fundamentals ?s 1-9

Which documentation example best reflects the complexity of client teaching by the nurse? "Told client to take antibiotic as ordered." "Client return demonstrated how to use glucometer." "Taught client about peak flows; client verbalized understanding." "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

Which data entry follows the recommended guidelines for documenting data? "Client is overwhelmed by the diagnosis of pancreatic cancer." "Client's kidneys are producing sufficient amount of measured urine." "Following oxygen administration, vital signs returned to baseline." "Client complained about the quality of the nursing care provided on previous shift."

"Following oxygen administration, vital signs returned to baseline." Explanation: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A client presents with a flare of lupus. Which statement made by the client would cause the nurse to suspect a stress reaction?

"I just had a baby 3 weeks ago." Explanation: The brain-immune connection suggests that changes in body chemistry during periods of stress may trigger an autoimmune (self-attacking) response like those associated with lupus. While having a baby can be positive it is stress both physically and emotionally and could be a stress trigger for the lupus flare. The other options present differences in lupus flare presentation, which is not specific to a stress response.

The nurse is discussing the use of the patient-controlled analgesia pump with the postoperative patient. Which of the following statements by the patient indicate a need for additional education? "I am able to push the button when I am in pain." "The dose is set so I cannot overdose myself." "I should not press the button more often than every 3-4 hours." "The medicine will help me control my pain."

"I should not press the button more often than every 3-4 hours." Explanation: Specific dosages and time intervals can be programmed into the machine to prevent overdose; medication is delivered when the patient pushes a control button.

A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I think the client would benefit from intravenous furosemide."

"I think the client would benefit from intravenous furosemide." Explanation: Situation, Background, Assessment, and Recommendations provides a consistent method for hand-off communication that is clear, structured, and easy to use. This technique was originally developed by the U.S. Navy to accurately transmit critical information and initially adapted by Kaiser Permanente of Colorado to facilitate nurse and physician communication. The S (Situation) and B (Background) provide objective data, whereas the A (Assessment) and R (Recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating the client has fluid volume overload is the assessment of the nurse.

A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I think the client would benefit from intravenous furosemide."

"I think the client would benefit from intravenous furosemide." Explanation: Situation, Background, Assessment, and Recommendations provides a consistent method for hand-off communication that is clear, structured, and easy to use. This technique was originally developed by the U.S. Navy to accurately transmit critical information and initially adapted by Kaiser Permanente of Colorado to facilitate nurse and physician communication. The S (Situation) and B (Background) provide objective data, whereas the A (Assessment) and R (Recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating the client has fluid volume overload is the assessment of the nurse.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A client has asked a nurse if he can read the documentation that his physician wrote in his chart. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

A group of nursing students is reviewing information about stress and coping. The students demonstrate an understanding of the information when they identify what as the outcome of coping?

Adaptation Explanation: The outcome of coping is adaptation. Allostasis refers to the process of re-establishing or maintaining homeostasis, which is the body's maintenance of physiologic balance within a certain range or "set point". Compensation, a defense mechanism, is the attempt to achieve respect or recognition in one activity as a substitute for the inability to achieve them in another endeavor.

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment?

Adds depth to existing information Explanation: A focus assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focus assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focus assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

A student nurse has learned about the role of endorphins in stress management and their potential to foster a sense of well-being. A client with a history of depression has initiated a discussion with the student about non-pharmacologic stress management techniques. What activity should the nurse recommend that may result in the release of endorphins?

Aerobic exercise Explanation: Aerobic exercise is known to cause a release of endorphins and consequent improvement in mood. This action alone will not resolve major depression but it has benefits in stress management. Socialization, sleep, and meditation each have therapeutic benefits but these activities do not cause a release of endorphins.

The cardiologist advises the client to undergo angioplasty, a procedure to clear blocked coronary arteries. The client refuses the procedure and the nurse later discovers that the client believes in naturopathy and is taking herbal extracts to clear the coronary arteries. Which action should the nurse take?

