NCLEX AQ- Fundamentals Skills

A registered nurse is teaching a nursing student about Erikson's theory of psychosocial development. To which age group does Industry versus Inferiority apply? 3 to 6 years 1 to 3 years 6 to 11 years Birth to 1 year

6 to 11 years Rationale According to Erikson's theory of psychosocial development, Industry versus Inferiority applies to the 6 to 11 years of age group. Initiative versus Guilt applies to the 3 to 6 years of age group. Autonomy versus Sense of Shame and Doubt falls in the 1 to 3 years of age group. The Trust versus Mistrust stage applies to the birth to 1 year age group.

Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation? Domain 1 Domain 2 Domain 3 Domain 4

Domain 2 Rationale Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

What are the demands of Roy's adaptation model that can be useful in helping the patient? Economical Pathological Physiological Psychological Dependence-independence

Physiological Psychological Dependence-independence Roy's adaptation model is an example of a grand theory and is based on the physiological, psychological, sociological, and dependence-independence adaptive modes. Economical and pathological adaptive modes are not part of Roy's theory.

Family resiliency

the ability of the family to cope with expected and unexpected stressors

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1. Lactated Ringer solution 2. 5% dextrose and water 3. 0.9% normal saline 4. 0.45% normal saline

0.9% normal saline

Arrange the order of critical thinking for an existing problem. 1.Making a conclusion 2.Evaluating the information 3.Recognizing the existing issue 4.Analyzing information about the issue

1.Recognizing the existing issue 2.Analyzing information about the issue 3. Evaluating the information 4. Making a conclusion

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? Side-lying with head elevated 45 degrees Sims with head elevated 90 degrees Semi-Fowler with legs elevated High-Fowler using the bedside table to rest the arms

High-Fowler using the bedside table to rest the arms Rationale The high-Fowler position elevates the clavicles and helps the lungs to expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

What is the primary focus of the nurse when providing evidence-based care to the client? Practice trends Research studies Clinical experience Problem-solving approach

Problem-solving approach Rationale Evidence-based practice is first and foremost a problem-solving approach to care. This problem-solving approach incorporates application of current best practice along with knowledge from research studies and clinical expertise.

Arrange in order the items of personal protection equipment (PPE) removed after performing a surgical procedure. Gown, mask, gloves, face shield

Gloves face shield gown mask

Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes? Neuman's system theory Swanson's theory of caring Orem's self-care deficit theory Mishel's theory of uncertainty in illness

Swanson's theory of caring Rationale Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.

Which statement regarding Roy's theory of nursing needs correction? 1 The Roy adaptation model views the environment as an adaptive system. 2 The need for nursing care occurs when the client cannot adapt to internal and external environmental demands. 3 The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. 4 All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

1. The Roy adaptation model views the environment as an adaptive system.

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? Increase oral fluid intake to 2 to 3 L/day. Maintain bed rest after discharge. Limit fluid intake to 1 L/day. Void at least every hour.

Increase oral fluid intake to 2 to 3 L/day. Rationale Increasing oral fluid intake to 2 to 3 L/day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall? Labeling Collecting Clustering Interpreting

Labeling The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting level include inaccurate data, missing data, and disorganization. Errors at the clustering level include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the interpreting level, errors include failure to consider conflicting cues and failure to consider cultural influences or developmental stage.

Which theory emphasizes the facilitation of the body's reparative processes by manipulating the client's environment? Orem's theory Watson's theory Leininger's theory Nightingale's theory

Nightingale's theory Rationale Nightingale's theory is based on facilitating the body's reparative processes by manipulating the client's environment. Orem's self-care deficit theory focuses on the client's self-care needs. Watson's theory is based on promoting health, restoring the client to health, and preventing illness. Leininger's theory is based on providing care consistent with emerging science and knowledge, with caring as the central focus.

Which nursing theory focuses on the client's self-care needs? Roy's theory Orem's theory Watson's theory Leininger's theory

Orem's theory Rationale Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.

A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? Potassium Sodium bicarbonate Carbon dioxide Sodium chloride

Sodium bicarbonate Rationale Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H 2CO 3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.

Before discharge after a myocardial infarction, a client asks the nurse when sexual activity can be resumed. What is the best response by the nurse? "Two weeks is the usual waiting time." "How long do you think you should wait?" "Have you discussed this with your primary healthcare provider?"" "You should wait until your heart feels stronger."

"Have you discussed this with your primary healthcare provider?"" Rationale The primary healthcare provider should be consulted, because the decision depends on the amount of damage to the heart muscle and extent of healing. It is false reassurance to determine an exact time and date; 2 weeks may be too early. Although the client's feelings should be considered, this is a medical decision that depends on the amount of damage to the heart muscle. Saying the client should wait for the heart to feel stronger is too vague and does not involve information from the primary healthcare provider.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? "I should carry objects about 18 inches from my body." "I should sleep on my stomach with a firm mattress." "I should carry objects close to my body." "I should pull rather than push when moving heavy objects."

"I should carry objects close to my body." Rationale By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

How many levels of critical thinking exist for nursing judgment? Record your answer using a whole number.

3 Rationale There are three levels of critical thinking in nursing judgment. The first level is basic critical thinking, in which the nurse has faith that the expert has the right answer to each problem. The second level is complex critical thinking. The nurse examines and analyzes information provided by the expert. A nurse engaging in this critical thinking may discover that another option is available with which to solve an issue. The third level of critical thinking is commitment. A nurse at this level can make choices without help from others. The nurse at this level of critical thinking takes full responsibility for every action in which he or she engages.

Which age is considered the phallic stage according to Sigmund Freud's developmental theory? Birth to 18 months 18 months to 3 years old 3 to 6 years old 6 to 12 years old

3 to 6 years old Rationale According to Sigmund Freud's developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage a. Six to 12 years of age is the latent stage. Eighteen months to 3 years of age is the anal stage.

A registered nurse is teaching a nursing student about Piaget's theory of cognitive development that includes four periods, which are related to age. Which age group corresponds with concrete operations? 2 to 7 years 7 to 11 years Birth to 2 years 11 years to adulthood

7-11 years According to Piaget's theory of cognitive development, the concrete operations period applies to the age group of 7 to 11 years of age. The preoperational period is during the age group of 2 to 7 years. The sensorimotor period applies to the age group of birth to 2 years. The formal operations period applies to the age group of 11 years to adulthood.

Which critical thinking skill does the nurse associate with the concept of maturity? Eagerness to acquire knowledge Being tolerant of different views Trust in own reasoning processes Ability to reflect on own judgments

Ability to reflect on own judgments Rationale Maturity is the ability of a critical thinker to reflect on his or her own judgments. A critical thinker realizes that multiple solutions are acceptable. Inquisitiveness is the eagerness to acquire knowledge. A critical thinker is considered open-minded if he or she respects the right of others to have different opinions and is tolerant of different views. The critical thinker possesses self-confidence and trusts in his or her own reasoning process.

