baby girl. Mrs. Grace says she wants to be a good mother and help her child develop in the best way possible. She asks the nurse, "What kind of self-concept is a baby born with?" The nurse's best answer is:

"No self-concept is present at birth."

Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety?

"Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life."

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?

"Sometimes a person returns to a previous stage."

A recently graduated nurse is talking to the charge nurse about spirituality and tells the charge nurse that it is difficult to understand why people have a hard time giving spiritual care to clients. The charge nurse identifies the new nurse's lack of understanding when the new nurse makes which statement?

"Spirituality and religion are the same thing."

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?

"Steri-Strips will hold my wound together until it heals."

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?

"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which scenario would be an example of assisted suicide?

Administering a lethal dose of medication

What type of wound dressings absorb exudate, but maintain a moist wound environment?

Alginates

A client has recently immigrated without his family. The client reports that he cannot find a job and has no friends here. The client reports that without his family he doesn't know who he really is and everything around him is different. Which nursing diagnosis is most appropriate?

Altered personal identity related to the new environment and separation from family

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

An appropriate nursing diagnosis for the family of a client dying of cancer, whose members have expressed sorrow over the forthcoming loss, would be:

Anticipatory Grieving related to loss of family member, as evidenced by sorrow

Which nursing action associated with successful tube feedings follows recommended guidelines?

Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure?

Clean the wound from the top to the bottom, and center to outside.

A client who has multiple sclerosis (MS) has been diagnosed with ineffective coping related to a diagnosis of chronic health alteration. What outcome is least appropriate to include in a plan of care?

Communicates a sense of helplessness to his spouse.

The school nurse is concerned about the week-long absence of Jerry, a third grader. The nurse visits the home and learns that Jerry has been diagnosed with appendicitis by a local clinic doctor. The parents, who are Christian Science church members, have had several church groups in to pray over Jerry. He is not improving and is getting worse. The nurse should do which of the following?

Contact Child Protection Services

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

Contact a podiatrist to care for toenails.

The son of a dying female client is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation

Contact the chaplain to arrange a visit with the client.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

A female client, prominent in the local media, has had surgery for a colostomy. The client avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis.

Disturbed Body Image related to colostomy as evidenced by avoidance of colostomy

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply an emollient as indicated.

A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?

Elevate the head of the bed.

The nurse is assisting an adolescent female with the identification and recognition of personal strengths. Which of the following is a technique the nurse will employ?

Encourage the client to identify strengths and ways to gain strengths she desires.

A nurse is paying particular attention to the spiritual needs of a client today. The nurse identifies that spiritual beliefs can have a positive effect on general health of a client in which ways? Select all that apply.

Endurance of extreme stress Support system Positive emotions

A nurse is developing a plan of care for an older adult to promote self-esteem. What intervention would be most appropriate to include?

Explain that his life experience will help to develop a plan of care.

A terminally ill client told her family, "I am ready to die." Her family is very upset that she has given up and wants the nurse to intervene. Which nursing intervention is most appropriate?

Explain to the family that acceptance is part of the grieving process.

A client has suffered an amputation of the right leg due to a motor vehicle accident. What would be an example of a maladaptive response?

Expressing they will never be a whole person again

A client with cancer has a family who is emotionally supportive of the client. Having a supportive family is which type of resource?

External resource

A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed?

Hematocrit 35%

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate?

Hindus: Vegetable plate

Which question would the nurse include on a self-concept assessment related to body image?

How do you feel about any physical changes you noticed recently?

What type of wound dressings are occlusive or semi-occlusive, limiting the exchange of oxygen between the wound and the environment

Hydrocolloid Dressings

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?

If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

Impaired tissue integrity

The pediatric nurse is caring for a boy 5 years of age, who is being seen in the clinic today. He is very worried that the doctor may harm his body. His mother asks the nurse if this is normal for this age. The nurse shares with the mother that the very young child worries about which of the following related to his body?

Intactness and mutilation

While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?

Islam

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Keep the swab and the inside of the culture tube sterile.

The nurse is working on an oncology unit and is visiting with colleagues about how to prevent burnout as a professional nurse. Everyone suggests things and the group comes up with a very good list of self-care behaviors and ways that will help prevent burnout. Which of the following would be good things to have on the list? Select all that apply.

Know that no one person can be all things to all people. Live life one day at a time and do your best. Emphasize your strengths and the things you do well.

A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?

Low serum albumin levels

How can nurses who provide care in long-term care settings best enhance the self-esteem of older adults who reside in these facilities?

