Fundamentals Exam 2 Blueprint Study Guide

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? 1. Increased tearing 2. Itching of the eye 3. Reduction in vision 4. Swollen eyelid

3. Reduction in vision A reduction in vision after cataract surgery indicates a problem, and the client should notify the provider immediately. Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

An American nurse tries to speak with a Korean client who cannot understand the English language. To effectively communicate to a client with a different language, which of the following should the nurse implement? A.Have an interpreter to translate. B.Speak slowly. C.Speak loudly and closely to the client. D.Speak to the client and family together.

A

Nursing care is based on helping relationships. In such relationships, the primary goal between the nurse and the patient includes which of the following? A.Establishing a relationship that promotes growth of the patient B.Establishing an intimate purposeful interaction C.Developing the nurse's personal identity D.Developing a casual relationship

A

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb" B. "Move your palm facing toward the inner part of your forearm" C. With your palm facing down, move your wrist sideways toward your little finger" D. "Bring the back of your hand as far back toward the wrist as you can"

A. "With your palm facing down, move your wrist sideways toward your thumb" B. is flexing the wrist C. is abducting the wrist D. is hyperextending the wrist

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2mm B. 4mm C. 6mm D. 8mm

A. 2mm

A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? A. borborygmi B. rebound tenderness C. tympani D. abdominal guarding

B. rebound tenderness (increase in pain when palpation is released) borborygmi = hyperactive bowel sounds tympani = loud, high-pitched sound abdominal guarding = voluntary tightening or tensing of muscles

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? A. a client who has persistent UTIs B. a client who has urge incontinence C. a client who is in the ICU for a GI bleed D. a client who has incontinence due to cognitive decline

C. a client who is in the ICU for a GI bleed precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill a = antibiotics, increased fluid intake, pain management b = pelvic floor exercises, meds, bladder retraining d = scheduled toileting, absorbent adult briefs

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease? A. loss of hair on the lower leg B. cool skin temperature in the lower leg C. palpable dorsalis pedal pulse D. regular, even wound barrier

C. palpable dorsalis pedal pulse

A nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? A. outer layer of the eyeball B. mucous membrane that lines the eyeball C. transparent layer that covers the iris & pupil D. colored portion in the center of the eye

C. transparent layer that covers the iris & pupil a = sclera b = conjunctiva d = iris

A nurse is preparing the patient for a blood lab draw. The patient asked, "Why am I getting this blood lab draw done?" What is the most appropriate nursing action? A.Have the patient sign consent form B.Explain the blood lab draw to the patient C.Have patient watch the video on the blood lab draw D.Ask the patient: "What has the physician told you?"

D. The RN should ask this because that is a way for the RN to assess the patient's understanding if the patient understands the plan of care includes blood lab draws

The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: A. Gastric motility, thereby facilitating glucose digestion. B.Respiratory effort, thereby decreasing activity intolerance. C.Overall cardiac output, thereby resuming resting heart rate D.Use of glucose and fatty acids, thereby decreasing blood glucose level.

D. Use of glucose and fatty acids, thereby decreasing blood glucose level. Rationale: Recent data in the United States show the prevalence of diabetes among adults aged 65 years and older to average around 28%. Obesity and a sedentary lifestyle are consistent contributing factors across all ethnic groups diagnosed with type 2 diabetes.

The nurse providing care to a group of patients during the night sets a goal of promoting restful sleep. The nurse defines sleep as A.an unconscious state in which arousal is not easily accomplished. B.a basic but unorganized behavior that is not necessary to survival. C.a state of chemical balance among acetylcholine, norepinephrine, and serotonin. D.a state during which a person lacks conscious awareness but can easily be aroused

D. a state during which a person lacks conscious awareness but can easily be aroused. Rationale: Sleep is a state during which an individual lacks conscious awareness of environmental surroundings and from which one can be easily aroused. Sleep is a basic, highly organized behavior

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A. irrigate the catheter B. assess for peripheral edema C. palpate for bladder distension D. check the catheter for kinks

D. check the catheter for kinks may be a sign catheter is blocked; check tubing for kinks and ensure urine flow is not obstructed

A nurse is caring for a client who has a nasogastric tube connected to suction. Which of the following indicates that the tube has become occluded? A. active bowel sounds B. passing flatus C. increase in gastric secretions D. increased abdominal distension

D. increased abdominal distension

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation

D. palpation

Where could you hear bronchovesicular sounds?