A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? Authority Autonomy Accountability Responsibility

Accoiuntability Rationale Accountability means being answerable for one's actions. The nurse's action of admitting the mistake and seeking instructions to correct it indicates accountability. Authority is the legitimate power to give instructions and make final decisions in a situation. Autonomy is freedom of choice and responsibility for the choices. Responsibility indicates the duties and activities that an individual is employed to perform.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? <p>The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?</p> Red blood cell count Sputum culture Arterial blood gas Total hemoglobin

Arterial blood gas Rationale Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

The nurse interviews a client about a current health problem. The nurse then obtains and documents the client's temperature, blood pressure, and heart rate. Which step of the nursing process is involved in this situation? Planning Diagnosis Assessment Implementation

Assessment Rationale The scenario is an example of the assessment phase of the nursing process. Assessment involves the collection of comprehensive data pertinent to the client's health. During the planning level of nursing care, the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The nurse analyzes the assessment data to determine the diagnoses during the diagnosis level of nursing practice. The nurse implements the health care plan identified for the client during the implementation level of the standards of nursing practice. This level may include administering prescribed medications or healthcare procedures.

Which statement is true for attachment in the newborn? Attachment occurs for the first 28 days. Attachment begins in the first week of birth. Attachment is the overlapping of soft skull bones. Attachment is the interaction between parent and child.

Attachment is the interaction between parent and child. Rationale Attachment is the interaction between the parent and child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns that had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? Blended family Extended family Alternative family Single-parent family

Blended family Rationale The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. A single-parent family is formed when one parent cares for the children following the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.

How can a nurse best evaluate the effectiveness of communication with a client? Client feedback Medical assessments Health care team conferences Client's physiologic responses

Client feedback Rationale Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

A client is ambivalent about making a change in health behavior. Which stage of health behavior does the nurse suspect? Preparation Maintenance Contemplation Precontemplation

Contemplation Rationale The nurse suspects that the client is in the stage of contemplation. This stage of health behavior is characterized by the client's attitude toward a change, and the client is most likely to accept that change over the next 6 months. In the preparation stage, the client believes that a change in behavior will be advantageous. The client may need assistance to bring about the change in behavior. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to receive any information about changes in behavior and may become defensive and confrontational.

What is the definition of descriptive research? Descriptive research tests how well a program, practice, or policy is working. Descriptive research measures the characteristics of persons, situations, or groups. Descriptive research is designed to establish facts and relationships concerning past events. Descriptive research explores the interrelationships among variables of interest without any active intervention.

Descriptive research measures the characteristics of persons, situations, or groups. Rationale Descriptive research is defined as a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. Evaluation research tests how well a program, practice, or policy is working. Historical research is designed to establish facts and relationships concerning past events. Correlational research explores the interrelationships among variables without any active intervention by the researcher.

Which theory describes the phenomenon of grief or caring? Grand theories Descriptive theories Prescriptive theories Middle-range theories

Descriptive theories Rationale Descriptive theories describe a phenomenon such as grief or caring. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories discuss interventions and expected outcomes for a specific phenomenon. They describe phenomena, speculate on why they occur, and describe their consequences. Middle-range theories have a more narrow scope than grand theories; these theories integrate theory-based research with nursing practices.

Which nursing intervention is performed for a middle-aged adult in restorative and continuing care? Establishing independence Focusing on problems related to sense of identity Reorganizing intimate relationships and family structure Determining the coping mechanisms of the client and the family

Determining the coping mechanisms of the client and the family Rationale The nurse should determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.

In which process of Swanson's theory is the nurse engaging when explaining neonatal care to a parent? Enabling Knowing Doing for Being with

Enabling Rationale According to Swanson's theory, the nurse is engaging in enabling when explaining the care of a neonate to a parent. Enabling includes informing/explaining/supporting/allowing, focusing, generating alternatives, validating, and giving feedback. The process of knowing includes avoiding assumptions, centering on the one being cared for, assessing thoroughly, seeking cues, and engaging the self or both. The process of doing for includes comforting, anticipating, performing skillfully, protecting, and preserving dignity. The process of being with includes being there, conveying ability, sharing feelings, and not burdening.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? Discharge in am Blood glucose monitoring ac and bedtime Erythromycin 250 mg TIW Dalteparin 5000 international units Sub-Q BID

Erythromycin 250 mg TIW Rationale TIW, indicating three times a week, is an unacceptable abbreviation. It may be mistaken for "three times a day" or "twice weekly." The abbreviation am for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of ac (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation Sub-Q, indicating the subcutaneous route, is an acceptable abbreviation. BID, indicating twice a day, is an acceptable abbreviation. International units must be completely spelled out instead of "IU" because it may be mistaken as a four.

A nursing student is listing the points that are applicable to grand theories of nursing. Which point mentioned by the nursing student needs correction? Grand theories require further specification through research. Grand theories are systematic and broad in scope and complex. Grand theories include Mishel's theory of uncertainty in illness. Grand theories do not provide guidance for specific nursing interventions.

Grand theories include Mishel's theory of uncertainty in illness. Rationale Mishel's theory of uncertainty in illness is not an example of a grand theory; it is a middle-range theory. Neuman's systems model is a grand theory. Grand theories require further specification through research. Grand theories are systematic and broad in scope and complexity. Grand theories do not provide guidance for specific nursing interventions; instead they provide the structural framework for broad and abstract ideas about nursing.

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? Binder Ice bag Elastic bandage Warm compress

Ice Bag Rationale Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage on the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? Labeling Collecting Clustering Interpreting

Interpreting Rationale An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.

A nurse changing the dressing on the client's perineum would fall into which zone? Public zone Intimate zone Personal zone Vulnerable zone

Intimate zone Rationale Changing a client's dressing on the perineum falls under the intimate zone. For this action, the appropriate interpersonal distance between the nurse and the client should be between 0 and 18 inches. A nurse lecturing a class of students or speaking at a community forum lies within a public zone. A personal zone refers to a nurse sitting on the client's bedside, taking a client's history, or teaching a client individually. The vulnerable zone is where special care is needed.

Which statement defines "information" gathered by the nurse? It is an individual piece of reality. It is a combination of pieces of reality. It is the organization and interpretation of data. It is the identification of relationship of various data.

It is the organization and interpretation of data. Rationale Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge.

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? <p>Which stage of Piaget&#x2019;s theory of cognitive development does the nurse observe in a preschooler?</p> Sensorimotor Preoperational Formal operations Concrete operations

Preoperational Rationale The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed form birth to 2 years. During this stage, the child learns about himself and his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

A senior nurse is explaining the importance of nursing theory to a group of nursing students. What statements are true about prescriptive theories? Prescriptive theories are action-oriented. Prescriptive theories test the validity and predictability of a nursing intervention. Prescriptive theories are more limited in scope and less abstract. Prescriptive theories guide nursing research to develop specific nursing interventions. Prescriptive theories address a specific phenomenon and reflect practice.

