Foundations Exam 3

A nurse is instructing her students on the role of hormones in sleep patterns. Which statement would indicate to the nursing instructor that the student needs additional education?

"A hyperactive thyroid can make the client sleepy all the time." Hyperthyroidism causes fragmented, short-wave stages, whereas hypothyroidism seems to cause excessive sleepiness and a lack of slow-wave sleep.

A client scheduled for outpatient surgery is requesting that the operating room be sprayed with holy water. Which is an appropriate response?

"Are you concerned how the surgery will go?" When providing spiritual care, nurses must be careful neither to avoid assisting clients nor to involve themselves without the desire of the client, but to base their decisions on the cues provided by the client. Cues occur when the client verbally or nonverbally invites the nurse to share a deeper spiritual connection. Such behaviors may include direct requests, singing of religious hymns, chanting, or praying.

The nurse is documenting care provided following the death of a client with terminal cancer who lived in a long-term care facility. Which statement will the nurse document first?

"Dr. Shepherd notified at 0940." In a long-term care environment, the nurses should contact the healthcare provider who will pronounce the client dead. In the interim, the nurse documents what is happening. After pronouncement of death, post-mortem care is provided and transport to the morgue can take place.

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?" Clients receiving chemotherapy may have altered gustatory or olfactory sensations. Asking about taste would be an assessment for this condition. Repeating softly spoken words assesses auditory disturbances, feeling assesses tactile disturbances, and reading assesses visual disturbances.

While the nurse is assessing an older adult client, which statement by the client requires further investigation?

"I need to go back to my room." Mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills, can be collected during the client history.

The nurse knows that a client understands the purpose of a sleep diary when the client states:

"I will record the time I go to bed and how long it takes me to fall asleep." Keeping notes of times of sleep and waking are important details to record in a sleep diary. The notes are usually maintained for 14 days and include specifics such as all wakeful activities and sleep patterns in strange environments.

After the physician has discussed euthanasia with a terminal client and his family, the nurse assesses their understanding of the topic. Which of the following statements by the family indicates that learning has occurred?

"It is alright to stop dialysis." Active euthanasia is taking specific steps to cause a client's death (lethal dose of barbiturates) and has been deemed both immoral and illegal in most states. Passive euthanasia is defined as withdrawing medical treatment (dialysis) with the intention of causing the client's death and is morally and legally justified. Allowing the client to stop eating would be a form of passive euthanasia.

A client 57 years of age with breast cancer needs a bilateral mastectomy. Having already established a strong therapeutic partnership with the client, how can the nurse best assess the client's self-concept in light of this bodily change?

"Now that it's completed, how are you feeling about the surgery that you had?" Assessment of a client's self-concept is challenging for the nurse; an open-ended question to the client may elicit the client's feelings on this matter. Discussing reconstruction, peers in similar circumstances, or the influence of the surgery on the client's lifestyle are probably less likely to facilitate assessment of the client's self-concept.

The nurse is participating in a discussion about controlled substances. Which statement, made by the nurse, indicates the nurse is aware of laws governing the distribution of controlled substances?

"Nurses are responsible for adhering to specific documentation about controlled substances." Nurses have specific responsibilities regarding controlled substances, including specific documentation. Violation of controlled substances at the workplace is serious and is considered a criminal act. Substance abuse is treatable and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; she is still liable for her actions.

The nurse, who frequently cares for spinal cord injury clients, is studying the effects of sensory deprivation. Which of her following statements is most accurate?

"Perceptual disturbances can include daydreams." Sensory deprivation can lead to perceptual, cognitive, and emotional disturbances. Perceptual responses can range from mild distortions such as daydreams, to gross distortions such as hallucinations. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position. Cognitive responses involve the client's inability to control the direction of thought content. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. With decreased sensory input, the RAS is no longer able to project a normal level of activation to the brain.

A nurse hired to work in an ambulatory setting attends new employee orientation. The nurse never worked in ambulatory before and is concerned about the Scope and Standards of Practice for Professional Ambulatory Care Nursing. Which response, given by the nurse educator, would further explain the Scope and Standards of Practice for Professional Care Nursing to the new nurse?

"The Scope and Standards of Practice for Professional Ambulatory Care Nursing deal with the professional obligations of a nurse working in the ambulatory setting." The Scope and Standards of Practice for Professional Ambulatory Care Nursing are the standards of care for nurses working in the ambulatory arena. It does not take precedent over the facility's policies and procedures, but must be worked in conjunction with the policies and procedures. It is not used for assessing nurses. NCLEX determines if a nurse is minimally competent to practice as a nurse.

The new hospice nurse is reviewing the concepts of loss and grief with her preceptor. Which of the following statements leads the preceptor to believe that the nurse has an understanding of grief and loss?

"The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." Normal expressions of grief may be physical, emotional, social (feeling detached from others and isolating oneself from social contact), and spiritual. Grief is an internal emotional reaction to loss and occurs with loss caused by separation (e.g., divorce) or by death. Clients lamenting their loss of youth are demonstrating a type of perceived loss, which is intangible to others. Situational losses are experienced as a result of unpredictable events; a child going to college would be a maturational loss for the parent.

A lawyer is describing the litigation process to a nurse named in a malpractice lawsuit. Which statements by the lawyer accurately describe this process? (Select all that apply.)

"The process of bringing and trying this lawsuit is called litigation." "The opinions of appellate judges are published and become common law." "Common law is based on the principle of stare decisis." The process of bringing and trying a lawsuit is called litigation. The opinions of appellate judges are published and become common law. Common law is based on the principle of stare decisis, or "let the decision stand." After a decision has been made in a court of law, the principle in that decision becomes the rule to follow in other similar cases. The other options listed are not true about the litigation process.

A client is admitted to the hospital with a medical diagnosis of terminal lung cancer. Which question is most important for the nurse to ask first?

"What have you been told about your condition?" Focused assessment for those experiencing loss, grief, and dying is directed toward determining the adequacy of the patient's and family's knowledge, perceptions, coping strategies, and resources. The priority is to assess what the client has been told about the condition in order to identify whether the client's and family's knowledge will allow them to make informed decisions that will serve their best interests. The other options are important, but not the first priority at this time. Also, the nurse should use open-ended questions when possible.

A nurse is preparing a presentation about ethical and legal issues for nurses. As part of the presentation, the nurse is planning to review the different types of laws. Which example would the nurse include as an intentional tort? Select all that apply.

-Assault -False imprisonment -Libel Intentional torts include assault, false imprisonment, and libel. Negligence is an unintentional tort. Misdemeanor is considered a crime.

The caregiver of a preschool-age child tells the nurse, "I am afraid my child sleeps too much," and reports that the child takes a daily 2-hour nap in addition to sleeping 12 hours at night. What is the appropriate nursing response?

"Your child should get 10-13 total hours of sleep time in a 24-hour period." Preschoolers, age 3-5, should get 10-13 total hours of sleep time in a 24-hour period. Newborns (0-3 months) require 14-17 total hours of sleep time in a 24-hour period. Infants (4-11 months) require 12-15 total hours of sleep time in a 24-hour period. School-agers (6-13 years old) require 9-11 total hours of sleep time in a 24-hour period.

A patient who recently underwent amputation of a leg complains of pain in the amputated part. What would be the nurse's best response?

"Your pain is a real experience." The pain that is often referred to an amputated leg where receptors and nerves are clearly absent is a real experience for the client. This type of pain is called phantom pain or phantom limb pain and is without demonstrated physiologic or pathologic substance. One theory suggests that sensory misrepresentations from the missing limb may still remain in the brain, thereby causing phantom pain. The pain is a real experience. This pain is not known as central pain syndrome. This pain is not referred to as "ghost pain".

The nurse attorney provides an educational session to the nursing staff on acts of negligence. Which responses by the staff would indicate to the attorney that the staff can accurately identify acts of negligence? Select all that apply.

-"I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a first-degree burn." -"I can be charged with negligence if I notify the heath care practitioner about a change in a client's status, but am unable to reach him and do not follow up or document." Negligence occurs when a nurse fails to provide care that another nurse with the same educational background would perform. Applying heat and burning the client's skin is not an act another prudent nurse would do. The nurse must act as the client's advocate by following up and documenting when a health care provider does not respond to a change in the client's condition. When a nurse follows correct policies for administering medications, following the standards of care and using equipment in the correct manner eliminates the risk of practicing in a negligent manner.

The mother reports her 4-year-old child wakes up frequently at night screaming. She also reports this occurs shortly after her son has fallen asleep. The nurse determines that the child takes a tub bath and the mother reads a story to her son prior to bedtime at 8 p.m. The nurse intervenes by stating what to the mother? Select all that apply.

-"It is common for this to occur in this age group." -"Comforting your child when this occurs may help." -"You may find a nightlight in his room is helpful." The description is a preschooler experiencing nightmares or night terrors, which is common in this age group. Nursing interventions include teaching the parents to comfort the child and provide a nightlight. The preschooler should not be placed in the parents' bed when this occurs as this will become a regular routine. The preschooler's bedtime routine appears satisfactory, and this should be continued.

A nurse is showing an older adult client with severe diabetes the correct method of self-administering an insulin injection. What should be the nurse's comment if the client continues making mistakes when learning how to self-administer an insulin injection? Select all that apply.

-"Lots of people have the same concern." -"You've just about figured out how to give yourself an injection." -"Try to angle the syringe a little more this way." Many adults are intimidated by learning a new skill, so encouragement and praise almost always improve performance. Comments such as, "Lots of people have that same concern" will help the client to feel less isolated. Positive corrective feedback such as, "You've just about figured out how to give yourself an injection; now, angle the syringe a little more this way," acknowledges and reinforces learning accomplishments, but at the same time provides significant correction to facilitate a better performance. Negative comments such as, "Why are you repeatedly holding the injection at the wrong angle?" or "It will be better if you ask someone responsible to administer the injection," will only make the client feel more nervous and intimidated.

A nurse and client are working together to help the client with lifestyle changes to promote improved health. Which is the best statement about contractual agreements? Select all that apply.

-"Our goals are defined, as are ways to meet them." -"With this contract, we show that we are both dedicated to helping you." A contractual agreement is not a formal document, nor is it binding. It lists common goals to client and nurse, but does not require completion of those goals. It is a document of partnership between the client and nurse to reach the goals they are both trying to meet.

A client reports to the nurse, "Sleep really isn't necessary." Which teaching by the nurse is appropriate? (Select all that apply.)

-"Sleep helps your blood flow to the brain." -"Sleep helps you to learn easier and remember more." -"Sleep helps your immune system to fight off infections." In addition to promoting emotional well-being, sleep enhances various physiologic processes. Sleep is believed to play a role in the following: reducing fatigue, stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaining the disease-fighting mechanisms of the immune system, promoting cellular growth and repair, and improving the capacity for learning and memory storage. It is not appropriate, nor accurate, to teach the client that sleep can be stressful or that sleep can cause mood fluctuations.

A newly hired graduate nurse meets with the nurse educator to discuss obtaining a client's informed consent for procedures. Which statements, made by the graduate, would indicate to the educator that further discussion is needed? Select all that apply.

-"When I sign the consent form as a witness, I am saying that the person knows all the risks and benefits of the procedure." -"I must make sure I give the client all necessary information about the procedure before I have the client sign the consent form." -"When a client is having surgery, it is my responsibility to get the consent." The person performing the procedure is responsible for obtaining informed consent. If the client has questions about the consent, the nurse may answer them. The nurse's signature indicates that the consent was signed and the nurse witnessed the client's signature. If there is an immediate threat to life or health, consent is not needed.

Which nursing actions describe the use of the professional value of altruism? Select all that apply.

