Midterm Review Fundamentals
The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water?
10-20 Minutes
The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus injury?
2
The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath?
20-30 Min
A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks?
20-30 minutes
A nurse is caring for a neonate who weighs 7 lb 3 oz at birth. What should the infant's weight be at 1 year?
20lbs 9oz
A newborn baby weighs 7 lb at birth. What does the nurse anticipate the baby's weight will be at 1 year of age?
21 lb
The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?
3 seconds
What is the average resting respiratory rate for a 12-month-old child?
30 breaths/min
The 125-lb nurse is preparing to lift a heavy object. What is the maximum amount of weight considered safe for the nurse to lift?
50 pounds
All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?
53-year-old admitted with a perforated ulcer
The mother of a 5-month-old child is concerned because the child cannot sit by himself. The nurse explains that sitting alone is not expected until the baby reaches what age?
7 months
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:
90 degrees
What should the water temperature be when preparing a tepid bath for a patient?
98.6F
The nurse is transporting a patient in respiratory isolation to the radiology department. What intervention should the nurse implement?
Apply a mask to the patient
What contribution did Joseph Lister introduce to medical practice?
Aseptic technique
How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter?
At least twice a day
Which family pattern is least open to outside influence?
Autocratic family pattern
A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
Bacterial Infection
What should the nurse do to protect his or her back when lifting or moving a patient?
Bending knees and hips
A health care provider documents that a patient has a scleral icterus. What is the cause of this coloring?
Billirubin
What theory claims that there is a hereditary basis for aging?
Biological programming theory
What basic philosophy in the United States is relevant to health care?
Biomedical therapy
A 14-year-old male patient has undergone a leg amputation. What should be the primary focus of the patient's care plan?
Body Image
During a physical assessment, the nurse notes that a patient's heart rate is 56 beats/min. What should the nurse document that the patient is experiencing?
Bradycardia
How does an interdisciplinary approach to patient treatment enhance care?
By preventing the fragmentation of patient care
What organization, established during World War II, provided nursing education and training?
Cadet Nurse Corps
The nurse spends a great deal of time in the room of a dying 12-year-old because the nurse knows that most children are aware of their condition and want the nurse to do which of the following?
Care about them
What should a medical record provide for all health care providers? (Select all that apply.)
Care given to the patient A patient's medical problems The patient's response to treatment Care planned for the patient
Where should the nurse place the load when carrying heavy objects?
Close to the body's midline
Auscultating the heart sounds should result in a "lub-dup" sound when using the bell and the diaphragm of the stethoscope. What causes the "lub" sound?
Closing of AV valves
A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area?
Collapse of blood vessels
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
Complains of chest pains
A nurse assessing a toddler should consider which finding abnormal?
Cyanotic nail beds
During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
Data clustering
What is the final stage of human growth and development?
Death
An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?
Dehydration
Upon being told of her father's death, the daughter cries out, "No! Oh, God, no!" What stage of grief is the daughter in?
Denial
Which is an example of a medical diagnosis?
Diabetes
Which theory of aging suggests that there should be a natural withdrawal between the individual and society?
Disengagement theory
What technique should the nurse use when disposing of linens contaminated with feces?
Don gloves only
During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated?
During inspiration
A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing?
Dyspnea
A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?
Dyspnea
What are some characteristics that cultures have in common? (Select all that apply.)
Economic practices Family systems Transportation systems Economic practices Survival modes
When assessing factors that may influence the patient's pulse rate, what should the nurse take into consideration? (Select all that apply.)
Emotion Age Sex Temp
The nurse is preparing an Orthodox Jewish patient's tray during Passover. What intervention is appropriate for this patient?
Encourage time for prayer
Which are true regarding communicating while using eye contact? (Select all that apply.)
Extended eye contact can lead to heightened anxiety. Making eye contact generally indicates an intention to interact. Extended eye contact can imply aggression. Eye contact is responsible for much communication
A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require?