Prescriptive theories are action-oriented. Prescriptive theories test the validity and predictability of a nursing intervention. Prescriptive theories guide nursing research to develop specific nursing interventions.

Which statement is true about prescriptive theories? Prescriptive theories are action-oriented. Prescriptive theories help to explain client assessment. Prescriptive theories focus on a specific field of nursing. Prescriptive theories are the first level of theory development.

Prescriptive theories are action-oriented. Rationale Prescriptive theories are action-oriented. They test the validity and predictability of a nursing intervention. These theories address nursing interventions for a phenomenon, describe the conditions under which the prescription occurs, and predict the consequences. Descriptive theories help to explain client assessment. A middle-range theory tends to focus on a specific field of nursing. Descriptive theories are the first level of theory development.

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client? Touch Reminiscence Reality orientation Validation therapy

Reality orientation Rationale A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.

Which statement made by a nursing student about Swanson's theory of caring needs correction? The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.

Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. Rationale Swanson's theory of caring provides a basis for identifying and testing nurse caring behaviors to determine if caring will improve client health outcomes. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.

What is the primary focus of nursing care in the "family as context" approach? The relationship among family members The health and development of an individual The ability of the family to meet their basic needs The family's process of caregiving for a sick member

The health and development of an individual Rationale In the "family as context" approach, the primary focus is the health and development of an individual in a specific environment. The relationship and family processes are the primary focus when the family is viewed as client. When the family is viewed as context, the focus is the ability of the family to meet the basic needs of the individual, not their own needs. The process followed by the family when caring for the sick family member is assessed when family is viewed as client.

Which example indicates that the nurse is following evidence-based practice? The nurse documents client care in an electronic health record. The nurse reads current nursing journals and uses the latest scientific methods. The nurse uses flowcharts and diagrams to record the client's progress. The nurse encourages the hospitalized client's family to bring home-cooked food.

The nurse reads current nursing journals and uses the latest scientific methods. Rationale Evidence-based practice requires the nurse to read current nursing journals and use the latest scientific methods. It also requires the integration of best current evidence with clinical expertise and client preferences while providing health care. The nurse uses informatics to document client care in an electronic health record. The nurse uses flowcharts and diagrams to record the client's progress and monitor the outcomes of client care. This helps the nurse to improve the quality of care. The nurse provides client-centered care by encouraging the hospitalized client's family to bring home-cooked food.

A client with colon cancer is receiving hospice care at home. What is the focus of hospice care? To ease the pain from illness To provide curative treatment To assist with activities of daily living To adapt to the limitations due to illness

To ease the pain from illness Rationale The focus of hospice care is palliative care to ease the pain caused by the illness. It is a system of family-centered care that allows clients to live at home with dignity. Hospice care does not provide curative treatment. The health care team follows an individualized plan of care for the client. Assisted living facilities offer long-term care for the older client in settings with a home-like environment. These facilities assist the client with activities of daily living. Rehabilitation facilities provide restorative care that helps the client to adapt the limitations caused by the illness.

Which is used for determining the hours of care and staff required for a group of clients? Flow sheets Acuity records Standardized care plans Discharge summary forms

Acuity records Rationale An acuity record is used to determine the hours of care and staff required for a given group of clients. A client's acuity level is based on the type and number of nursing interventions. Accurate acuity ratings justify overtime and the number and qualifications of staff needed to safely care for clients. A flow sheet helps to assess data about a client; this data includes vital signs and routine repetitive care. Standardized care plans based on an institution's standards of nursing practice are preprinted and established guidelines used to care for clients who have similar health problems. Discharge documentation includes medications, diet, community resources, follow-up care, and medical contact information in case of an emergency or query.

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what? Attempts to minimize the illness Lacks an emotional response to the illness Refuses to discuss the condition with the client's spouse Expresses displeasure with the prescribed activity program

Attempts to minimize the illness Rationale Attempts to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.

The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying? Risk taking Confidence Thinking independently Responsibility and authority

Confidence Rationale The critical thinking attitude of confidence grows with experience and the nurse is able to shift the focus from remembering the procedure to caring for the client's needs. The nurse builds a bond of trust by displaying confidence while performing a procedure. Risk taking involves recommending alternative methods to client care or questioning a primary healthcare provider's order. A nurse who reads nursing literature and shares ideas about nursing interventions with other nurses uses independent thinking. Responsibility and authority are critical thinking attitudes. A responsible nurse follows procedure manuals while caring for the client and reports problems immediately.

A nurse helps a client to clarify health problems and choose appropriate courses of action. What competency in community-based practice is the nurse exercising? Educator Caregiver Counselor Epidemiologist

Counselor Rationale When a nurse is helping a client to identify and clarify health problems and choose appropriate courses of action to solve those problems, the nurse is acting as a counselor. The nurse acts as an educator by establishing relationships with community service organizations. The nurse acts as an epidemiologist when he or she is involved in case finding, health teaching, and tracking incident rates of an illness. The nurse acts as a caregiver when he or she provides appropriate, individualized nursing care for specific clients and their families.

Which of these databases should the nurse use to obtain a broad view on biomedical and pharmaceutical studies? PubMed EMBASE MEDLINE PsycINFO

EMBASE So close! Rationale The EMBASE database is a good source of biomedical and pharmaceutical studies. PubMed is the health science library at the National Library of Medicine; this database offers free access to many journal articles. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. PsycINFO is a good resource for psychology and psychology-related healthcare disciplines.

The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? 94.2 85.3 89.4 91.5

Hypothermia is classified as mild hypothermia (body temperature of 34 °C to 36 °C/93.2 °F to 96.8 °F), moderate hypothermia (body temperature of 30 °C to 34 °C/86 °F to 93 °F), and severe hypothermia (body temperature below 30 °C/86 °F). Client B, with a body temperature of 85.3 °F, is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 86 °F. Clients A, C, and D do not have a temperature less than 86 °F; therefore, they may not need rewarming through cardiopulmonary bypass.

Which component of decision-making refers to the duties and activities an individual is employed to perform? Authority Autonomy Responsibility Accountability

Responsibility Responsibility refers to all duties and activities an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

What is the main focus of community health nursing? To meet the acute care needs of a population To improve the quality of health in a population To influence political processes affecting public policies To assess the healthcare needs of an individual or family

To improve the quality of health in a population Rationale Community health nursing is a nursing practice focusing on the healthcare of individuals, families and groups with a community. Its main focus is to improve the quality of life and health of a population by preserving, protecting, promoting, or maintaining health. The acute and chronic care of an individual or family is provided by community-based nursing. Instead of focusing on institutional care, community-based nursing brings healthcare within the reach of the community. Factors influencing health services such as political process affecting public policies are handled by public health nursing. Community-based nursing focuses on the fulfillment of the healthcare needs of an individual or family.