Ask the client to opt for herbal therapy and also undergo the procedure Explanation: The nurse should suggest that the client try both interventions. Considering the individuality of health beliefs and the risk of not undergoing angioplasty in a timely manner, the nurse should encourage the client to undergo the surgery and simultaneously continue his herbal extract treatment. In stating that herbs are not effective, the nurse does not respect the client's beliefs. Assuming that herbal medicines could lead to further complications is nontherapeutic because the nurse includes personal opinion in the discussion. The nurse should avoid showing disapproval of the client's choice of healing because this does not make for therapeutic communication.

When preparing client teaching materials, how does the nurse best assess a client's preferred learning style? Observe the client's behaviors. Provide teaching that works for the broadest base of clients. Ask the client, "Do you learn better by seeing how to use an inhaler, believing how the inhaler works, or showing me how to use the inhaler after I show you?". Determine client learning needs based upon age and ability to hear effectively.

Ask the client, "Do you learn better by seeing how to use an inhaler, believing how the inhaler works, or showing me how to use the inhaler after I show you?". Explanation: One way to determine the client's preferred learning style is to ask the client about the client's personal learning preference. The other options are less effective for assessing a client's preferred learning style.

A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client? Assessing importance Elicit-provide-elicit Evoking change talk Prioritizing

Assessing importance Explanation: Using the 0 to 10 scale is a key aspect of assessing importance with motivational interviewing. It helps the nurse to understand the client's feelings toward the recommended activity and can help start a conversation about why the client chose that rating number—and what the nurse could do to increase the number.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes in to the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse NOT DO in this situation? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report error to primary provider.

Attach a copy of the incident report to the chart. Explanation: For legal reasons the nurse should not attach a copy of the incident report to the chart. The nurse should, however, fill out an incident report, stop the infusion and document the time, and report the error to the primary provider.

The parents of an infant suffering from apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents? Educational levels Home environment Infant bonding Baseline knowledge of these concepts

Baseline knowledge of these concepts

Which ethical principle refers to the obligation to do good?

Beneficence Explanation: Beneficence is the duty to do good and the active promotion of benevolent acts. Fidelity refers to the duty to be faithful to one's commitments. Veracity is the obligation to tell the truth. Nonmaleficence is the duty not to inflict, as well as to prevent and remove, harm; it is more binding than beneficence.

A nurse is caring for a woman 28 years of age who has delivered a baby by Cesarean section. She describes her pain as a 9. The nurse medicates her for pain. This is an example of which ethical framework?

Beneficence Explanation: Beneficence means doing or promoting good. The treatment of the client's pain is the nurse's act of doing good.

A nursing instructor is describing the neuroendocrine regulation of physiologic functioning involved with stress and coping. What would the instructor most likely address as exerting overall control?

Central nervous system Explanation: The central nervous system (CNS) consists of the brain and spinal cord and controls behaviors in the body. The brain has the overarching control over neuroendocrine, autonomic, and immune function.

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which is an example of a written form of communication? Checklists Notepad E-mail SMS

Checklists Explanation: The nurses can use the checklist method to share the client's health status with other health personnel involved in the client's care. Some other examples of written forms of communication include the nursing care plan, the nursing Kardex, and flow sheets. Notepads, e-mails, and SMS (short message service) are not examples of written forms of communication that the nurses should follow. Reference:

What is a misconception about chronic disease?

Chronic illnesses cannot be prevented.

A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym? Client reports of pain Client history Client's chief report Client interventions

Client reports of pain Explanation: The SOAP format (subjective data, objective data, Assessment [the caregiver's judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR (problem-oriented medical record). A client complaint of pain is subjective data (S).

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? Affective Psychomotor Cognitive Behavioral

Cognitive

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

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This is an example of what learning theory? Adaptive learning theory Behavioral learning theory Cognitive learning theory Developmental learning theory

Cognitive learning theory Explanation: Cognitive learning theory is the result of people wanting to make sense of the world around them by assimilating and processing information to gain new understandings and insights.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders. Explanation: If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

What ensures continuity of care? Reassessment Critical thinking Communication Integration

Communication

The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: 7-year-old male, diabetes mellitus type 1 with a hemoglobin A1C of 8.3%, BMI of 31.7, BMI percentile of 99. What are the most appropriate learning diagnoses for this first session? Deficient Knowledge: Readiness for enhanced nutrition, and risk for disturbed body image. Deficient Knowledge: Risk for chronic low self esteem, and risk for unstable blood glucose level. Deficient Knowledge: Risk for imbalanced nutrition: more than body requirements, and sedentary life style. Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance.

Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance. Explanation: The data present for the nurse to use for planning the educational session do not give enough information to determine the parents' concepts on their child's health. Before making judgments on their readiness to learn, the nurse must assess them. There are not enough data to support sedentary lifestyle. When making a diagnosis, do not address actual problems as risks. With the hemoglobin A1C of 8.3%, the nurse knows that the client's glucose control is an actual problem, as is a BMI of 31.7 and a BMI percentile of 99. The assessment data on the client do reflect enough data to make the learning diagnoses of imbalanced nutrition and ineffective health maintenance.

The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: 7-year-old male, diabetes mellitus type 1 with a hemoglobin A1C of 8.3%, BMI of 31.7, BMI percentile of 99. What are the most appropriate learning diagnoses for this first session? Deficient Knowledge: Readiness for enhanced nutrition, and risk for disturbed body image. Deficient Knowledge: Risk for chronic low self esteem, and risk for unstable blood glucose level. Deficient Knowledge: Risk for imbalanced nutrition: more than body requirements, and sedentary life style. Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance.

Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance. Explanation: The data present for the nurse to use for planning the educational session do not give enough information to determine the parents' concepts on their child's health. Before making judgments on their readiness to learn, the nurse must assess them. There are not enough data to support sedentary lifestyle. When making a diagnosis, do not address actual problems as risks. With the hemoglobin A1C of 8.3%, the nurse knows that the client's glucose control is an actual problem, as is a BMI of 31.7 and a BMI percentile of 99. The assessment data on the client do reflect enough data to make the learning diagnoses of imbalanced nutrition and ineffective health maintenance.

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis Explanation: During the second phase of the nursing process (Diagnosis) the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.

The nurse is evaluating a client and the body's response to a stressful situation. What alterations should the nurse monitor? Select all that apply. Dilated pupils Increased digestive function Hypoglycemia Increased pulse Inhibition of urination

Dilated pupils Increased pulse Inhibition of urination

A female client undergoing chemotherapy for breast cancer has lost all her hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Disturbed Body Image related to loss of hair Explanation: The client has a problem with her body image because she has lost her hair. The evidence would be the client's statement. The etiology cannot be a medical diagnosis, so the etiology of breast cancer would be incorrect. The other two statements do not contain an etiology. Nursing diagnoses must identify an etiology to direct the client's care.

The nurse is planning the discharge from the hospital of an 84-year-old client after recovery from hip surgery. The client intends on returning home, but the client's children and hospital care team are skeptical of the client's ability to safely live on their own and rehabilitate their hip. A family meeting has been organized. How can the care team minimize the client's anxiety and foster therapeutic communication during this process? Ensure that the client maintains as much control over the decisions as possible. Ask the client's physician to present a unified plan. Emphasize the potentially unsafe consequences of living independently. Present two options to the client and ask the client to choose one.

Ensure that the client maintains as much control over the decisions as possible. Explanation: In most circumstances, it is important to promote an older adult's control over decisions as much as possible. It would be unfair to ask the physician to coerce the client or to limit options to two alternatives. Emphasizing the risks of living alone may be construed as a form of manipulation.

The registered nurse is performing a nutritional assessment to ensure that the client's diet is optimal for wound healing. The nurse's intervention can be traced back to which of nursing's key people's contributions to nursing?

Florence Nightingale Explanation: Florence Nightingale's contributions to nursing included the recognition of the importance of nutrition to health. Clara Barton established the Red Cross. Dorothea Dix was a pioneer for reform of treatment for the mentally ill. Linda Richards began the practice of keeping records and writing orders.

Which contributor to the nursing profession established two missions: sick nursing and health nursing?

Florence Nightingale Explanation: Nightingale established nursing as a profession with two missions. "Sick nursing" was helping clients use their own reparative processes to get well and "health nursing" was to prevent illness.

What is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity?

Health

What is a dynamic state in which a person constantly adapts to changes in the internal and external environment?

Health is a dynamic state in which a person constantly adapts to changes in the internal and external environment.

