Funds CP Test 1 CH 9, 13, 14

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? 1. Risk for falls 2. Pneumonia 3. Hypertension 4. Congestive heart failure

1. Risk for falls

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress? 1. Reinforcement 2. Motivation 3. Positive feedback 4. Health promotion

3. positive feedback

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? 1. Fill in quiet spaces and pauses. 2. Avoid the impulse to interrupt. 3. Fill in the words for the client. 4. Focus mainly on verbal comments.

2. avoid the impulse to interrupt

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory? 1. Adaptive learning theory 2. Cognitive learning theory 3. Behavioral learning theory 4. Developmental learning theory

2. cognitive learning theory

Which nursing skill uses all five senses? 1. Listening 2. Observation 3. Documentation 4. Caring

2. observation

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class? 1. Programmed instruction 2. Role-playing 3. Role modeling 4. Panel discussion

2. role playing

A pediatric nurse provides education to numerous clients. Which group of children benefits most from being involved in the teaching-learning process? 1. Preschoolers 2. School-age children 3. Toddlers 4. Infants

2. school age children

Which is a characteristic of person-centered care? 1. It can be used in hospital settings. 2. It is independent of other disciplines. 3. It is a framework for providing care. 4. It involves general care for all clients.

3. It is a framework for providing care

Which activity is the clearest example of the evaluation step in the nursing process? 1. Taking a client's blood pressure on both arms at the beginning of a shift 2. Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading 3. Checking the client's blood pressure 30 minutes after administering captopril 4. Recognizing that the client's blood pressure of 172/101 is an abnormal finding

3. checking the client's BP 30 min after administering captopril

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: 1. objective data. 2. nursing diagnosis. 3. intervention. 4. outcome.

4. outcome

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? 1. "The client's right leg is cold to the touch, from the knee to the foot." 2. "The client reports having heartburn after breakfast." 3. "The client's sister reports that the client has unrelieved pain." 4. "The client reports nausea following eating."

1 "The client's right leg is cold to the touch, from the knee to the foot."

Which are examples of subjective data? Select all that apply. 1. A client reports being cold and requests an extra blanket. 2. A nurse observes a client wringing the hands before signing a consent for surgery. 3. A client feels nauseated after eating breakfast. 4. A client describes pain as an 8 on the pain assessment scale. 5. A client's blood pressure is elevated following physical activity. 6. A nurse observes redness and swelling at an intravenous site.

1 A client reports being cold and requests an extra blanket 3 A client feels nauseated after eating breakfast 4 A client describes pain as an 8 on the pain assessment scale

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. 1. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. 2. Outcomes can be short- and long-term. 3. Outcome setting allows for individualization of the plan of care. 4. All plans of care are the same for clients with certain medical diagnoses. 5. Only the client is involved in outcome setting, not the family.

1 A plan of care should be comprehensive and ongoing 2 Outcomes can be short and long term 3 Outcome setting allows for individualization of the plan of care

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action? 1. Assess the client and re-evaluate the vital signs. 2. Direct the UAP to take the blood pressure in the other arm with a large cuff. 3. Review the client's medication list and notify the nursing supervisor. 4. Notify the health care provider of the blood pressure result.

1 Assess the client and re-evaluate the vital signs

The nurse is teaching a client about enoxaparin sodium for the first time. This client has never given a self-injection before. Which action(s) are appropriate for the nurse to take? Select all that apply. 1. Review medication data sheets to ensure correct dosage. 2. Weigh the client to select the needle size. 3. Have the client demonstrate the proper technique for injection. 4. Gather all necessary supplies for injection teaching. 5. Provide a printed diagram highlighting the injection site.

1 Review medication data sheets to ensure correct dosage 3 Have the client demonstrate the proper technique for injection 4 Gather all necessary supplies for injection teaching 5 Provide a printed diagram highlighting the injection site

The nurse is planning client education based on the developmental stage of the client. Which nursing actions best reflect this consideration? Select all that apply. 1. The nurse includes a school-age child in the teaching and learning process. 2. The nurse provides lengthy explanations of a procedure to a preschool child. 3. The nurse avoids relating education for an adult to a social role. 4. The nurse provides material that is useful immediately to adult clients. 5. The nurse determines the learning needs of the client. 6. The nurse directs the health education for a 3-year-old to the parents.

1 The nurse includes a school-age child in the teaching and learning process 4 The nurse provides material that is useful immediately to adult clients 5 The nurse determines the learning needs of the client 6 The nurse directs the health education for a 3 yo

Which statements are true about informatics in nursing practice? Select all that apply. 1. The use of informatics can help manage knowledge and mitigate error. 2. Informatics only involves documentation of timely and accurate charting. 3. Utilization of information services helps to support decision making. 4. Nurses should value technologies that support error prevention and care coordination. 5. Computers do not help with communication, but deter it because of the lack of personal interaction.

