N300 Exam 3

An 82-year-old man tells the nurse that he is having difficulty hearing and that he has "too much earwax." Considering the patient's age, which question would the nurse ask? -"Have you ever experienced impacted earwax?" -"Do you have an upper respiratory infection?" -"Do you swim in a pool with chlorinated water?" -"Have you noted a change in the color of the earwax?"

"Have you ever experienced impacted earwax?"

Which question would the nurse ask as part of the CAGE questionnaire? -"Have you ever argued with your partner after drinking alcohol?" -"Have you ever been hurt or wounded as a result of your drinking?" -"Have you ever felt bad or guilty about your drinking or drug use?" -"Have you ever used or had a drink to get rid of stress and worries?"

"Have you ever felt bad or guilty about your drinking or drug use?"

After the birth of a baby, a divorced mother is finding it difficult to care for the baby and work at the same time. Which question would the nurse ask the patient during the crisis assessment? -"Do you know that you are in a situational crisis?" -"What does your husband do?" -"How is your work and responsibility as a mother affecting your life?" -"Where is your husband now? Why didn't you bring him along?"

"How is your work and responsibility as a mother affecting your life?"

After a health care provider informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. Which response would the nurse provide first? -"Don't be sad. People live with cancer every day." -"Have you thought about how you are going to tell your family?" -"I can sit with you for a while if you would like to talk." -"I know another patient whose colon cancer was cured by surgery."

"I can sit with you for a while if you would like to talk."

A 62-year-old male patient has just been told he has a terminal illness. Which statement indicates that the patient is spiritually distressed because of the diagnosis of terminal illness? -"I have nothing to live for now." -"What will happen to my wife when I die?" -"How much longer do I have to live?" -"I need to go to church and pray for a miracle."

"I have nothing to live for now."

Which statement made by the student nurse to the registered nurse indicates a correct understanding of beneficence? -"Avoidance of harm or hurt is beneficence." -"Support of a particular cause is beneficence." -"Agreement to keep promises is beneficence." -"Taking positive actions to help others is beneficence."

"Taking positive actions to help others is beneficence."

A visually impaired patient presents to the clinic with knee pain. The nurse decides to assess the patient's visual sphere. Which question would the nurse include? (Select all that apply.) -"What problem do you have with your vision?" -"Do you use any device to correct your vision?" -"Do you often ask people to repeat what they said?" -"Have you tried to correct your vision?" -"Have you ever felt a ringing in the ear?"

-"What problem do you have with your vision?" -"Do you use any device to correct your vision?" -"Have you tried to correct your vision?"

A home health patient reports frequent episodes of flatulence. Which sign and/or symptom would the nurse expect the patient to report? (Select all that apply.) -Abdominal fullness -Pain -Cramping -Loose watery stools -Involuntary passage of stools

-Abdominal fullness -Pain -Cramping

What are the characteristics of quality documentation?

-Accurate -Detailed -Timely -Precise measurements -Correct spelling -Proper use of abbreviations

What are the three safeguards for protected health information (PHI) that nurses must understand understand and be able to implement?

-Administrative -Physical -Technical

The nurse is obtaining a spiritual history from a patient admitted with renal failure. Which factor influences a patient's spirituality? (Select all that apply.) -Age -Gender -Culture -Religion -Education

-Age -Gender -Culture -Religion -Education

Which common response is associated with general adaptation syndrome (GAS)? (Select all that apply.) -Alarm -Resistance -Exhaustion -Helplessness -Intrusive recollection

-Alarm -Resistance -Exhaustion

Which stage encompasses general adaptation syndrome (GAS)? Select all that apply. -Alarm reaction -Resistance -Appraisal -Crisis -Exhaustion

-Alarm reaction -Resistance -Exhaustion

Which factor may contribute to a patient's fatigue and insomnia from abusing alcohol? (Select all that apply.) -Nightmares -Slow onset of sleep -Awakening often during sleep -Inability to fall asleep -Reduced rapid eye movement sleep

-Awakening often during sleep -Reduced rapid eye movement sleep

Which physiological symptom is observed in the nurse who has a sleep disorder because of working rotating shifts? (Select all that apply.) -Blurred vision -Increased reflexes -Decreased judgment -Slowed response time -Increased visual alertness

-Blurred vision -Decreased judgment -Slowed response time

A victim of gang violence has a fight-or-flight response to an attack. Which change would the victim experience? (Select all that apply.) -Contracted pupils -Bronchiolar dilation -Increased respiratory rate -Decreased arterial blood pressure -Increased blood flow to the skeletal muscles

-Bronchiolar dilation -Increased respiratory rate -Increased blood flow to the skeletal muscles

The nurse, after administering antibiotics, is updating a patient's chart in the emergency department. Which element of the report does the nurse accurately document to limit nursing liability in case of a legal claim? (Select all that apply.) -Current medications given -Discontinued medications -Drug allergies -Name of drug manufacturer -Size, shape, and color of the pills

-Current medications given -Discontinued medications -Drug allergies

Healthcare informatics facilitates the integration of what four components?

-Data -Information -Knowledge -Wisdom to support patients, nurses, and other providers in decision making in all roles and settings

The nurse is teaching a patient about healthy bowel habits and includes which information? (Select all that apply.) -Laxatives should be used regularly. -Dietary fiber should be an essential component of the diet. -Fluid intake should be at least six to eight glasses of water per day. -Physical exercises should be avoided to prevent constipation. -Stress management techniques should be practiced.

-Dietary fiber should be an essential component of the diet. -Fluid intake should be at least six to eight glasses of water per day. -Stress management techniques should be practiced.

A patient is suffering from spiritual distress. Of which patient feeling would the nurse be aware? (Select all that apply.) -Doubt -Being cheated -Loneliness -Loss of faith -Desire to kill others

-Doubt -Loneliness -Loss of faith

Which outcome is expected after effective documentation? (Select all that apply.) -Reduction of the level of care required -Facilitation of proper insurance reimbursement -Efficient use of time -Enhanced continuity of care -Protection for the nurse from legal recourse

-Efficient use of time -Enhanced continuity of care -Protection for the nurse from legal recourse

A 45-year-old single mother lives with her 10-year-old son who has Down syndrome. The mother's facial expressions demonstrate fatigue and malaise. She has an unkempt appearance and has no interest in going out and meeting people. The nurse understands that the mother is experiencing caregiver role strain. Which finding noted by the nurse indicates caregiver role strain? (Select all that apply.) -Fatigue and malaise -Unkempt appearance -Lack of interest in socialization -The disease condition of the patient's son -Single motherhood

-Fatigue and malaise -Unkempt appearance -Lack of interest in socialization

Documentation in the electronic health record requires nurses to be skill in the use of what?

-Flow sheets -Narrative formats for recording patient information

Which statement describes the purpose of the incident report? (Select all that apply.) -Identifies loopholes in the operation of the health care system -Provides good, quality health care -Documents a patient's negative feedback related to the health care delivered -Determines the severity of the punishment to be delivered -Identifies the need to change a procedure or policy

-Identifies loopholes in the operation of the health care system -Provides good, quality health care -Identifies the need to change a procedure or policy

Which primary mode encompasses stress intervention? (Select all that apply.) -Increase the resistance to stress. -Identify the triggers to stress. -Isolate oneself from others to de-stress. -Decrease the number of situations that produce stress. -Learn skills to reduce the body's response to stress.

-Increase the resistance to stress. -Decrease the number of situations that produce stress. -Learn skills to reduce the body's response to stress.

Which response is a sign or symptom of the alarm reaction stage of general adaptation syndrome? (Select all that apply.) -Increased heart rate -Low blood pressure -Constricted pupils -Increased blood glucose levels -Increased mental alertness

-Increased heart rate -Increased blood glucose levels -Increased mental alertness

When caring for a patient who is suffering from a serious illness, the nurse encourages the patient to follow his or her spiritual practices. How does spirituality help in healing? (Select all that apply.) -Decreases the risk of infection in the patient. -Helps treat without any medication. -Increases the pain threshold of the patient. -Decreases stress and increases the immune response. -Reduces perception of pain and anxiety.

-Increases the pain threshold of the patient. -Decreases stress and increases the immune response. -Reduces perception of pain and anxiety.

Identify the measures to ensure safety for a patient who has no sensation on one side of the body.

-Instruct the patient to obtain proper foot sizing and not to wear tight shoes -Inspect feet to determine whether there are any pressure areas from shoes on the foot with limited sensation -Test the temperature of bath water with the hand or foot on the side of the body with sensation -Do not use heating pads or hot-water bottles on the affected side -Lie on the back or unaffected side -When sitting in a chair readjust weight off affected side or stand up and move around frequently (e.g., every hour or every 90 minutes). -Teach the patient and family how to assess skin on the affected side for breakdown or tissue injury.