A nursing instructor is working with a class of first semester nursing students. The instructor explains the interrelatedness of health and wellness. What would be the best definition the nursing instructor could give of health?

Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. Explanation: Health is viewed as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. The other options would not be the best definition of health.

A nurse instructor explains the concept of health to the students. Which statement accurately describes this state of being?

Health is a state of optimal functioning.

A nurse is developing the plan of care for a client and establishes several nursing diagnoses based on assessment data. The nurse demonstrates an understanding of nursing diagnoses by focusing on which area?

Human responses to actual or potential health problems Explanation: The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiologic responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the physician to validate the problem reflects medical diagnoses or collaborative problems.

Which description best summarizes the level of responsibility of the licensed nurse as related to assessment?

Identifies the information needed from individuals or groups to provide an appropriate nursing database Explanation: While assessing clients, the LPN/LVN gathers data by interviewing, observing, and performing a basic physical examination of people with common health problems with predictable outcomes. Option B is the description of the LPN/LVN's responsibility for implementing care. Option C is the associate degree nurses's responsibility level for assessment. Option D is the baccalaureate nurse's level of responsibility for assessment.

Which are considered internal stressors? Select all that apply.

Illness Hormonal change Fear Explanation: A stressor is anything that is perceived as challenging, threatening, or demanding. Stressors may be internal (e.g., an illness, a hormonal change, or fear) or external (e.g., loud noise or cold temperature).

The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize?

Impaired concentration Explanation: Impaired concentration is consistent with a cognitive symptom associated with stress. Difficulty falling asleep and lack of interest in sex are physical symptoms associated with stress, and angry outbursts are emotional symptoms associated with stress.

After assessing a client, the nurse formulates several nursing diagnoses. Which would the nurse identify as an actual nursing diagnosis?

Impaired urinary elimination Explanation: Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.

The Healthy People initiative targets the improvement of health for all. In addition to eliminating health disparities, what are the broad goals of this plan?

Increasing the quality and length of a healthy life Explanation: Two broad goals of the Healthy People initiative are to (1) increase quality and years of healthy life and (2) eliminate health disparities. Healthy People initiatives will help with treatable problems but will not prevent problems. The initiative does not apply a systematic approach to health improvement or increase technological innovations.

A nurse working in a long-term care facility has an older adult male client who is very confused. Which ethical dilemma is posed when using restraints in a long-term care setting?

It threatens autonomy. Explanation: Because there are safety risks involved when using restraints on older adult clients who display confusion, this is a common ethical problem in long-term care settings, as well as other health care settings. Restraints limit the individual's autonomy because they are perceived as imprisonment. Restraints should not limit personal safety. Often, restraints increase confusion, and they prevent self-directed care.

A nurse is forming an education plan for a client who is being discharged from the nursing unit after cardiac catheterization. Which diagnosis and intervention are most appropriate for this client? Knowledge Deficient: Risk for altered perfusion secondary to re-occlusion Knowledge Deficient: Altered urinary output related to catheterization Knowledge Deficient: Impaired mobility related to lying flat for 8 hours Knowledge Deficient: Risk for ineffective breathing pattern related to incisional pain

Knowledge Deficient: Risk for altered perfusion secondary to re-occlusion Explanation: Urinary output should not be changed from a cardiac catheterization. The incision for this procedure may require 8 hours of lying flat, but mobility returns to baseline before discharge home. The risk for ineffective breathing pattern would not be due to incisional pain, which would be in the groin or elbow. Educating the client to be aware for the safety issue of chest pain resulting from the newly opened coronary arteries becoming re-occluded and blocking blood flow to the heart is the highest priority focus.

The nurse is planning to teach a 75-year-old client about administering medication. How can the nurse enhance the client's ability to learn? Provide links to websites that contain information related to the medication Exclude family members from the session Use color-coded materials Make the information relevant to the client's condition

Make the information relevant to the client's condition Explanation: Studies have shown that older adults can learn and remember if the information is paced appropriately, relevant, and followed by appropriate feedback.