Focused
What type of assessment is performed continuously throughout nurse-patient contact?
Focused
Which health belief system is commonly referred to as "third-world" beliefs and practices?
Folk health belief system
According to Piaget, what is the cognitive developmental level of the adolescent?
Formal Operational Stage
A child who is able to use a systematic, scientific problem-solving approach is in which of the Piaget's stages of cognitive development?
Formal operational thought
Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?
From the inner toward the outer canthus
What must the nurse do before applying a safety reminder device (SRD)?
Get a health care provider's order
The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about?
Hand hygiene
What should the nurse be diligent in to provide a safe environment for the patient?
Hand hygiene between patient contacts
What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?
Have a clinical reason for reading the record
A nurse is caring for an Orthodox Jewish woman immediately after she has given birth. What can the nurse expect regarding the spouse's participation in his wife's care?
He will avoid physical contact with the patient
The LPN/LVN assists a patient into the semi-Fowler's position per health care provider order. What would indicate that this patient is in the correct position?
Head of bed is at a 30-degree angle
A nurse is performing an admission assessment on a patient with suspected tuberculosis. What assessment findings by the nurse are consistent with tuberculosis?
Hemoptysis
What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person?
Holistic health care
If the nurse aggressively says to a patient, "Why couldn't you have asked me to give you your pain medication when I was in here earlier?" What feeling is the patient most likely to demonstrate?
Humiliation and worthlessness
What is an example of an appropriate Patient problem?
Impaired skin integrity
Which is an example of a patient problem?
Impaired skin integrity
What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.)
Incorrectly recording the time of an event Documenting an incorrect date Charting events in advance Failing to record verbal orders
The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
Informed consent
How will the nurse correctly replace a patient's dentures after cleaning?
Inserting the top first
Who is the legal owner of the patient's medical record?
Institution
Why is documentation especially significant in managed care?
Institutions are reimbursed only for patient care that is documented
A disaster situation occurs and involves an explosion in a hospital laundry. What would this be classified as?
Internal
What does documentation of type of care, time of care, and signature of the person prove?
Interventions were implemented to meet the patient's needs
A mother asks the nurse when she should introduce solid foods into her infant's diet. What would be the most correct response?
Introduce only one new food at a time
When assessing a patient, the nurse notes a yellow tinge to the patient's skin. How should the nurse document this finding?
Jaundice
Which of the following measures would be included in a teaching plan to instruct new parents on reducing the incidence of sudden infant death syndrome?
Keep an infant's room well ventilated
What action exemplifies a nurse practicing medical asepsis in performing daily care?
Keeping bed linens off the floor
Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?
Leaving a copy of the patient's history and physical in the photocopier
A health care provider needs to insert a vaginal speculum into a patient for a vaginal examination. In what position should the nurse place the patient?
Lithotomy
When assessing a patient with hepatitis, the nurse notes a yellow tinge to the patient's skin. What does the nurse understand as the most likely cause of the jaundice?
Liver
When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
Logging off
What is the site of the most common strain injury acquired by the nurse when working?
Lumbar muscle group
What would be the best method for a literate, English-speaking patient on a ventilator to communicate his or her needs?
Magic slate or paper and pencil
How may a nurse caring for a pediatric patient best be perceived as nonthreatening?
Maintaining an open posture
What are some characteristics of microorganisms? (Select all that apply.)
May be infectious Pathogens that cause disease Involved in a life process of their own Can enter the body via skin, air, or blood
A 53-year-old woman complains of night sweats and mood swings. The nurse recognizes that these symptoms most likely relate to which condition?
Menopause
A patient requests a consultation between the health care provider and a religious leader known as an Imam. What is this patient's cultural belief?
Muslim
What should the nurse begin by assessing when performing a head-to-toe assessment?
Neurologic
When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?
Neurologic Assessment
The nurse is preparing to bathe a patient. What should the room temperature be set at?
No cooler than 68°F (20°C)
A nurse communicates with a patient by maintaining eye contact and through the use of touch. What type of communication technique is the nurse demonstrating?