-A nurse demonstrates an understanding of the culture of his or her client. -A nurse becomes a mentor to a student nurse working on the floor. -A nurse respects the right of a Native American/First Nations client to call in a shaman for a consultation. Altruism is a concern for the welfare and well-being of others. The nurse would be demonstrating altruism when the nurse becomes a mentor to a student nurse working on the floor. The nurse would also be demonstrating this trait if the nurse shows an understanding of the culture of the client. Another more specific example of altruism is a nurse respecting the right of a Native American/First Nations client to call in a shaman. The nurse protecting the privacy of a client with AIDS is confidentiality.

Nurses practice the professional value of autonomy when providing nursing care for clients. Which nursing actions best describe the use of this value? Select all that apply.

-A nurse reads The Patient Care Partnership to a visually impaired client. -A nurse collaborates with other health care team members to ensure the best possible treatment for a client. The professional value of autonomy is the right to self-determination. When the nurse reads The Patient Care Partnership to a visually impaired client, the nurse is demonstrating autonomy. A nurse collaborating with other health care team members to ensure the best possible treatment for a client is another example. The other examples are not examples of autonomy.

Nurses may commit both intentional and unintentional torts when practicing within the profession. What are examples of intentional torts in nursing practice? Select all that apply.

-A nurse threatens to hit an older client who has dementia and is wailing. -A nurse seeks employment in a hospital after falsifying credentials on a resume. -A nurse places a client who is a fall risk in restraints without the proper order. -A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI). Torts may be intentional or unintentional acts of wrongdoing. Some of the intentional torts for which nurses may be held liable include assault and battery. Examples of intentional torts would include a nurse threatening to hit an older client who has dementia and who is wailing; a nurse seeking employment in a hospital after falsifying credentials on a resume; a nurse placing a client who is a fall risk in restraints without the proper order; a nurse making disparaging remarks to the staff about a client who has a sexually transmitted infection. A nurse forgetting to put the side rail up on a crib would be an example of an unintentional tort, as would a nurse not reporting a change in client condition in a timely manner.

A nurse is conducting an in-service program for a group of hospice nurses. When describing the grief response in adults and older adults as compared to children, which would the nurse most likely include? Select all that apply.

-Adults and older adults grieve more continuously. -Adults and older adults do not seek an immediate replacement for the lost loved one. In contrast to children, adults tend to grieve more intensely and more continuously, but for a relatively shorter period of time. Furthermore, adults usually do not seek an immediate replacement for the lost loved one but rather may move toward this after achieving some resolution of their grief. Middle-age adults who have a relatively stable lifestyle and adequate support systems usually cope well with loss.

Which religious groups would the nurse anticipate to regard Saturday as the Sabbath? (Select all that apply.)

-Adventist -Judaism Saturday and Sunday are considered the Sabbath in the religions of the Adventist and Judaism.

Nurses practice within the legal and mandatory standards of the nursing profession. What are examples of voluntary standards in nursing? (Select all that apply.)

-American Nurses Association Standards of Practice -Professional standards for certification of individual nurses in general practice -Process of certification Voluntary standards in nursing would include the American Nurses Association (ANA) Standards of Practice, the process of certification, and professional standards for certification of individual nurses in general practice. State nurse practice acts is not an example of voluntary standards in nursing. Rules and regulations of nursing are not examples of voluntary standards in nursing.

As the nurse admits a new client to the unit for elective surgery, the nurse should facilitate the practice of religion by doing which of the following? Choose all that apply.

-Arrange for the client's pastor to visit if desired. -Attempt to meet religious dietary restrictions. -Respect the need for privacy during periods of prayer. The following are means the nurse can use to help the client continue normal spiritual practices in the unfamiliar environment of the hospital or care center: • Familiarize the client with the religious services and materials available within the institution. • Respect the client's need for privacy or quiet during periods of prayer. • Assist the client to obtain devotional objects and protect them from loss or damage. • Arrange for the client wishing to receive the sacraments to do so. • Attempt to meet the client's religious dietary restrictions. • Arrange for the client's minister, priest, or rabbi to visit if the client so wishes. Proselytizing is never acceptable in professional settings. Addressing spiritual issues should not be coercive. Praying with clients should not be initiated by the nurse unless there is no pastoral care available and the client requests it. Comparing and contrasting religious beliefs is not likely to benefit the client.

A middle-age client reports to the nurse that he has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. Which instruction does the nurse provide to the client? Select all that apply.

-Avoid activities after 5 p.m that are stimulating. -Participate in a quiet activity, such as reading, prior to attempting to fall asleep. To promote good sleep hygiene, the client should avoid any stimulating behaviors after 5 p.m. Quiet activities, such as reading, are acceptable. The client should avoid taking naps and ingesting caffeine. Chocolate has caffeine. Bed should be used for sex and sleep only, not watching television.

The 3-year-old son of a practicing Protestant family is a new client. The family is interested in teaching the son some of their religious traditions. Based on his age, which activities would be appropriate? Select all that apply.

-Bedtime prayer -Prayer before meals -Holy day celebrations Stories and religious symbols are best introduced to children during the school-age years.

What are characteristics of rapid eye movement sleep? Select all that apply.

-Blood pressure and pulse rate show wide variations and may fluctuate rapidly. -A person is unable to move during this stage. -Theta waves often have a sawtooth or notched appearance. During REM sleep, blood pressure and pulse rate show wide variations and may fluctuate rapidly, a person is unable to move, and theta waves often have a sawtooth or notched appearance. Muscles are relaxed but muscle tone is maintained. Sleepwalking and bed-wetting are most likely to occur during NREM.

A nurse assessing children for spirituality keeps in mind which central themes in children's descriptions of God, based on David Heller's study? Select all that apply.

-Children have a notion of a God who works through human intimacy. -Children believe in the interconnectedness of human lives. -Children show considerable anxiety in the face of God's power. Studies have shown that the central themes in all the children's descriptions of their beliefs in God included the following: · Notion of a God who works through human intimacy and the interconnectedness of lives · Belief that God is involved in self-change and growth and transformations that make the world fresh, alive, and meaningful · Attributing to God tremendous and expansive power and then showing considerable anxiety in the face of this power · Image of light

A nurse determining the effects of religion on the lifestyle of clients considers that which religions prohibit the use of alcohol? Select all that apply.

-Christian Science -Church of Jesus Christ of Latter-Day Saints -American Muslim Mission Religions that prohibit the use of alcohol include Christian Science, Church of Jesus Christ of Latter-Day Saints, and American Muslim Mission. The Roman Catholic religion, Hinduism, and Judaism do not prohibit the responsible use of alcohol.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

-Depression -Sleeplessness -Decreased interest in activities Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.

The nursing instructor is teaching about spirituality and asks a nursing student about the factors that can influence a client's spirituality. Which responses by the student are accurate? Select all that apply.

-Developmental considerations -Family -Ethnic background -Formal religion Among the many factors that can influence a person's spirituality, the most important are developmental considerations, family, ethnic background, formal religion, and life events.

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include?

-Do not drive while taking pain medication. -Do not smoke without someone else present. -Avoid alcohol. The teaching plan developed by the nurse should include instructions to take the medication with food to prevent stomach irritation. It should also include not smoking without someone else present to decrease the risk of the client falling asleep and starting a fire. The client should also be instructed to avoid alcohol and to avoid driving. The client does not need to avoid diary products.

A nurse is being sued for malpractice in a court of law. What elements must be established to prove that malpractice or negligence has occurred? Select all that apply.

-Duty -Breach of duty -Causation The elements that must be established to prove that malpractice or negligence have occurred include duty, breach of duty, and causation. Intent to harm would be intentional torts. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Punitive damages are monetary compensation awarded in a legal case to the injured party.

The nurse recognizes liability requires specific elements that must be established to prove that malpractice or negligence has occurred. Identify the specific elements. (Select all that apply.)

-Duty -Breach of duty -Causation -Damages Elements of liability are duty, breach of duty, causation, and damages. Misrepresentation occurs in fraud. Breach of confidentiality is a violation of HIPAA.

A student nurse is preparing a presentation on sleep hygiene practices. What information should the nurse include? Select all that apply.

-Eliminate caffeine intake 6 hours prior to bedtime. -Do not watch television in bed. -Use blackout or other types of curtains/blinds to keep the room as dark as possible. Caffine is a stimulant and can interfere with sleeping. Establishing a routine of only sleeping in bed, not reading or watching television there, and keeping the room as dark as possible may help decrease insomnia. Taking a hot bath or doing exercise prior to bedtime may increase the time it takes to fall asleep. These activites should been done at least 1 to 2 hours prior to bedtime.

The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (Select all that apply.)

-Encourage deep breathing. -Play the client's favorite music. -Promote a restful environment. Anxiety, lack of sleep, and muscle tension may all increase the client's perceived intensity of pain. Therefore, the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay with the client in the room at all times, is not indicated and may cause the client's anxiety level to increase.

A middle-aged client reports to the nurse that the client has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. What should the nurse instruct the client to try? (Select all that apply.)

-Establish a set time to go to sleep each night. -Perform moderate exercise three or four times each week. -Participate in an enjoyable activity each day. Behaviors that will promote sleep include establishing a regular routine, such as time, for bedtime, exercising three to four times each week, and participating in an activity that is enjoyable each day. The client should avoid alcohol and eat a small carbohydrate snack prior to bedtime.

A nurse is reading a journal article that describes Bandura's self-efficacy model. Which influencing factor would the nurse expect to read about in the article? Select all that apply.

-Experience -Modeling by others -Social persuasion -Physiologic factors Four factors influence self-efficacy: experience, modeling by others, social persuasion, and physiologic factors. Experience refers to a person's actual successful or unsuccessful attempts to master a skill, such as trying to quit smoking. Modeling can come from many sources, including family, friends and media. Social persuasion involves trying to convince the individual of the merits of changing. Finally, physiologic factors are the physical responses to new situations.

A client with an altered self-concept would most likely exhibit which emotional responses? Select all that apply.

-Feelings of worthlessness -Helplessness -Guilt Emotional changes with self-concept dysfunction include feelings of depersonalization, hopelessness, helplessness, alienation, fear of rejection, anger, sadness, shame, guilt, inadequacy, worthlessness, and suspicion of others. Emotional responses may be blunted or inappropriately intense.

The nurse is preparing to teach a client about enoxaparin sodium for the first time. This client has never given a self-injection before. Which actions are appropriate for the nurse to take? Select all that apply.

-Gather supplies for injection teaching. -Review medication data sheets. Enoxaparin sodium is not given IM, nor does it require injection diagrams. Needle size is not determined by client size. Before doing anything else, the nurse must first assess her personal knowledge of enoxaparin sodium injections to ensure the client is taught accurately. Reviewing medication data sheets and gathering teaching equipment are appropriate actions.

A nurse is assessing a dying client for realism of expectations and perception of condition. Which interview questions address this concern? Select all that apply.

-Have you had any previous experience with this condition before? -How do you see the next few weeks playing out? -What do you think may be happening in the midst of all of this? A focused assessment regarding realism of expectations and perception of condition includes the following questions: Have you had any previous experiences with this condition or with the death of someone you love? What are your expectations in this case? How do you see the next few weeks (days) playing out? What are your fears, hopes, concerns, worries? What good do you think might be happening in the midst of all this? The objective is to discover whether the client and family have unrealistic expectations or misperceptions about the diagnosis, prognosis, and care options that could interfere with their decision making and coping. Asking the client if he knows how to contact his doctor, what he has been told about his condition, and how well others around him are coping don't address these objectives.

The nurse is preparing a focused assessment guide to assess clients for self-esteem. Which questions address personal identity? Select all that apply.