Which statement about the lithotomy position is accurate? (Select all that apply.) -It helps detect murmurs. -It facilitates insertion of a vaginal speculum. -It is adopted for examination of female genitalia. -The patient is lateral with flexion of the hip and knee. -The patient is supine, while the legs are raised and knees flexed.

-It facilitates insertion of a vaginal speculum. -It is adopted for examination of female genitalia. -The patient is supine, while the legs are raised and knees flexed.

Which information is true about the large intestine? (Select all that apply.) -It is shorter than the small intestine. -It has no absorptive role. -It has a role in the elimination function. -It can develop hemorrhoids. -It has longitudinal muscles that prevent regurgitation.

-It is shorter than the small intestine. -It has no absorptive role. -It has a role in the elimination function. -It can develop hemorrhoids.

What are three key functions of the health care record?

-It provides a legal and financial record of care -It aids in clinical education and research -It guides professional and organizational performance improvement

Which action would the nurse take during inspection to get the best results? (Select all that apply.) -Make sure that adequate lighting is available. -Use a penlight or lamp to inspect body cavities. -Inspect each area for size, shape, color, symmetry, position, and abnormality. -Expose the patient completely for an easy inspection. -Check for side-to-side symmetry.

-Make sure that adequate lighting is available. -Use a penlight or lamp to inspect body cavities. -Inspect each area for size, shape, color, symmetry, position, and abnormality. -Check for side-to-side symmetry.

What information does the documentation for a safe plan for discharge include?

-Medications -Diet -Community resources -Follow-up care -Contact information for whom to call with questions or in case of an emergency

When treating a patient who is Muslim, which factor would the nurse keep in mind? (Select all that apply.) -Muslims consume alcohol in moderation. -Muslims do not eat pork. -Muslims do not pray 5 times a day. -Muslims do not eat meat on Fridays. -During Ramadan, Muslims eat only after sunset.

-Muslims do not eat pork. -During Ramadan, Muslims eat only after sunset.

The senior nurse is discussing with student nurses the serious reportable events included on the National Quality Forum (NQF) list. Which environmental event would be discussed? (Select all that apply.) -Physical assault of the patient -Patient death caused by burns from agency equipment -Patient death associated with falls -Sexual assault of the patient -Patient death caused by electrocution

-Patient death caused by burns from agency equipment -Patient death associated with falls -Patient death caused by electrocution

Which patient would be at high risk of hypothermia? (Select all that apply.) -Patients who have angina -Patients who are homeless -Patients who have kidney disorders -Patients who have taken drugs or alcohol in excess -Patients who are exposed to carbon monoxide

-Patients who have angina -Patients who are homeless -Patients who have taken drugs or alcohol in excess

Which measure would the nurse emphasize to prevent urinary infections in females? (Select all that apply.) -Proper handwashing -Use of indwelling catheters -Frequent sexual intercourse -Wiping from front to back after voiding and defecation -Adequate fluid intake

-Proper handwashing -Wiping from front to back after voiding and defecation -Adequate fluid intake

Which characteristic is an advantage of effective documentation? (Select all that apply.) -Repetition of therapy -Saving time -Minimizing error -Effective continuity of patient care -Omission of treatment

-Saving time -Minimizing error -Effective continuity of patient care

Which source is responsible for the formation of values in an individual? (Select all that apply.) -History books -Schools -Governments -Social institutions -Religious traditions

-Schools -Governments -Social institutions -Religious traditions

Which category constitutes the various forms of crises? (Select all that apply.) -Emotional -Situational -Adventitious -Psychological -Developmental

-Situational -Adventitious -Developmental

Which organization addresses the quality of health care documentation? (Select all that apply.) -American Nurses Association (ANA) -The Joint Commission -Diagnosis-related groups (DRGs) -National Committee for Quality Assurance (NCQA) -Health Insurance Portability and Accountability Act of 1996 (HIPAA)

-The Joint Commission -National Committee for Quality Assurance (NCQA)

A patient who has malabsorption syndrome asks the nurse about the process of nutrient absorption. Which response would the nurse give the patient? (Select all that apply.) -The ileum absorbs fats and bile salts. -The duodenum absorbs iron and vitamins. -The jejunum absorbs carbohydrates and proteins. -Nutrients are absorbed into the blood vessels. -Plant fiber undergoes absorption in the small intestine.

-The ileum absorbs fats and bile salts. -The jejunum absorbs carbohydrates and proteins. -Nutrients are absorbed into the blood vessels.

What is a cause of eye infections in patients who wear contact lenses? (Select all that apply.) -The use of homemade saline -Wearing lenses while driving -Wearing lenses while swimming -The use of lenses with reduced visual acuity -Contamination of the lens' storage cases

-The use of homemade saline -Wearing lenses while swimming -Contamination of the lens' storage cases

Which symptom is associated with carpal tunnel syndrome? (Select all that apply.) -Tingling -Weakness -Numbness -Blurred vision -Reduced taste sensation

-Tingling -Weakness -Numbness

A senior nurse is talking with student nurses about spirituality. Which conceptual element is included in spirituality? (Select all that apply.) -Transcendence -Faith and hope -Inner strength and peace -Meaning and purpose in life -Connectedness -Culture

-Transcendence -Faith and hope -Inner strength and peace -Meaning and purpose in life -Connectedness

The nurse is practicing according to the professional nursing code of ethics. Which action is in accordance with the standards of responsibility? (Select all that apply.) -Protecting the patient's right to privacy -Trying to remain competent to practice -Being responsible for delegated tasks -Being willing to respect professional obligations -Supporting the health, safety, and rights of the patients

-Trying to remain competent to practice -Being responsible for delegated tasks -Being willing to respect professional obligations

Which event might cause an adventitious crisis in a person? (Select all that apply.) -Tsunami -Earthquake -Childbirth -Death of a pet -Leg amputation

-Tsunami -Earthquake

The nurse finds that a patient is very sensitive to visual glare. Which appropriate nursing intervention is helpful for the patient? (Select all that apply.) -Use blinds on the windows. -Use a telescopic lens. -Use a pocket magnifier. -Wear sunglasses outside. -Use yellow or amber lenses.

-Use blinds on the windows. -Wear sunglasses outside. -Use yellow or amber lenses.

Which is the mode for exchanging information among members of the health care team? (Select all that apply.) -Pictures -A thesis -Written reports -Oral communication -Electronic cards

-Written reports -Oral communication

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain.

1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 4. "Children are able to receive palliative care."

Which statement made by the patient indicates an understanding of sleep-hygiene practices? 1. "I usually drink a cup of warm milk in the evening to help me sleep." 2. "If I exercise right before bedtime, I will be tired and fall asleep faster." 3. "I know it does not matter what time I go to bed as long as I am tired." 4. "If I use hypnotics for a long time, my insomnia will be cured."

1. "I usually drink a cup of warm milk in the evening to help me sleep."

Which statements from a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply.) 1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 3. "A short nap late in the evening will lead to a more restful night of sleep." 4. "I am going to start eating dinner closer to my bedtime" 5. "I will start to exercise regularly during the day."

1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 5. "I will start to exercise regularly during the day."

The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."

1. "I'll recognize abnormal lumps because they are very painful."

Match the following actions (1 through 4) with the terms (a through d) listed below: a. Advocacy b. Responsibility c. Accountability d. Confidentiality 1. You see an open medical record on the computer and close it so that no one else can read the record without proper access. 2. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the provider and your head nurse and follow agency procedure. 3. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider ab out the patient's request. 4. You tell your patient that you will return in 30 minutes to give him his next pain medication.

1. = d (Confidentiality) 2. = c (Accountability) 3. = a (Advocacy) 4. = b (Responsibility)

Which statements properly apply an ethical principle to justify access to health care? (Select all that apply.) 1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 3. Access to health care is a privilege in the United States, not a right. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics.

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient

1. Allowing the patient to discuss the experience

Identify each threat to safety as an individual risk factor or a developmental risk factor. 1. An older adult has limited finances. 2. A young toddler likes to explore objects by placing them in his mouth. 3. A 55-year-old patient has a residual gait change due to a stroke. 4. A school-age child chooses to play ice hockey. 5. A patient newly diagnosed with diabetes has low health literacy.

1. An older adult has limited finances. (INDIVIDUAL) 2. A young toddler likes to explore objects by placing them in his mouth. (DEVELOPMENTAL) 3. A 55-year-old patient has a residual gait change due to a stroke. (INDIVIDUAL) 4. A school-age child chooses to play ice hockey. (DEVELOPMENTAL) 5. A patient newly diagnosed with diabetes has low health literacy. (INDIVIDUAL)

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

1. Appearance and behavior

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.

1. Ask the patient about any allergies and reactions. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain

Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (Select all that apply.) 1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 3. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified. 5. Whether a person has a job is an objective measure, but it does not play a role in understanding quality of life.

1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified.

The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." After determining that the patient's hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply.) 1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 3. Demonstrate how to wash the earmold and microphone with hot water. 4. Discuss the importance of having wax buildup in the ear canal removed. 5. Recommend a chemical cleaner to remove difficult buildup.