A student is preparing for their first client care assignment. The student wakes up at 4 AM with a pounding pulse and diarrhea. What type of adaptive response to stress is the student experiencing? General adaptation syndrome Mind-body interaction Local adaptation syndrome Coping or defense mechanism

Mind-body interaction Explanation: The student's response to stress exemplifies the mind-body interaction and illustrates a link between psychological stressors and the physiologic stress response. A person perceives a threat on an emotional level as though it is a physiologic threat, and the body prepares itself for the fight-or-flight response.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis. Explanation: Nurse-initiated interventions are derived from the nursing diagnosis and do not require a physician's order. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client.

What guidelines do nurses follow to identify the client's health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes?

Nursing process

The nurse has to complete a cardiac assessment on a client. Which level of human proxemics would be appropriate for the nurse in completing this assessment on the client? Intimate Personal Social Public

Personal Explanation: In traditional Western cultures, the areas of personal space or communication zones are approximately as follows: Intimate (within 6 inches): behavior with loved ones, sharing secrets, physical assessment in health care. Personal (6 inches to 4 feet; 15 cm to 1.2 m): general conversation, interviews, teaching one-on-one, private conversation. Social (4 to 12 feet; 1.2 to 3.7 m): demonstrations, group interactions, parties. Public (more than 12 feet; 3.7 m): lectures, behavior with strangers.

A hospice nurse is caring for a client dying of lung cancer. According to Maslow's hierarchy of needs, what dimension of care should the nurse consider primary in importance when caring for a dying client?

Physiologic Explanation: Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. Such a hierarchy of needs is a useful framework that can be applied to the various nursing models for assessment of a client's strengths, limitations, and need for nursing interventions. The other answers are incorrect because they are not of primary importance when caring for a dying client.

A physician, while treating a client, asks the nurse to use the social readjustment rating scale tool. What does this tool predict?

Potential for developing a stress-related disorder Explanation: Holmes and Rahe (1967) developed the Social Readjustment Rating Scale tool to predict a person's potential for developing a stress-related disorder. The rating scale is based on the number and significance of social stressors a person has experienced within the previous 6 months. This scale does not assess the type or the level of stressor. It also does not treat the stressor.

What level of prevention is noted when the nurse educates a group of mothers of school-age children on self breast examinations?

Primary prevention Explanation: Primary prevention focuses on the health of a person with the goal of preventing disease or illness. Self-breast examination education is primary prevention.

What dual purpose does an audit serve?

Quality assurance and reimbursement

A new graduate is having difficulty coping with the role transition from student to registered nurse (RN). Which defense mechanism is being exhibitied when stating, "I hate going in to work on weekends. The aides are lazy, the clients are all complaining, and the families are all crazy!"

Reaction formation Explanation: New RNs are often faced with a tremendous challenge—adapting to the "real world." While wanting to maintain the compassion, empathy, and altruism that caused them to choose health care as a profession, the realities of day-to-day conflict and stress at work are difficult to accept and may be even more difficult to resolve. Sometimes the new nursing graduate will cope by using reaction formation—developing attitudes that are opposite to what the nurse really would prefer to do (or needs to do) in the situation.

A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing?

Resistance stage Explanation: The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore. In the alarm stage, the stimulating neurotransmitters and neurohormones prepare the client for a fight-or-flight response. When one or more adaptive/resistive mechanisms can no longer protect the client experiencing a stressor, exhaustion occurs. The body loses its capability to fight stress. The primary stage is not related to stages of stress and is applicable for stress prevention.

The Five Rights of Delegation are:

Right Task. Right Circumstances. Right Person. Right Directions/Communication. Right Supervision/Evaluation.

When nurses at any level perform delegation, what is part of the guidelines they must follow? (Select all that apply.)

Right task Right circumstance Right person Explanation: Regardless of whether it is an RN delegating to an LPN or a UAP or an LPN delegating to an UAP, delegation requires adhering to the following six guidelines: (1) Right task: matching the client's needs with the caregiver's skills; (2) Right circumstance: ensuring that the situation is appropriate; (3) Right person: knowing the unique competencies of the caregiver; (4) Right direction (communication): providing sufficient information; (5) Right supervision: being available for assistance; (6) Right follow-up: validating that the task was completed, obtaining the results, and analyzing if further actions are necessary.

The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated?