-How would you describe yourself? -What would you list as your strengths? -What are your fears in life? Personal identity is assessed by asking the clients to identify how they would describe themselves to others in regards to personal characteristics and traits, strengths, and fears. Changes a person would make to the body refers to body image. How satisfied one is with oneself refers to self-esteem. Identifying the status of relationships with others refers to role performance.

A nurse is caring for a client who is spiritually distressed. Which of the following are the factors that affect the spiritual distress of a client? Select all that apply.

-Inability to reconcile a current life situation with spiritual beliefs -Separation from the religious community or supports Factors affecting spiritual distress include inability to reconcile a current life situation with spiritual beliefs and separation from the religious community or supports. Disconnectedness to self can be expressed through an inability to seek a religious leader or an inability to introspect.

The nurse is caring for 7-year-old Marcie today. Marcie is struggling with developing and maintaining a positive self-concept due to burn scars on her face from an accident 4 years ago. She does not remember the incident, but she is very aware of how she appears to others. She is admitted for her third plastic surgery to remedy the scar tissue. The nurse is aware of which key factors that affect self-concept? Select all that apply.

-Internal and external resources -Stressors -Illness or trauma Almost any life experience can influence a person's self-concept. Key factors include developmental considerations, culture, internal and external resources, history of success and failure, stressors, and illness or trauma. Height and weight and appropriate role models may affect self-concept in negative or positive ways, but they fall under the key factor categories. They are not, in and of themselves, key factors.

A nurse is providing care to a 9 1/2-year old child who is terminally ill. When talking with the child, the nurse would need to understand that the child most likely views death as which type of event? Select all that apply.

-Irreversible -Universal -Inevitable At around 9 years of age, children perceive death realistically as irreversible, universal, inevitable, and natural. During the early school years, a child perceives death as unnatural, reversible, and avoidable.

A nurse is conducting grief resolution for a client who lost his wife in a motor vehicle accident in which he was the driver. Which interventions best accomplish this goal? Select all that apply.

-Listen to expressions of grief. -Include significant others in discussions and decisions as appropriate. -Communicate acceptance of discussing the loss. Grief resolution involves dealing with the loss. Listening to the client's expressions of grief, including significant others in discussions, and communicating acceptance helps the client deal effectively with the loss. Encouraging the client to keep silent about the event, not being empathetic, and avoiding identification of fears does not help the client in dealing with the loss.

When speaking to a client who is hard of hearing, the nurse should take which action? Select all that apply.

-Look directly at the client's eyes. -Speak only when facing the client. A sudden loss of sensory perception through a sensory deficit can cause total disorientation because compensation does not occur immediately. Compensation for a deficit usually occurs when loss of function is gradual. The client may change his behavior to adapt to the sensory deficit, such as turning a functioning ear toward a speaker to hear, or measuring the temperature of bath water with a thermometer (if there is decreased sensation of the extremities). Physiologic compensation also occurs, with the remaining senses becoming more acute. For example, a blind person may develop a more acute sense of smell or hearing.

Which factors affect the grieving process? Select all that apply.

-Meaning of loss -Circumstances of loss -Personal stressors -Sociocultural resources Factors affecting grieving include meaning of loss, circumstances of loss, religious beliefs, personal resources and stressors, and sociocultural resources and stressors.

Which client populations are at high risk for inadequate pain management? Select all that apply.

-Neonates and infants -Young children -Clients with dementia -Older adults with chronic pain Client populations who are not able to communicate pain effectively are at highest risk for inadequate pain management. These clients are the neonates, infants, young children, and patients with dementia. Adults older than age 65 years experience pain more frequently than do younger adults and endure moderate to severe pain for twice as long as younger adults. However, many see pain in the elderly as part of the normal aging process and it is therefore undertreated.

Nurses follow nursing practice rules when working within the profession. What are examples of state-mandated rules? (Select all that apply.)

-Nurse practice acts -Nursing educational requirements -Composition and disciplinary authority of board of nursing Examples of state-mandated rules would include nurse practice acts, nursing educational requirements, and composition and disciplinary authority of boards of nursing. Delegation trees, medication administration, and Medicare and Medicaid provision for reimbursement of nursing services are not examples of state-mandated rules.

A nurse is part of a group named in a malpractice lawsuit. The plaintiff is suing for general damages. Which items would be addressed? Select all that apply.

-Pain -Suffering -Disfigurement -Disability For a plaintiff to prevail in a malpractice suit, the plaintiff must have suffered damages. The purpose of the suit is to compensate for these damages. General damages include pain and suffering, disfigurement, and disability. Special damages are for losses and expenses related to the injury, such as medical expenses and lost wages.

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

-Patient and nurse's expectations of one another -Orientation to treatment center and staff -The medical and nursing regimens and how the patient can participate in care The topics that the nurse would be most likely to explore with a client with the aim of restoring health would include the following: client and nurse's expectations of one another, orientation to treatment center and staff, and the medical and nursing regiments and how the client can participate in care. The nurse would not include immunizations, community resources, and hygiene as topics most likely to explore with a client with the aim of restoring health.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply.

-People vary widely in their responses to loss. -Stages occur at varying rates among people. -Some people actually skip some stages of grief altogether. In reality, the stages of the grief cycle model are not as discrete as the model indicates. However, it is helpful to use the model as a general guide, while keeping in mind that people may vary greatly in their responses to loss and still fall within the normal response range. Grieving persons may go through the stages at varying rates, go back and forth between stages, or skip stages.

A nurse is reviewing The International Council of Nurses (ICN) Code of Ethics for Nurses. Based on this code, the nurse would identify which responsibility as being fundamental? Select all that apply.

-Promoting health -Preventing illness -Restoring health -Alleviating suffering According to the ICN Code of Ethics, nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. The need for nursing is universal.

The nurse provides postmortem care for a client who is not undergoing an autopsy. To achieve the desired outcome of this procedure, which nursing actions should be included? (Select all that apply.)

-Remove any tubes and replace soiled dressings -Place an identification tag on the client's ankle -Provide emotional support to the client's family -Ensure the death certificate has been signed When a client dies, the nurse's responsibilities include caring for the client's body, caring for the family, and discharging specific legal responsibilities. After the client has been pronounced dead, the nurse is responsible for replacing soiled dressings and removing tubes. The mortician will wash the body. The nurse is legally responsible for placing identification tags on either the shroud or the garment the body is clothed in and the ankle to ensure that the body can be identified even if it is separated from its shroud. After a client has died, the nurse provides emotional support and care to the client's family. Legal responsibilities of the nurse include ensuring that a death certificate is issued and signed.

A nurse is developing a plan of care for a client with a negative self-concept. The nurse implements the interventions based on the understanding that a positive self-concept is most important for the client to meet which need? Select all that apply.

-Self-actualization -Esteem Self-concept is the frame of reference that influences how a person handles situations and relationships. It is crucial to esteem and self-actualization, the highest needs in Maslow's hierarchy of needs. Although safety, love and belonging, and physiologic are needs, self-concept is not most important for meeting these needs.

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

-Self-knowledge -Self-expectation -Social self Self-perception is how a person explains behavior based on self-observation. How one perceives oneself has several dimensions: self-knowledge, self-expectations, social self, and self-evaluation. Self-esteem refers to how one feels about himself.

A nurse is counseling adolescents in a group home setting. What aspect of self-esteem is developed in this age group? (Select all that apply.)

-Sense of self is consolidated. -Emphasis is on sexual identity. -Parental influences on self-concept are often rejected. Developmental changes affecting the self-concept of the adolescent includes development of secondary sex characteristics; rapid body changes; sense of self is consolidated; emphasis on sexual identity; parental influences on self-concept are often rejected; peers become more important; and movement is toward development of own identity. Importance on meeting role expectations well is developed in adulthood. A sense of being trusted and loved, and differentiation of self and non-self develops during childhood.

The nurse is planning strategies to increase sensory stimulation for patients in isolation. Which considerations should the nurse keep in mind? (Select all that apply.)

-Sensory functioning tends to decline progressively throughout adulthood. -An individual's culture may dictate the amount of sensory stimulation considered normal. -Different personality types demand different levels of stimulation. Because sensory functioning tends to decline throughout adulthood, it is especially important for the nurse to plan stimulating activities for these patients in isolation. Culture and personality guide the amount and level of sensory stimulation necessary for individuals. The amount of stimuli different individuals consider optimal is not constant; this could lead to over stimulation. Sensory functioning develops over time; it isn't established at birth. Medically fragile infants should have a decrease in environmental stimulation.

A nurse is working with a 60-year-old man who has been diagnosed with onset insomnia. He tells the nurse that he wakes up at least once during the night. Which are good examples of health promotion for this client? Select all that apply.

-The nurse advises the client to exercise no closer than 6 hours to bedtime. -The nurse encourages the client to remove the television from his bedroom. -The nurse encourages the client to minimize caffeine intake several hours prior to bedtime. -The nurse helps the client come up with a bedtime routine that he can implement each night. Avoiding strenuous activities and caffeine for several hours before bedtime can help an individual who is having difficulty falling asleep. This client could also benefit from removing any distractions in his bedroom, by improving his sense of security, by decreasing any feelings of social isolation, and by creating a routine around bedtime. Teaching the client that shorter unbroken sleep periods are not normal not only provides him with false information but may also cause him to feel abnormal.

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 nurse can transmit her self-concept to the newborn. -The parents can convey their sense of competence to the newborn -Anxiety felt by those caring for the newborn can be sensed by the newborn. Newborns have undifferentiated selves; they do not experience a separate existence from others. Parents and other caregivers transmit their self-concepts, sense of competence in new roles, and amount and intensity of anxiety they feel to newborns. When parents are reasonably calm and communicate warmth and acceptance to newborns, they help their babies establish the basis for positive self-concept.

Nurses plan client learning based on the client's developmental stage. Which nursing actions best reflect this consideration? Select all that apply.

-The nurse directs the health education for a 3-year-old to the parents. -The nurse includes a school-age child in the teaching-learning process. -The nurse uses the same learning strategies for an adolescent as for an adult. -The nurse provides material that is useful immediately to adult clients. Looking at clients' development stages, the nurse would develop and carry out actions based on the individual client needs. The nurse would direct the health education for a 3-year-old to the parents. The nurse would include a school-age child in the teaching-learning process. The nurse would use the same learning strategies for an adolescent as for an adult. The nurse would provide material that is useful immediately to adult clients. The nurse would not provide lengthy explanations for a procedure to a preschool child because of the client's development stage. The nurse would not avoid relating education for an adult to a social role.

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What are examples of legal safeguards for the nurse? Select all that apply.

-The nurse obtains informed consent from a client to perform a procedure. -The nurse educates the client about The Patient Care Partnership. -The nurse documents all client care in a timely manner. Examples of legal safeguards for the nurse would include the nurse obtaining informed consent from a client, the nurse educating the client about The Patient Care Partnership, and the nurse documenting all client care in a timely manner. Legal safeguards for the nurse would not include the nurse executing physician orders without questioning them. Legal safeguards for the nurse would not include the nurse claiming management is responsible for inadequate staffing leading to negligence. Legal safeguards for the nurse would not include the physician being responsible for administration of a wrongly prescribed medication.

A nurse seeks to incorporate the principle of bioethics known as nonmaleficence when caring for clients in a long-term care facility. Which nursing actions best exemplify this principle?

-The nurse performs regular client assessments for pressure ulcers. -The nurse follows "medication rights" when administering medicine to clients. The concept of nonmaleficence refers to the avoidance of causing harm. Examples of nonmaleficence include the nurse performing regular client assessments for pressure ulcers. Nonmaleficence would also include the nurse following "medication rights" when administering medicine to clients. The other options listed are not true examples of the nurse incorporating the principle of nonmaleficence.