Either side of the sternal border anteriorly and between the scapulae posteriorly. (moderately loud with medium pitch)

Secondary Prevention

Identifies illness, provides treatment, and conducts activities that help prevent a worsening health status. -communicable disease screening, case finding -early detection, treatment of diabetes mellitus -exercise programs for older adults who are frail

Tertiary Prevention

Prevents long-term consequences of a chronic illness or disability and to support optimal functioning. -Begins after an injury or illness -Prevention of pressure ulcers after spinal cord injury -Promoting independence after traumatic brain injury -Referrals to support groups -Rehabilitation center

Primary Prevention

Promotes health and prevents disease with specific protections. -immunization groups -child car seat education -nutrition, fitness activities -health education in schools

A nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care? a. A nurse did not read back a verbal medication prescription to a provider. b. A nurse did not return to a client's room with a promised blanket. c. A nurse documents client care as soon as it is completed. d. A nurse forgot to call a client's family after performing a procedure.

a. A nurse did not read back a verbal medication prescription to a provider. Standards of care guide nursing practice to perform safe & effective care. Failing to verify a medication prescription can result in harm to a client and is therefore a breach of the standard of care.

T/F: The nurse will hear rhonchi or gurgling sounds over the trachea and bronchi if the airways are narrow due to secretions or swelling.

True

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular sounds. (soft and low-pitched sounds)

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? a. "cardiac output is the amount of blood flow through the heart in 1 minute" b. "cardiac output is the amount of blood ejected from the atria" c. "cardiac output is the ability of muscle fibers in the ventricles to stretch" d. "cardiac output is the resistance of the ventricles to pump blood through the heart"

a. "cardiac output is the amount of blood flow through the heart in 1 minute"

A nurse is performing a medication reconciliation for a client who is being transferred to a LTCF. Which of the following actions should the nurse take? (Select all that apply.) a. place the medication reconciliation form with the client's transfer documents. b. reinforce teaching about the medications to the client upon discharge. c. add medications the client is no longer taking in the medication reconciliation. d. include OTC meds in the medication reconciliation. e. compare the client's home meds with prescribed discharge meds.

a. place the medication reconciliation form with the client's transfer documents. b. reinforce teaching about the medications to the client upon discharge. d. include OTC meds in the medication reconciliation. e. compare the client's home meds with prescribed discharge meds.

A nurse in an emergency department is caring for four clients. Which of the following clients requires mandatory reporting? a. An adolescent client who has a fractured tibia following a football game. b. A young adult client who is positive for tuberculosis. c. An older adult client who has dementia, a history of falls, & bruising on their knees. d. A preschooler who has frequent enuresis.

b. A young adult who is positive for tuberculosis. Diseases & illnesses that are considered a threat to public health, such as TB, HIV, & influenza, require mandatory reporting to the health department to track & develop prevention & protection protocols.

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what the doctor said." Which of the following actions should the nurse take? a. Explain the procedure in detail to the client. b. Ask the provider to discuss the procedure with the client. c. Encourage the client to reread the consent form before signing. d. Tell the client that the surgeon will explain it to them in the operating room.

b. Ask the provider to discuss the procedure with the client. If the client states that they are unclear about a procedure, the nurse should contact the provider to return to answer the client's questions. The nurse should verify that the client has adequate knowledge to make the treatment decision before the client signs the informed consent form.

What sounds will be heard over the trachea?

bronchial sounds (high-pitched, hollow, loud)

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include? a. anxiety can decrease a client's RR. b. opioid analgesics can increase a client's RR. c. pain can decrease a client's RR. d. fever can increase a client's RR.

d. fever can increase a client's RR. The RN should include that an increased body temp can cause an increase in RR. Other factors include physical exertion, chronic lung disease, & anxiety.