Science of nursing Explanation: The science of nursing is the knowledge base for the care provided by the nurse. In this example, the nurse is using this knowledge base to decide how best to care for the client by giving or not giving the blood pressure medication. The art of nursing is the application of the knowledge. In this example it would be demonstrated by the nurse actually giving or holding the medication. Quality improvement activities and the conduction of research influence the science and the art of nursing by helping build the body of knowledge that is the science of nursing.

A woman over the age of 40 years has an annual mammogram. What level of prevention does this represent?

Secondary prevention Explanation: Secondary prevention includes screening for those at risk to develop illness, or those who could be diagnosed early in the process, and thus receive prompt treatment.

A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation?

Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. Explanation: Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis and if adaptation fails, the result is disease. When adaptation fails, the result is disease. If a person is overwhelmed by stress that person may never adapt. Acute anxiety and depression are frequently associated with stress.

Which accreditation is a legal requirement for a school of nursing to exist?

State Board of Nursing accreditation

While delivering patient care, the home healthcare nurse has the ability to see the whole picture and how various parts are related to the client's diagnosis and problems in the home environment. What skills does the nurse possess that allow her to see the connection of various parts of the situation?

System skills Explanation: Systems skills are those that help a person see the whole picture and how various parts relate.

Which are correctly written client goals? Select all that apply.

The client will identify five low-sodium foods by October 9. The client will rate pain as a 3 or less on a 10-point scale by 1700 today. The client will eat at least 75% of all meals by May 5. Explanation: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (eat), how well (75%) under what circumstances (not always included), and by when (May 5). "Understand" and "know" are vague and are not action-oriented.

What best describes the utilitarian theory of ethics?

The consequences of an action determine if it is right or wrong. Explanation: According to utilitarian theory, the rightness or wrongness of an action depends on the consequences of the action. In the deontologic theory, an action is right or wrong independent of its consequences.

A nurse has become aware of a conflict between a client's children, one of whom want to withhold the client's recent cancer diagnosis from her in the belief that the client would "give up hope" if she became aware of her condition. Which response to this situation most clearly represents a deontological perspective?

The morality of the withholding information from a client is the primary concern Explanation: Deontology is ethical study based on duty or moral obligations. It proposes that the outcome is not the primary issue; rather, decisions must be based on the morality of the act itself. Consequently, priority would not be placed on precedents or the wishes of the majority of family members.

Which of the following reflects the diagnosis phase?

The nurse identifies that the client does not tolerate activity. Explanation: Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Performing wound care is an example of implementation. Setting a tolerable pain rating with the client is an example of planning. Documenting the client's response to pain medication is an example of evaluation.

When teaching an older adult how to control stress through relaxation techniques, the nurse should consider which assumption concerning such learners? As an adult matures, his/her self-concept becomes more dependent; therefore, this person must be made aware of the importance of reducing stress. The older adult is less concerned with the immediate usefulness of the material being taught than with the quality of the material. Older adults are the least likely to resist learning because of preconceived ideas about the teaching/learning process. The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction. Explanation: Gerogogic learners are practical thinkers and use experience in the teaching/learning process.

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?

The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention. Explanation: The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits. The informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.

Two nurses meet at their home, where one of the nurses discusses a client who had been physically abused. The next day, the client is shifted to another nursing unit after a surgical procedure and becomes the care of the second nurse who had been part of the original discussion. Nurse No. 2 asks the client about the physical abuse. The client discovers that his original nurse revealed the information and is hurt. What would be the charges if the client files a suit?

The nurses could be charged for slander. Explanation: Slander is the character attack uttered orally in the presence of others. The injury is considered to occur because the derogatory remarks attack a person's character and good name. In this case, the nurse can be charged with slander. If the defamation had been written, it would be libel. Even if the discussion took place at home and Nurse No. 2 was involved in the care, the revelation was without the client's consent. Even if the nurse is off-duty or may not be directly involved in the client's care, the nurse can still be charged with slander.

During the Crimean War, which was fought between Russia and the alliance of England, Turkey, France, and Sardinia, what was the major achievement for nursing?