Maximize the autonomy of residents in organizing their routines.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

A nurse is caring for Mr. Glanden, who recently underwent a lung resection. As the nurse is completeing the physical assessment, he asks to have the elders from his church perform a "laying on of hands". The nurse interprets this as a healing process associated which of the following religions?

Mormon

A nursing student is studying spirituality and completing a report on the Mormon faith. Which fact about Mormonism should the student include in the report?

Mormons are not allowed to use tobacco or alcohol.

Mrs. Dopson is a 75-year-old widow who lost her last offspring to cancer last month. She shares with the nurse that she fears being alone. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people?

Need for love and relatedness

Mr. Baker is an 81-year-old patient who can no longer live alone safely and is being admitted to a long-term-care facility. He grew a large garden every summer and took pleasure in sharing the produce with neighbors. He now tells the nurse that he feels he is of no use to anyone. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people?

Need for meaning and purpose

Which nursing action helps to maintain a sense of self for clients?

Offering a simple explanation before initiating any procedure

A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition?

Peripheral parenteral nutrition

The nurse is assessing for information about a client's self-concept. The information needed first is about which of the following?

Personal identity

When a nurse asks a client to describe her personal characteristics and traits, the nurse is most likely assessing the client for what self-concept factors?

Personal identity

The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems?

Plan and coordinate a multidisciplinary team conference including the chaplain.

The nurse is providing care for a client who is ordered nothing by mouth (n.p.o.). What is an important nursing intervention?

Provide frequent mouth care.

The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client?

Psychological reasons for overeating should be explored, such as eating as a release for boredom.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

RDA level

An older adult client who is very sick but very spiritual and has a deep faith asks the nurse to say a prayer for her. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse?

Read a passage from the Bible to the client

While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements?

Religion is a collection of spiritual beliefs and practices.

The nurse is reviewing the health assessment of a client. The nurse is concerned that the client may have a deficiency of Vitamin D. Which condition most supports this suspicion?

Rickets

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion?

Roman Catholic

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document?

Serosanguineous

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Soak in a warm bath for drainage.

The nurse discusses the client's fears and doubts openly and serves as a nonjudgmental listener.

Some people actually skip some stages of grief altogether. People vary widely in their responses to loss. Stages occur at varying rates among people.

An appropriate nursing diagnosis for a bedridden hospitalized client who tells the nurse that he has not missed a Methodist church service in 50 years would be:

Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt

The nurse caring for a bedridden hospitalized client who states that this will be the first time that he has missed a Methodist church service in 50 years plans care based on which of the following NANDA-I diagnoses?

Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt

A college foreign exchange student is living with a family in England and is confused about the daily Catholic prayers and rituals of the family. The student longs for the comfort of her fundamentalist Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?

Spiritual alienation

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury?

Stage IV

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

Which nursing intervention is inappropriate when developing a plan of care to modify a negative self-concept?

Teaching the client that everything will work out better than she expects

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia.

Mr. Cooney, age 85, is in advanced stages of pneumonia with a no-code order in his chart. Which nursing care action will help establish a trusting nurse-client relationship?

The nurse discusses the client's fears and doubts openly and serves as a nonjudgmental listener.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A dying client requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this client?

The nurse should select a formal prayer or Bible passage to use to pray aloud.

A nurse is providing care to a newborn. When implementing care to foster the infant's self-concept, which information would the nurse need to keep in mind? Select all that apply.

The parents can convey their sense of competence to the newborn The nurse can transmit self-concept to the newborn. Anxiety felt by those caring for the newborn can be sensed by the newborn.

A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?

Total parenteral nutrition (TPN)

After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply?

Use silence and allow the husband to express his emotions.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers.

A client recently diagnosed with cancer informs the nurse that they value faith and finds comfort in their faith. The nurse is aware that faith is best defined as:

a belief in something for which there is no proof or material evidence.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

hydrocolloid dressings

What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit in the kitchen with a knife?

impaired skin integrity related to open wound

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?

medications listed on the client's medication administration record (MAR)

Which set of terms best reflects nursing's view of clients as holistic beings?

mind, body, spirit

According to Shelly and Fish, which of the following is a spiritual need underlying all religious traditions?

need for meaning and purpose

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:

negative nitrogen balance.