1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 4. Discuss the importance of having wax buildup in the ear canal removed.

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial 2. Conversion 3. Dissociation 4. Displacement

1. Denial

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

1. Encourage involvement in nonthreatening group social activities. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (Select all that apply.) 1. Ethics of care pays attention to the context in which caring occurs. 2. Ethics of care is used only by nurses because it is part of the Nursing Code of Ethics. 3. Ethics of care requires understanding the relationships between involved parties. 4. Ethics of care considers the decision maker's relationships with other involved parties. 5. Ethics of care is an approach that suggests a greater commitment to patient care. 6. Ethic of care considers the decision maker to be in a detached position outside the ethical problem.

1. Ethics of care pays attention to the context in which caring occurs. 3. Ethics of care requires understanding the relationships between involved parties. 4. Ethics of care considers the decision maker's relationships with other involved parties.

Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel? (Select all that apply.) 1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient's room 4. Giving a patient a cup of coffee 5. Monitoring for the effect of the sleeping medication that was given

1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient's room

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately

1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately

A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) 1. Immediately phone in to the hospital alert system the exact location of the fire. 2. Direct the nurse technician to place empty stretchers behind the fire doors. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. 5. Close the room doors of patients who cannot get out of bed, and keep them in their rooms.

1. Immediately phone in to the hospital alert system the exact location of the fire. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms.

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.

1. Increase fiber and fluids in the diet. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day.

Which nursing intervention(s) best promote(s) effective sleep in an older adult? (Select all that apply.) 1. Limit fluids 2 to 4 hours before sleep. 2. Ensure that the room is completely dark. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers. 5. Encourage walking an hour before going to bed.

1. Limit fluids 2 to 4 hours before sleep. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers.

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1. Maintain regular bowel elimination. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back.

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.

1. Pay attention to the patient's spiritual identity throughout the course of her illness. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence.

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices

Match the fall prevention intervention with the scientific rationale. Fall prevention: 1. Prioritize nurse call system responses to patients at high risk. 2. Place patient in a wheelchair with wedge cushion. 3. Establish elimination schedule with bedside commode. 4. Use a low bed for patient. 5. Provide a hip protector. 6. Place nonskid floor mat on floor next to bed. Scientific rationale: A. Maintains comfort and makes exit difficult B. Makes it difficult for patients with lower extremity weakness to stand C. Reduces slipping when walking D. Reduces fall impact E. Ensures rapid response for help F. Reduces chance of patient trying to get out of bed on own

1. Prioritize nurse call system responses to patients at high risk. / ENSURES RAPID RESPONSE FOR HELP 2. Place patient in a wheelchair with wedge cushion. / MAINTAINS COMFORT AND MAKES EXIT DIFFICULT 3. Establish elimination schedule with bedside commode. / REDUCES CHANCE OF PATIENT TRYING TO GET OUT OF BED ON OWN 4. Use a low bed for patient. / MAKES IT DIFFICULT FOR PATIENTS WITH LOWER EXTREMITY WEAKNESS TO STAND 5. Provide a hip protector. / REDUCES FALL IMPACT 6. Place nonskid floor mat on floor next to bed. / REDUCES SLIPPING WHEN WALKING

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

1. Providing respect 2. Viewing the patient as a whole 4. Showing interest 5. Being present

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1. Referral to social service process reestablishing the child's disability payment 3. Coordinating hospital-based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection

A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) 1. Sharing information about senior transportation services 2. Reassuring the patient that loneliness is a normal part of aging 3. Maintaining distance while talking to avoid overstimulating the patient 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

1. Sharing information about senior transportation services 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.

1. Stop the instillation.

A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat a large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.

1. Take brief, 20-minute naps no more than twice a day. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.

Match each intervention for promoting child safety with the correct developmental stage: school-age child or preschooler. 1. Teach children proper bicycle and skate board safety. 2. Teach children how to cross streets and walk in parking lot. 3. Teach children proper techniques for specific sports. 4. Teach children not to operate electric toothbrushes while unsupervised. 5. Teach children not to talk to or go with a stranger. 6. Teach children not to eat items found in the grass.

1. Teach children proper bicycle and skate board safety. (SCHOOL-AGE) 2. Teach children how to cross streets and walk in parking lot. (SCHOOL-AGE) 3. Teach children proper techniques for specific sports. (SCHOOL-AGE) 4. Teach children not to operate electric toothbrushes while unsupervised. (PRESCHOOLER) 5. Teach children not to talk to or go with a stranger. (PRESCHOOLER) 6. Teach children not to eat items found in the grass. (PRESCHOOLER)

A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) 1. Teaching how activities such as reading and using crossword puzzles provide stimulation 2. Moving him to a room away from the nurses' station 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions 5. Providing auditory stimulation for the patient by keeping the television on continuously

1. Teaching how activities such as reading and using crossword puzzles provide stimulation 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions

The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical elements of this case? 1. The health care team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources. 2. The patient should enroll in a clinical trial of a new technology that can do the work of the liver, similar to the way dialysis treats kidney disease. 3. The social worker should look into enrolling the patient in Medicaid, since many states offer expanded coverage. 4. A family meeting should take place in which the details of the patient's poor prognosis are made clear to his family so that they can adopt a palliative approach.

1. The health care team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources.

Resolution of an ethical problem involves discussion with the patient, the patient's family, and participants from appropriate health care disciplines. Which statement best describes the role of the nurse in the resolution of ethical problems? 1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations 2. To study the literature on current research about the possible clinical interventions available for the patient in question 3. To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal views 4. To allow the patient and the physician private time to resolve the dilemma on the basis of ethical principles

1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations

The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer user name and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged in to a computer to save time if you only need to step away to administer a medication

1. Using a strong password and changing your password frequently according to agency policy 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care

While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. Tell me what your husband was like. 4. I know this must be hard for you. Let me tell you what might help. 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

How many hours of sleep are typically required to prevent fatigue in a 6-year-old child? -6 hours -8 hours -10 hours -12 hours

12 hours

Which patient is at higher risk of motor vehicle accidents according to the Centers for Disease Control and Prevention (CDC)? -2-year-old toddler -30-year-old young adult -55-year-old adult -16-year-old adolescent

16-year-old adolescent

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are better than prescription medications because prescription medications can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."

2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls."

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F).

2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F). 3. "I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis."

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church."

2. "I have nothing to live for now." 3. "Why would my God do this to me?"

The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? 1. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. 3. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours.

2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record.

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? 1. "I'll give the baby a bottle to help her fall asleep." 2. "We'll place the baby on her back to sleep." 3. "We put the baby's stuffed animals in the crib to make her feel safe." 4. "I know the baby will not need to be fed until morning."

2. "We'll place the baby on her back to sleep."

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents. 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her."

2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 4. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her." 3. "I'll have the doctor come out and talk to you as soon as possible." 1. "Can I contact someone to help you?"

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal.

2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary.

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry.

2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 5. Encourage the patient to eat whenever he or she is hungry.

When designing a plan for pain management for a patient follow- ing surgery, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. If the nurse's actions are driven by respect for autonomy, what aspect of this scenario best demonstrates that? 1. Assessing the patient's pain on a numeric scale every 2 hours 2. Asking the patient to establish the goal for pain control 3. Using alternative measures such as distraction or repositioning to relieve the pain 4. Monitoring the patient for oversedation as a side effect of his pain medication

2. Asking the patient to establish the goal for pain control

A postoperative patient with a three-way indwelling urinary cath- eter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.

2. Assess the patency of the drainage system. 3. Measure urine output.

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Establish a toileting schedule. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.

2. Establish a toileting schedule.

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2. Hanging the urinary drainage bag below the level of the bladder

A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.) 1. Walk one-half step behind and slightly to her side. 2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs. 4. Stand one step ahead of mom at the top of the stairs. 5. Place yourself alongside your mom and hold onto her waist.

2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs.

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.) 1. Slow, cautious behavioral style 2. Inattention and neglect, especially to the left side 3. Cloudy or opaque areas in part of the lens or the entire lens 4. Visual spatial alterations such as loss of half of a visual field 5. Loss of sensation and motor function on the right side of the body

2. Inattention and neglect, especially to the left side 4. Visual spatial alterations such as loss of half of a visual field

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.

2. Initiate bowel or habit training program to promote continence.

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.

2. Leave the catheter there and start over with a new catheter.

A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? 1. Allergy history 2. Medication history 3. Patient age 4. Patient's occupation 5. Physical exam of neuromuscular function

2. Medication history 3. Patient age 5. Physical exam of neuromuscular function

What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

2. Mottling

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

2. Palliative care is for any patient, any time, any disease, in any setting. 4. Palliative care relieves the symptoms of illness and treatment.