A nurse is writing a letter to a U.S. Congressman to support the promotion of health care issues. Which guidelines would ensure a properly written letter? (Select all that apply.)

-The nurse should state the purpose of the letter briefly and clearly in the first paragraph. -The nurse should name the city and state where he or she lives and votes. -The nurse should restate exactly what the legislator should do at the end of the letter. Writing a letter to a U.S. Congressman should be in the format of a formal letter, stating the nurse's concerns in a way that best relays this information. The formal letter should state the purpose of the letter briefly and clearly in the first paragraph, state the city and state when the nurse lives and votes, and restate exactly what the legislator should do at the end of the letter. The letter should be kept to one page. The letter should be addressed to one legislator only, not a group of individuals.

The nursing instructor is teaching a class on spiritual health and its importance in nursing care. When talking about the model using the unifying approach, which of the following does the spiritual dimension affect? Select all that apply.

-The physiological dimension -The psychological dimension -The sociological dimension In the unifying approach, the spiritual dimension grounds or affects the physiological, psychological, and sociological dimensions. There is not a unifying dimension but a unifying approach. The integrated approach is a separate model and is not a dimension.

The characteristics of somatic senses include discrimination of which of these? Select all that apply.

-Touch -Pressure -Vibration -Positioning Touch, pressure, vibration, and positioning are all somatic senses. Auditory acuity is associated with normal hearing. Odors are associated with normal smell.

The nurse understands that Fowler's theory of faith development views faith as a way of knowing the world. Faith progresses throughout the lifespan. Place the following stages in the correct order of development.

-Undifferentiated-Primal -Intuitive-Projective -Mythic-Literal Faith -Individuative-Reflective Faith -Universalizing Faith Fowler's stages of faith development: Undifferentiated-Primal, Intuitive-Projective, Mythic-Literal Faith, Synthetic-Conventional, Individuative-Reflective Faith, Conjunctive Faith, Universalizing Faith.

When providing nursing care to clients, nurses are required to adhere to ethical values and legal rules to guide behavior. Which values would be included? Select all that apply.

-Veracity -Fidelity -Privacy -Confidentiality Ethical values and legal rules guide the behavior of health care professionals toward clients and their families. These include veracity, fidelity, privacy, and confidentiality.

For which conditions would the nurse assess a client to determine if he is able to adequately receive the data necessary to experience the world? Select all that apply.

-a stimulus -a receptor or sense organ -an intact nerve pathway -a functioning brain For a person to receive the necessary data to experience the world, four conditions must be met: · A stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present. · A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. · The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. · A particular area in the brain must receive and translate the impulse into a sensation. A response and an arousal mechanism are not included in these conditions.

A nurse is providing anticipatory guidance to the parents of a toddler regarding ways to promote self-concept and personal identity. Which actions would the nurse recommend? Select all that apply.

-allowing exploration of the surroundings -assisting in maintaining self-control For a toddler, the nurse would encourage the parents to allow the toddler to explore his surroundings and to assist the toddler in maintaining control. Privacy and socialization are important areas for the school-age child. Stimulation is important for an infant.

A nurse is conducting a program for a local community support group about grieving. The nurse would describe grief as fulfilling which function? Select all that apply.

-allowing the outer reality of loss to become internally accepted -altering the emotional attachment to that which was lost Grief has several important functions: to make the outer reality of the loss into an internally accepted reality; to alter the emotional attachment to the lost person or object; and to make it possible for the bereaved person to become attached to other people or objects. Grief does not prepare the client for the loss nor does it allow the person to avoid the experience the loss more fully. Grief is a necessary and normal reaction to loss.

Which assessment findings indicate a potential self-concept dysfunction? Select all that apply.

-depersonalization -feelings of inadequacy -inability to make decisions -refusal to make eye contact Emotional changes with self-concept dysfunction include depersonalization, hopelessness, helplessness, alienation, fear of rejection, anger, sadness, shame, guilt, inadequacy, worthlessness, and suspicion of others. Behavioral changes indicating self-concept dysfunction include lack of interest in activities, inability to make decisions, withdrawal from social situations, isolation, refusal to look in the mirror, refusal to look at an affected body part or discuss a limitation, avoidance of responsibility, show of hostility toward others, refusal to make eye contact, and negative verbalizations about self.

Which objective data may suggest that a client has altered self-concept? Select all that apply.

-lack of eye contact -hand-wringing -below-the-knee amputation of the right lower extremity Objective data about the client's self-concept are gathered through direct observation. Client statements are subjective data.

A nurse has applied soft wrist restraints to a client following endotracheal intubation. Which documentation is essential while using restraints? (Select all that apply.)

-patient assessment findings every 2 hours -foley catheter draining clear yellow urine -.9NS IV infusing at 100 ml/hr When restraints are applied, charting must indicate regular client assessment; provisions or administration of fluids, nourishment, and bowel and bladder elimination; and attempts to release the client from the restraints for a trial period. Additional order completion and presence of family in the room are not required documentation for client restraint.

A nurse is serving on an ethics committee. Which of the following are roles of the nurse? Select all that apply.

-serving as a liaison between the family and the committee members -presenting explanations about technical terminology -advocating for the client's wishes The nurse has an important role as the member of an ethics committee. These include serving as a liaison, advocating for the client, and explaining terminology. Making final decisions and discontinuing a ventilator are not within the role and scope of the nurse.

The nurse is caring for 42-year-old Jack, who is admitted after taking an overdose of sleeping pills. He is withdrawn and declines to eat or engage in conversation, except to say he is a failure at everything. The nurse is aware that potential causes of poor self-concept at this age can be related to which of the following? Choose all that apply.

-unsatisfying career choice -failure to accept role responsibility -failure to develop meaningful goals The adult can have poor self-concept related to failure to accept role responsibilities (e.g., parenting) or failure to develop meaningful goals and therefore just drifting through life. An unsatisfying career or job can also cause an adult to have a poor self-concept.

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

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

The parents of a newborn ask when they can expect the baby to sleep through the night. The nurse responds that the baby will most likely sleep through the night by:

3 months of age Most infants sleep through the night by 3 months of age, but nocturnal awakenings continue to be frequent during the latter half of the first year

A nurse teaches the parents of a toddler about normal sleep patterns for this age group. How many hours of sleep per night is normal near the end of this stage?

8 - 10 hours Need for sleep declines as this stage progresses. The toddler may initially sleep 12 hours at night with two naps during the day, but end this stage sleeping 8 to 10 hours a night and napping once during the day.

Which is not a lifespan consideration for sensory perception?

A newborn's sensory perception is very refined. A newborn's sensory perception is rudimentary. Newborns see only gross patterns of light and dark or bright colors.

A woman has responded to her recent diagnosis of lung cancer by making extensive plans for overseas travel with her children, despite the fact that her oncologist has informed her of her extremely poor prognosis. The client is adamant that she does not want to discuss her cancer and the nurse consequently recognizes that the client is likely in the denial stage of grief. How can the nurse best facilitate the client's healthy grieving?

Address the client's diagnosis and prognosis at a later time or date. In the absence of the client's readiness to become more aware of her situation, the nurse should respect the client's current position and revisit the matter when the client is more ready. It is disrespectful, and likely counterproductive, to have others reiterate the message, to provide written material, or to increase the amount of detail if the client is not ready to engage at this time.

The health care provider prescribes cold therapy every 4 hours for a client after foot surgery. The nurse places the ice pack directly on the client's skin and returns 60 minutes later. After removal of the ice pack, the skin is pale and cold to the touch. The client develops frostbite and begins a lawsuit for malpractice. When reviewing the case, the nurse attorney recognizes which most important statement about the malpractice suit?

All elements are in place to hold the nurse liable. All four elements are met: The nurse had a duty. The duty was breached. It is easy to find causation: an ice pack directly on skin for 60 minutes, and harm (development of frostbite) was done.

The nurse is assisting a male client 55 years of age to understand the anatomy and physiology of the heart following a heart attack. What type of learning is taking place?

Andragogy Andragogy is the art and science of helping adults learn.

A female client experienced facial burns in a motor vehicle accident. Recently, the client told her nurse, "I can't stop worrying that my fiance isn't going to want me anymore." Which of the following nursing diagnoses is most clearly suggested by the client's statement?

Anxiety While issues related to adjustment, coping, and hopelessness may underlie or result from the client's feelings, her expression of worry is primarily indicative of the nursing diagnosis of Anxiety.

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

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

A nurse caring for an older adult client following a total abdominal hysterectomy documents administration of morphine 4 mg intravenously for pain of 8 on 1-10 scale, bed in the lowest position, bed alarm on, side rails up times two, and call light in reach. After the nurse leaves the room, the client gets out of bed and falls. In which order should the nurse proceed?

Assess the client for injury. Assist the client back into bed. Notify the physician. Document the incident. Complete an incident report.

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 Conducting a spiritual assessment is an essential aspect of maintaining health and providing holistic and sensitive nursing care. Following the assessment, if the client has additional questions or concerns related to spirituality, the nurse may suggest follow-up with a chaplain as necessary.

A nurse volunteers to serve on the hospital ethics committee. Which of the following indicates that the nurse knows what the purpose of an ethics committee is?

Assist in decision making based on the client's best interests. An ethics committee will meet when a client is unable to make an end-of-life decision and the family cannot come to a consensus. The committee members are there to advocate for the best interest of the client. The committee would not convince, decide, or present options about the type of care. This is not the role of an ethics committee.

A middle-age client reports to the nurse that he has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. Which instruction does the nurse provide to the client? Select all that apply.

Avoid activities after 5 p.m that are stimulating. Participate in a quiet activity, such as reading, prior to attempting to fall asleep. To promote good sleep hygiene, the client should avoid any stimulating behaviors after 5 p.m. Quiet activities, such as reading, are acceptable. The client should avoid taking naps and ingesting caffeine. Chocolate has caffeine. Bed should be used for sex and sleep only, not watching television.

The nurse uses the acronym TEACH when planning care for patients on a busy hospital ward. Which intervention accurately represents an aspect of this acronym? (Select all that apply.)

A—The nurse acts on every teaching moment. C—The nurse clarifies often. H—The nurse honors the patient as a partner in the education process. the acronym TEACH stands for the following: T: Tune into the patient. E: Edit patient information. A: Act on every teaching moment. C: Clarify often. H: Honor the patient as a partner in the education process. The "T" does not stand for the nurse turns to the doctor for support. The nurse does not education the client before teaching as the "E" in TEACH. The "H" does not stand for the nurse helps the client cope when education fails.

A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?

Battery The nurse has committed a mistake and can be sued for battery because of unlawfully carrying out a procedure that the client had refused. Battery is an assault and includes negligent touching of another person's body or clothes or anything attached to or held by that other person. Assault is the threat of touching another person without his or her consent. Negligence may be an act of omission or commission. Defamation of character in spoken words is called slander. Libel is defamation of character in written words.

A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. When discussing the nurse's action, the charge nurse appropriately identifies which wrongdoing the nurse has violated?

Battery The nurse has committed battery by performing CPR against the client's wishes. Assault occurs when a person threatens to touch a client without consent. Fraud is a willful and purposeful misrepresentation, whereas defamation occurs when a derogatory remark is made about another person.

A nurse is working on a pediatric psychiatry floor. One of the nurse's clients is a 17-year-old girl who was admitted to the hospital for anorexia nervosa. The nurse decides, based on his assessment of this client, that he is going to help the teen accept responsibility for herself, help her define realistic goals, help her utilize resources to enact change, and will reward positive outcomes. Which nursing intervention is the nurse using with this client?

Behavioral change The nurse is using behavioral change to help his client change her current behavior and to assist her with improving her self-concept problems.