A client who is taking supplements complains of severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

niacin

When a client provides a return demonstration of appropriate food selections for carbohydrates, which food does the nurse acknowledge as rich in carbohydrates? (Select all that apply.)

oatmeal, milk, bread

The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?

older adults living on a fixed income

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?

overweight

A nurse is assisting a terminally ill female client with bathing. The client tells the nurse that she has great respect and faith in a particular spiritual leader. The nurse interprets this information as fulfilling which need for the client?

sense of security for present and future

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

What type of bath is preferred to decrease the inflammation after rectal surgery?

sitz

The nurse is caring for a client on a telemetry unit following a myocardial infarction. The client has undergone numerous medication changes since the event. Which food should be avoided when a client is taking warfarin sodium following a myocardial infarction?

spinach

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should:

take measures to ensure privacy during the counselor's visit.

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?

teenager who is in the second trimester of pregnancy

Upon assessment, the client reports that they do not belong to an organized religion. The nurse is correct to interpret this statement as:

the client is not affiliated with a specific system of belief regarding a higher power.

A terminally ill client tells the nurse that he does not belong to an organized religion. It is safe for the nurse to assume:

the client may still be deeply spiritual.

A client with a diagnosis of colon cancer has required the creation of an ostomy following bowel surgery. Which factor is most likely to influence the client's adjustment to this change?

the coping mechanisms that the client possesses

Which of the following factors is most likely to present a challenge to the self-concept of a man 79 years of age?

the man's increasing level of dependence on his children

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?

traditional bed bath with linen change

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body

underneath the breasts and in between skin folds

Following surgery, the surgeon informed the client's spouse that invasive cancer was found during the procedure and the client may only have days to live. The client's spouse has told the physician and the nurse that they do not want the client to know the severity of the diagnosis. How will the nurse respond?

understanding that this directive would violate the client's rights

The nurse is caring for a middle-age client who is admitted after taking an overdose of benzodiazepines. The client states, "I lost my job and I am just a failure at everything." The nurse is aware that potential causes of poor self-concept at this age can be related to which factors? Choose all that apply.

unsatisfying career choice failure to accept role responsibility failure to develop meaningful goals

A rehabilitation nurse is caring for Steve Branson, a 23-year-old man, who has suffered a spinal cord injury and has tetraplegia. One of the rehabilitative goals for Steve is to attain adaptive patterns of behavior related to his injury. Which of the following would indicate that he is achieving this goal? Choose all that apply.

uses available resources makes decisions related to his care

A client who has bleeding tendencies has a deficiency in which vitamin?

vitamin k

Which clients, at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? (Select all that apply.)

pregnant teenagers older adults living on fixed incomes people with substance abuse problems

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

protein

The nurse is caring for four clients. For which client is a sitz bath most appropriate?

51-year old with hemorrhoids

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

A woman consumes pasta, grains, and other carbohydrates for which purpose?

energy

When conducting a spiritual assessment, the nurse must be sensitive to the client's personal beliefs. Which questions should the nurse ask? Select all that apply.

"Is religion or God significant to you?" "Do you feel your faith is helpful to you?" "Is there anyone from your church you would like to talk to?"

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?

"According to research, vegetarians have a higher incidence of obesity than others." Correct response:

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

"It is important to keep your sutured incision clean."

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate?

"It must be very difficult for you."

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?

"My husband and I are ordering a product that has megadoses of vitamins."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?

"Very little scar tissue will form."

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states

"Why did this have to happen to me?"

A nursing instructor, after teaching about the importance of spirituality, identifies a need for further teaching when overhearing a student make which of the following statements?

"You can provide quality nursing care to clients even though you ignore the spiritual dimension of health."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

The wound care nurse is performing assessment of clients. Which wound complications does the nurse report to the health care provider? Select all that apply.

- viscera protruding through the incisional area - a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5 - fistula formation - partial disruption of wound layers

A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb/ 65.7 kg

At what period of life do nutrient needs stabilize?

Adulthood

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?

Assess the client's cultural views regarding hygiene and self-care.

The nurse receives a "do not resuscitate" (DNR) order for a dying client. What should the nurse do next?

Assess the client's spiritual needs

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

Assess the wound for active bleeding.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals.

Which is a recommended guideline when removing contact lenses from a client's eyes?

Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Corticosteroids

A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake?

Encourage the client to eat in the dining room.

A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis

The nurse's client states that his pastor is coming in a few hours to pray with him and offer sacrament. The nurse plans to do the following things in preparation for this. Select all that apply.

Have a chair available near the bed. Clear the room of unnecessary items. Clear the bedside table; cover with clean towel.

enlarged thyroid

Iodine

The nurse is on the third day of caring for a client who recently underwent a colectomy. During the physical assessment, a discussion about spirituality develops. The client reports feeling some guilt about being in the hospital because her religion opposes modern science, including medicine. The nurse recognizes this as a belief of which of the following groups?