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply.) 1. Loss of autonomy caused by health problems 2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply.) 1. Give patients a cup of coffee 1 hour before bedtime. 2. Plan vital signs to be taken before the patients are asleep. 3. Turn television on 15 minutes before bedtime. 4. Have patients follow at-home bedtime schedule. 5. Close the door to patients' rooms at bedtime.

2. Plan vital signs to be taken before the patients are asleep. 4. Have patients follow at-home bedtime schedule. 5. Close the door to patients' rooms at bedtime.

Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.) 1. Always use a single cutting board to prepare foods for cooking. 2. Refrigerate leftovers as soon as possible. 3. Always buy vegetables in packages marked "prewashed." 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation.

2. Refrigerate leftovers as soon as possible. 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation.

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

2. Sit down and talk with the patient; have her discuss her feelings and listen attentively.

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

The home care nurse is instructing an assistive personnel about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply.) 1. Use of fluorescent lighting 2. Use of warm incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies 5. Indirect lighting to reduce glare

2. Use of warm incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies

What percentage of sleep time in young adults is rapid eye movement (REM) sleep?

20%

The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time:

2000

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) 1. "I'm going to learn to drive a car, so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3. "I'm going to let the occupational therapist assess my home to improve efficiency." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. "I feel refreshed when I wake up in the morning." 2. "I use soft music at night to help me relax." 3. "It takes me about 45 to 60 minutes to fall asleep." 4. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

3. "It takes me about 45 to 60 minutes to fall asleep."

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? 1. The amount of family support 2. A 3-day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3. A thorough physical assessment

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert 1⁄4 inch more.

3. Advance the catheter to the bifurcation of the drainage and

A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing

3. Bacon and eggs

9. Place the following steps for applying a wrist restraint in the correct order: 1. Pad the skin overlying the wrist. 2. Insert two fingers under the secured restraint to be sure that it is not too tight. 3. Be sure that the patient is comfortable and in correct anatomical alignment. 4. Secure restraint straps to bedframe with quick-release buckle. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.

3. Be sure that the patient is comfortable and in correct anatomical alignment. 1. Pad the skin overlying the wrist. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly. 2. Insert two fingers under the secured restraint to be sure that it is not too tight. 4. Secure restraint straps to bedframe with quick-release buckle.

When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation

3. Charting-by-exception (CBE)

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. Post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

3. Chronic illness 4. Insomnia 5. Depression

The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)

3. Clinical decision support system (CDSS)

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3. Collect one fecal smear from three separate bowel movements.

A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

3. Did either prayer or meditation prove helpful to you?

An older adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply.) 1. Talk to the patient at a distance so he or she may read your lips. 2. Keep your arms at your side; speak directly into the patient's left ear. 3. Face the patient when speaking; demonstrate ideas you wish to convey. 4. Position the patient so that the light is on his or her face when speaking. 5. Verify that the information that has been given has been clearly understood.

3. Face the patient when speaking; demonstrate ideas you wish to convey. 5. Verify that the information that has been given has been clearly understood.

The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? 1. Tell patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 5. Position patient's hand on back of chair.

3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 2. Walk at a relaxed pace. 1. Tell patient when you are approaching the chair. 5. Position patient's hand on back of chair.

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

3. Have the patient relax the foot while lying supine. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology? 1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action. 2. The single focus on power imbalances does not apply to all situations in which ethical problems occur. 3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. 4. The focus on consequences rather than on the "goodness" of an action makes decision makers uncomfortable.

3. In a diverse community it can be difficult to find agreement on

A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine whether her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise.

3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine whether her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise.

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) 1. Conducting a home-safety assessment and identifying hazards in the patient's living environment 2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Alerting other nurses and health care providers about patient's visual status during hand-off reports

3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Alerting other nurses and health care providers about patient's visual status during hand-off reports

The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.) 1. Ask the health care provider to order a restraint. 2. Recommend insertion of a urinary catheter. 3. Provide scheduled toileting rounds every 2 to 3 hours. 4. Institute a routine exercise program for the patient. 5. Keep the bed in high position with side rails down. 6. Keep the pathway from the bed to the bathroom clear.

3. Provide scheduled toileting rounds every 2 to 3 hours. 4. Institute a routine exercise program for the patient. 6. Keep the pathway from the bed to the bathroom clear.

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

3. Providing culturally and religiously sensitive care in body preparation

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

3. Report the time and amount of first voiding.

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

3. Respiratory rate of 8 breaths/min

A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) 1. A current safety inspection sticker is on the IV fluids pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.

3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.

The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient, observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."

3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.

Which measurement is in the normal range for the length of an adult female urethra? -2 cm -4 cm -15 cm -19 cm

4 cm

Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? 1. "My pain medicine helps me feel better." 2. "I know I will get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I feel so much closer to God after I read my Bible and pray."

4. "I feel so much closer to God after I read my Bible and pray."

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a colonoscopy every 2 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer."

4. "Tell me what you mean when you say you can't go on any longer."

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. 4. CPOE improves patient safety by reducing transcription errors.

4. CPOE improves patient safety by reducing transcription errors.

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

4. Have you experienced frequent, small liquid stools recently?

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

4. Insulin aspart 8u SQ every morning before breakfast

The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4. Lactose intolerance

What is the best response for the nurse to give if a patient asks the nurse to send a photo of an x-ray to him via a messaging tool in a social media site? 1. Yes, if you remove all patient identifiers before sending 2. No, because the patient's x-ray results should be discussed with a provider 3. Yes, because respect for autonomy means honoring this patient's request 4. No, because health information of any kind should not be shared on social media

4. No, because health information of any kind should not be shared on social media

A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? 1. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. 2. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking. 3. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. 4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient.

4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient.

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5. Drape patient with the sterile square and fenestrated drapes. 7. Prepare sterile field and supplies. 2. Lubricate catheter. 4. Cleanse urethral meatus with antiseptic solution. 1. Insert and advance catheter. 6. When urine appears, advance another 2.5 to 5 cm. 3. Inflate catheter balloon. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5. Remove the old pouch. 8. Cleanse and dry the peristomal skin. 7. Assess the stoma and the skin around it. 2. Measure the stoma. 6. Trace the correct measurement onto the back of the wafer. 3. Cut the hole in the wafer to fit around the stoma and not leave 4. Press the pouch in place over the stoma. 1. Close the end of the pouch.

Which time frame would be the approximate duration required by a person to resolve a crisis?

6 weeks

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia. During this hospitalization, the mother lost her entitlement check. After which time frame would the nurse expect the mother to regain stability? -2 weeks, when the child's pneumonia begins to improve -6 weeks, when she adjusts to the child's respiratory status and reestablishes the entitlement checks -1 month, when the child goes home and the mother gets help from a food pantry -6 months, when the child is back in school

6 weeks, when she adjusts to the child's respiratory status and reestablishes the entitlement checks

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 9. Elevate the head of the bed. 2. Collect any needed specimens. 5. Speak to the family members about their possible participation. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 3. Remove all tubes and indwelling lines. 1. Bathe the body of the deceased. 4. Position the body for family viewing. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control.

The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution? 1. List all the possible actions that could be taken to resolve the problem. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 3. Develop and implement a plan to address the problem. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 6. Recognize that the problem requires ethics.

6. Recognize that the problem requires ethics. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 1. List all the possible actions that could be taken to resolve the problem. 3. Develop and implement a plan to address the problem.

Which patient is most likely to experience sensory deprivation? -A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities -A 14-year-old girl isolated in the hospital because of severe immune system suppression -A hearing-impaired 66-year-old woman who lives in an assisted-living agency -A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

A 14-year-old girl isolated in the hospital because of severe immune system suppression

Which assessment finding does the nurse associate with a problem with bowel elimination? -A bowel movement every 5 days -Loose abdominal skin -Bowel sounds every 5 to 15 seconds -Absence of peristaltic waves on the abdomen

A bowel movement every 5 days

Which patient is likely to experience anticipatory grief? -A man diagnosed with gallstones -A teenager who fractured the left leg -An older adult diagnosed with a stage 1 pressure injury -A middle-age adult diagnosed with amyotrophic lateral sclerosis (ALS)

A middle-age adult diagnosed with amyotrophic lateral sclerosis (ALS)

The nurse reviews type of enemas and determines that a hypertonic solution enema is most appropriate for which patient? -An infant who is unable to defecate -A dehydrated patient who has constipation -A patient who cannot tolerate a large volume of fluid -A patient with a dangerously high serum potassium level

A patient who cannot tolerate a large volume of fluid

The nurse reviews the care of four patients and determines that which patient has the highest risk of constipation? -A patient who is taking antibiotics -A patient who is taking opioid analgesics -A patient who has undergone an endoscopy -A patient who drinks 1.5 L of fluids per day

A patient who is taking opioid analgesics

Which behavioral change would the nurse observe in an intimate partner violence (IPV) victim? -A sense of helplessness -Dependence on a caregiver -Underuse of health services -Preoccupation with others' or own genitals