The nursing care resulted in a decrease of the death rate of soldiers to 1% from 60%. Explanation: The significant achievement of nursing during the Crimean War was the decrease in the death rate of British soldiers, which went from being as high as 60% to becoming as low as 1%. This was possible due to the care given by the nurses under the guidance of Florence Nightingale. This was made possible by providing better living and sanitary conditions for the soldiers. This achievement of the nurses was appreciated by the servicemen and their families. The first training school for nurses was opened after the war and not during the war.

On admission, a physician diagnoses a client with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of chronic pain. What is the nurse diagnosing?

The response of the client to the illness Explanation: Nursing diagnoses, based on assessment, do not duplicate medical assessments. Medical diagnoses target data pointing to pathologic conditions, whereas nursing diagnoses focus on the client's potential or actual response to health problems.

What is the major difference between nursing students today and nursing students 50 years ago?

Today's students reflect a more diverse population.

Which of the nurse's actions is most likely to promote a client's compliance with their antiretroviral drug regimen for the treatment of human immunodeficiency virus (HIV)? Use interactive and learner-appropriate teaching techniques. Ensure that teaching materials are evidence-based and explicitly referenced. Emphasize the consequences of noncompliance at various points in client teaching. Refer to the characteristics of the HIV virus when explaining how antiretrovirals treat HIV.

Use interactive and learner-appropriate teaching techniques. Explanation: Noncompliance has serious consequences for the health of clients. It can often be prevented by ensuring that client teaching is interactive and appropriate to the needs and development of each individual learner. Client education should indeed be evidence-based, but this does not necessarily enhance compliance. Overemphasizing the negative and grounding the education in virology or other forms of science will also not guarantee compliance.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.

Use minimum disclosure policy to release the information.

When providing care to a client, what perspective is followed by the nurse?

Viewing client's health as a balance of body, mind, and spirit Explanation: A nurse practices from the perspective of holism. Holism means viewing an individual's health as a balance of body, mind, and spirit. Treating only the body will not necessarily restore optimal health. When providing health care to a client, a nurse should not view the client's health as per the client's health belief or along with the client's family's health.

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Wellness Diagnosis Explanation: Readiness for Enhanced Coping is an example of a wellness diagnosis. Two cues must be present for a valid wellness diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

A nurse has chosen to characterize a new initiative as "wellness promotion" rather than "health promotion." Which statement best describes the difference between the concept of wellness and the concept of health?

Wellness is an active state, whereas health is a more passive state dependent on the absence of disease. Explanation: Good health is a passive state wherein the person is not ill. Wellness is a more active state, regardless of one's level of health. Wellness is not contingent on the resolution of disease or illness and it supersedes age. Both health and wellness can be influenced by nursing practice.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Write a narrative note in the designated nursing section. Place the narrative note chronologically after the respiratory therapist's note. Review the laboratory results under the physician section. Use a critical pathway to document the physical assessment.

Write a narrative note in the designated nursing section. Explanation: Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

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? 1 Assess the client for injury. 2 Complete an incident report. 3 Notify the physician. 4 Document the incident. 5 Assist the client back into bed.

You Selected: Assess the client for injury. Assist the client back into bed. Notify the physician. Document the incident. Complete an incident report. Following a fall, the nurse should assess the client before moving the client. If the client can be moved, safely return the client to bed and make sure the client is secure per safety procedures. The nurse should then notify the physician. The nurse should document the incident and interventions or treatments provided. Finally, an incident report should be completed.

Which of the following best describes stress?

a response to changes in the normal balanced state

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 Explanation: 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 nurse is working with a 15-year-old client with sickle cell anemia. He was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care? asking only the client's parents to be present at the education session including a note about who was taught this new information in the client's chart ensuring the client that the conversation is confidential except under extreme circumstances answering questions openly and honestly

asking only the client's parents to be present at the education session Explanation: Peers are often more influential than parents, nurses or teachers at this age. It is often appropriate to include a close friend in on the education session.