Jehovah's Witnesses

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients items

During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her 6-month-old infant. What does the nurse inform the mother?

New foods should be introduced one at a time for a period of 5 to 7 days.

The nurse works in the emergency department and feels like they are becoming somewhat jaded about her nursing practice. The nurse talks to the supervisor about this and suggests making some goals for enhancing their self-concept as a professional nurse. Which of the following would be an important goal to establish that would build up the nursing self-concept?

Schedule time every day to meet personal needs.

What term best describes a person's sense of his own adequacy and worth?

Self-esteem

Which dimension would a nurse include when assessing a client's self-perception? Select all that apply.

Self-knowledge Self-expectation Social self

A nurse is educating a client about smoking cessation. The nurse determines that the client has high self-efficacy. Which outcome would the nurse expect to occur?

The client will be able to stop smoking.

Which vitamin is found only in animal foods?

Vitamin B12

Which question would the nurse ask to assess a client's self-identity during a focused self-concept assessment?

What are your personal strengths?

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to:

Which situation is most likely to warrant an autopsy?

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

The nurse promotes the self-concept of the parents of an infant age 6 months admitted to the hospital with a fever and dehydration by:

allowing the parents to participate in the infant's care.

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect:

alopecia

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?

anemia

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross?

anger

A nurse is caring for a client who had an appendectomy earlier in the day. The client now has bowel sounds and is passing flatus. Which food is appropriate for the nurse to serve to the client at this time?

apple juice A postoperative client whose bowel sounds return and is passing flatus is ready to begin a diet. The first diet offered is a clear liquid diet. Apple juice is a clear liquid because it can be seen through. Sherbet and Ensure would belong on a full liquid diet. Chopped fruit is a mechanically altered diet and is typically used when a client has chewing or swallowing difficulty.

Which of the following is an appropriate intervention for body image disturbance?

assisting the client in exploring thoughts and feelings related to body image changes

A client with uncontrolled hypertension experienced a stroke a week ago, leading to significant motor losses. A successful and normal adaptive response to these new limitations is evident if the client:

exhibits signs of grief.

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

back rub

A client is deficient in found to be deficient in vitamin K. What complications should the nurse closely assess for related to this deficiency?

bleeding tendencies

A nurse in a clinic is caring for a female client who is of childbearing age. Which vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy

folic acid

An infant who was born with Down syndrome, gastrointestinal anomalies, and cardiac defects has required nearly continuous hospitalization in the neonatal intensive care and pediatric care units of the hospital during her first year of life. To counteract the negative effects of prolonged hospitalization, the nurse should:

facilitate as many opportunities as possible for infant-parent attachment.

A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating?

faith

The client states "I have lifted my cancer to God and am accepting of God's plan for me." This is an example of an adaptive expression of spiritual needs labeled:

faith

A teenage client comes to the clinic and tells the nurse that she has not had a period for the last 2 months. After assessment and lab work, the client is told that she is 3 months' pregnant. She begins to sob and says she is too young to have a baby. When the nurse offers counseling for an abortion, the client gets even more upset and says that she cannot have an abortion as it is not permitted in her church. This client is most likely which of the following?

catholic

The nurse is helping a client who eats a normal diet of 2000 calories daily to read a nutritional label on a box of cereal. Which nutrient does the nurse identify as appropriate for this client?

cholesterol less than 300 mg

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

client will participate in self-care measures by the end of the week.

A nurse is assessing a client who has experienced significant trauma affecting her body appearance. The nurse identifies a nursing diagnosis of Disturbed Body Image. When developing the plan of care, which information would be most important for the nurse to consider? Select all that apply.

client's perception of the alteration client's view of the importance of the alteration on the body part or function feelings associated with the change in body image

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

contusion

What type of wound dressings are highly absorbent, maintain a moist wound environment, do not adhear to the wound, and insulate the wound?

foams

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence.

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan?

difficulty swallowing

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to:

eat foods high in folic acid.

The nurse is educating a client with anemia about increasing iron in the diet. Which foods will the nurse teach the client that are high in iron? (Select all that apply.)

egg yolks spinach tofu liver

A nurse introduces herself to a visually impaired client, addresses the client by name, speaks to the client respectfully, and explains all the nursing activities. The nurse is implementing health promotion with this client by which mechanism?

fostering a sense of self

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

gauze

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:

hair should be washed as often as necessary.

While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying:

his faith

An adolescent states, "I want to go to college and learn to be a chef." This is an example of:

self-expectation.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

true