A sense of helplessness

Which stage of dying, according to the Kubler-Ross theory, is reflected in the patient's statement, "I miss my partner. I will never get my partner back?" -Anger -Denial -Bargaining -Acceptance

Acceptance

Which type of loss is illustrated when a young adult loses a limb from diabetes and is very upset about it? -Actual -Perceived -Necessary -Maturational

Actual

In the FICA assessment tool for evaluating spirituality, what does the letter A stand for? -Address -Ambition -Adherence -Accessibility

Address

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: -Situational -Maturational -Adventitious -Developmental

Adventitious

Which type of crisis does a recent victim of violence experience? -Situational -Adventitious -Maturational -Developmental

Adventitious

Which type of crisis is an earthquake that has killed more than 7000 people? -Situational -Maturational -Adventitious -Developmental

Adventitious

Which hormonal release does the renin-angiotensin system stimulate? -Aldosterone -Erythropoietin -Prostaglandin E2 -Antidiuretic hormone

Aldosterone

Which hormone causes retention of water, resulting in an increase in blood volume? -Aldosterone -Erythropoietin -Angiotensin II -Antidiuretic hormone

Aldosterone

According to the American Hospital Association, a red wristband is given for which category? -Allergies -Poisoning -Risk of falls -Immunization

Allergies

Which action would the nurse take when preparing to assess a patient's abdomen, genitalia, and rectum? -Place the patient in the prone position. -Change latex gloves to vinyl or nitrile gloves. -Ask the patient to assume the lateral recumbent position. -Allow the patient to use the restroom.

Allow the patient to use the restroom.

Which loss occurs when the lost person is physically present but not psychologically available? -Actual -Maturational -Necessary -Ambiguous

Ambiguous

Which patient finding is the nurse likely to observe when performing assessments? -A school-age child who sleep 15 hours a day -A teenager with an upcoming final falling asleep promptly at bedtime -An adult who falls asleep quickly after vigorous exercise before bedtime -An infant taking several naps during the day

An infant taking several naps during the day

Which statement by a student indicates effective learning about urinary diversions? -A ureterostomy uses an ideal pouch to replace the urinary bladder. -An orthotropic neobladder allows the patient to void through the urethra. -A continent urinary reservoir drains the renal pelvis when the ureter is obstructed. -A nephrostomy tube is created by transplanting the ureters into a closed-off part of the intestinal ileum.

An orthotropic neobladder allows the patient to void through the urethra.

Which condition might a patient with chronic kidney disease and decreased production of erythropoietin experience? -Anemia -Hematuria -Proteinuria -Hypertension

Anemia

Which hormone causes vasoconstriction and stimulates the release of aldosterone? -Renin -Erythropoietin -Angiotensin II -Antidiuretic hormone

Angiotensin II

Which type of grief is exemplified when the parents feel severe grief and loss after seeing their child suffering with cancer? -Normal -Anticipatory -Complicated -Disenfranchised

Anticipatory

Which increased hormonal secretion leads to oliguria? -Aldosterone -Erythropoietin -Parathyroid hormone -Antidiuretic hormone (ADH)

Antidiuretic hormone (ADH)

Resolving an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which action describes the role of the nurse in the resolution of ethical dilemmas? -Articulating a unique point of view, including knowledge based on clinical and psychosocial observations -Awaiting new clinical orders from the physician -Limiting discussions about ethical principles -Allowing the patient and the physician to resolve the dilemma without regard to personally held values or opinions regarding the ethical issues

Articulating a unique point of view, including knowledge based on clinical and psychosocial observations

A patient states he does not believe in the existence of God. Which belief does this statement indicate about the patient? -Agnostic -Atheist -Academic -Anarchist

Atheist

Which physical examination technique is the nurse performing when listening to heart sounds? -Palpation -Inspection -Percussion -Auscultation

Auscultation

Which factor is the greatest risk of injury for an adolescent? -Home accidents -Physiological changes of aging -Poisoning and child abduction -Automobile accidents, suicide, and substance abuse

Automobile accidents, suicide, and substance abuse

Which stage of dying is being described when a terminally ill patient tells the nurse, "I would do whatever you say. Please relieve me of this illness?" -Anger -Denial -Depression -Bargaining

Bargaining

Which type of sleep disorder does the nurse suspect when a patient has jet lag? -Disorders of arousal -Adjustment sleep disorder -Rapid eye movement (REM) sleep-behavior disorder -Behaviorally induced circadian rhythm sleep disorder

Behaviorally induced circadian rhythm sleep disorder

Which drug increases a patient's sleep time? -Nicotine -Stimulants -Antidepressants -Benzodiazepines

Benzodiazepines

A patient has reduced taste sensation and is finding food less appealing. The nurse would instruct the patient to avoid which activity? -Smelling baked bread -Smelling cooked garlic -Blending or mixing foods -Eating food of different textures

Blending or mixing foods

After an assessment, the nurse finds that a patient has reduced tactile sensation. How does the nurse improve the patient's tactile sensation? -By avoiding rubbing the back of the patient -By providing touch therapy to the patient -By avoiding turning and repositioning -By recommending special wrist splints

By providing touch therapy to the patient

The family member of an adult patient complains that the patient is a long-term smoker. Which health risk factor does the nurse anticipate? -Infectious disease -Neurological disorder -Cardiovascular disease -Gastrointestinal disorder

Cardiovascular disease

Which finding is common among victims of intimate partner violence (IPV)? -Single leg fracture -Extreme thirst -Change in voice -Blood on underclothing

Change in voice

Which action made by the nurse during palpation of a patient's skin would require follow-up from the charge nurse? -Checking turgor and elasticity by using the dorsal of the hand -Checking texture using the palmar surface of the hand -Checking thickness with the palmar surface of the hand -Checking temperature using the dorsal of the hand or fingers

Checking turgor and elasticity by using the dorsal of the hand

Which condition will the nurse focus the care plan on when caring for a patient who says, "I feel sleepy, fatigued, and depressed during the daytime?" -Narcolepsy -Parasomnia -Chronic insomnia -Restless legs syndrome

Chronic insomnia

Which disorder may lead to a decrease in erythropoietin production? -Hypertension -Hypothyroidism -Diabetes mellitus -Chronic kidney diseases

Chronic kidney diseases

There are seven key steps in the resolution of an ethical dilemma. Which step involves distinguishing among facts, opinions, and values? -Clarifying values -Negotiation a plan -Verbalizing the problem -Evaluating the plan over time

Clarifying values

Which description is accurate for a system warning alerting the nurse an intervention is inappropriate for a patient because of risk? -Electronic health record -Clinical documentation -Clinical decision support system -Computerized provider order entry

Clinical decision support system

Where does normal defecation begin? -Anus -Colon -Stomach -Small intestine

Colon

Which ego-defense mechanism helps a patient with psychosis make up for a deficiency by emphasizing a positive feature? -Denial -Regression -Identification -Compensation

Compensation

Which type of grief is exemplified when a father refuses to accept the death of a child and no longer has a job, avoids communication with others, and remains aloof? -Normal -Complicated -Anticipatory -Disenfranchised

Complicated

Which ego-defense mechanism would a patient with psychosis display if he or she complains of sudden paralysis in the right hand after receiving medication he or she did not want? -Regression -Conversion -Identification -Displacement

Conversion

Which effect will likely occur in a patient who takes an antidepressant for depression? -Decreased total sleep time -High blood pressure -Difficulty breathing -Increased daytime sleepiness

Decreased total sleep time

Which bone-related change would the nurse expect to see in a patient with chronic renal failure? -Calcification -Demineralization -Increased bone density -Bone marrow hyperplasia

Demineralization

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c (a measure of blood sugar control over the past 90 days) has increased, by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? -Denial -Conversion -Dissociation -Displacement

Denial

Which ego-defense mechanism does a patient with psychosis demonstrate by refusing to consciously acknowledge anything that causes intolerable emotional pain? -Denial -Regression -Conversion -Identification

Denial

Which ego-defense mechanism would a patient with schizophrenia exhibit when he or she refuses to believe the diagnosis? -Denial -Conversion -Displacement -Compensation

Denial

Which ego-defense mechanism would an irate patient with psychosis show when resisting any counseling help? -Denial -Conversion -Dissociation -Displacement

Denial

Which stage of the Kubler-Ross theory is reflected in the patient's statement, "I will seek a second opinion and have the tests done again at another hospital?" -Anger -Denial -Bargaining -Depression

Denial

In which stage of dying does a patient realize the full impact of the loss? -Anger -Denial -Depression -Bargaining

Depression

Which action would the nurse take to address the "F" portion of the FICA assessment tool during an assessment of a patient's spiritual needs? -Establish overall life satisfaction. -Determine the patient's belief in a higher power. -Ask about the impact of the illness on work. -Evaluate the impact of the patient's family on health and illness.

Determine the patient's belief in a higher power.