A client with a leg fracture is hospitalized. The registered nurse instructs the nursing student to interrogate the client to ascertain the reason for the injury. Which question would help to determine an extrinsic factor? Do you have clear vision? Are you taking any sedatives or hypnotics? Were you wearing inappropriate shoes? Do you have a history of postural hypotension?

Were you wearing inappropriate shoes? Rationale Extrinsic factors include environmental hazards outside and within the home. Asking the client about his or her footwear will help to ascertain whether there was an extrinsic factor that may have caused the fall. Intrinsic factors include impaired vision, the taking of sedatives or hypnotics, and a history of a postural hypotension.

Which of the following statements about a case manager is correct? "A case manager identifies and implements new and more effective approaches to problems." "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." "A case manager helps clients identify and clarify health problems and chooses appropriate courses of action to solve these problems." "A case manager applies a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families."

"A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." Rationale A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families. A change agent helps identify and implement new and more effective approaches to problems. A counselor helps clients identify and clarify health problems and choose appropriate courses of action. A caregiver applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families.

A registered nurse is teaching a nursing student about systems theories with a specific reference to Neuman's systems theory. Which statements made by the nursing student post teaching are accurate? Select all that apply. "Factors that change the environment also affect an open system." "The components are interrelated and share a common purpose to form a whole." "A system is composed of separate components and the components can be open or closed." "Neuman's systems theory defines a total-person model of holism and a closed-systems approach." "An open system interacts with the environment, with an exchange of information between the system and the environment."

"Factors that change the environment also affect an open system." "The components are interrelated and share a common purpose to form a whole." "An open system interacts with the environment, with an exchange of information between the system and the environment." Rationale Factors that change the environment also affect an open system. The components are interrelated and share a common purpose to form a whole. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. A system is composed of separate components, and there are two types of system, open or closed. Neuman's systems theory defines a total-person model of holism and an open-systems approach.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? "You do not need to wear them while you are awake, but it is important to wear them at night." "You will need to apply them in the morning before you lower your legs from the bed to the floor." "If they bother you, you can roll them down to your knees while you are resting or sitting down." "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

"You will need to apply them in the morning before you lower your legs from the bed to the floor." Rationale Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

What is a stressor? A stressor is any stimuli that can produce tension and cause instability within the system. A stressor exists within the client system, such as the physiological and behavioral responses to illnesses. A stressor exists outside the client system; external stressors include changes in healthcare policies or increased the crime rates. A stressor is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

A stressor is any stimuli that can produce tension and cause instability within the system. Rationale A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

The leader is advising the nursing student to avoid making careless assumptions. Which critical thinking skill does the leader wants the nursing student to learn? Analysis Inference Evaluation Explanation

Analysis Rationale The leader is advising the nursing student to adopt an analysis skill. Analytical skills involve a nurse being open-minded while looking at the client's information and avoiding the making of careless assumptions. Inference skills focus on the meaning of the findings and its significance. Evaluation involves looking at all situations objectively and using criteria to determine the results of nursing actions. Explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.

How does a nurse prepare a "factual" record when performing a client documentation? By providing a logical order for the communication By using exact measurements for each activity of the client By providing complete and appropriate information in each client record By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

By recording descriptive and objective information of what the nurse sees, hears, feels, and smells Rationale A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a complete and appropriate record that includes all essential information.

A registered nurse is teaching a nursing student about the concepts that make up a theory. Which point noted by the nursing student needs correction? Concepts consist of interrelated theories. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences.

Concepts consist of interrelated theories. Rationale A theory consists of interrelated concepts. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences.

A client is in a state of ambivalence. Which of these stages of health behavior will the nurse suspect? Preparation Maintenance Contemplation Precontemplation

Contemplation Rationale The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude towards a change; the client is most likely to accept that change in the next six months. The stage of preparation is when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about the changes in the behavior.

With reference to the nursing process as a system, what is content? Content is the end product of a system. Content serves to inform a system about how it functions. Content is the product and information obtained from the system. Content is the data or information that comes from a client's assessment.

Content is the product and information obtained from the system. Rationale With reference to the nursing process as a system, the content is the product and information obtained from the system. Output is the end product of a system. Feedback serves to inform a system about how it functions. Input is the data or information that comes from a client's assessment.

What type of research explores the interrelationship among variables of interest without any active intervention by a researcher? Historical research Evaluation research Exploratory research Correlation research

Correlation research Rationale Correlation research involves the exploration of the interrelationship among variables of interest without any active intervention by a researcher. Historical studies are designed to establish facts and relationships concerning past events. Evaluation research tests how well a program, practice, or policy is working. Exploratory research is an initial study designed to develop or refine the dimensions of phenomena.

Taxonomy Domains (NIC)

Domain 1: Physiological: Basic. care that supports physical functioning Domain 2: Physiological: Complex. care that supports homeostatic regulation Domain 3: Behavioral. care that supports psychosocial functioning and facilitates life-style changes Domain 4: Safety. care that supports protection against harm Domain 5: Family. care that supports the family unit Domain 6: Health System. care that supports effective use of the health care delivery system Domain 7: Community. Care that supports the health of the community

Which domain of the nursing intervention phase includes electrolyte and acid-base management? Domain 1 Domain 2 Domain 3 Domain 4

Domain 2 Rationale Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiologic complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

Which psychophysiological factors can influence communication between a nurse and a client? Select all that apply. Privacy level Emotional status Information exchange Level of caring expressed Growth and development

Emotional status Growth and development Rationale Growth and development and emotional status are two psychophysiological factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? Knowing Enabling Doing for Being with

Enabling Rationale The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

Which professional standard does the nurse feel is most important for critical thinking? Logical thinking Evaluation criteria Accurate knowledge Relevant information

Evaluation criteria Rationale An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? Evaluation Explanation Interpretation Self-regulation

Explanation Rationale Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? Use the new product sample when changing the dressing. Cleanse the site with alcohol first and then with povidone-iodine. Cleanse the site with the new product first and then follow the agency's protocol. Follow the agency's policy unless it is contradicted by a primary healthcare provider's prescription.

Follow the agency's policy unless it is contradicted by a primary healthcare provider's prescription. Rationale Agency policy determines procedures; if the procedure is out of date or problematic, the nurse should contact the primary healthcare provider for a change in the prescription. The nurse cannot use another product without a primary healthcare provider's prescription. The nurse will be risking liability if agency policy is not followed unless the prescription is changed by the primary healthcare provider. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer to a multiple-choice item. If answer choices contain an absolute (e.g., none, never, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices.