A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the RN include about measuring body temp? a. tympanic temp can be affected by environmental temp b. temporal temp is inaccurate in children under 3 years of age c. axillary temp reflects rapid changes in a client's core body temp d. oral temperature is easily accessible despite a client's position.

d. oral temperature is easily accessible despite a client's position. One advantage of oral temp is that it is easily accessible despite a client's position. The oral temp is an accurate measurement of body surface temp but does not reflect core temp.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (Select all that apply) A. coarse grating tone B. intermittent popping or bubbling sound C. heard on inspiration & expiration D. snoring sound on expiration E. pain with breathing

A, C, E

A nurse is caring for a client who is undergoing a diagnostic evaluation following an episode of chest pain. The client tells the nurse, " I am not sick, and I want to go home!" Which of the following responses should the nurse make? A. "Am I correct in understanding that you feel well?" B. "People aren't admitted to hospitals unless they are sick" C. "Why do you feel that way" D. "If you're fine, then why is your heart beating irregularly?"

A. "Am I correct in understanding that you feel well?"

A nurse is teaching a client who has a new ileostomy. The client states, "I'd rather be dead than have to live with this all my life." Which of the following responses should the nurse make? A. "You appear upset. Would you like to talk?" B. "I'll ask the provider to prescribe a medication to help you relax" C. "There's no reason to feel like that. Things will get better." D. I am sorry that you are going through this. I would feel the same way."

A. "You appear upset. Would you like to talk?"

While communicating with a patient, the nurse notices that the patient's facial expressions seem to exhibit disagreement. Which statement made by the nurse might have caused a barrier in communication? A."You are wrong to show hostility for no apparent reason." B."I don't understand. Would you please explain?" C."Please explain your position in more detail." D."I'm sorry; I'll stay with you for a while."

A. "You are wrong to show hostility for no apparent reason." Barriers to therapeutic communication include asking too many questions, fire-hosing information (giving a massive amount of information at one time), asking why, changing the subject inappropriately, failing to probe, expressing approval or disapproval, offering advice, providing false reassurance, stereotyping, and using patronizing language. The therapeutic communication technique that should be implemented is to seek clarification and use "I" statements. If a message is unclear, seek clarification through use of probing questions or reflective comments, such as "Tell me more," or "When you say ... what do you mean?"

A nurse is performing ROM exercises on a client's feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet? A. "point your toes toward the floor" B. "turn the soles of your feet out, away from the body" C. "point your toes up toward your nose" D. "turn the bottoms of your feet in, toward the midline"

A. "point your toes toward the floor" b=eversion c=dorsiflexion d=inversion

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? A. Attempt to increase the clients' self motivation B. Keep detailed records of each client's progress C. Test client learning after each teaching session D. Avoid discussing topics that might increase clients' anxiety

A. Attempt to increase the clients' self motivation

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1cm (0.5in) above the ear canal during administration B. Apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner ear canal for 30 minutes following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration

A. Hold the dropper 1cm (0.5in) above the ear canal during administration

During a health history interview, a patient tells the nurse, "I am nearsighted." Which term does the nurse use in the patient's medical record to document this information? a. Myopia b. Hyperopia c. Presbyopia d. Astigmatism

A. Myopia is the medical term used to describe nearsightedness when documenting information in the medical record.

Which one of the following variable means increasing the vulnerability of an individual or a group to an illness or accident? A. Risk Factor B. Illness Behavior C. Lifestyle Management D. Negative Health Behavior

A. Risk Factor Rationale: Risk factor is any situation, habit, or social or environmental condition that increases the vulnerability of the individual to an illness.

An elderly uncooperative and confused patient, who grew up in another culture has difficulty understanding the nursing staff. Which of the following is a priority in caring for this patient? A.Understanding of cultural norms B.Understanding about dementia groups C.Discuss feelings about culture with another nurse D.Understanding about re-socialization groups

A. Understanding of cultural norms

The nurse is caring for a Patient who is expressing anxiety about their upcoming out patient procedure. Which action by the nurse is most therapeutic? A.Further explore the client's feelings B.Discuss the competency of the surgeon C.Explain that other clients have done well following this type of surgery D.Tell the client not to worry and that everything will be ok

A.Further explore the client's feelings Rationale: it is therapeutic to allow the client to express their feelings

A nurse is inspecting & palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply) A. visible pulsations observed in the carotid area on both sides of the neck B. full, bounding pulse noted bilaterally in the carotid arteries upon palpation C. distension of the jugular vein on one side of the neck D. flattening of the jugular veins when the client sits upright E. the left carotid artery pulse is weak

B, C, E a=expected b=fluid overload, heart failure c=right-sided heart failure, obstruction in blood vessel d=expected e=should be moderate in strength bilaterally

A nurse is developing a health promotion program on healthy eating and exercise for high school students. Which statement made by a student is related to the individual's perception of susceptibility to an illness? A.I don't have time to exercise because I have to work after school every night." B."I am worried about becoming overweight and getting diabetes because my father has diabetes." C."The statistics of how many teenagers are overweight is scary." D."I've decided to start a walking club at school for interested students."