The nurse fails to contact the physician regarding a client who had an open-reduction internal fixation of the tibia and has experienced increasing leg pain (unrelieved by pain medication) for the past 4 hours. Which element of liability has been violated?

Breach of duty Failure to contact the physician and report the client's condition does not meet the expected standard of care and is a breach of duty. Duty refers to an obligation to use due care and is defined by the standard of care appropriate for the nurse-client relationship. Causation shows that the failure to meet the standard of care actually caused injury. Damages are the actual harm or injury to the client.

The evening nurse received a change-of-shift report from the day nurse. The day nurses' report states, "The client required intubation for respiratory distress this morning, but has been stable all day." The evening nurse collects the following information during the first assessment: Skin flushed. Client lethargic. Temperature 103.0°F. A review of the client's chart reveals that the client's last assessment was done 7 hours earlier. A review of the findings by the nurse attorney determines which facts might be in place regarding liability? Select all that apply.

Breach of duty has occurred. The nurses had a duty to care for the client and breached duty by not assessing the client in 7 hours. No determination of the nurse or facility's response is made until a complete investigation is done.

Which one of the following teaching activities would most likely be implemented by an occupational health nurse?

Cardiopulmonary resuscitation In an occupational health setting, employees range in age from approximately 16 to older than 60 years. Given the vast age range, cardiopulmonary resuscitation education would be appropriate for all ages. Industrial nurses conduct classes on plant safety, and CPR is included in those presentations.

Which learning domain is the focus for instruction when the nurse educates a new mother about the breast and its role in milk production for feeding the newborn?

Cognitive Educating a new mother about the physiology of the breast and its role in milk production is an example of cognitive learning.

A patient in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which of the following effects of sensory deprivation might the patient be experiencing?

Cognitive response Cognitive responses involve the patient's inability to control the direction of thought content. Typically, attention span and ability to concentrate are decreased. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position, coordination, and equilibrium. Emotional typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. A physical response does not relate to thought processes.

Which nursing title is being recognized by the American Association of Nursing? This nurse aids and assists the clients with spiritual needs in the community setting.

Congregation care nurse Some clients want nurses to prearrange visits from pastors, priests, or other members of the religious community after their return home or transfer to another health care facility. In some areas of the United States, faith communities have developed various health ministries. One of these, called congregation care nursing, parish nursing, or faith community nursing, is considered a specialty area of practice, recognized by the American Association of Nursing and having its own standards of practice. Parish nurses work in churches across the country providing health promotion and health screening activities to individuals in the community. Parish nurses view clients holistically, addressing spiritual issues as well as health issues that arise for individuals in their faith community.

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 Child Protective Services can intervene immediately, and have the child hospitalized and treated against the parents' wishes. Allowing the parents to make life/death decisions about their minor child could place the child in harm's way. Insisting the parents take the child to a hospital or threatening them will a lawsuit will only cause ill feelings toward you and will not likely change the parents' minds.

It has been determined that a client who sustained a head injury following a motorcycle accident is brain dead. The client did not have an organ donation directive. However, the client did have records to indicate a wish not to have prolonged life support. What is the most appropriate action for the nurse?

Contact the organ procurement team to discuss organ donation with the family. The organ procurement team should be contacted as soon as possible to discuss transplantation with the family. This discussion cannot wait as the fragility of organs increases as time passes. While it is important to honor a client's wishes, life support cannot be withdrawn until the potential for organ donation is determined even if doing so contradicts a person's advanced directive because life support that has the potential to save lives overrides the desire to withdraw life support.

A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However, the client asks the nurse not to put on vest restraints. What would be the best nursing action?

Contact the physician and obtain necessary orders. If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. The nurse should not sedate the client and then restrain him, as the nurse could be charged with battery if there is restraint without orders. Applying a wrist restraint instead of a vest restraint is like compromising with the client, which is unethical.

The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse?

Contact the physician. The nurse should contact the physician, as PCA therapy for pain management is contraindicated for clients with sleep apnea. This is due to the fact that oversedation in clients with sleep apnea poses a significant health risk. PCA therapy is also contraindicated in confused clients, infants and very young children, cognitively impaired clients, and clients with asthma.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

Coping strategies Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed.

Nursing documentation is inclusive. Which is the best example of documentation of a teaching plan?

Cord care shown to mother, questions answered. Return demonstration observed. Documentation of teaching must include who was taught, the topic taught, and some indication of the success of the learning plan. Only the answer with a mother being taught cord care and a return demonstration is complete.

When examining values, a nurse notes that one country uses physician-assisted suicide and another country considers physician-assisted suicide as illegal and punishable with imprisonment. How are these two views on physician-assisted suicide affected?

Culturally Daily living is expressed in many traditions and customs; understanding these differences is cultural value orientation.

A nurse cultivates dispositions that enable practicing nursing in a manner in which he or she believes in. This nurse is displaying what essential element of ethical agency?

Ethical character Ethical character is the development or cultivation of virtues such as humility, courage, and integrity to name just a few. The development or cultivation of these virtues allows the nurse to practice in a manner in which the nurse believes in.

After teaching a staff development program about the major world religions and their view of health and illness, the nurse determines that the teaching was successful when the participants identify which statement as best reflective of Buddhism?

Dietary restrictions on some holy days. In Buddhism, there are dietary restrictions on some holy days. In Hinduism, the soul has no beginning or end. In Islam, all outcomes are seen as being predetermined. Christianity involves beliefs that focus on the Old and New Testaments.

The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports roadblocks to each action and continues to smoke. What is the best action of the nurse?

Discuss the client's case with a colleague. The focus is not to have the client please the nurse, but to improve client health behaviors. Telling a client that his efforts are disappointing is not an effective communication technique and can result in disruption of the therapeutic trust relationship between the nurse and client. The client does not necessarily need therapy just because initial attempts have been unsuccessful. The client desires not to have medication, so arranging for medications goes against the client's wishes in the plan of care. A colleague may shed light on additional actions based on experience with similar issues in the past.

As the nurse performs the physical assessment, he is looking for clues about the client's self-concept, which will also tell him a little about the client's coping ability. The client, who is scheduled for surgery today, is twisting a tissue into small shreds. At the same time the client states, "I have no concerns about this procedure...a piece of cake!" The nurse suspects that the client has some real concerns about the procedure. Which is the best nursing action?

Discuss the noted discrepancy with the client. A client might give what he or she believes are the desired or socially acceptable responses to interview questions. When a client reveals a discrepancy between actions and verbal response, it is important to discuss these actions with the client. Talking to the spouse deletes the client from a needed conversation. Asking if there is anything concerning the client may only produce what the client thinks the nurse wants to hear or illicit a Yes or No response. Notifying the physician is premature because the nurse does not have anything definite to report.

A client is brought to the emergency department by her son, who states, "I am unable to care for my mother anymore." The nurses identifies this son's ethical problem as being which of the following?

Distress Ethical distress is when someone wants to do the right thing but is not able to. The son brings his mother to the emergency department to maintain her safety, although he needs to take care of her. The other choices may be part of the son's decision; however, the immediate problem is one of distress.

The nurse is preparing a care plan for a client recently diagnosed with obstructive sleep apnea. The client complains of daytime sleepiness, fatigue and excessive snoring that "wakes me up". What nursing diagnosis would be appropriate for this client?

Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring Disturbed sleep pattern related to periods of apnea as evidenced by excessive snoring is the correct nursing diagnosis. The medical diagnosis of obstructive sleep apnea should not be used in the nursing diagnosis.

A 73-year-old man has been the primary caregiver for his wife, who has multiple sclerosis (MS). After 30 years with the disease she died and he has become increasingly withdrawn and refuses to leave the house. Which nursing diagnosis is most appropriate?

Disturbed personal identity related to the unresolved crisis of his wife's death The client is experiencing disturbed personal identity as he is no longer a spouse or a caregiver. This is related to the recent death of his chronically ill spouse. Without her to care for he is unable to define who he is or what his role is without her. He does not have low self-esteem or disturbed body image.

Which statement best conveys the concept of ethical agency?

Ethical practice requires a skill set that must be conscientiously learned and nurtured. Ethical agency must be cultivated in the same way that nurses cultivate the ability to do the scientifically right thing in response to a physiologic alteration. It is inaccurate to assume that it will passively develop from the presence of other ethical practitioners, or from years of experience. It is not an innate characteristic of personality.

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. Acceptance (an attitude of complacency) occurs after clients have dealt with their losses and completed unfinished business. After tying up all loose ends, dying clients feel prepared to die. Some even happily anticipate death, viewing it as a bridge to a better dimension. Nurses can help clients to pass from one stage to another by providing emotional support and by supporting the client's choices concerning terminal care. Facilitating the client's directives helps to maintain the client's personal dignity and locus of control. Accepting that death will occur and giving up are not the same thing and giving up is not expected.

Which example of nursing documentation is the most appropriate concerning a teaching session?

Family requested education on turning client. Explanation of use of draw sheet and body mechanics provided. Family coached through turning and repositioning client. Members state confidence and understanding. Complete documentation must always include the topic taught and who was present during the teaching session.

A female client is brought to the emergency room with matted hair, bruising, and malnutrition. The nurse suspects physical abuse and neglect. The nurse states, "this happens to many women." Which type of ethical approach is the nurse exhibiting?

Feminist A feminist approach is one where the focus is on specific female problems and concerns, and the statement "this happens to many women" is an example of this. The other choices are not correct as they are not reflective of this ethical approach.

A nurse is providing care for a client with cancer. The client's wife indicates that she does not want her husband to be told he is terminal. This is a breach of which ethical principle?

Fidelity The principle of fidelity involves being faithful to the client, who has the right to the truth. The other choices do not reflect this principle.

A child on a pediatric unit hits one of the other children and subsequently has video game privileges revoked for the rest of the day. The next day the same child plays with the other children without any problems in order to avoid losing video game privileges again. According to Kohlberg, the child is demonstrating what stage of development?

First-level preconventional stage As children progress to toddlerhood, morals and values development begins as they identify behaviors that elicit reward or punishment. Kohlberg refers to this process as the first-level preconventional stage when children learn to distinguish right from wrong and understand the choice between obedience and punishment.

A nurse is caring for a 45-year-old male client who lost function in both of his legs due to an automobile accident. Which of the following should the nurse do first to personalize the learning?

Gather pertinent information from the client. To personalize the learning, the nurse must first gather pertinent information from the client. Analyzing the client's behavior, preparing the training plan for the client, and developing confidence in the client are the next steps to personalize the learning.

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies?

Health care institution The health care institution determines the unit and institutional policies. These policies may vary from institution to institution. Such policies may include clinical procedures, policies specific to the institution, and personnel and employment policies.

A dying client tells the nurse that he doesn't want to see his family because he doesn't want to cause them more sadness. Which action by the nurse is most appropriate?

Help the client clarify his values. Values clarification is a method of self-discovery by which people identify their personal values and value rankings. The client's value of family may be obscured because of his overwhelming need to protect his family.

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

How do you feel about any physical changes you noticed recently? Body image is the person's subjective view of one's physical appearance. Therefore, asking a patient how he or she feels about physical changes addresses body image. "Do you like who you are?" assesses a person's self-esteem. Asking "Who influenced you the most growing up?" and "Who would you most like to be?" assesses a person's self-expectation.

When a nurse provides a cool glass of water to the client with inflamed throat tissue, the nurse cautions the client not to drink very hot liquids because they can produce

Hyperalgesia Swallowing very hot fluid would produce hyperalgesia pain in inflamed pharyngeal tissue.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods. The medulla and midbrain are part of the reticular activating system (RAS), which plays a part in the cyclic nature of sleep. The cerebral cortex does not have any role in the sleep process.

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

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

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.