Nonverbal
A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?
Normal Pulse
What essential part of the admission procedure is performed by the RN?
Obtaining a health history
How can a family best assist a toddler who is attempting to feed himself?
Offer the child finger foods
If a patient has an order for an interagency transfer, where does the nurse explain that the patient will be moved?
One facility to another
A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital?
Only offers protection while on duty
What should a nurse do when encountering a mercury spill?
Open any outside windows
What is the stage of family development that begins at the birth or adoption of the first child?
Parenthood stage
What is the termination of tube feedings to a dying patient considered?
Passive euthanasia
What is the basis for designing and selecting nursing interventions to meet patient needs?
Patient problem
What does the nurse use as a basis for documentation in focus charting?
Patient problems
What is the family pattern in which the male usually assumes the dominant role and functions in the work role, controls the finances, and makes most of the decisions?
Patriarchal family pattern
What is the process used to appraise the practice of an individual nurse known as?
Peer review
During a head-to-toe assessment, the nurse assesses the patient's abdomen. Which area should the nurse assess next?
Perineal
According to Maslow's hierarchy of needs, what is an individual's most basic need?
Physiologic
The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.)
Place bath blanket over patient on top sheet. Remove spread and blanket separately. Position patient to far side of bed.
The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim?
Poison control center
A nurse is standing at the bedside with the patient lying in bed. What can the nurse be construed as demonstrating?
Power
A 5-year-old who has an imaginary friend with whom he converses frequently is displaying characteristics consistent with which of Piaget's stages of cognitive development?
Preoperational stage
A child who has just begun to demonstrate egocentric thinking is in which of the Piaget's stages of cognitive development?
Preoperational thought
A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 96°F (35.5°C)?
Record the findings
A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified?
Registered nurse
A nurse instructing a group of parents about safety rules for infants and young children should include which of the following measures in the teaching plan?
Remove plants from the child's reach
A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement?
Remove the patient from the sitz bath and return to bed
A nurse is caring for a patient who is a Latter-Day Saint. The nurse is aware members of this faith may wear sacred undergarments. What intervention is appropriate for the nurse caring for this patient?
Remove the undergarments in emergency situations only
The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings?
Spend extra time with the patient
Which of the five aspects of human functioning must a nurse address when dealing with a grieving person? (Select all that apply.)
Spiritual Physical Intellectual Emotional
What bacteria can lie dormant when conditions for growth are not favorable?
Spores
What is the most dependable and practical method to use when sterilizing instruments for the operating room?
Steam under pressure
What is the term for a generalization about a form of behavior, an individual, or a group?
Stereotype
What is a method used to kill all microorganisms, including spores?
Sterilizing
The nurse from New York City is caring for a patient from Atlanta, Georgia. What difference between the nurse and patient may cause them to experience difficulty in communicating?
Subculture
As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?
Symptoms
What is true about the use of silence in therapeutic communication? (Select all that apply.)
The ability to use silence effectively requires skill and timing Prolonged periods of misunderstood silence can cause tension Maintaining silence is an effective therapeutic communication technique
A nurse is caring for the dying mother of a 7-year-old child. What is important for the nurse to understand regarding the child?
The child associates death with aggression
Which of the following must the nurse recognize regarding the health care delivery system?
The major goal is to achieve optimal levels of health care
The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient?
The need for some type of exercise
What is true about nurse practice acts?
The nurse must know the nurse practice act within his or her state.
During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
The patient is short of breath on exertion
Which of the following would lead the home health nurse to make a patient problem of unresolved grief for a patient who was widowed 5 months ago?
The patient said tearfully, "I can't believe he is gone."
The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM?
The point of pain
A nurse instructs a unlicensed assistive personnel about moving older adult patients in bed. When should the nurse intervene when observing the unlicensed assistive personnel perform a return demonstration?
The unlicensed assistive personnel is pulling the patient across bed linens
A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding?