1 The use of informatics can help manage knowledge and mitigate error 3 Utilization of information services helps to support decision making 4 Nurses should value technologies that support error prevention and care coordination

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client? 1. Auscultate the chest for breath sounds. 2. Apply supplemental oxygen by face mask as needed. 3. Document "impaired oxygenation" on the nursing care plan. 4. Collaborate with the client to form goals.

1 auscultate the chest for breath sounds

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments? 1. The nurse 2. The physician 3. The nursing supervisor 4. The case manager

1 the nurse

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment? 1. A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment 2. A 51-year-old male who walks to most places because of a lack of transportation, has a low income, and works days 3. A 45-year-old female who is unsure of the benefit of psychiatric care, on a fixed income, and has good family support 4. A 36-year-old male who uses public transportation, is unable to read, and wants to confer with a pastor

1. A 28 yo female who works nights, is willing to try, and asks about insurance coverage of the appointment

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching? 1. Blocking 30 minutes of time for skill teaching 2. Using dolls to demonstrate psychomotor skills 3. Giving stickers as a reward for task completion 4. Ensuring the client's parents are present

1. Blocking 30 minutes of time for skill teaching

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? 1. Determine whether the prescribed treatment was effective. 2. Administer an additional liter of intravenous fluids. 3. Check the client's skin turgor. 4. Formulate a plan of care based on risk for dehydration.

1. Determine whether the prescribed treatment was effective

When is the best time for a nurse to take a client's health history? 1. As soon as possible after a client presents for care 2. After the client is settled and feels ready 3. Within 24 hours of admission 4. Anytime before the client is discharged

1. as soon as possible after a client presents for care

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: 1. complete the postoperative assessment. 2. administer pain medication. 3. expect the client to be drowsy, and let the client rest. 4. evaluate the abdominal dressing for drainage.

1. complete the post-op assessment

A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client? 1. Critical reflectivity 2. Reflective skepticism 3. Thoughtful practice 4. Reflection in action

1. critical reflectivity

A client, who has limited finances and limited capacity for education, requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, the nurse must first: 1. implement critical thinking skills. 2. develop a relationship with the client. 3. determine what care has been provided. 4. engage the services of a social worker.

1. implement critical thinking skills

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? 1. Repositioning the client 2. Administering a placebo 3. Administering extra pain medication 4. Documenting opioid dependence

1. repositioning the client

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client? 1. Risk for Impaired Parenting 2. Risk for Loneliness 3. Acute Pain 4. Ineffective Infant Feeding Pattern 5. Ineffective Breastfeeding

1. risk for impaired parenting

Which statement is true of the nursing process? 1. Scientific problem solving can occur within the nursing process. 2. Trial-and-error problem solving is an efficient use of the nurse's time. 3. It is more appropriate in medical surgical settings than community health care. 4. It is a valid alternative to using intuition to respond to nursing situations.

1. scientific problem solving can occur within the nursing process

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing? 1. Time-lapse 2. Focused 3. Complete 4. Emergency

1. time lapse

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: 1. uses critical thinking to direct care for the individual client. 2. applies intuition and routine care for clients. 3. uses scientific problem solving to meet client problems. 4. employs communication to meet the client's needs.

1. uses critical thinking to direct care for the individual client

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. 1. Ecchymosis on upper left arm 2. Client states, "I feel so sad all of the time." 3. Blood pressure 140/82 mm Hg 4. Client states, "I am in pain." 5. Clothes visibly soiled and hair greasy

2 Client state, "I feel so sad all of the time." 4 Client states, "I am in pain."

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? 1. The nurse asks the client what name the client would like to be called. 2. The nurse introduces oneself to the client by pointing to the nurse's name badge. 3. The nurse verifies the client's name. 4. The nurse sits on eye level with the client.

2 The nurse introduces oneself to the client by pointing to the nurse's name badge

Which piece of client information is subjective? 1. Ptosis, a drooping of the eyelid, on the right side 2. Generalized myalgia or muscle pain 3. A temperature of 102°F (38.9°C) 4. Leukoplakia on the client's oral mucosa

2 generalized myalgia or muscle pain

A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply. 1. The client's job 2. Literacy level 3. Learning style preferences 4. Size of family 5. Available resources

2 literacy level 3 learning style preferences 5 available resources

Which strategy should the nurse use when providing education to the older adult client? 1. Teach from books only and remain calm. 2. Remain calm and conduct the teaching session in a quiet environment. 3. Teach in a monotone voice in a quiet environment. 4. Avoid the use of colorful materials and keep the session short.

2. Remain calm and conduct the teaching session in a quiet environment

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response? 1. Proceed with teaching about the decongestant. 2. Reteach the length of time to take the prescription. 3. Ask the client to restate the teaching that was provided. 4. Tell the client to take the antibiotic until symptoms subside.

2. Reteach the length of time to take the prescription

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? 1. Tell the client how to move the walker as the client ambulates. 2. Describe how the walker can improve the client's quality of life. 3. Explain how the walker supports the client's lower extremities. 4. Fully discuss the rationale for using the walker.