How is proper documentation of a patient's health information most useful to medical insurance companies? -Provides preventive care to the patients -Determines the diagnosis-related group (DRG) of the patient -Reduces the cost of the monthly premium paid by the patient -Decreases the cost of health care services provided to the patient

Determines the diagnosis-related group (DRG) of the patient

Which examination may be recommended for a patient in whom fecal impaction is suspected? -Gastroscopy -Barium swallow -Fecal occult blood test -Digital examination of the rectum

Digital examination of the rectum

Which type of grief is exemplified when a patient states, "I have been depressed since the death of my ex-husband"? -Normal -Anticipatory -Complicated -Disenfranchised

Disenfranchised

Which type of grief response describes a woman who experiences the loss of a very early term pregnancy and her friend suggests to her that she can "always try again?" -Delayed -Anticipatory -Exaggerated -Disenfranchised

Disenfranchised

A sexual assault victim comes into the emergency department with cuts on his hands from smashing glass vases. Which ego-defense mechanism is at play in this scenario? -Denial -Dissociation -Identification -Displacement

Displacement

In which ego-defense mechanism does a patient with schizophrenia transfer his or her emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute? -Denial -Dissociation -Displacement -Compensation

Displacement

Which ego-defense mechanism would a young patient with psychotic tendencies show if he or she beats up a younger sibling after getting frustrated with the caregiver? -Regression -Dissociation -Displacement -Compensation

Displacement

A victim of sexual assault is brought into the emergency department. When the nurse asks if the patient knows where she is, the patient is completely confused. Which ego-defense mechanism might this patient be experiencing? -Dissociation -Identification -Displacement -Compensation

Dissociation

With which ego-defense mechanism would a patient with psychosis lose track of time and his or her normal thought processes? -Denial -Dissociation -Identification -Compensation

Dissociation

Which term describes leakage of urine despite voluntary control of urination? -Urgency -Dribbling -Hesitancy -Incontinence

Dribbling

The ability to review patient education provided by other nurses is common in which type of record system? -Information technology -Electronic health record -Personal health information -Administrative information system

Electronic health record

Which intervention is appropriate to include in the plan of care for a patient experiencing narcolepsy? -Instruct the patient to increase carbohydrates in the diet. -Have patient limit fluid intake 2 hours before bedtime. -Preserve energy by limiting exercise to morning hours. -Encourage patient to take one or two 20-minute naps during the day.

Encourage patient to take one or two 20-minute naps during the day.

According to attachment theory, which action represents disorganization and despair? -Feeling lethargic and loss of appetite -Emotional outbursts of tearful sobbing -Separating oneself from the lost relationship -Endless examination of how and why the loss has occurred

Endless examination of how and why the loss has occurred

Which hormone increases blood glucose levels during physiological stress? -Aldosterone -Parathyroid -Epinephrine -Antidiuretic hormone

Epinephrine

Which hormone stimulates red blood cell production? -Renin -Aldosterone -Erythropoietin -Antidiuretic hormone

Erythropoietin

Which type of grief is exemplified when the survivor of a motor vehicle accident attempts suicide because of feeling responsible for the friend's death? -Delayed -Masked -Exaggerated -Ambiguous

Exaggerated

Which factor may increase urine production? -Use of anticholinergics -Excessive alcohol intake -Enlargement of the prostate gland -Occurrence of local trauma during pelvic surgery

Excessive alcohol intake

Which symptom is the most common complaint by patients who have narcolepsy? -Sleep paralysis -Sudden muscle weakness -Excessive daytime sleepiness -Vivid dreams while falling asleep

Excessive daytime sleepiness

A 72-year-old patient with bilateral hearing loss wears a hearing aid in the left ear. Which approach best facilitates communication with the patient? -Speak directly into the patient's left ear. -Approach the patient from behind and speak frequently. -Face the patient when speaking; speak slower and in a normal volume. -Face the patient when speaking; use a louder-than-normal tone of voice.

Face the patient when speaking; speak slower and in a normal volume.

Which concept related to spiritual health is a patient experiencing when she states that she knows her husband loves her even when he cannot be by her side? -Faith -Hope -Transcendence -Connectedness

Faith

Which complaint is common in patients with obstructive sleep apnea? -Fatigue -Anxiety -Increased sex drive -Evening headaches

Fatigue

Which theory considers the importance of relationships in solving ethical dilemmas but lacks a focus on universal principles? -Deontology -Utilitarianism -Feminist ethics -Consensus in bioethics

Feminist ethics

Which bowel elimination problem is associated with abdominal fullness; cramping; distention; and severe, sharp pain? -Diarrhea -Flatulence -Hemorrhoids -Fecal incontinence

Flatulence

Which place is appropriate to document urine output in the patient's chart? -Admission sheet -Operative report -Physician's prescription sheet -Flow sheet

Flow sheet

Ethical dilemmas often arise over a conflict of opinion. Which action is the critical first step in negotiating differences of opinion? -Consult a professional ethicist to ensure that the steps of the process occur in full. -Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. -Ensure that the attending physician or health care provider has written an order for an ethics consultation to support the ethics process. -List the ethical principles that inform the dilemma so negotiations agree on the language of the discussion.

Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma.

Which area is the nurse preparing to assess when instructing a patient to assume the lithotomy position? -Heart -Rectum and vagina -Musculoskeletal system -Genitalia and genital tract

Genitalia and genital tract

The cluster of capillaries in each nephron is referred to by which term? -Urethra -Trigone -Detrusor -Glomerulus

Glomerulus

Which belief does an atheist profess? -A supernatural power governs the universe. -God is the ultimate being in the universe. -God does not exist. -Sins from the past have to be faced in the current life.

God does not exist.

At the end of a shift, the nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fulfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. This describes which type of report? -Discharge summary -Incident report -Hand-off report -Telephone report

Hand-off report

Which safety precaution lowers the risk of sudden infant death syndrome (SIDS) in a 1-year-old child? -Immunizing the infant -Filling crib with pillows -Having the infant sleep on his or her side or back -Attaching pacifier to string and placing it around the child's neck

Having the infant sleep on his or her side or back

After performing a physical assessment of a patient with altered bowel elimination, a nurse suspects that the patient has an obstruction of the small intestine. Which finding supports the nurse's suspicion? -Swelling and pain in the rectal area -Abdominal skin appearing stretched -High-pitched and hyperactive bowel sounds on auscultation of the abdomen -The occurrence of bowel sounds ever 5 to 15 seconds on auscultation of the abdomen

High-pitched and hyperactive bowel sounds on auscultation of the abdomen

A patient hospitalized with heart failure states that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. Of which concept is this an example? -Hope -Faith -Values -Connectedness

Hope

A patient is diagnosed with end-stage renal disease. The patient tells the nurse, "I know I am going to be all right, and I will be healthy again. I believe in God, and He will make things right. My spouse and I have yet to tour the world." Which kind of spiritual belief does this patient exhibit? -Hope -Self-transcendence -Transcendence -Agnosticism

Hope

While assessing a victim of intimate partner violence, which common physical indicator would the nurse anticipate? -Overmedicated -Undermedicated -Human bite marks -Pain when urinating

Human bite marks

Which condition is associated with early morning wakefulness and fatigue? -Liver failure -Hypertension -Hyperthyroidism -Restless legs syndrome

Hypertension

With which ego-defense mechanism would a patient with psychosis unconsciously manifest behavior similar to an idolized individual? -Regression -Conversion -Identification -Displacement

Identification

What hormonal change in the urinary system might a pregnant woman experience? -Urinary incontinence -Urinary tract infections -Increased urinary production -Incomplete bladder emptying

Increased urinary production

According to the National Quality Forum, which event is included under patient-protection events? -Abduction of a patient -Infant discharge to the wrong person -Disability associated with a medication error -Surgery performed on the wrong body part

Infant discharge to the wrong person

Which group is at the highest risk of lead poisoning? -Adults -Infants -Adolescents -Older adults

Infants

Which sleep disorder would the nurse monitor for in a woman who experiences menopausal symptoms such as hot flashes, mood swings, and irritability? -Nocturia -Insomnia -Restless legs syndrome -Central sleep apnea

Insomnia

Which assessment is performed first while the nurse initiates the general survey? -Inspecting appearance and behavior -Taking measurement of vital signs -Observing specific body systems -Conducting a detailed health history

Inspecting appearance and behavior

Which type of anemia will likely lead to restless legs syndrome? -Folate -Cobalamin -Vitamin B12 -Iron

Iron

The nurse is reviewing the medical record of a patient admitted with cystitis. Which condition is associated with this diagnosis? -Bloodstream infection -Irritation of the bladder -Infection of the upper urinary tract -Urination with burning or pain

Irritation of the bladder

Which statement is true regarding the ethical theory of utilitarianism? -It looks for the presence of principle in action regardless of the outcome. -The rightness of autonomy is the guiding principle to answer ethical dilemmas. -It determines the value of the action based on its usefulness and the outcome. -It determines the action as right or wrong based on its "right-making characteristics."