Thready Pulse
The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted?
Through inhalation of the spores
The health care provider orders a patient to be placed in the reverse Trendelenburg's position. How should the nurse place the bed?
Tilted with the foot of the bed down
A health care provider orders a patient to be placed in the Trendelenburg's position. How will the nurse position the bed?
Tilted with the head of the bed down
What is the purpose of QA (quality assurance)?
To evaluate care results against accepted standards
The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation?
To follow the order
Culture varies from patient to patient. Why is it important that the nurse understand and accept each person as an individual?
To provide holistic care
One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene?
To stimulate appetite
A patient does not speak English; therefore, the nurse cannot use words to provide comfort during a painful procedure. What is another intervention that may provide comfort to this patient?
Touch
What type of fire extinguisher should the nurse use when the oxygen concentrator machine malfunctions and causes an electric fire?
Type C
How can the nurse demonstrate warmth and acceptance when listening to a patient?
Uncrossing her arms
How may a newly licensed LPN/LVN practice?
Under the supervision of a health care provider or RN
A nurse instructs a unlicensed assistive personnel about the proper use of a gait belt and is observing a return demonstration. What action by the unlicensed assistive personnel should cause the nurse to intervene?
Unlicensed assistive personnel is walking on the patient's strong side
When speaking to a person of a different culture, how should the nurse consider modifying his or her communication style? (Select all that apply.)
Use of touch Use of eye contact Reference of address Meaning of gestures
What implementation might the nurse use to improve safety during a transfer?
Using a transfer belt
A nurse teaching the mother about infant oral hygiene instructs the mother to offer the infant sips of:
Water
The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse?
With hold your opinion
A young nurse caring for a dying patient hastens through the care and leaves the room as quickly as possible. What common reaction to the care of the dying is the nurse exhibiting?
Withdrawal
The nurse is caring for an African-American patient. Who would the nurse expect to be the primary decision maker in the patient's family?
Women
How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula?
at least every 8 hours
A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:
malpractice
A patient states, "My husband has told me how he feels about my having a mastectomy." The nurse nods and says, "Go on." This is an example of:
minimal encouraging
The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.)
sensation pain skin temp color
What is a patient problem considered when a problem is suspected but data to support it are lacking?
A possible patient problem
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
Complains of pruritus
What is a set of learned values, beliefs, customs, and practices shared by a group?
Culture
What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources?
Diagnosis-related groups
Which are acceptable secondary sources for data? (Select all that apply.)
Diagnostic reports Family members Textbooks Other health professionals
During a physical assessment, the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing?
Diaphoresis
When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include? (Select all that apply.)
Diet Family history of illness Smoking Exercise
What makes home health care documentation unique?
Different health care providers need access
When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?
Discuss it with the charge nurse, asking for direction
A nurse assessing a 4-month-old infant would expect the infant to do which of the following?
Hold head at a 90-degree angle while prone
During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.)
Invasion of privacy HIPPA Violation
A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse's actions exemplify?
Malpractice
What is the term used to describe cultures in which women make decisions about health care and provide the care and discipline to the children?
Matriarchal
What is the family pattern in which the female assumes primary dominance in the areas of childcare and homemaking, as well as financial decision making?
Matriarchal family pattern
A nurse tells a patient, "This PM you are going for an abdominal A&P, an H&H, as well as an IV pyelogram. Please sign these consent forms." What may this use of medical jargon cause?
Misinterpretation
What is the title of the American Hospital Association's 1972 document that outlines the patient's expectations to be treated with dignity and compassion?
Patient's Bill of Rights
What is the documentation format that uses the acronym SOAPE?
Problem-oriented
What fundamental principle must the nurse first observe when confronted with an ethical decision?
Respect for people
What is known as the last stage in the life cycle?
Senescence stage
What does the nurse recognize as the initial step in conducting an assessment of a patient?
The nursing health history
During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
The patient complains of generalized discomfort
A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?
Variance
A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?