2. describe how the walker can improve the client's quality of life

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? 1. Inform the client that the data are not correct. 2. Validate the questionable data. 3. Disregard the questionable data. 4. Inform the physician of the questionable data.

2. validate the questionable data

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data? 1. At the end of the data-gathering process 2. In the middle of the data-gathering process 3. Both during the collection and at the end of the collection 4. During the collection of data only

3 both during the collection and at the end of the collection

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? 1. "Osteoarthritis in my knees may be because of my weight." 2. "I can lower my blood pressure by losing weight." 3. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week." 4. "I can monitor my caloric intake by measuring portions."

3. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week"

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? 1. Implementation 2. Planning 3. Assessment 4. Diagnosis

3. Assessment

Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease? 1. Psychosocial development 2. Motor development 3. Intellectual development 4. Emotional maturity

3. Intellectual development

Which statement best conveys the role of intuition in nurses' problem solving? 1. In experienced nurses, intuition can be a valid replacement for scientific problem solving. 2. Intuition is an unreliable mode of thinking that should be avoided. 3. Intuition can be a clinically useful adjunct to logical problem solving. 4. Intuition is reliable when those nurses implementing it have a special "gift."

3. Intuition can be a clinically useful adjunct to logical problem solving

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? 1. The nurse decides to turn the client every 4 hours because everyone is too busy to help. 2. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. 3. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. 4. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help.

3. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care

An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will: 1. exercise every day for at least 30 minutes. 2. only eat three meals per day. 3. create an exercise plan that is realistic and valued. 4. stop eating meat and walk every day after dinner.

3. create an exercise plan that is realistic and valued

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? 1. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. 2. Do not allow the client to review the client's own nursing diagnoses. 3. Prioritize the nursing diagnoses. 4. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return.

3. prioritize the nursing diagnoses

The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education? 1. The client will demonstrate improved coping skills. 2. The client will have restoration of breast function. 3. The client will be able to perform proper breast self-examination for breast cancer detection and prevention. 4. The client will demonstrate self-efficacy and improved body image.

3. the client will be able to perform proper breast self-exam for breast cancer detection and prevention

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client? 1. Ask if the client would like the door opened or closed when finished 2. Concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time 3. Point out potential nursing care plan goals while assessing 4. Explain the nurse will need to touch the client during the assessment

4 Explain the nurse will need to touch the client during the assessment

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client? 1. Hunger 2. Sleepiness 3. Low anxiety 4. Pain

4 pain

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices? 1. "How many sexual partners have you had in the past 6 months?" 2. "Do you use condoms?" 3. "Are you in a committed relationship?" 4. "How do you protect yourself when having sex?"

4. "How do you protect yourself when having sex?"

The nurse is teaching a client with diabetes how to inject daily insulin. Which method is most effective in evaluating the teaching? 1. Ask the client to repeat the steps of injection in order. 2. The nurse uses a brochure to explain how to give an injection. 3. Provide a teaching session that includes a question and answer discussion. 4. Ask the client to demonstrate how to self-inject the morning insulin.

4. Ask the client to demonstrate how to self-inject the morning insulin

Which statement regarding critical thinking in nursing is true? 1. It makes judgments based on conjecture. 2. It shows trends and patterns in client status. 3. It supplies validation for reimbursement. 4. It is a systematic way of thinking.

4. It is a systematic way of thinking

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? 1. Clinical reasoning 2. Reflection 3. Experience 4. Nursing process

4. Nursing process

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning? 1. Affective 2. Psychomotor 3. Interpersonal 4. Cognitive

4. cognitive

A nurse is caring for an older adult client with arthritis. Which action is the priority for the nurse when conducting the health education for the client? 1. Divide information into manageable amounts. 2. Identify how long the education session will last. 3. Provide an environment that promotes learning. 4. Find out what the client wants to know.

4. find out what the client wants to know

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? 1. Self-actualization 2. Love and belonging 3. Self-esteem 4. Safety and security 5. Physiologic

4. safety and security

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? 1. The client demonstrates proper technique for injecting insulin. 2. The client expresses a desire to improve nutritional intake and lose weight. 3. The client prepares the skin for the administration of an insulin injection. 4. The client describes signs and symptoms of hypoglycemia.

4. the client describes s/s of hypoglycemia

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? 1. Previous experiences have little impact on learning. 2. The material presented should focus on future application. 3. Peer group acceptance is a critical issue for this age group. 4. Their readiness to learn is often related to a developmental task or social role.

4. their readiness to learn is often related to a developmental task or social role

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? 1. Reassess the client's temperature in 2 hours and chart this data. 2. Inform the unlicensed assistive personnel to document the finding. 3. Verbally report the finding to the charge nurse at the change of shift. 4. Verbally report the finding immediately to the client's physician.

4. verbally report the finding immediately to the client's physician