Which nursing interventions enhance comfort in an imminently dying client in the hospital? Select all that apply. Frequently repositioning the client Maintaining oral hygiene in the client Limiting frequent visits of the family members Measuring the vital signs of client frequently Applying body lotion to the client's skin daily

Frequently repositioning the client Maintaining oral hygiene in the client Applying body lotion to the client's skin daily Rationale The nurse provides comfort care to the client who is in the process of dying to ensure client comfort. Prolonged bed rest may cause back pain and skin issues; to reduce the pain, the nurse frequently repositions the client on the bed. Poor oral and skin hygiene may cause discomfort to the client, so the nurse carefully maintains the client's oral and skin hygiene. The nurse does not limit the visitation of family members because these visits may reduce the client's emotional stress. There is no need to measure the vital signs regularly in an imminently dying client, and doing so may increase discomfort in the client.

Which statement about Henderson's theory of nursing care is correct? Henderson's self-care deficit theory focuses on the client's self-care needs. Henderson's theory is based on stress and the client's reaction to the stressor. Henderson's concept of the environment includes the suggestion that nurses do not need to know all about the disease process differentiated nursing from medicine. Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental.

Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental. Rationale Henderson's theory comprises 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental. Orem's self-care deficit theory focuses on the client's self-care needs. The Neuman systems model is based on stress and the client's reaction to the stressor. Nightingale's concept of the environment includes the suggestion that nurses do not need to know all about the disease process differentiated nursing from medicine.

Which healthcare system focuses solely on palliative care? Hospice Rehabilitation Assisted Living Extended care facilities

Hospice Rationale A hospice is a system of family-centered care that allows clients to live and remain at home with comfort, independence, and dignity while easing the pain of terminal illness. The focus of hospice care is palliative care, not curative treatment. Rehabilitation restores a person to his or her fullest physical, mental, social, vocational, and economic potential possible. Assisted living offers an attractive long-term care setting with an environment reminiscent of home and with some resident autonomy. An extended care facility provides intermediate medical, nursing, or custodial care to clients recovering from acute illnesses or clients with chronic illnesses or disabilities.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? Fatigue related to weight loss secondary to COPD Imbalanced nutrition: less than body requirements, related to fatigue Imbalanced nutrition: less than body requirements, related to COPD Ineffective breathing pattern, related to alveolar hypoventilation

Imbalanced nutrition: less than body requirements, related to fatigue Rationale The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

Which statement about Orem's theory needs to be corrected? 1. It determines self-care needs. 2. It explains the types of nursing care. 3. It aids in the design of nursing interventions. 4. It describes factors supporting the health of the family.

It describes factors supporting the health of the family. Orem's theory explains the factors within a client's living situation. These factors may support or interfere with the client's self-care abilities, but they do not refer to the family's health. This theory interprets data that determine a client's self-care needs, self-care deficits, and self-care abilities. Orem's theory explains, predicts, or describes nursing care that will help the client in bettering his or her health. The theory also aids in the design of nursing interventions for the promotion of self-care by the client during times of illness, such as asthma, diabetes mellitus, or arthritis

A 70-year-old client needs to undergo heart surgery but cannot afford it. The client seeks the assistance of a nurse. Which is the preferred program that the nurse may suggest? Medicaid Medicare Managed care organization Preferred care organization

Medicare Rationale The nurse should discuss the Medicare program to this client. This health insurance program is designed for clients 65 years of age and older. There are four parts of Medicare; part A takes care of the medical, surgical, and psychiatric costs. Medicaid is a state-operated program that provides long-term care to low-income families and disabled older clients. The nurse may suggest this program in case of disabilities, but Medicare is the preferred choice. Managed care organizations (MCO) provide comprehensive preventive and treatment services to a specific group of voluntarily enrolled people. Preferred care organizations (PCO) narrow down the list of hospitals, physicians, and healthcare providers preferred by the member. PCO and MCO members need to pay from his or her own pocket in order to afford these facilities.

A nursing student notes the characteristics of middle-range theories. Which points noted by the nursing student are accurate? Select all that apply. Middle-range theories are systematic and broad in scope and complexity. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Middle-range theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching. Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, qualit

Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Rationale Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Mishel's theory of uncertainty in illness is an example of a middle-range theory; it focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories are more limited in scope and less abstract than grand theories. Middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching.

The Magnet Recognition Program for health care organizations is based on fourteen forces of magnetism related to five magnet model components. Which force of magnetism is assessed to review the structural empowerment of the organization? Quality of care Quality improvement Interdisciplinary relationships Personnel policies and programs

Personnel policies and programs Rationale Health care organizations that apply for Magnet status must demonstrate innovations in professional practice. One of the forces of magnetism that impacts the structural empowerment of the organization is its personnel policies and programs. Personnel policies of an organization should provide an innovative environment in which the staff are developed and empowered. Empirical quality outcomes are reviewed by assessing the quality of care. New knowledge, innovations, and improvements are reviewed by assessing the quality improvement of the health care organization. Interdisciplinary relationships are assessed to review exemplary professional practice.

A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain? Domain Paradigm Phenomenon Environment or situation

Phenomenon Rationale A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon. The domain is the perspective of a profession. A paradigm is a pattern of thought that is useful in describing the domain of a discipline. Environment or situation includes all possible conditions affecting clients and the settings in which their health care needs occur.

A client with bone cancer is receiving hospice care at home. The hospice program also provides respite care. What is the purpose of respite care? Assisting the client with meals and personal care Providing short-term relief to the family caregiver Providing skilled nursing interventions for the client Providing counseling and treatment for behavioral problems

Providing short-term relief to the family caregiver Rationale Hospice programs are focused at providing pain relief to the client. Some hospice programs also provide short-term relief or "time-off" to the family caregiver. This enables the caregiver to leave the home to attend to other activities while the client is looked after by a responsible person. Services in an assisted living facility provide meals and personal care to the clients. A skilled nursing facility or an intermediate care facility provides skilled interventions such as intravenous administration of fluids, wound care, or long-term ventilator management. Psychiatric facilities provide counseling and treatment to clients for behavioral problems.

Which healthcare system is required after a physical or mental illness, injury, or chemical addiction? Rehabilitation Intensive care Psychiatric facilities Extended care facilities

Rehabilitation Rationale Clients require rehabilitation after a physical illness, mental illness, injury, or chemical addiction. An intensive care unit is required when a client needs close monitoring in addition to medical care. Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities.

Which characteristic indicates that nursing is a profession? The nurse is trained to perform specific tasks. The nurse is required to follow a code of ethics. The nurse is required to have a collection of specific skills. The nurse has limited autonomy in decision making and practice

The nurse is required to follow a code of ethics. Rationale Nursing is a profession because it follows a code of ethics, which are the philosophical ideals of right and wrong that define the principles the nurse uses to care for the clients. Nursing is not just a collection of specific skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner. Nursing is a profession because nurses have autonomy in decision making and practice in accordance with the state and federal laws and regulations. Nursing is a profession because its members must not only possess basic nursing education but extended education to explore new methods of health care.