B. "I am worried about becoming overweight and getting diabetes because my father has diabetes. Address the students' concerns. Educate the what diabetes is and what it can lead to it.

A nurse is caring for a client who has a new diagnosis of breast cancer. The client becomes quiet and withdrawn and says to the nurse, "What do you think people will say about me when I'm gone?" Which of the following responses should the nurse make? A. "What are you worried they will say about you?" B. "The thought of having breast cancer may seem hopeless" C. "Maintaining a positive attitude can influence your recovery" D. "You will be remembered as a kind person"

B. "The thought of having breast cancer may seem hopeless"

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me" B. "Would you like to talk about how you feel?" C. "Nobody expects you to look beautiful in the hospital". D. "I understand how you feel. I would feel the same way"

B. "Would you like to talk about how you feel?"

Which patient is at highest risk for obstructive sleep apnea? A. 82-year-old male with Parkinson's disease who has dysphagia B. 68-year-old obese male who smokes one pack of cigarettes per day C. 18-year-old female with cystic fibrosis who has recurrent pneumonia D.35-year-old female with a BMI of 22 kg/m2 who has seasonal allergies to pollen

B. 68-year-old obese male who smokes one pack of cigarettes per day Rationale: Risk of obstructive sleep apnea increases with obesity (BMI > 28 kg/m2), age more than 65 years, neck circumference > 17 inches, craniofacial abnormalities, and acromegaly.

A public health nurse is responsible for several activities in the local community. Through which of the following actions is the nurse is implementing tertiary prevention? A. Teaching stress reduction techniques to parents of children who have developmental delays B. Advocating for the expansion of mental health rehabilitation facilities with community leaders C. Performing screenings for depression for older adult clients D. Coordinating a drive through clinic for influenza immunizations

B. Advocating for the expansion of mental health rehabilitation facilities with community leaders

A nurse is caring for a client who has symptoms of chills, fever, no sweating, headache, nasal congestion, and stiffness and pain in the shoulders, upper back, neck, and back of the head that are common in Chinese culture and is called as syndromes of Wind. This is an example of which of the following? A.Culture shock. B.Culture-bound syndrome. C.Cultural awareness. D.Culture biased.

B. Culture-bound syndrome is a combination of psychiatric and somatic symptoms that are common in one culture group or not another.

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site *not on this test oops*

B. Edema at the infusion site not gonna be on this test oops

Of the following statements, which one is most true of health and illness? A. Health and illness are the same for all people B. Health and illness are individually defined by each person C. People with acute illnesses are actually healthy D. People with chronic illnesses have poor health beliefs

B. Health and illness are individually defined by each person Rationale: Each person defines health and illness individually, based on a number of factors.

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time of 1.5 sec

B. Inability to cry or speak

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? A. Health history B. physical examination C. review of systems D. interview

B. Physical examination

Which studies are used to diagnose insomnia? A. EEG B.Self-report C. Actigraphy D. Polysomnography

B. Self-Report Rationale: The diagnosis of insomnia is based on self-report of difficulty falling or remaining asleep. EEG is used with polysomnography sleep studies to diagnose other sleep disorders. Actigraphy measures gross motor activity in the large muscles in the arms, legs and torso e.g. throwing, kick boxing

A nurse is providing teaching to a client about healthy lifestyle changes. The client states, "I work long hours. I never have time for exercising or eating anything besides fast food." Which of the following goals should the nurse include in the client's nursing plan of care? A. The client will improve overall health by the next visit. B. The client will introduce two green vegetables into her diet by the end of the month. C. The client will reduce daily stress and increase activity by exercising. D. The client will reduce her weight by 4.5kg (10lb) within 2 weeks.