The nurse is caring for a client who is recovering from a suicide attempt. Which nursing intervention would be inappropriate for this client?

Implement all-new coping mechanisms. Active listening, expression of both positive and negative feelings, and inclusion of family and friends builds trust, safety, and a sense of acceptance, love, and belonging. Building on past positive coping mechanisms enhances a sense of self-control and self-esteem.

During the health education session at the health care facility, the nurse notes that a client is able to recognize what is being taught, and is able to describe the information to others. The client is also able to explain the information learned. What is the final learning stage of the client in this case?

Independent use of new learning The final learning stage for the client in this case is the independent use of the new learning. The client demonstrates the ability to recall the information being taught by describing it to others. Involvement of the client in the health education in an active way is required to maintain the attention and the concentration of the client. Repetition of information for memorization is a technique to teach illiterate clients.

An older adult female client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. She is tearful and verbalizes that she feels lonely and abandoned in the hospital unit. The nurse noticed that family visits daily and that there are flowers and cards in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client?

Ineffective Coping; verbalizes support systems. When considering appropriate evaluation criteria, be certain it relates directly to the diagnosis, and the diagnosis relates to the assessment data. There are not data to support unilateral neglect. Tying shoes evaluates client abilities, not mobility. The nurse assessed that the family visits daily, so the family process is functional. Ineffective coping is appropriately evaluated by identification of coping mechanisms, such as support systems.

Abortion of a fetus is a sensitive topic for most religions. Which religion clearly forbids abortion?

Islam For the Islam religion, contraception is permitted by Islamic law. Abortion is forbidden.

A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which of the following is the nurse attempting to enact?

Justice The ethical principle of justice includes an effort to fairly distribute benefits and to minimize discrimination, even when circumstances make this difficult to achieve. This is demonstrated by the nurse's efforts to fairly distribute her time and care.

A parent of a high school student age 17 years is allowing the child to make the decision on the college he will attend. When the child requests direction from the parent in making this decision, the parent responds by informing him that he will need to make this decision on his own. This is an example of which type of value transmission?

Laissez-faire This situation demonstrates laissez-faire value transmission, which is characterized by allowing the adolescent to explore values on his own and the development of a personal value system. The laissez-faire approach involves little or no guidance and can lead to confusion and conflict. Through modeling, children learn which is of high or low value by observing parents, peers, and significant others. The moralizing mode of value transmission teaches a complete value system and allows little opportunity for the weighing of different values. Responsible choice encourages children to explore competing values and to weigh their consequences while support and guidance are offered.

A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support his sensory needs?

Limit lighting, visual, and vestibular stimulation. To facilitate developmentally supportive care, it is recommended that medically fragile infants have limited light, visual, and vestibular stimulation to simulate being in the womb.

A client who is admitted for a debilitating disease is talking to the nurse. She relates that family is the only thing that matters, stating that family helps fulfill all the spiritual needs by first fulfilling the most basic of all needs. What is this basic need?

Love Love develops from the basic human need to love and be loved, and we cannot be spiritually whole, spiritually healthy, unless this need is met.

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. Maximizing autonomy and control is likely to enhance the self-esteem of older adults who may be very aware of their increasing dependence and loss of control. Encouraging frank discussion and interaction with other generations are also positive interventions, but these are less direct methods of fostering self-esteem. It is inappropriate to completely remove all risk of failure from older adults' activities.

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs The time of death is generally preceded by a period of gradual diminishing of bodily functions. During this time, the nurse may observe increased intervals between respirations, weakened and irregular pulse, and skin color may change or become mottled. The client will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and possibly the administration of a transdermal anticholinergic drug may be required.

Mrs. Dupree is a 55-year-old patient with end-stage renal failure who has asked to be taken off dialysis. She now shares with the nurse that she has mistreated her only daughter in the past and would like to reconcile this before she dies. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people?

Need for forgiveness According to Shelly and Fish (1988), the three spiritual needs underlying all religious traditions and common to all people are the need for meaning and purpose, the need for love and relatedness, and the need for forgiveness.

An emergency department nurse and health care team are caring for a semiconscious child age 2 years with numerous fractures and evidence of cigarette burns. They suspect child abuse. The nurse reports the family to the child abuse hotline. The nurse is following which ethical principle?

Nonmaleficence The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm.

A home care nurse visits a client who is confined to bed and is cared for by her daughter. The daughter is known to suffer from chemical dependence. The home is cluttered and unclean. During the assessment the nurse notes that the client is wet with urine and has dried feces on her buttocks, and demonstrates signs of dehydration. After caring for the client, the nurse contacts the physician and reports the incident to Adult Protective Services. This is an example of which ethical framework?

Nonmaleficence The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm. Autonomy means to respect the rights of clients or their surrogates to make health care decisions. Justice means to give each individual his due. Fidelity means to keep promises.

Whenever possible, the nurse who is treating the pain of older adults should avoid the use of which drug(s)?

Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs carry a risk of renal and gastric complications in older adults and should be used with particular caution. The use of opioids such as fentanyl, hydromorphone, and morphine requires vigilant pain assessment and close monitoring for side effects, but the drugs are not contraindicated.

A nurse integrates knowledge of developmental levels and their influence on self-concept when planning client care. The nurse would expect a client in which developmental stage to begin to examine the meaning of self?

Older adult Older adults begin to examine the meaning of self. They begin to look at the meaning of life in relation to roles previously discarded. The preschooler's sense of self is more defined than that of a toddler but is still undergoing development. Preschoolers often imitate adult roles, but do not question or examine the meaning of self. Adolescents are in the process of defining their identity and self-concept. They do not examine the meaning of self. Early adulthood involves forming intimate relationships, choosing a career, establishing a home base, and starting a family. Young adults are still in the process of experiencing new events and roles. They do not commonly engage in examination of the meaning of self.

The emergency room nurse is caring for a boy who will need a lumbar puncture. The physician prescribes EMLA cream to decrease the pain associated with the procedure. When should the nurse administer the EMLA?

One hour prior to the procedure EMLA is a prescription analgesic that must be administered and covered with an occlusive dressing for 1 hour prior to the procedure.

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

Pain can be a source of fear and threat to the toddler's security. During the toddler and preschool years, children are achieving a sense of autonomy. Because pain can be a source of fear and threat to security, children respond with crying, anger, physical resistance, or withdrawal.

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. Nursing Intervention Scientific Rationale 1. Offer client opportunity for one-on-one nurse-client relationship. Actively listen to the client. Allow expression of negative feelings. 2. Plan and coordinate a multidisciplinary team conference including the chaplain. Facilitate a care-planning conference involving the social support network including family and friends. 3. Explore past coping mechanisms, including use of music, scripture, prayer, and relaxation techniques. Help client identify times when he can use various alternative strategies. 4. Use the "life review" technique focusing on faith/spiritual development. Help client explore ways to use this experience in a unique way such as sharing in a group or with medical students or other health care professional students. 1. Initiating a one-on-one relationship establishes a climate of acceptance and builds trust and safety. 2. Initiating a multidisciplinary social network of conferences facilitates a sense of acceptance, love, and belonging. 3. Building on past positive coping mechanisms enhances a sense of self-control and self-esteem. 4. By focusing on personal faith/spirit, the client can gain new insights into his relationship with God and can sense hope and the potential for creativity or self-actualization.

A school nurse is discussing bike and outdoor safety measures with a group of Boy Scouts. What type of health education and counseling is the nurse providing to this group of children?

Preventing illness Preventing illness includes first aid, safety, immunizations, screening, and identification and management of risk factors. Promoting health focuses on developmental and maturation issues, hygiene, nutrition, exercise, mental health, and spiritual health. Restoring health focuses on developing self-care practices that promote recovery. Facilitating coping assists the client in learning to cope with permanent health alterations.

A nurse understands the client's stage of sleep that requires the greatest stimulus to awaken a client is:

REM sleep The NREM arousal threshold is usually greatest in stage IV NREM, but it is harder to arouse a person who is in REM sleep than NREM sleep. REM rebound is the term for accumulating REM sleep in balance over time.

The nurse is caring for 13-year-old Carol, who is being seen in the clinic today. She is very worried that the doctor may need to look at her body. Her mother asks the nurese if this behavior is normal for this age. The nurse shares with the mother that the adolescent worries about which of the following related to her body?

Rapid changes The adolescent worries about the rapid changes occurring to the body. The adult is concerned with fitness, energy, sexuality, and style. The young child is fearful of bodily mutilation and desires very much to have an intact body.

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. Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable, and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion; nor is it a recent development.

With the help of the nurse, the parents of an infant who died shortly after birth arrange for a funeral service. Which stage of grief, according to Engel, involves the rituals surrounding loss, including funeral services?

Restitution Restitution is the stage of grief that involves the rituals surrounding loss; with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Shock and disbelief involve the person being in denial or having a numbed response to the death. Developing awareness is characterized by physical and emotional responses such as anger, emptiness, and crying. Resolving the loss involves dealing with the void left by the loss.

The nurse is conducting a health history with an adolescent client. During the interview, the adolescent tells the nurse that he usually reads with the television on in the background but gets distracted by the sound of his neighbor's dog. Based on the nurse's understanding of normal sensory perception and the client's information, the nurse identifies what as being involved?

Reticular activating system The reticular activating system (RAS) is responsible for awareness of the world, is highly selective, and allows discrimination between meaningful stimuli and unimportant stimuli. The nerve endings in the skin are sensory receptors for tactile stimuli, while the auditory receptors are responsible for hearing. The cerebral cortex receives impulses from the RAS and is responsible for the perception of stimuli.

A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system?

Reticular activating system The reticular activating system (RAS) is responsible for bringing together information from the cerebellum and other parts of the brain with information obtained from the sense organs. Awareness of the world depends on the RAS, which is located between the nerve centers of the medulla oblongata in the brain stem. Sensory, visceral, kinesthetic, and cognitive input stimulate the RAS.

A young woman has just started a nursing program. She is trying to balance going to school full-time, a part-time job, and spending time with her family. Recently she has been feeling a lot of stress and doesn't feel as if she is able to do any of the three very well. Which role problem is this young woman experiencing from this role transition?

Role strain Role strain occurs when the person perceives himself as inadequate or unsuited for a role and can occur when a person is forced to assume many roles. Role ambiguity occurs when a person lacks knowledge of role expectations. This lack of knowledge causes anxiety and confusion. Role conflict is related to expectations concerning the role.

The nurse is assisting a client with his meal selection for the next day. The client states, "I can't have meat tomorrow, it's a Holy Day." The nurse recognizes that the client is a member of which religious organization?

Roman Catholic Roman Catholics observe fasting and abstinence from meat on certain Holy Days.

Mrs. Bryant is 40 years old. Her family nurse practitioner has prescribed a mammogram as part of Mrs. Bryant's annual examination. Mammograms are an example of which type of preventative healthcare?

Secondary prevention Secondary prevention seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit disability.

A student nurse who has not maintained healthy relationships with his or her peers would be at risk for what self-concept disturbance?

Self-esteem disturbance The need for self-esteem is the need to feel good about oneself and to believe that others hold one in high regard; therefore, if someone has not maintained healthy relationships with his or her peers, he or she would be at risk for self-esteem disturbance. Personal identity describes a person's conscious sense of who he or she is. The question, "How would you describe yourself to others?" addresses what a person feels is his or her personal identity. Body image is the person's subjective view of one's physical appearance. Role performance is one's ability to successfully live up to societal as well one's own expectations regarding role-specific behaviors.

When asked to describe oneself, the client states, "I am a 47-year-old Hispanic male, married with two children, and I work as a finance manager." What is this client demonstrating?

Self-knowledge Self-knowledge is the description of the global self which includes basic facts such as race, age, marital status, occupation, gender, and cultural background.