Which factors contribute to the concept of a culture? Select all that apply. language art and music items and clothing worn type of disease contracted beliefs about health practices styles used for communication

beliefs about health practices styles used for communication art and music language items and clothing worn

Which stereotypical ideas about older adult clients does the nurse associate with the concept of ageism? Select all that apply. physically impaired cognitively enhanced burdensome to family financially independent uninterested in intimacy

burdensome to family uninterested in intimacy physically impaired

The nurse is caring for a postoperative client. The physician has written orders for a pain medication, and the order gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called:

collaborative functioning. Explanation: Nurses manage collaborative problems using both nurse- and physician-prescribed interventions to reduce the risk of complications

A nurse engages in professional rituals as a means to standardize practice and ensure efficiency. In doing so, the nurse integrates understanding of:

common and observable expressions of culture.

A client shares with the nurse how much she appreciates understanding the physiology of her breastfeeding. She states, "I felt very comfortable with what you explained to me and I feel I will be successful at breastfeeding." In affective learning, this represents: creating an educational opportunity for the future. creating an atmosphere for discussion of feelings. creating specific learning sessions for new information. creating rational thought and learning.

creating an atmosphere for discussion of feelings. Explanation: When working with clients to change beliefs, values, and attitudes, the nurse creates an atmosphere in which clients can honestly and freely discuss their feelings and emotions.

A client has just been diagnosed with cancer. As part of the plan of care, the nurse attempts to explore the client's feelings about the diagnosis to foster looking at alternatives. The nurse implements this action based on the understanding that looking at alternatives promotes: exploration of options for the client's consideration. sharing of information about the client's health. assistance for the client to put unclear thoughts into words. aid for the client to describe concerns and problems.

exploration of options for the client's consideration. Explanation: Looking at alternatives means exploring options for the client's consideration. When more options are identified, the client's perceived choices are increased. Giving information involves sharing information about the client's health and well-being in a timely manner and based on what is currently known about the client's condition. Seeking clarification means helping the client put into words unclear thoughts or ideas. Encouraging elaboration is a technique used to help the client describe more fully the concerns or problems being discussed.

A nurse is preparing to write a nursing diagnosis for a client. Which activity would the nurse need to do first?

identify the significant data Explanation: The first step is to look at the data for cues. Significant data or cues will then be clustered. During cue clustering, critical thinking is used to analyze and synthesize the cues; that is, how they fit into a particular problem. The cues are then put together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters; that is, to see the whole picture and attach meaning to the cluster. Once the nursing diagnosis is selected, it should be validated with the client.

What is the nurse accountable for, according to state nurse practice acts?

making nursing diagnoses Explanation: State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law.

When communicating with clients nurses need to be very careful in their approach. This is particularly true when communicating using: written material. audio-visual material. demonstration. medical terminology.

medical terminology. Explanation: Another filter is the particular language system into which the person is socialized. Nurses are socialized into health care or medical jargon. To effectively educate and communicate, the nurse should limit medical jargon.

A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. The client's right to self-determination is best protected by:

respecting the client's desire to have the uncle make choices on her behalf. Explanation: The right to self-determination (autonomy) means that it should never be forced on anyone. The client has the autonomous right to defer her decision-making to another individual if she freely chooses to do so.

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission Explanation: It is important to evaluate client outcomes early and frequently. Reserving evaluation for the time of discharge or after discharge is inappropriate, even if the designated time criteria for the outcome specifies "by time of discharge."

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

to be sure the intervention is safe Explanation: Nurses reassess the client and review the plan of care before initiating any nursing intervention. This is done to make sure that the plan of care is still responsive to the client's needs, and is safe for the particular client. In this case, the nurse would not give oral fluids to an unconscious client.

A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. The nurse helps the client to get up, makes him comfortable, and then informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

to evaluate quality care and potential risks for injury to the client Explanation: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. Incident reports determine how to prevent hazardous situations and serve as a reference in case of future litigation. Accurate and detailed documentation often helps to prove that the nurse acted reasonably or appropriately in the circumstances. It may not always serve as a method of determining the nurse's fault in the incident. The document does not evaluate the immediate care provided to the client, rather states the actions taken.

Although all of the following are nursing responsibilities, which one would be expected of a nurse with a baccalaureate degree?

using research findings to improve practice Explanation: Nurses with baccalaureate degrees are expected to use research findings to improve practice. Graduates from vocational, diploma, and associate degree programs do not have coursework in nursing research and are not expected to independently use it in clinical practice. Nurses from all levels of education provide direct care, administer medications, and collaborate with other health care providers.

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

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