B. The client will introduce two green vegetables into her diet by the end of the month.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take? A. suction for 30 sec with each pass B. allow 2 min in between suctioning to reoxygenate the lungs C. use a rotating motion when inserting the catheter D. set the suction pressure to 180 mmHg

B. allow 2 min in between suctioning to reoxygenate the lungs. allow client to cough & deep breathe & lungs to reoxygenate

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? A. develop accurate data B. develop a plan of care C. validate previous data D. evaluate outcomes of care

B. develop a plan of care the first action the nurse should take using the nursing process is to assess the client & develop a plan of care. ADPIE

A nurse is performing a physical exam of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? A. lordosis B. kyphosis C. ankylosis D. scoliosis

B. kyphosis ("hunchback")

The patient states, "When I found out about my spouse cheating on me, it triggered a whole range of feelings. I need to talk with my spouse but I do not know how to do it right because I don't want to make my spouse mad." What response by the nurse would best help the patient in this situation? A."Do you mean that you have a hard time controlling your emotions." B."It sounds like you feel you are to blame." C."Do you want to talk about your feelings?" D."I hear you. That must be frustrating."

C. "Do you want to talk about your feelings?" Assess if the patient is readiness to talk. Allow the patient to express their feelings.

A nurse is assessing a client who has sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"

C. "What do you think caused the onset of your pain?"

A nurse is preparing to deliver a food tray to a Jewish client. The nurse checks the food on the tray and notes that the client has received hamburger and whole milk as a beverage. Which is the appropriate action for the nurse? A.Ask the dietary department to replace the hamburger with crabs. B.Replace the whole milk with fat-free milk. C.Call the dietary department and ask for a new meal tray. D.Deliver the designated food tray to the client.

C. "You may not cook a young animal in the milk of its mother" -Torah says (Ex.23:19). From this, it is derived that milk and meat products may not be combined together. Not only may they not be cooked together, but they may not be served together on the same table and surely not eaten at the same time. This rule is followed observantly by the Jewish people so the appropriate nursing action is to call the dietary department to change the meal tray of the patient.

A nurse is assisting a 10-year-old patient with cancer on the use of chemotherapy medication through role playing and storytelling. Which domain of learning is being utilized? A.Cognitive B.Psychomotor C.Affective D.Motivational

C. Affective Rationale: Role play and storytelling are examples of using the affective domain for learning.

A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: A.Giving any medication is not allowed. B.Surgery is strictly prohibited. C.Blood products can not be administered. D.Alternative medicines can be advised.

C. Among Jehovah's Witnesses, the administration of blood and blood products is prohibited.

Which of the following complications is due to immobility? Which of the following findings should the nurse expect? (Select all that apply. A. Abdominal surgery B. Diarrhea C. Crackles in the lungs D.Pressure Ulcer E. Contractures of the extremities

C. Crackles in the lungs is correct. Crackles in the lungs are a complication of immobility, due to mucus that collects in the dependent airways. The client often cannot cough effectively and oxygenation status declines. D. Pressure ulcers is correct. Pressure ulcers are a complication of immobility, due to increased pressure on skin and bony prominences, which affects tissue metabolism E. Contractures of the extremities is correct. Contractures of the extremities are a complication of immobility because of disuse of muscles and joints.

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? A. death is unacceptable under any circumstances. B. Magical thinking helps avoid thoughts of death C. Death is viewed as an interruption of what might have been D. Death is a natural consequence of a deteriorating body.

C. Death is viewed as an interruption of what might have been

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis

A nurse is caring for a Chinese client who is hospitalized due to pneumonia. Based on their culture, which of the following is believed to be the cause of the illness? A.An illness is cast by an enemy. B.An illness is a result of punishment for sins. C.An illness may be attributed to overexertion. D.An illness may be given by someone who did not want it.

C. Illness for Chinese people may be attributed to prolonged sitting or lying or to overexertion.

Which of the following food items would be appropriate for a Jewish client who follows a kosher diet? A.Shrimp and mussels. B.Beef and pork. C.Tuna and salmon. D.Cheese and milk.

C. In the Jewish religion, Only fish that have scales and fins are allowed such as tuna and salmon.

The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate action? A.Walk around the client so that the nurse can constantly face the client. B.Call the attention of the client by speaking loudly. C.Continue with the instructions, then conforming a client's understanding. D.Hand over a written instruction and discuss only what the client doesn't understand.