A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing her judgments based on her expertise. Which of the following types of health care decision making does this represent?

Shared decision making Shared decision making is recommended by most Ethicists and involves the client's preferences and the nurse's expertise to make the best decision. The Paternalistic model involves the clinician making the decisions and the Patient Sovereignty model involves the patient making all the decisions without input from the clinician.

A pediatric nurse is working with a girl 16 years of age who is concerned that her parents will shun and reject her upon finding out that she is pregnant. Based upon Coopersmith's four bases of self-esteem, this adolescent is concerned about which base of self-esteem?

Significance Significance is the way a person feels he or she is loved and approved of by the people important to that person. Competence is the way tasks that are considered important are performed. Virtue is the attainment of moral-ethical standards. Power is the extent to which a person influences his or her own life and others' lives.

Which describes an ascribed role?

Son An ascribed role is one in which the person has no choice (e.g., to be born a male and therefore be someone's son). On the other hand, assumed roles are ones that are chosen. This includes the choice to be a nurse, a husband, or a mother.

The nurse is caring for a client who must receive medication overnight. As the nurse prepares to administer the medication, the client is noted to have relaxed muscle tone, is not moving, snores, and is difficult to arose. How will the nurse document this stage of sleep?

Stage 3 Clients in Stage 3 sleep phase have entered the early phase of deep sleep. They may snore, and will exhibit relaxed muscle tone with little or no physical movement. They are difficult to arouse. Clients in other sleep stages do not exhibit these characteristics.

The nurse enters a client's room as the client and his family are praying. Which is the most appropriate action of the nurse?

Step outside the door until the prayer is finished. By stepping outside the door, the family and client will not be rushed to finish the prayer. Stepping up to the bedside may distract the client and or family.

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

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

A nurse student states, "I feel good that I put an indwelling catheter in my client without any problem even though it was an emergency." This demonstrates which factor affecting self-concept?

Stress tolerance Coping and stress tolerance influence self-concept. People who are able to adapt to stress and resolve conflicts through coping tend to develop healthy self-concepts.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?

The client exhibits restless, uncharacteristic behavior after receiving the drug. Paradoxical effects of hypnotics involve a stimulating effect or mental changes. Tolerance, somnolence, and respiratory depression are not indicative of paradoxical effects.

A nurse is developing a contractual agreement with a client. Which statement is true of a contractual agreement?

The contract serves to meet the client's learning outcomes. A contractual agreement is a pact between two people setting out mutually agreed-upon goals. The contracts are usually informal and not legally binding. The contract can serve to motivate the client and nurse to do what is necessary to meet the learning needs of the client; the contract does not serve to meet nursing goals.

Nursing students in an ethics class have been asked to define "ethics." What would be the best definition of ethics?

The formal, systematic study of moral beliefs. Ethics is a formal inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil as they relate to human conduct and human flourishing. "Morals" usually refers to personal or communal standards of right and wrong.

Which characteristic is associated with REM sleep?

The individual's facial muscles are twitching. REM sleep is associated with eye movement, small muscle twitching, large muscle immobility, and irregular respirations. Stage I of NREM sleep may include muscle jerking that awakens the individual, and it is the transitional stage between wakefulness and sleep. In the later stages of NREM sleep, the individual becomes increasingly difficult to arouse.

A nurse comes across a screaming child in the park. The child was hit by a baseball bat, resulting in a swollen and reddened left arm. Any attempt to move the child's left arm results in the child screaming intensely. The nurse used two baseball bats to make a split, which she applied to the child's left arm. The child is transported to the hospital and later develops compartmental syndrome of the left arm. The nurse requests a meeting with the nurse attorney to discuss the possibility of being involved in a litigious suit by the child's family. After a review of the events, which important information will the attorney share with the nurse concerning the case?

The nurse is protected by the Good Samaritan Act, which states the nurse may give emergency care using good judgment. The nurse is protected by the Good Samaritan Act, which states the health practitioner may give emergency care in a prudent manner using good judgment. The nurse used two sturdy objects to immobile the child's arm; therefore, she was not grossly negligent. A prudent nurse would have done the same. The Good Samaritan Act states the health care practitioner is not obligated to assist; however, it protects the practitioner if she decides to render emergency care.

When teaching an adult client how to control stress through relaxation techniques, the nurse should consider what assumption concerning adult learners?

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction. Knowles (1990) listed the following four assumptions about adult learners: (1) As people mature, their self-concept is likely to move from dependence to independence. (2) The previous experience of the adult is a rich resource for learning. (3) An adult's readiness to learn is often related to a developmental task or a social role. (4) Most adults' orientation to learning is that material should be useful immediately, rather than at some time in the future. With this in mind, adult learners would appreciate the nurse being able to draw from previous experiences of the client to emphasize the importance of stress reduction. The other options do not apply to Knowles's assumptions about adult learners.

Which party is responsible for obtaining informed consent from a client?

The person performing the procedure, study, or treatment Obtaining informed consent is the responsibility of the person who will be performing the diagnostic or treatment procedure or the research study. The nurse's roles are to confirm that a signed consent form is present in the client's chart and to answer any client questions about the consent.

Which of the following is objective data related to self-concept?

The person refuses to make eye contact. Objective data constitutes what the nurse can observe with her own eyes. Other objective data that may be collected include a missing body part, a concealment of a body part, or weeping.

Which of these is a situational transition?

The transition from being married to being divorced. Situational transitions are associated with a change in relationships.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which of the following as a characteristic of an adult learner?

Their readiness to learn is often related to a developmental task or social role. An adult's readiness to learn is often related to a developmental task or social role. The previous experience of the adult is a rich resource for learning. Most adults' orientation to learning is that material should be useful immediately. Peer group acceptance is a critical issue for the adolescent group.

Which developmental stage does Erikson term autonomy vs. shame?

Toddler According to Erikson, autonomy vs. shame should be the developmental level of a toddler.

The mother of a toddler brings the child to the clinic for a well-child visit. The nurse is teaching the mother about ways to promote a positive self-concept. Which concept would the nurse need to integrate into the education plan?

Toddlers lack an understanding of where their bodies end. Toddlers have a rudimentary body image. Although they know the self as separate from others, they have no clear definition of where the body ends. For example, some toddlers may not want to flush the toilet after defecating because they see the stools as part of them. Toddlers are not aware of specific influences, only general feelings or thoughts. They do, however, understand others' responses to behavior.

What are standards for decision making that endure for a significant time in one's life?

Values Values are standards for decision making that endure for a significant time in one's life.

An oncology client in an outpatient chemotherapy clinic asks several questions regarding his care and treatment. The nurse explains the clinic's routine, typical side effects of the chemotherapy, and ways to decrease the number of side effects experienced. Which characteristic is the nurse demonstrating?

Veracity Veracity means telling the truth, which is essential to the integrity of the client-provider relationship

A nursing instructor is preparing a class presentation about sensory perception across the lifespan. At which developmental stage would the instructor describe sensory perception as at its peak?

Young adult A young adult's sensory perception function is at its peak. However, as people reach middle age, they begin to notice certain changes in their sensory system. Eyesight diminishes, sounds become more muffled, and the other sensory systems deteriorate. Preschoolers are in the process of building their sensory perception skills by investigating and learning about the environment. Sensory perception in an adolescent is still in the process of development. At this developmental stage, adolescents are learning to make independent responses based on what is perceived through the senses. As people reach older adulthood, sensory systems deteriorate and sensory perception is weak.

Which client would be the best candidate for a nurse to use motivational interviewing?

a 28-year-old female with elevated blood glucose for 8 months Clients who are working on improving their health and physical condition are motivated. If a client has not shown positive changes in months, motivational interviewing may be helpful to find ways to help the client become involved with making lifestyle changes.

The nurse recognizes that sleep deprivation related to environmental concerns will apply to which clients? Select all that apply.

a 67-year-old male who has two beers during the late night newscast a 32-year-old male machinist, two pack a day smoker an 84-year-old male hospitalized for prostate surgery Alcohol consumption, smoking, pain, and/or a new environment all predispose clients to sleep disruption. The teen with a Saturday job is not particularly in distress. Antilipemics and aspirin do not interfere with sleep patterns.

A nurse caring for clients in a skilled nursing facility assesses client motivation to participate in care. Based on the health belief model, which clients would be most motivated? Select all that apply.

a client who views a disease as a serious threat A client who believes there are actions that will reduce the probability of contracting the disease A client who believes that the threat of taking actions against a disease is not as great as the disease itself The individuals that would be most motivated to participate in care based on the health belief model would be a client who views a disease as a serious threat, a client who believes that there are actions that will reduce the probability of contracting the disease, and a client who believes that the threat of taking action against a disease is not as great as the disease itself. Clients who would not be most motivated to participate in care include the client who does not view himself as susceptible to the disease; the client who believes that noncompliance is not an option; and the client who believes that doing nothing is preferable to painful treatments.

The nurse understands that when a client is talking about the voices in his head, the client is experiencing:

a hallucination. Hallucinations, sensory impressions that are based on internal stimulations, have no basis in reality. Hearing voices when no one is there is a typical auditory hallucination. Delusions are fixed beliefs, not based in reality. Illusions are misperceptions of actual stimuli.

A nurse is caring for a client who is a practicing Jehovah's Witness. The physician orders two units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the client's beliefs even though his blood counts are very low. What is the best description of the nurse's intentions?

acting in the client's best interest Nurses' ethical obligations include acting in the best interest of their clients, not only as individual practitioners, but also as members of the nursing profession, the health care team, and the community at large.

A client has recently lost his father. The client spent about 6 months deeply mourning his loss and is just now able to function at his pre-loss level. He was helped in this process by his strong social support. This client is most likely a(an):

adult. Adults tend to grieve more intensely and more continuously, but for a relatively shorter period of time than children. Having a good social network helps with this process, as well as having a stable lifestyle.

A nurse is working on a medical surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action made by the nurse is considered negligent if injury results from this action?

asking the LPN/LVN to teach a new diabetic client how to administer insulin Negligence is harm that results because a person did not act reasonably. As nurses perform the role of delegators, they must know which tasks are legal and appropriate for particular healthcare providers to perform (scope of practice), as well as the policy for the facility at which they are employed. Teaching is not in the current scope of practice for a LPN/LVN, and can be considered negligent. The other actions are within the scope of practice for registered nurses.

An 80-year-old woman's spiritual development is focused on integrating and resolving many of the apparently contradictory extremes in the human experience. This client is exhibiting:

conjunctive faith. Older adults notice the polarities or extremes in life such as young and old, rich and poor, masculine and feminine, constructive and destructive, and self awareness and self-denial. These tensions, enhanced or precipitated by personal and environmental situations, demand integration and resolution. This is referred to as conjunctive faith.

A nurse observes another nurse place an unused dose of narcotics in their pocket. If caught, the nurse could be charged with which type of crime?

felony A felony is a serious criminal offense, and includes actions such as stealing narcotics, murder, falsifying medical records, and insurance fraud. A misdemeanor is a minor criminal offense; a tort is a lawsuit in which a plaintiff charges that a defendant committed a deliberately aggressive act. Negligence is harm that results because a person did not act reasonably.

The nurse must instruct a 35-year-old client with Down syndrome about use of an albuterol rescue inhaler. Which of the following demonstrates individualization of the education plan for this client?

client understanding of illness, motor skills and developmental stage assessed, clarification provided Distractions to learning, such as the television or meal time, will diminish any education plan. An authoritarian style of teaching does not honor the client as a partner in the learning process. Age does not necessarily determine developmental stage. Assessing developmental stages, understanding of the problems, clarification of difficult areas, and ensuring that the client is physically able to perform the task are all aspects of a well-planned education session for all clients.

