Fundamentals EAQ

Arrange the order of steps involved in the evidence-based practice process.

1. Ask the clinical question. 2. Collect the most relevant and best experience. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Share the outcomes of evidence-based practice.

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? A) Attempt to identify the client's concerns. B) Reassure the client the surgery is routine. C) Report the client's anxiety to the healthcare provider. D) Provide privacy by pulling the curtain around the client.

A) Attempt to identify the client's concerns The nurse should assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the healthcare provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

How can a nurse best evaluate the effectiveness of communication with a client? A) Client feedback B) Medical assessment C) Health care team conferences D) Client's physiologic responses

A) Client feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding.

Which nursing action would be considered a part of self-regulation in the decision-making process? A) Reflecting on one's own experiences B) Looking at all situations objectively C) Supporting findings and conclusions D) Making careful assumptions about a client's information

A) Reflecting on one's own experiences Self-regulation requires the nurse to reflect on his or her own experiences. Explanation requires looking at all situations objectively. Findings and conclusions are supported by explanation. Analysis requires the nurse to not make any careless assumptions.

Which approach is a comforting approach that communicates concern and support? A) Touching B) Mirroring C) Knowing the client D) Providing presence

A) Touching

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? A) Prevent a client from pulling out an IV when there are concerns the client is confused or cannot follow instructions B) Prevent an adult client from getting up at night when there is insufficient staffing on the unit. C) Maintain immobilization of the leg to prevent dislodging after a skin graft D) Keep an older adult client from falling out of bed after a surgical procedure

B) Prevent an adult client from getting up at night when there is insufficient staffing on the unit.

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? A) "I should serve food that is easy to eat." B) "I should assist the client with eating." C) "I should monitor weight and food intake once a month." D) "I should offer food supplements that are tasty and easy to swallow."

C) "I should monitor weight and food intake once a month." The nurse should monitor an older client's weight and food intake at least once a day because of the client's dementia.

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation? A) Planning B) Evaluation C) Assessment D) Diagnosis

C) Assessment

What critical thinking skill is applicable when knowledge and experience is used to care for clients? A) Analysis B) Evaluation C) Explanation D) Interpretation

C) Explanation

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? A) Planning B) Evaluation C) Assessment D) Implementation

D) Implementation

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply. Privacy level Emotional status Information exchange Level of caring expressed Growth and development

Emotional status and growth and development Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

What are the goals of care when working with families according to the family health system? Select all that apply. To improve family health or well-being To help the family prepare for later transitions To assist in family management of illness conditions To promote positive family behaviors to achieve essential tasks To achieve health outcomes related to the family's areas of concern

To improve family health or well-being To assist in family management of illness conditions To promote health outcomes related to the family's areas of concern

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? A) Attention span B) Primary language C) Coping mechanisms D) Activity and coordination

A) Attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

Which therapeutic communication technique is most useful for the nurse to use when the client begins to repeat previously mentioned issues in the same therapeutic conversation? A) Focusing B) Clarifying C) Paraphrasing D) Summarizing

A) Focusing Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

During follow-up visits, the client's child reports to the nurse, "I tell my parent every day about what may happen if medications aren't taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client's motivational level? A) Not motivated B) Intrinsically motivated C) Extrinsically motivated with self-determination D) Extrinsically motivated without self-determination

A) Not motivated If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? A) Provide perineal care. B) Turn and position the client. C) Give a complete bed bath. D) Document the bowel movement.

A) Provide perineal care. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

Which nursing practice is associated with the self-regulation skill? A) Reflecting on one's own experience. B) Reflecting on one's own behavior. C) Supporting one's findings and conclusions. D) Clarifying any data one is uncertain about.

A) Reflecting on one's own experience.

What type of functional health pattern would the nurse explain describes values and goals? A) Value-belief pattern B) Role-relationship pattern C) Self-Perception-self-concept pattern D) Health-perception-health-management pattern

A) Value-belief pattern Value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client for making choices or decisions

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing? A) Place the dressing in a bedside trash can B) Place the dressing in a red bag/hazardous transfer bag C) Contact Environmental Services to pick up the bag D) Transport the bag to the laboratory to be placed in the incinerator.

B) Place the dressing in a red bag/hazardous transfer bag Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; thus, the dressing should be placed in a red bag or hazardous materials bag.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? A) Sharing hope B) Sharing humor C) Sharing empathy D) Sharing observations

B) Sharing humor

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? A) "I should carry objects 18 inches from my body." B) "I should sleep on my stomach with a firm mattress." C) "I should carry objects close to my body." D) "I should pull rather than push when moving heavy objects."

C) "I should carry objects close to my body." By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? A) Decrease peristalsis B) Minimize electrolyte imbalance C) Decrease bacteria in the intestines D) Treat inflammation caused by malignancy

C) Decrease bacteria in the intestines

Which professional standard does the nurse feel is most important for critical thinking? A) Logical thinking B) Relevant information C) Evaluation criteria D) Accurate knowledge

C) Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? A) Analysis B) Evaluation C) Explanation D) Interpretation

C) Explanation The critical-thinking skill of explanation involves using knowledge and experience to provide client care. The nursing practice of assessing whether the obtained data is true is called analysis. Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions is an evaluation skill. The nursing practice of being orderly in data collection and looking for patterns to categorize data refers to interpretation.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? A) It shows empathy. B) It uses distraction. C) It gives false reassurance. D) It makes a value judgment.

C) It gives false reassurance.

Which component of decision-making refers to the duties and activities an individual is employed to perform? A) Authority B) Autonomy C) Responsibility D) Accountability

C) Responsibility

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? A) Reminiscence B) Reality orientation C) Validation therapy D) Therapeutic communication

C) Validation therapy Validation therapy is the psychosocial concern involved in accepting the descriptive statements made by a confused older client. Reminiscence is recalling the past. Reality orientation involves helping a confused older client agree with the nurse's statements. Therapeutic communication enables the nurse to perceive and respect the older client's uniqueness and healthcare expectations.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? A) Kidney dysfunction B) Cardiovascular disease C) Eye problems, such as glaucoma D) Accidents, including their prevention

D) Accidents, including their prevention Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development.

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? A) Time available for care B) Validity of problem C) Method for providing care D) Effectiveness of the interventions

D) Effectiveness of the interventions When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

Which skill in critical thinking requires to be orderly in data collection? A) Analysis B) Inference C) Evaluation D) Interpretation

D) Interpretation Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? A) Suddenness of the change B) Obviousness of the change C) Extent of the change D) Perception of the change

D) Perception of the change

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? A) Listening B) Spiritual caring C) Providing presence D) Relieving pain and suffering

D) Relieving pain and suffering