The patient expectorates red-tinged sputum
During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
The patient is jaundiced
During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
The patient is pacing back and forth while chanting
The infection control officer is observing hospital staff for appropriate use of aseptic technique. What observation demonstrates the need for more instruction on surgical asepsis?
Touching the edge of a sterile field with sterile gloves
What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased?
Transferring
What important safety precaution should the home health nurse teach parents in order to prevent burns to small children?
Turn pot handles on stoves away from reach
A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?
Weak Pulse
What organized approach might the nurse use when performing a complete physical examination?
A head-to-toe assessment
What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital? (Select all that apply.)
Assign only female staff to care for her. Allow privacy for prayer. Keep her head and extremities covered as much as possible.
The nurse is caring for a Muslim patient. What dietary selection should the nurse serve to this patient?
Chicken and rice NO PORK
The nurse tells a mother that the blueprint for all inherited traits, such as height, is found in which of the following?
Chromosomes
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
Complains of diplopia
When a nurse protects the information in a patient's record, what ethical responsibility is the nurse fulfilling?
Confidentiality
During a physical assessment, the patient complains of difficulty in passing stools. What should the nurse document that the patient is experiencing?
Constipation
Which theory of aging suggests that previously developed coping abilities and the ability to maintain previous roles and activities are critical to adjustment to old age?
Continuity theory
What type of body temperature remains relatively constant?
Core
During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing?
Coughing
A nurse working in a long-term care facility is admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer's disease. What should this nurse take into consideration when caring for the resident? (Select all that apply.)
Cultural background has an important role in determining the resident's status Home remedies may have value even if harmful
When a nurse informs a patient's spouse that the patient has died, the spouse states, "You must be mistaken." Which of Kübler-Ross's stages of dying is the spouse demonstrating?
Denial
What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination?
Designated as "pass"
Which are considered phases of the nursing process? (Select all that apply.)
Diagnosis Outcome identification Assessment Evaluation Implementation
The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient?
Diamond position
What stage of family development involves the grown children departing from home?
Disengagement stage
What will the nurse implement when an error is made when documenting in a patient's chart?
Draw a single line through the error
The health care provider orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.)
Encourage patient to void before being weighed Weigh patient at the same time each day Ensure same amount of clothing is worn by patient
What is the stage of family development that begins when the couple acknowledges that they are considering marriage?
Engagement/commitment stage
What is an important consideration when developing the care plan?
Ensure the patient is involved in the process
The nurse informs a group of college students that young adults will face which challenges in this particular time of life? (Select all that apply.)
Establishing intimacy Relations with extended family Job security Selecting housing Starting a family
What is the stage of family development that extends from the wedding until the birth of the first child?
Establishment Stage
A nurse examines whether patient interventions have been appropriate and expected outcomes have been met. The nurse is demonstrating which step in the nursing process?
Evaluation
When assessing the home for fall risks and increased safety for an 85-year-old, what should be a suggestion of the home health nurse?
Excess furniture be removed
Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds?
Holistic health belief system
What additional complication does a disease caused by a virus have compared to a disease caused by bacteria?
Is not killed by antibiotics
How is a durable power of attorney helpful to an incapacitated patient?
It directs an agent to make health care decisions
Changes in health care reimbursement measures have resulted in which of the following changes regarding care of the terminally ill?
More patients die at home
The nurse discovers during the intake assessment of a 5-year-old child that the child lives with his biological parents and siblings. How would the nurse categorize this family type?
Nuclear family
What document identifies the roles and responsibilities of the LPN/LVN?
Nurse Practice Act
An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention?
Nurse practice act
The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care. What is this legally binding situation?
Nurse-patient relationship
What type of disease results in a structural change in an organ that interferes with its functioning?
Organ Disease
Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection?
Prodromal
Separation anxiety includes which stages? (Select all that apply.)
Protest Despair Detachment
What type of organism causes malaria?
Protozoan
What is the best way for a nurse to avoid a lawsuit?