It determines the value of the action based on its usefulness and the outcome.

Which statement about fecal incontinence is correct? -It is the inability to control the passage of feces and gas from the anus. -It is an increase in the number of stools and the passage of liquid, unformed feces. -It results when a patient has unrelieved constipation and is unable to expel the hardened feces retained in the rectum. -It is characterized by infrequent bowel movements (less than three per week) and hard, dry stools that are difficult to pass.

It is the inability to control the passage of feces and gas from the anus.

The nurse is assessing a patient who has multiple myeloma and is in need of a bone marrow transplant. This patient does not have health insurance and cannot pay out of pocket for the procedure. Which ethical principle would be discussed regarding the patient's condition? -Justice -Fidelity -Autonomy -Beneficence

Justice

The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months and does not have health insurance or enough cash. Which principle is the priority in a discussion about ethics? -Accountability, because the nurse is accountable for the well-being of this patient -Respect for autonomy, because this patient's autonomy will be violated if the patient does not receive the liver transplant -Ethics of care, because the caring thing is to provide this patient with the resources for a liver transplant -Justice, because the first and greatest question in this situation is how to determine the just distribution of resources

Justice, because the first and greatest question in this situation is how to determine the just distribution of resources

The nurse is preparing to administer erythropoietin to a patient who presents with a deficiency. The nurse knows that the patient needs this medication because of dysfunction in which organ? -Liver -Bone -Kidney -Spleen

Kidney

Which position would the nurse ask the patient to assume to examine the rectum? -Prone -Knee-chest -Dorsal recumbent -Lateral recumbent

Knee-chest

Which patient may experience intangible loss? -Lost a hand -Lost both parents -Lacks confidence -Has transient paralysis

Lacks confidence

A patient reports to the nurse, "Every time that I eat ice cream, I experience diarrhea and cramping." The nurse suspects which condition? -Food allergy -Irritable bowel -Lactose intolerance -Decreased peristalsis

Lactose intolerance

Which part of the gastrointestinal tract plays a major role in bowel elimination? -Stomach -Esophagus -Small intestine -Large intestine

Large intestine

A patient reports a burning sensation and pain while passing urine. Which assessment would the nurse perform? -Ask if other family members are sick. -Determine height and weight. -Look for presence of blood in the urine. -See if the patient has a history of hypertension.

Look for presence of blood in the urine.

Which action would the nurse take when preparing to perform a physical examination on an adult patient? -Complete the consent form before the examination. -Maintain the appropriate room temperature. -Keep the room lights on dim for a calm atmosphere. -Ask the patient's family members to sit beside the patient.

Maintain the appropriate room temperature.

The nurse examines a patient's stool specimen and notes that the stool is oily. The nurse suspects which cause of this assessment finding? -Infection -Intestinal irritation -Infestation of parasites -Malabsorption syndrome

Malabsorption syndrome

Which type of complicated grief response is observed in a patient who is unaware that the disruptive behavior is a result of a loss? -Chronic -Masked -Delayed -Exaggerated

Masked

When an ethical dilemma occurs on the unit, can nurses resolve the dilemma by taking a vote? -Yes; ethics is essentially a democratic process, with all participants sharing an equal voice. -No; an ethical dilemma involves the resolution of conflicting values and principles rather than simply the identification of what people want to do. -Yes; ethical dilemmas otherwise take up time and energy that is better spent at the bedside performing direct patient care. -No; most ethical dilemmas are resolved by deferring to the medical direct of the ethics department.

No; an ethical dilemma involves the resolution of conflicting values and principles rather than simply the identification of what people want to do.

The point of the ethical principle to do no harm is to reassure the public that, in all ways, the health care team not only works to heal patients but agrees to do this in the least painful and harmful way possible. Which principle describes this agreement? -Beneficence -Accountability -Nonmaleficence -Respect for autonomy

Nonmaleficence

Which principle of health ethics refers to the avoidance of harm or hurt? -Justice -Autonomy -Beneficence -Nonmaleficence

Nonmaleficence

Which type of enema is used in infants and children? -Soapsuds -Tap water -Normal saline -Hypertonic solution

Normal saline

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? -Nurses understand the principle of autonomy in guiding respect for patients' self-worth. -Nurses have a scope of practice that encourages their presence during ethical discussions. -Nurses develop a relationship to the patient that is unique among all professional health care providers. -The nurse's code of ethics recommends that the nurse be present at any ethical discussion about patient care.

Nurses develop a relationship to the patient that is unique among all professional health care providers.

A health care organization has incorporated information and computer technology. Which system will help the organization comply with the requirements of accrediting agencies? -Nursing documentation system -Clinical decision support system -Nursing clinical information system -Bar-code medication administration system

Nursing clinical information system

Which factor influencing urinary elimination in older adults does the nurse know to be true? -Older adults have an increased bladder capacity. -Older adults generally experience decreased bladder irritability. -Older adults have an increased frequency of bladder contractions during bladder filling. -Older adults have an increased ability to hold urine between the initial desire to void and an urgent need to void.

Older adults have an increased frequency of bladder contractions during bladder filling.

Which disorder is caused by increased secretion of antidiuretic hormone (ADH)? -Dysuria -Oliguria -Polyuria -Hematuria

Oliguria

Which class of drug does the nurse suspect is responsible for the patient reporting daytime drowsiness and a lack of dreams? -Antibiotics -Antipyretics -Opiates -Diuretics

Opiates

The nurse is caring for a patient who exhibits slow movements associated with Parkinson's disease. Which type of urinary incontinence would the nurse assess for in this patient? -Transient incontinence -Functional incontinence -Reflex urinary incontinence -Overflow urinary incontinence

Overflow urinary incontinence

Which portion of the hand is used to assess the thickness of skin? -Finger pads -Palmar surface -Dorsum -Fingertips

Palmar surface

Which patient is at risk of fatigue? -Patient A: age 2, 12 hrs of sleep -Patient B: age 7, 8 hours of sleep -Patient C: age 11, 10 hours of sleep -Patient D: age 14, 9 hours of sleep

Patient B: age 7, 8 hours of sleep

Where does the nurse access the information to contact the guardian of a patient? -Discharge summary -Nurse's admission assessment -Nurse's notes -Patient care summary

Patient care summary

Which section of the traditional source record does the nurse use to record patient demographic information? -Nurse's notes -Patient care summary -Graphic sheet and flow sheet -Nurse's admission assessment

Patient care summary

Which physical assessment technique is the nurse using when tapping a patient's skin with the fingertips to vibrate underlying tissues and organs? -Palpation -Inspection -Percussion -Auscultation

Percussion

Which patient would be suspected to have an electrolyte imbalance? -Patient with risk of falls -One exposed to carbon monoxide -Individual with lower-extremity weakness -Person exposed to heat for an extended period

Person exposed to heat for an extended period

Which behavioral finding would alert the nurse to possible older-adult abuse? -Quiet demeanor -Short time between injury and treatment -Knowledge of explicit sexual matters -Physical and/or cognitive impairment

Physical and/or cognitive impairment

Which gland in the patient's body will initiate general adaptation syndrome (GAS)? -Parotid -Pituitary -Pineal -Adrenal

Pituitary

Which method is appropriate for the nurse to dispose of printed patient information? -Rip several times and place in a standard trash can. -Place in the patient's paper-based chart. -Place in a secure canister marked for shredding. -Burn the documents.

Place in a secure canister marked for shredding.

Which scale is used to weigh infants? -Bed -Chair -Platform -Standing

Platform

A patient complains that he or she is not able to pass urine completely. Even after voiding, the patient does not feel that the bladder is empty. Which test can be done to assess the postpaid residual (PVR) in the patient? -Portable noninvasive bladder ultrasound device -Cystoscopy -X-ray of the abdomen -Intravenous pyelography (IVP)

Portable noninvasive bladder ultrasound device

When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

Post-traumatic stress disorder (PTSD)

When assessing a 45-year-old patient's sensory status, which assessment finding does the nurse consider a normal part of aging? -Presbyopia and the need for glasses for reading -Reduced sensitivity to odors -Impaired balance and coordination -Reduced taste discrimination

Presbyopia and the need for glasses for reading

An emergency department nurse is caring for a patient who was severely injured in a car accident. The patient's family is in the waiting room. They are crying softly. The nurse sits down next to the family, takes the mother's hand, and says, "I can only imagine how you're feeling. What can I do to help you feel more at peace right now? " In this example the nurse is demonstrating: -Prayer -Presence -Coaching -Instilling hope

Presence

The nurse is caring for a patient with muscle weakness. The patient is provided with skid-proof footwear. Which safety measure is implemented in this situation? -Enabling to remain alert -Promoting cooperation -Allowing for safe exit from bed -Preventing falls from slipping on the floor

Preventing falls from slipping on the floor

In which section would the nurse place subjective and objective data? -Care plan -Database -Problem list -Progress notes

Progress notes

Patients with which type of urinary incontinence can be at risk of severe elevation of blood pressure and pulse rate and diaphoresis? -Functional incontinence -Stress urinary incontinence -Reflex urinary incontinence -Urge urinary incontinence

Reflex urinary incontinence

A teenage victim of physical abuse begins sucking her thumb. Which ego-defense mechanism would this exemplify? -Denial -Conversion -Regression -Identification

Regression

With which ego-defense mechanism would a patient experience a return to an earlier stage of development to cope with stressors? -Regression -Conversion -Dissociation -Displacement

Regression

According to the philosophy of the ethics of care, which aspect is most important when solving ethical dilemmas? -Patients -Relationships -Ethical principles -Code of ethics for nurses

Relationships

In which stage of mourning by Bowlby's attachment theory does a person accept change, acquire new skills, and build new relationships? -Numbing -Reorganization -Yearning and searching -Disorganization and despair

Reorganization

A patient states, "My religion does not permit me to bathe today." Which nursing action would be most appropriate? -Tell the patient that the health care provider has prescribed a bath today. -Insist that a bath be taken because it is the patient's scheduled bath day. -Call an appropriate cleric and ask whether the patient is telling the truth. -Request clarification of the patient's beliefs and adapt a plan for bathing accordingly.