C. Most Chinese maintains a formal personal space with others, which is a form of respect. Most Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the instructions

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? A.An acceptance of the treatment. B.Client understanding of the preoperative procedures. C.Reflecting a cultural value. D.Client agreement to the required procedures.

C. Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

When does discharge planning for clients begin? A. After a diagnosis has been established B. Once the long-term needs are identified C. Upon admission to a health care facility D. When the acute care therapies are completed

C. On admission to a health care facility Rationale: Discharge planning begins at the time of admission. Client strengths and resources are assessed in order to meet the client's limitations and improve post outcomes following discharge.

The nurse recognizes which patient is at greatest risk for glaucoma? A. Patients of Asian descent B. Patients with chronic neuromuscular diseases C. Patients with diabetes D. Patients who have recently undergone cardiac surgery

C. Patients with diabetes Diabetic patients are known to have an increased risk for developing glaucoma. Diabetic retinopathy, which is a complication of diabetes, can result in damage to the blood vessels in your retina. This can cause abnormal blood vessels to grow in your eye, which can block your eye's natural drainage system and eventually lead to glaucoma.

Which of the following would be associated with detached retina? a. Pain in the affected eye b. Total loss of vision c. Sense of a curtain falling across the field of vision d. Yellow discoloration of the sclera

C. The patient would complain of a sense of a curtain falling across the field of vision if they had a detached retina. There is no pain associated with retinal detachment. This is an ophthalmic emergency to protect the patient's vision.

A nurse is observing a patient's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? A.The patient enacts nonverbal communication consciously B.Nonverbal communication is a poor reflection of what the patient feels C.The patient's sociocultural background influences nonverbal communication D.Nonverbal communication conveys less truth than what the patient states verbally

C. The patient's sociocultural background influences nonverbal communication

A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs NG tube intubation for gastric decompression? A. a 6yr old child who ingested a toxic substance B. a 60 yr old client who has a GI hemorrhage C. a 40 yr old client who has a post-op bowel obstruction D. a 20 yr old who has malabsorption syndrome

C. a 40 yr old client who has a post-op bowel obstruction NG tube should be inserted for decompression to remove gastric secretions. will assist in relieving abdominal distension, nausea, & pain a = gastric lavage b = compression d = enteral feedings

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A. a continuous sensation of vibration felt over the 2nd and 3rd left intercostal spaces B. a high-pitched, scraping sound heard in the 3rd intercostal space to the left of the sternum C. a brief thump felt near the 4th or 5th intercostal space near the midclavicular line D. a whooshing or swishing sound over the second intercostal space along the left sternal border

C. a brief thump felt near the 4th or 5th intercostal space near the midclavicular line this is where you would inspect & palpate the PMI. it occurs as the apex of the heart bumps against the chest wall with each heartbeat. this is an expected finding

A nurse is admitting a client who has major depressive disorder. The client states, "This has been the worst day of my life." Which of the following responses should the nurse offer? A. "You should focus on positive things instead of negative things." B. "We all have a bad day from time to time" C. "Why would someone with so much to live for say that" D. "Please sit down and talk to me about your feelings"

D. "Please sit down and talk to me about your feelings"

A clinic nurse is preparing to examine a Hispanic child who was brought by the mother for his first physical check-up. While assessing the child, the nurse would avoid doing which of the following? A.Weighing the client. B.Asking the mother questions about the child. C.Having an interpreter if necessary. D.Admiring the child

D. Admiring a Hispanic-American child during the first encounter with a stranger should be avoided since this may give the child with the "evil eye" (the child will get sick). If this is done, it can be avoided by touching the child afterward.

Which of the following clients has the lowest risk of diabetes mellitus and stroke? A.A 45-year-old African-American woman. B.A 35-year-old Native-American man. C.A 30-year-old Hispanic-American man. D.A 25-year-old Asian-American woman.

D. Among the choices, Asian Americans have the lowest risk of diabetes mellitus and stroke due to their health and dietary practices.

Which of the following children is at risk of recurrent otitis media (OM)? A. An 18-month-old infant who lives with a smoker B. A 2-year-old child who has had two ear infections in the past 6 months C. A 6-month-old infant who has a sibling who had tubes inserted at 3 years of age D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period

D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period A first episode of OM that occurs within 3 months of life increases risk of recurrent OM. Recurrent OM is three episodes within the past 3 months or four episodes within the past year.