Provide compassionate, competent care
The nurse is delivering a meal tray to a female Muslim patient. What intervention is most appropriate for this patient?
Providing her with a female nurse
When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratches frequently. How should the nurse document this finding?
Pruritus
How can the medical record be used in litigation? (Select all that apply.)
Public record Documentation of time lapses Evidence of omission of care Proof of adherence to standards
A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?
Pulse deficit
The patient should be assessed as soon as possible after admission. Who performs this initial assessment?
RN
An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action?
Report the bruises to the charge nurse
If in response to the patient statement, "I am upset about all this lab work" the nurse responds, "You're upset?" What is this is an example of?
Restating
The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method?
Review of symptoms
There are four categories of factors that increase an individual's vulnerability to develop a disease: genetic, physiologic, age, and lifestyle. What is the term for these factors?
Risk Factors
The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem that may increase because of the use of SRDs? (Select all that apply.)
Risk for impaired circulation Immobility Risk for skin impairment Incontinence
What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient?
Rubor and edema appear around the wound
What is classified as information provided by the family when a patient is unable to provide data during assessment?
Secondary
A nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse?
She is feeling hurried
The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective?
Sign
What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques?
Silence
A nurse needs to auscultate a patient's lung sounds. In what position should the nurse place the patient?
Sitting
When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. How should the nurse document this finding?
Skin Pallor
A person can spread a bacterial infection by which actions? (Select all that apply.)
Sneezing at work Leaving used tissue on the lavatory Kissing others
Where can a nurse refer the family of a patient to find a source of financial aid to meet medical expenses?
Social Services
Which nursing intervention is complete and correct?
"Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse"
A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesics. What statement would be an example of the nurse demonstrating aggressive communication?
"I will only medicate you every 4 hours."
When a mother asks the nurse about introducing solid foods into the child's diet, which of the following would be the best answer?
"Introduce one solid food at a time several days apart."
Which question below is open-ended?
"What are you most looking forward to in Europe?"
Although the patient denies pain, the nurse observes the patient breathing rapidly with clenched fists and facial grimacing. What is the nurse's best response to these observations?
"What you are saying and what I am observing don't seem to match."
The patient complains of generalized discomfort
. Ethnic stereotypes
Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?
. RN
The nurse recognizes that during the first 5 months of life, an infant is expected to gain approximately how many pounds per month?
1.5
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema. When did the edema disappear?
10-15 seconds
What is the leading cause of injury and death among infants and young children?
Accidents
The nurse is sitting in a chair near the patient's bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating?
Active listening
Which theory of aging suggests that the older person who is more socially active is more likely to adjust well to aging?
Activity Theory
The home health nurse assesses that the goal of grief resolution has been accomplished when the nurse observes that a widow has performed which activities? (Select all that apply.)
Adjusted to an environment without the spouse Sought new relationships
How should the nurse assist the patient with moving when pain is anticipated?
Administer medication before ambulation
What role is the nurse who diligently works for the protection of patients' interests playing?
Advocate
A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.)
Aging tends to result in loss of flexibility and joint mobility The skin of older adults is more fragile and susceptible to injury Older adults sometimes become fearful when hydraulic lifts are used for transfers
Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law?
American Hospital Association's Patient's Bill of Rights
The emergency department nurse is assessing a puncture wound of the foot. What is the most likely type of infection in this wound?
Anaerobic bacterial infection
During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing?
Anorexia
A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective?
Appears to be anxious
A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for:
civil battery
When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.)
Apply cuff snuggly Apply approx 2 inches above the antecubital fossa
What is a nursing program considered when certified by a state agency?
Approved
The nurse considers the feelings and needs of a patient by stating, "I know you are concerned about your surgery tomorrow. How can I help you?" What type of communication is this?
Assertive
What should the nurse do before approaching a grieving family member?
Assess level of resolution
What premise is Maslow's hierarchy of needs based on?
Basic needs must be met before the next level of needs can be met