A nurse is in the process of conducting research. What action indicates that the nurse is designing the study? The nurse gathers all relevant articles and focuses on reviewing the literature. The nurse obtains approval from the proper authorities and enlists the research subjects. The nurse checks whether all investigators are following the appropriate study protocol. The nurse prepares questionnaires and selects the treatment plans necessary for the study.

The nurse prepares questionnaires and selects the treatment plans necessary for the study. Rationale The stage of designing the study is when the nurse chooses the instrumentation for conducting the study. In this stage, the nurse prepares questionnaires and selects physiological measures, interviews, and treatments necessary for the study. The first stage of the research process involves identifying of the problem. At this stage the nurse may gather all relevant articles and review literature for the purpose of conducting the research. The stage of conducting the study involves the nurse obtaining approval from the appropriate authorities and enlisting research subjects. The nurse also monitors whether all investigators are following the appropriate study protocol in order to ensure accuracy of the findings.

What is the purpose of block and parish nursing? To provide services to older clients To promote health throughout a school curriculum To provide nursing services with a focus on health promotion and education To provide primary care to a client population living in a community

To provide services to older clients Rationale In block and parish nursing, nurses living within a neighborhood provide services to older clients or those unable to leave their homes. Health promotion throughout a school curriculum is provided by school health. Nurse-managed clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. Community health centers are outpatient clinics that provide primary care to a client population living in a community.

What is the function of the Professional Standards Review Organizations (PSROs) set up by the federal government? To identify "Never Events" in health care To set national priorities to transform healthcare To review the quality, quantity, and cost of hospital care To eliminate overuse of diagnostic and treatment services

To review the quality, quantity, and cost of hospital care That's right! Rationale The federal government set up PSROs to review the quality, quantity, and cost of hospital care. The National Quality Forum defined a list of 28 "Never Events" in health care. Death or injury due to medication error is an example of a "Never Event." The National Priorities Partnership is a group of 28 organizations from a variety of health care disciplines that work together to transform health care on a national level. Medicare-qualified hospitals have utilization review committees to review admissions and identify and eliminate overuse of diagnostic and treatment services for clients on Medicare.

A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain? "Can you describe your pain to me?" "Is your pain associated with movements?" "Can you rate your pain on a scale of 0 to 10?" "Do you notice your pain worsening with any activity?"

"Can you describe your pain to me?" Rationale The nurse may ask the client to describe the pain or to point the area that hurts. It may help to assess the nature of the pain. Asking about effect on pain with movement may help to assess precipitating factors. The severity of a pain could be identified by asking the client to rate it on a scale from 0 to 10. The precipitating factors can be identified by asking the client about worsening of the pain with a particular activity.

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse? "Why are you always laughing?" "Your laughter is a cover for your fear." "Does it help to joke about your illness?" "The person who laughs on the outside cries on the inside."

"Does it help to joke about your illness?" Rationale The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? "I would, but my back hurts today." "Okay. It will be my good deed for the day." "Of course. I want to do whatever I can for you." "I would like to, but it is not in my job description."

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.

A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family? "Please do not worry, everything will be alright." "I am sorry; I do not have any information about the client." "You will have to wait for the primary healthcare provider." "Please wait; I will update you as soon as I have any information."

"Please wait; I will update you as soon as I have any information." Rationale The nurse should update the client's relatives once he or she receives relevant information. This action helps the nurse to maintain the nurse-client relationship. The nurse must not provide false reassurances because this action affects the family's ability to adjust to any bad news. If the nurse does not have any information about the client, the nurse must find out details and inform the client's family. The nurse should not avoid the situation by asking the relatives to speak to the primary healthcare provider.

A registered nurse is teaching a nursing student about Maslow's hierarchy of needs. Which statement made by the nursing student needs correction? "The hierarchy of basic human needs includes five levels of priority." "The second level includes safety and security needs, which involve physical and psychological security." "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life."

"The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." Rationale The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization.

A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? "Let me get my preceptor." "Wash your hands before and after any client care." "Clean all instruments and work surfaces with an approved disinfectant." "Ensure proper disposal of all items contaminated with blood or body fluids."

"Wash your hands before and after any client care." Rationale The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? "No, try to be in your sense of reality." "Yes, today is the day that you just mentioned." "You should try improving your awareness level." "Try to recall your past memories associated with the day."

"Yes, today is the day that you just mentioned." Rationale Validation therapy an approach to communication with a confused client with dementia. In this approach, the nurse accepts the description of the time and place as stated by the client. Therefore, the statement "Yes, today is the day that you just mentioned" represents the use of validation therapy. Asking the client to reorient himself or herself to reality and asking him or her to improve his or her awareness level are examples of the reality orientation approach. Reminiscence is an approach that asks the client to recall his or her past experience.

Which approach is a comforting approach that communicates concern and support? 1. Touch 2. Listening 3. Knowing the client 4. Providing a positive presence

1. touch

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1. Activity theory 2. Continuity theory 3. Disengagement theory 4. Gerotranscendence theory

4. Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.

Which description is most appropriate for the family centered care approach? The nursing care is focused on the client as an individual. A collaborative plan of care is developed to achieve optimal health. The healthcare provider is the expert in developing a plan of care. The nursing care is based solely on standards of practice.

A collaborative plan of care is developed to achieve optimal health. Rationale Family-centered care is commonly used to describe optimal health care as experienced by families. The term is frequently accompanied by terms such as "partnership," "collaboration," and families as "experts" to describe the process of care delivery. Family care addresses the family versus one individual. The healthcare provider collaborates with the family to develop a plan of care. Evidence based standards of practice are incorporated into a collaborative family centered care plan. Standards are not the only guidelines considered in a family centered plan of care.

What should the nurse educator instruct a graduate nurse who is seeking employment? Select all that apply. Be a role model to the nursing staff Attend workshops and conferences Motivate other educators on the nursing unit Work on developing effective communication Approach institutions that provide mentoring

Attend workshops and conferences Work on developing effective communication Approach institutions that provide mentoring Rationale The nurse educator should instruct the graduate nurse to attend workshops and conferences to develop collaborative skills and communication. A graduate nurse should work on developing effective communication with peers and members of the healthcare team. The graduate nurse should seek employment in institutions that provide mentoring for new graduate nurses. The nurse manager can be an effective leader by being a role model for the nursing staff. The nurse manager should motivate others on the nursing unit to make an empowering work environment.

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? Mask Clean gloves Sterile gloves Shoe covers

Clean Gloves Rationale Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Mask, sterile gloves, and shoe covers are not required for this situation.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's Correct3 End-stage renal 4 Gastroesophageal reflux

Correct3 End-stage renal One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with patient care, remove the gown first and then remove the gloves.