The nurse correlates which assessment to the presence of bulging blood vessels within the posterior portion of the eye? A. Expected changes associated with advancing age B. Require monitoring every 3 to 5 years by the practitioner C. Require immediate surgical intervention D. Can indicate increased IOP

D. Can indicate increased IOP With IOP, blood vessels are visualized as bulging with an ophthalmic exam.

The patient is in the ICU and becoming more irritable as the days go by. The nurse determines the patient is not getting enough sleep. What actions will best help facilitate the patient's sleeping? A.Give the patient a back rub B.Keep the lights on during the day C.Talk to the patient when he wakes up at night D.Do the vital signs and treatments at the same time

D. Do the vital signs and treatments at the same time. Rationale: Combining patient care activities to avoid frequently disturbing the patient's sleep will help the patient get more sleep and thus be less irritable. A back rub may help but keeping the lights off in the room at night and only talking to the patient if the patient wants to talk will best facilitate sleep.

During the admission assessment the nurse notices that the patient has a hearing impairment. Which of the following is the best way to communicate with this patient? A.Provide the assessment questions in written format B.Have a family member present during the assessment C.Conduct only the physical portion of the assessment at this time D.Face the patient directly and speak slowly in a low-pitched voice

D. Face the patient directly and speak slowly in a low-pitched voice. Loud music or raised volume on the television can muffle the patient's hearing. Turn down the volume or just turn them off. It is best to communicate in a quiet environment. Raising your voice does not help either.

A clinic nurse is performing an admission assessment for an African-American client scheduled for an emergency appendectomy. Which of the following questions would be inappropriate for the nurse to ask for the initial evaluation? A.Do you have any allergy to medicines? B.When did the pain start? C.Do you have any difficulty breathing? D.How close is your family during these situations?

D. For African-Americans, asking personal questions during the initial encounter is prohibited since it may view as a way of interfering with them.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated B. The sound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing.

D. Granulation tissue fills the wound during healing.

A nurse is caring for a patient with depression who refuses further treatment. Which of the following nursing actions would be most helpful? A.Accept the decision and make no comments to the patient C.Talk to the patient and try persuade the patient to change his mind C.Inform the spouse and ask the spouse to persuade the patient to change his mind D.Make sure the patient has accurate information and understands the consequences of the decision

D. Make sure the patient has accurate information and understands the consequences of the decision Rationale : the RN's job is to educate no matter the decision the patient and family decide on. Make sure to document what was reviewed I the communication and teaching.

The nurse expects the practitioner to prescribe which of the following to treat glaucoma? A. Strict bedrest B. Low-fat, low-sodium diet C. A tight patch to the affected eye D. Mydriatic eye drops

D. Mydriatic eye drops Direct application of medication via eye drop is most commonly accepted treatment for glaucoma.

A nurse is caring a Native American client who experiences emotional distress due to a family problem. In anticipating pharmacological treatment for the client, the nurse understands that they would most likely: A.Establish the trust of the health care provider first before accepting the treatment. B.Call a clergy to ask for the religious preference of the treatment. C.Manage the emotional distress on their own to avoid disgrace D.Resort with the use of herbal medicines with healing properties.

D. Native American cultures often use a variety of herbs or other plant and root remedies.

An occupational health nurse is teaching a group of clients about work environment risks. Which of the following actions is the nurse performing? A. Case management B. Secondary Prevention C. Tertiary prevention D. Primary prevention

D. Primary prevention

A client in a clinic setting tells the nurse, "I haven't seen my son for 2 weeks." The nurse replies "Your son has not come to see you for 2 weeks?" This is an example of the nurse using which of the following therapeutic communication techniques? A. Reflecting B. Questioning C. Focusing D. Restating

D. Restating

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2 point discrimination B. Glasgow coma scale C. Babinski relfex D. Romberg test

D. Romberg test

A nurse is performing a general client survey and finds that the client has a body mass index of 23. Which of the following should the nurse document? the client... A. has no nutritional risks or deficits B. is at high risk for obesity-related health problems C. will need a referral to a dietitian D. has a BMI within the expected preference range

D. the client has a BMI within the expected preference range expected range: 18.5-24.9

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

Glaucoma