Request clarification of the patient's beliefs and adapt a plan for bathing accordingly.

Which condition will likely result when a person is moderately fatigued because of exercising 2 hours before bedtime? -Insomnia -Sleep apnea -Restful sleep -Excessive daytime sleepiness

Restful sleep

A patient with which documented finding would be provided with a yellow wristband according to the American Hospital Association (AHA)? -Allergies -Risk of falls -Hypothermia -Does not require resuscitation

Risk of falls

Which dimension of spirituality includes "a sense of authentically connecting to one's inner self?" -Faith -Hope -Connectedness -Self-transcendence

Self-transcendence

A patient is diagnosed with breast cancer. She is upset about the diagnosis. Which type of crisis is the patient experiencing? -Situational -Adventitious -Developmental -Maturation

Situational

Which type of loss is exemplified when a patient sustains severe injuries leading to loss of function from a motor vehicle accident? -Actual -Perceived -Situational -Maturational

Situational

A patient who is confined to bed has reduced tactile sensation. This patient is at risk of which condition? -Aphasia -Hyperesthesia -Skin breakdown -Macular degeneration

Skin breakdown

Which factor is the leading cause of injuries involving home medical oxygen? -Smoking -Lead poisoning -Exposure to severe cold for long periods -Exposure to high concentrations of carbon monoxide

Smoking

Which statement is true regarding spirituality? -Spirituality is a simple concept. -Spirituality has five overlapping constructs. -Spirituality has the same meaning for every individual. -Spirituality has scientific relations to one's health outcomes.

Spirituality has five overlapping constructs.

Which theory includes denial and acceptance? -Stages of dying -Attachment theory -Rando's "R" process model -Grief tasks model

Stages of dying

Which safety precaution would the nurse follow to reduce the risk of falls in a patient with hemiparesis? -Stand on the patient's unaffected side when using a walker. -Stand on the patient's affected side when using a cane and a gait belt. -Perform range-of-motion exercises before ambulating. -Have the patient frequently touch one hand with the other hand.

Stand on the patient's affected side when using a cane and a gait belt.

Which mnemonic would a patient follow if his or her clothing or skin is burning? -PASS -RACE -Back to sleep -Stop, drop, and roll

Stop, drop, and roll

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2019 (0900) 2. Repositioned patient on left side. 3. Medicatedwithhydrocodone-acetaminophen 5/325mg, 2tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage 7. Rates pain 7/10 at location of surgical incision.

Subjective: 4. "The pain in my incision increases every time I try to turn on my right side." Objective: Everything else

Which position provides easy access to a patient's pulse sites during a physical examination? -Prone -Supine -Lithotomy -Dorsal recumbent

Supine

A head nurse is teaching the physiology of fight-or-flight responses to student nurses. Which system is responsible for these phenomena? -Renin-angiotensin -Respiratory -Sympathetic nervous -Parasympathetic nervous

Sympathetic nervous

Which law is the nurse violating when faxing a patient's medical record to an unknown number? -The American Recovery and Reinvestment Act (ARRA) -The Health Insurance Portability and Accountability Act of 1996 (HIPAA) -The Health Information Technology for Economic and Clinical Health Act (HITECH) -The Joint Commission (TJC) Act

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. She is not attentive as the nurse asks questions. At one point, she shouts answers to questions about her diet. However, as the nurse speaks, the patient consistently smiles and nods in agreement. Which assessment would the nurse make regarding this patient? -The patient has a visual deficit. -The patient is normal. -The patient has a hearing deficit. -The patient has sensory overload

The patient has a hearing deficit.

Which aspect of care would be included when teaching a patient with narcolepsy? -The need to perform strenuous exercise -The importance of avoiding caffeine -The recommendation to take regular naps of no more than 20 minutes -The proper method of using continuous positive airway pressure (CPAP)

The recommendation to take regular naps of no more than 20 minutes

Which statement describes utilitarianism? -The value of something is determined by its usefulness to society. -People's values are determined by religious leaders. -The decision to perform a liver transplant depends on a measure of the moral life that the patient has led so far. -The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician or health care provider.

The value of something is determined by its usefulness to society.

Sleep apnea is classified by how many types?

Three: central, obstructive, and mixed

How does nursing documentation support reimbursement to health care agencies?

Through accurate accounting of the use of services and equipment and medications administered.

How does effective nursing documentation limit liability?

Through objective description of what happened to a patient and indicating that individualized, goal-directed nursing care was provided based on nursing assessment.

Which age-group is at the highest risk of accidental poisoning at home? -Adults -Toddlers -Older adults -Adolescents

Toddlers

Which type of incontinence is most likely to be associated with a urinary tract infection? -Transient incontinence -Functional incontinence -Stress urinary incontinence -Overflow urinary incontinence

Transient incontinence

Which health promotion intervention is important to teach parents and children to prevent hearing impairment? -Avoid activities in which there may be crowds. -Delay childhood immunizations until hearing can be verified. -Prophylactically administer antibiotics to reduce the incidence of infections. -Use protective devices when involved in activities associated with high-intensity noises.

Use protective devices when involved in activities associated with high-intensity noises.

What should be documented in the health care record when information relevant to care is communicated by telephone?

Verification of information through use of a read-back process

The nurse is educating a woman about measures to reduce the risk of urinary tract infections while having an indwelling urinary catheter with a leg bag. Which instruction would the nurse include in the teaching? -Decrease fluid intake. -Wash hands frequently. -Empty every 8 hours. -Wipe from back to front after defecation.

Wash hands frequently.

When is patient safety enhanced?

When health care professionals eliminate the use of dangerous abbreviations, acronyms, symbols, and dose designations from their documentation.

The nurse is caring for an older patient with glaucoma. When developing a discharge plan, which intervention enables the patient to function safely with existing deficits and continue a normal lifestyle? -Encourage the patient's family to visit him or her once a month. -Suggest to the patient that he or she consider moving to a long-term care facility. -Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. -Work closely with the patient to identify ways to modify his or her home environment, and refer the patient to appropriate community-based resources.

Work closely with the patient to identify ways to modify his or her home environment, and refer the patient to appropriate community-based resources.

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. Cranial Nerves: 1. XII Hypoglossal 2. V Trigeminal 3. VI Abducens 4. IV Trochlear 5. X Vagus Cranial Nerve Function: Motor innervation to the muscles of the jaw Lateral movement of the eyeballs Sensation of the pharynx Downward, inward eye movements Position of the tongue

XII Hypoglossal: Position of the tongue V Trigeminal: Motor innervation to the muscles of the jaw VI Abducens: Lateral movement of the eyeballs IV Trochlear: Downward, inward eye movements X Vagus: Sensation of the pharynx

Which stage of the attachment theory of grief and mourning is characterized by emotional outbursts of tearful sobbing? -Numbing -Reorganization -Yearning and searching -Disorganization and despair

Yearning and searching

The nurse is caring for a patient who is very depressed and decides to complete a spiritual assessment using the FICA tool. Using the FICA assessment tool, match the criteria with the appropriate assessment question. Criteria: 1. F-Faith 2. I-Importance of spirituality 3. C-Community 4. A - Interventions to address spiritual needs Assessment question: a. Tell me if you have a higher power or authority that helps you act on your beliefs b. Describe which activities give you comfort spiritually c. To whom do you go for support in times of difficulty? d. Your illness has kept you from attending church. Is that a problem for you?

a. Tell me if you have a higher power or authority that helps you act on your beliefs / FAITH b. Describe which activities give you comfort spiritually / INTERVENTIONS TO ADDRESS SPIRITUAL NEEDS c. To whom do you go for support in times of difficulty? / COMMUNITY d. Your illness has kept you from attending church. Is that a problem for you? / IMPORTANCE OF SPIRITUALITY