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Endogenous Opioid Theory?

contacting the healthcare provider to prescribe opioid medication The Endogenous Opioid Theory is based on the fact that nociceptors contain receptors that can bind with neurotransmitters called endogenous opioids that modulate pain. The other interventions support other theories.

Which of these is a physiological change during NREM sleep?

decreased brain activity from wakefulness Brain activity decreases from wakefulness. During slow-wave sleep (SWS), muscles are relaxed, but muscle tone is maintained during NREM. Sympathetic nerve activity decreases from wakefulness and body temperature is regulated at a lower level from wakefulness.

When a nurse asks herself questions such as "Why am I here?," the nurse is attempting to:

develop a philosophical base for clearer thinking. In terms of spiritual care, the nurse's own background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining spirituality, values, and beliefs is essential.

A widow has just returned home from the funeral of her husband. She feels alone in her home. Her family has left to go back to their home in another area of the country. What stage of Engel's model does this represent?

developing awareness Developing awareness occurs as the reality and meaning of the loss penetrate the person's consciousness.

A nursing student's attitude is defined as:

disposition toward situations. An attitude is one's disposition toward an object or a situation; it can be a mental or emotional mindset, and it can be positive or negative.

When discussing spirituality with the mother of an 8-year-old child, the nurse instructs the mother that children of this age:

enjoy lore and legends of religious groups. Childhood is the period when lore, legends, language, and symbols of a particular religious group are best presented.

During stage 3 sleep, the client may experience:

enuresis. Stages 3 and 4 are the stages during which snoring, sleepwalking (somnambulism), and bedwetting (enuresis) are most likely to occur.

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 By treating the client respectfully and personally, the nurse is fostering a sense of self. The nurse pays special attention to the client's individuality and emotional needs by explaining all the nursing activities, which will promote the client's self-concept. To implement health promotion by identification of strengths, the nurse would assist the client in identifying and cultivating his personal strengths, such as a nice smile, hobbies, and strong health maintenance patterns. The nurse would assist the client in positive self-evaluation by focusing on positive attributes and pointing out accomplishments that deserve positive feedback. The nurse assists the client in goal formulation by identifying the desired outcome.

The nurse would recognize that an obese, male client who has been diagnosed with obstructive sleep apnea (OSA) faces an increased risk of:

heart disease. In healthy people, OSA may impair cardiac function over time and lead to the development of heart failure. If heart failure has already been diagnosed, OSA may result in progression of this condition. OSA is not directly associated with depression, respiratory acidosis, or seizure activity.

Individuals who are Christian Scientists may not approve of:

immunizations. Some groups, such as Christian Scientists and the Amish, have been legally exempted from immunizations; however, many medical decisions are reviewed on a case-by-case basis depending on the client's age and imminence of death.

The mother of a child diagnosed with leukemia starts crying and states "We are being cursed because my husband changed his religion." The nurse identifies this as:

impaired religiosity. It is important to differentiate between Impaired Religiosity and Spiritual Distress. Spiritual Distress is characterized by a disturbance in an individual's person belief system. Impaired Religiosity, however, involves challenges in exercising the beliefs of an individual's chosen faith community.

A newlywed couple has moved to another city due to a job opportunity. The couple would be at risk for alteration in self-concept related to:

inadequate coping Lack of support systems and inability to prioritize and problem solve contribute to inadequate self-esteem.

A school-age child is attending an afterschool function without her parents. Which stage, according to Erickson, is the child in?

industry vs. inferiority School-age children are in the stage of industry vs. inferiority, in which socialization and competence are developing.

Which nursing interventions support the older adult client's sensory needs while admitted in the hospital?

keeping the room well lighted Preventing sensory dysfunction enables clients to interact with the environment optimally. Keeping the room well lighted allows for better visualization of the environment.

The nurse educator is discussing sleep interventions with students. Sleep restriction can best be defined as:

limiting time in bed to actual sleep time. Sleep restriction is the concept of limiting time in bed, so that sleep does not become fragmented. Shortening sleep time on purpose will promote sleep deprivation. Never sleeping in a new environment is unrealistic. Stimulants may be used to treat narcolepsy, but that is not related to sleep restriction.

A child with a leg cast tells the nurse that he has pain inside his cast. Which type of stimulus is most likely causing this pain?

mechanical Receptors in the skin may be stimulated by mechanical, thermal, chemical, and electrical agents. Pressure from a cast is a mechanical agent causing pain. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt of a static charge is an electrical stimulant.

Which of the following is an example of a diffuse pain?

pain related to stomach cancer Diffuse pain is pain that covers a large area, and often the client is unable to point to a specific area without moving the hand over a large surface, such as the entire abdomen. Pain related to appendicitis is sharp pain. Pain related to an MI can be sharp and/or shifting. Pain related to a sore throat is usually dull pain.

A nurse is of the Catholic faith and votes pro-life. He is considered to have:

personal values. Personal values are ideas or beliefs a person considers important and feels strongly about.

Nurse Hudson is a practicing Baptist. She works with Nurse Hassan, who is active in the Muslim community. Nurse Sanchez was raised Roman Catholic. The three of them often assist each other in understanding different practices when caring for a client of a different faith. This is best described as:

pluralism. These nurses working together to understand a wide variety of religious beliefs is a form of pluralism.

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory?

providing temple massage when head hurts Administering temple massage reflects the Gate-Control Theory. The other actions support other theories.

Based on your knowledge of pain and the body's response, when assessing a client in pain, you would anticipate the:

pupils are dilated. Acute pain stimulates the sympathetic nervous system and produces the following objective symptoms: increased blood pressure, increased pulse, increased respiratory rate, dilated pupils, and diaphoresis.

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

referred pain Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage.

A client who experienced domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Neuromatrix Theory?

removing items from the room that remind client of former spouse Removing items that remind the client of a former spouse reflects the Neuromatrix Theory. Administering a backrub reflects the Gate-Control Theory. Asking the client how sensory stimuli produces pain reflects the Pattern Theory. Having the healthcare provide order the client's opioid medication reflects the endogenous opioid theory.

The nurse is talking with the son of a client with end stage renal failure and late stage dementia. The client can no longer live at home, and the son states, "I live 500 miles away. I don't know what to do." Which type of living arrangement will the nurse teach the son about?

residential care Nursing homes or long-term care facilities can provide around-the-clock nursing care for clients who cannot live independently or do not have family that can provide in-home care. Acute care is not appropriate, as the client's condition is known and is not unstable. The client needs more monitoring than home care can provide. Respite care is used to provide rest for caregivers.

A student nurse has recently started a new job in a long-term care facility. In the interview, the student was told that she would receive two weeks of orientation prior to working on her own. After the first night of work, the student was told she was now allowed to work on her own. This situation may lead to:

role ambiguity Role ambiguity occurs when the person lacks knowledge of role expectations, which fosters anxiety and confusion which can lead to feelings of uncertainty about how to be successful in this new role. Role conflict is related to expectations concerning the role. Role conflict can be described as intrapersonal (role expectations conflict with the person's values), interpersonal(when the person's expectations differ from that of some significant other), or interrole (exists when a person is expected to fulfill two or more roles simultaneously). Role strain occurs when the person perceives himself as inadequate or unsuited for a role. This can occur in any role or because of having to fill too many roles. People make multiple role transitions in a lifetime.

Asking a client to describe himself is one way to assess his:

self-concept. Self-concept is the mental image a person has of himself. It is the person's meaning when stated as "I" or "me." Self-perception is how a person explains behavior based on self-observation. Self-knowledge or self-awareness involves a basic understanding of himself, a cognitive perception. It is consciousness of one's abilities: cognitive, affective, and physical. Social self is how a person sees himself in relation to social situations, including behavior and interaction with others.

During an interview, the client tells the nurse, "I know who I am and I know my strengths and weaknesses." The nurse interprets this statement as indicating:

self-concept. Self-concept is the mental image a person has of oneself. It is the person's meaning when stated as "I" or "me." Self-concept is the frame of reference that influences how a person handles situations and relationships. Self-expectation involves the "ideal" self — the self a person wants to be. It is the setting of present and future goals. Social self is how a person sees himself in relation to social situations, including behavior and interaction with others. Self-evaluation is the conscious assessment of the self, leading to self-respect or self-worth. "Have I met my expectations? Do I like who I see in the mirror? Do I like how I behave?"

A client has expressed great relief at the improvement in her hearing after irrigation of her ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to:

sensory reception. Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli. In this case, sound is unable to stimulate the organs of hearing and the client does not have a deficit in the perception, transmission, or reaction to sound.

A client is describing how he thinks others see him. This is a description of the client's:

social self. Social self is how a person sees himself in relation to social situations, including behavior and interaction with others. Self-concept is the mental image a person has of himself. It is the person's meaning when stated as "I" or "me." Self-perception is how a person explains behavior based on self-observation. Self-knowledge or self-awareness involves a basic understanding of himself, a cognitive perception. It is consciousness of one's abilities: cognitive, affective, and physical.

Which example indicates the use of an internal sensory receptor?

spitting out of hot coffee Sensory function begins with reception of stimuli by the senses. Externally, stimuli are visual (sight), auditory (hearing), olfactory (smell), gustatory (taste), and tactile (touch). Their respective receptor organs are the eyes, ears, olfactory receptors in the nose, taste buds of the tongue, and nerve endings in the skin. Internally, the kinesthetic and visceral senses receive stimuli. Their receptors are nerve endings in the skin and body tissues. The kinesthetic sense influences awareness of the placement and action of body parts. The visceral sense receives stimuli that affect awareness related to the body's large interior organs. Vision, hearing, smell, and taste are termed special senses. Touch, kinesthetic (or proprioceptive) sensation, and visceral sensation are termed somatic senses (Widmaier, Raff, & Strang, 20013).

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep?

taking a diuretic at 9 a.m. and 5 p.m. daily Various factors may affect sleep. Taking a diuretic, particularly late in the day, is a common cause for sleep problems. The diuretic may still affect the client at hours of sleep. The other behaviors are acceptable in promoting sleep: exercising more than 2 hours before sleep, ingesting caffeine early in the day, and using a white noise machine to keep the environment quiet.

Which of the following is a characteristic of the care-based approach to bioethics?

the promotion of the dignity and respect of clients as people The care-based approach to bioethics focuses on the specific situations of individual clients, and characteristics of this approach include promoting the dignity and respect of clients and people. The need to emphasize the relevance of clinical experience and the need for an orientation toward service are part of the criticisms of bioethics. The deontologic theory of ethics says that an action is right or wrong independent of its consequences.

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in:

total disorientation. A sudden loss of sensory perception through a sensory deficit can cause total disorientation because compensation does not occur immediately.

The nurse is caring for a client who demonstrates a health literacy concern. The nurse adjusts client teaching in which way?

uses videos, diagrams, and pictures rather than focusing on verbal teaching To address health literacy concerns, the nurse should avoid technical language, limit information to three to five key points, and be specific rather than general. Using medical terminology to help the client feel smarter, providing general teaching instead of specific teaching, and giving instructions in multiple ways are not effective ways to adjust client teaching for those who demonstrate low health literacy.

A public health nurse is involved in planning a community outreach program for a large assisted living community. Due to the aging population within the community, the program will offer hypertension screening and management. This decision is based on which principle?

utilitarianism Teleology, also known as utilitarianism, is ethical decision-making process based on final outcomes and what is best for the most people. The choice that benefits many people justifies harm that may come to a few. The nurse did not display veracity, nonmaleficence, or autonomy in this scenario.

The differences between the pro-life and abortion rights movement are an example of:

values inquiry. Values inquiry is a method of examining social issues and the values that motivate human choices.