Don an N95 respirator mask before entering the room. Rationale A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? Administer the prescribed as needed (PRN) sedative. Encourage the client to express feelings. Explain the postprocedure course of treatment. Reassure the client that there are others with this problem.

Encourage the client to express feelings. Rationale Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus should be on the client, not others. Reassurance may cut off communication and deny emotions.

Which statement defines the term family resiliency? Family resiliency is the uniqueness of each family. Family resiliency is the ability of the family to cope with stressors. Family resiliency is the intrafamilial system of support and structure. Family resiliency is the ability of the family to transcend.

Family resiliency is the ability of the family to cope with stressors. Rationale Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? Heredity Hypertension Cigarette smoking Diabetes mellitus

Heredity Rationale Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.

Which statement is true about the nursing model "team nursing"? The registered nurse is responsible for all aspects of client care. Client care can be delegated to other healthcare team members. The registered nurse works directly with the client, family members, and healthcare team members. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. Rationale In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? Hypernatremia Hyponatremia Hyperkalemia Hypokalemia

Hyponatremia Rationale The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

Which step in the research process is similar to the assessment step of the nursing process? Analyzing the results Conducting the study Developing hypothesis Identifying the problem

Identifying the problem Rationale Identifying the problem, which includes reviewing literature, formulating a theoretical framework, and identifying the study variables is similar to assessment in the nursing process. Analyzing the results of research is similar to the evaluation phase of the nursing process. Conducting the study is similar to the implementation phase of the nursing process. Developing the hypothesis coincides with the diagnosis phase of the nursing process.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation

Implementation Rationale The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? Diagnosis Evaluation Assessment Implementation

Implementation Rationale The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

nursing model "team nursing"

In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? Plasma Interstitial Dense tissue Body secretions

Interstitial Rationale Interstitial fluid constitutes about 16% of body weight, which is 10 to 12 L in an adult male of 68 kg (150 lb). Plasma is 4% of body weight. Dense tissue is part of the intracellular component. Body secretions are derived from extracellular fluid and are calculated as part of the 20% of the total body weight.

Which opposing conflict does a young adult face according to Erikson's theory of psychosocial development? Intimacy versus Isolation Identity versus Role Confusion Autonomy versus Sense of Shame and Doubt Generativity versus Self-Absorption and Stagnation

Intimacy versus Isolation Rationale According to Erikson's theory of psychosocial development, a young adult is likely to face Intimacy versus Isolation. An adolescent is likely to face Identity versus Role confusion. A toddler age 1 to 3 years of age is likely to face Autonomy versus Sense of Shame and Doubt. A middle-aged adult is likely to face Generativity versus Self-Absorption and Stagnation.

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? Have the client void every 2 hours. Maintain the client in an isolation room. Spend time with the client to allow verbalization of feelings. Wear two pairs of gloves when touching the client during care.

Maintain the client in an isolation room. Rationale During radiation therapy with radium implants, the client is placed in isolation so that exposure to radiation by family and staff is decreased. Voiding every 2 hours is unnecessary; a full bladder will not disrupt the seeds. Excess exposure to radiation is hazardous to personnel. Gloves will not protect the nurse from radiation.

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? Assess the resources available to the family Meet the client's family's comfort and nutritional needs Meet the client's comfort, hygiene and nutritional needs Determine the family's need for rest and their stage of coping

Meet the client's comfort, hygiene and nutritional needs Rationale When viewing family as context, the nurse mainly focuses on the client's comfort, hygiene, and nutritional needs. Family as context means focusing on the health and development of a client. When viewing family as a system, the nurse mainly focuses on assessing the resources available to the family. Family as system includes both family as context and family as a client. When viewing family as a client, the client's family comfort and nutritional needs are focused on, and the nurse determines the family's needs for rest and their stage of coping.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? Primary Secondary Superinfection Nosocomial

Nosocomial Rationale A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where? In the axillae On the hands On the right side On the side that the client prefers

On the hands Rationale Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side or the side the client prefers.

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? Colitis Stomatitis Paralytic ileus Gastrocolic reflux

Paralytic ileus Rationale After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family? Orem's theory Peplau's theory Leininger's theory Henderson's theory

Peplau's theory Rationale Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? <p>A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what?</p> Suddenness of the change Obviousness of the change Extent of the change Perception of the change

Perception of the change Rationale It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? Fairness Humility Discipline Perseverance

Perseverance Rationale Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, he or she demonstrates perseverance. Fairness requires the nurse to listen to both the sides in any discussion. Humility is associated with recognizing the need for more information for making a decision. When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? Place a surgical mask on the client. Other than standard precautions, no additional precautions are needed. Minimize close physical contact. Cover the client's legs with a blanket.

Place a surgical mask on the client. Rationale Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? Postural drainage Cupping the chest Nasotracheal suctioning Frequent changes of position

Postural drainage Rationale Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a healthcare provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, but will not prevent their accumulation.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Maintain immobilization of a client's leg to prevent dislodging a skin graft. Keep an older adult client from falling out of bed following a surgical procedure.

Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Rationale Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

What interventions should the nurse perform while caring for an actively dying client? Select all that apply. Admit the client in hospice care. Perform aggressive laboratory tests. Provide client and family reassurance. Keep the client undisturbed for a long time. Perform symptom management in the client.

Provide client and family reassurance. Perform symptom management in the client. Rationale The nurse should provide comfort care in an actively dying client. In comfort care, the nurse should reassure the client and family to reduce their emotional anxiety. The nurse should perform symptom management to improve the client's quality of life. The client should not be admitted into hospice care if he or she is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? Provide perineal care. Turn and position the client. Give a complete bed bath. Document the bowel movement.

Provide perineal care. Rationale Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

The plan of care for the client was to lose 7 lbs (3.2 kg) by the end of the month. The client only lost 3 lbs (1.4 kg). How should the nurse respond? Assume that the client has been cheating on the diet. Increase the goal for next month to keep the client on track. Reevaluate the plan of care for appropriateness. Discontinue the plan of care because it did not work.

Reevaluate the plan of care for appropriateness. Rationale If client outcomes have not been met, the process is reviewed from the beginning. The nurse evaluates whether the outcomes and nursing interventions were realistic, measurable, and achievable. If not, revision of client outcomes and interventions are necessary to determine whether the plan should be maintained, modified, discontinued, or referred to another healthcare professional. Assuming the client has been cheating on the diet, increasing the goal for next month, and discontinuing the plan of care are not positive steps to help the client reach the goals realistically.

A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence? Establish long-range goals for the client. Identify errors that the client can correct. Reinforce success in tasks accomplished. Demonstrate ways to promote self-reliance.

Reinforce success in tasks accomplished. Rationale Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client.

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? Encouraging frequent naps Strengthening the concept of ageism Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high-carbohydrate diet

Reinforcing the client's strengths and promoting reminiscing Rationale Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death? Revising the client's will and planning a visit to a friend Alternately crying and talking openly about death Getting second, third, and fourth medical opinions Refusing to follow treatments and stating they won't help anyway

Revising the client's will and planning a visit to a friend Rationale Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time. Crying and talking openly about death are signs of depression. Going from healthcare provider to healthcare provider demonstrates disbelief, denial, or desperation. Refusing to follow treatments and stating that the client is going to die anyway indicates anger and hopelessness, not acceptance.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? Right task Right person Right supervision Right communication

Right communication Rationale Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations while delegating a task. Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person is delegating a task to the correct person who has the ability to perform said task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.

What should the community nurse teach about the risk of adolescent pregnancy? Risk for premature birth Risk for having a large baby Risk for chromosomal defects Risk for increased weight gain

Risk for premature birth Rationale The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? Prioritize psychosocial needs over physical needs. Use the Nursing Outcomes Classification (NOC) only. Use nursing knowledge to plan outcomes and disregard client and family desires. Set priorities and outcomes using the client's and family input.

Set priorities and outcomes using the client's and family input. Rationale Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.

Which developmental changes should be evaluated in girls around 12 years of age? Motor skills Visual acuity Skeletal growth Hormonal changes

Skeletal growth Rationale Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? Nuclear family Extended family Single-parent family Skip-generation family

Skip-generation family Rationale A skip-generation family form is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

Which standards would the nurse explain are important for critical thinking? Select all that apply. Specific Fairness Relevant Confidence Independence

Specific Relevant Rationale The standards important for critical thinking are specific and relevant knowledge about a task. Fairness, confidence, and independence are the attitudes required for critical thinking.

Which theories are most relevant to development in adults? Select all that apply. Piaget's theory Erikson's theory Kohlberg's theory Stage-Crisis theory Life Span approach

Stage-Crisis theory Life Span approach Rationale The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with the psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? The baby has a head lag when pulled to sit. The baby can turn from the side to the back. The baby can turn from the abdomen to the back. The baby supports much of his own weight when he or she is pulled to stand.

The baby has a head lag when pulled to sit. Rationale A normal five-month-old infant should be able to sit up without a head lag. This finding should cause the nurse to conduct a further assessment. A baby should be able to turn from the side to the back by four months of age. At five months of age, the baby should be able to turn from the abdomen to the back. The baby should be able to support much of his own weight when pulled to stand by the age of five to six months.

Which assessment finding is associated with depression? The client has islands of intact memory. The client has impaired recent and remote memory. The client has impaired recent and immediate memory. The client needs step-by-step instructions for simple tasks.

The client has islands of intact memory Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? All nursing functions will be completed by discharge. All invasive intravenous lines will remain patent. The client will remain awake, alert, and oriented at all times. The client will be free of signs and symptoms of infection by discharge.

The client will be free of signs and symptoms of infection by discharge. Rationale Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse? The client's gag reflex has returned. The client is confused due to anesthesia. The client is nauseated and wants to vomit. The client's airway is becoming obstructed.

The client's gag reflex has returned. Rationale The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not obstruct the airway.

During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding? The nurse restores the client's sense of reality. The nurse builds self-esteem by asking about a client's previous achievements. The nurse agrees to a confused client's incorrect statement. The nurse meets the expressed and unexpressed needs of the client.

The nurse builds self-esteem by asking about a client's previous achievements. Rationale Reminiscence theory involves helping the client to recall past experiences to help resolve current conflicts. A nurse who builds a client's self-esteem by asking about his or her previous achievements is using the theory. Reality orientation is associated with the restoration about the sense of reality. Validation therapy is associated with agreeing with a confused older client's incorrect statement. The nurse may use therapeutic communication to address the expressed and unexpressed needs of the client.

Which nurse is using complex critical thinking skills when caring for a client? The nurse talks to the client to identify reasons for a particular behavior. The nurse seeks the assistance of a senior nurse to set up an insulin pump. The nurse follows the agency's manual to apply a Foley catheter to a client. The nurse takes action without involving others and accepts accountability.

The nurse talks to the client to identify reasons for a particular behavior. Rationale A nurse practicing complex critical thinking skills begins to analyze and examine choices more independently. Talking to a client to identify reasons for a particular behavior, such as refusal to take pain medication or use of alternative therapy for pain involves the use of complex critical thinking skills. An example of basic critical thinking skills is a nurse who depends on manuals or experts and a nurse who seeks the assistance of a senior nurse to set up an insulin pump. A nurse who takes action without involving others and accepts

What are the goals of care when working with families according to the family health system? Select all that apply. To improve family health or well-being To help the family prepare for later transitions To assist in family management of illness conditions To promote positive family behaviors to achieve essential tasks To achieve health outcomes related to the family's areas of concern

To improve family health or well-being To assist in family management of illness conditions To achieve health outcomes related to the family's areas of concern Rationale When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

Why does the nurse establish "moderately hard" client-centered goals? Select all that apply. To decrease the cost of treatment during therapy To decrease the number of follow-up visits by the client To achieve the goal in a shorter period of time with less effort To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal

To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal Rationale Healthcare providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.

Which approach is a comforting approach that communicates concern and support? Touch Listening Knowing the client Providing a positive presence

Touch Rationale Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Listening is a critical component of nursing care and is necessary for meaningful interactions with clients. Knowing the client comprises both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that conveys a closeness and sense of caring.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? Attention span Primary language Coping mechanisms Activity and coordination

attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

Which intervention reflects the nurse's approach of "family as a context"? Trying to meet the client's comfort Evaluating the client family's coping skills Evaluating the client family's energy level Trying to meet the client family's nutritional needs

Trying to meet the client's comfort Rationale In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

To prevent septic shock in the hospitalized client, what should the nurse do? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures. Rationale Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply. <p>Which fine-motor skills may be observed in an 8 to 10 month-old infant? <b>Select all that apply.</b> </p> Using pincer grasp well Picking up small objects Showing hand preference Crawling on hands and knees Pulling oneself to standing or sitting

Using pincer grasp well Picking up small objects Showing hand preference Rationale The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

What is exploratory research? It is a study that tests how well a program, practice, or policy is working. It is a study designed to develop a hypothesis about the relationships among phenomena. It is a study that explores the interrelationships among variables of interest without any active intervention by the researcher. It is a study that measures characteristics of situations, or groups, and the frequency with which certain events or characteristics occur.

it is a study designed to develop a hypothesis about the relationships among phenomena. Rationale Exploratory research is an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena. Evaluation research is a study that tests how well a program, practice, or policy is working. Correlational research is a study that explores the interrelationships among variables of interest without any active intervention by the researcher. Descriptive research is a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur.