NU 2520 (exam 4)

"In general, clinicians are more likely to screen patients regularly if they fit under which 4 desired circumstantial criteria...

(If they...) recieve training are female are younger (in age) are RN's (not Dr's)

A group of RN's are discussing advantages of using computerized provider order entry (CPOE). Which statement indicates that the RN's understand the advantage of using CPOE? a. "CPOE reduces transcription errors." b. "CPOE reduces the time needed for health care providers to write orders." c. "CPOE eliminates verbal and telephone orders from health care providers." d. "CPOE reduces the time nurses use to communicate with health care providers."

A (CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly, thus eliminating the need to transcribe orders. There is no evidence that CPOE reduces the time needed for providers to write orders for their patients, or the time nurses must spend communicating with providers. Nurses use CPOE systems under certain circumstances to enter orders given by a provider in person, or over the phone.)

A depressed Pt is crying & verbalizes feelings of low self-esteem & self-worth such as, "I'm such a failure ... I can't do anything right." What is the RN's best response? a. Remain with the Pt until he or she validates feeling more stable. b. Tell the Pt that is not true and that every person has a purpose in life. c. Review recent behaviors or accomplishments that demonstrate skill ability. d. Reassure the Pt that you know how he is feeling & that things will get better.

A (Demonstrating acceptance of the patient by supportively sitting with him or her builds a therapeutic nurse-patient relationship. The nurse's presence signals value and allows the patient to explore issues of self-concept and self-esteem.)

The RN is working the evening shift at a hospital that uses military time for documentation. The RN administered morphine 2 mg intravenously (IV) for pain at 3:45 PM Then changed the dressing over the patient's abdominal incision at 5:34 PM Then administered Ancef 1 g IV at 8:00 PM. Using correct military time, which of the following is the correct label of documentation for each task w/ the time that it was completed? a. 1545, 1734, 2000 b. 0345, 1734, 2000 c. 1545, 0534, 0800 d. 0345, 0534, 0800

A (Military time is essentially the same as civilian time for the hours between 1 a.m. and 12 noon, with the exception that you add a leading "0" to times before 10:00 a.m. (ex: 08:00 instead of 8:00 a.m.). To convert military time to civilian time: For a military time that's 13:00 or larger, simply subtract 12:00 to get the standard time (ex: If someone says "Meet me in room 202 at 15:45, subtract 12:00 from 15:45 to get 3:45 pm). To convert standard time to military time: add 12:00 to any time from 1:00 p.m. to 11:00 p.m. (ex: If you want to say 6:30 p.m. in military time, add 12:00 to 6:30 to get 18:30).)

Place the steps of the scientific method in their correct order. The number 1 being the first step of the process. 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. a. 4, 3, 1, 5, 2 b. 3, 4, 1, 2, 5 c. 4, 3, 2, 1, 5 d. 3, 4, 1, 5, 2

A (The correct order of the steps of the scientific method are: 1. Identifying the problem, 2. Collecting data, 3. Formulating a question or hypothesis, 4. Testing the question or hypothesis, and 5. Evaluating results of the test or study.)

A RN just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the RN considers what affected the inability of the mother to breastfeed + the mother's obesity & inexperience. The RN's review of the situation is called: a. Reflection. b. Perseverance. c. Intuition. d. Problem solving.

A (The mother had difficulty the first time breast feeding. The nurse relied on reflection to consider her previous actions, review what was successful and the opportunities for improvement. The nurse has not yet problem solved but might do so after reflection and anticipating the patient's next clinic visit.)

An RN is preparing medications for a Pt. The RN checks the name of the med on the label w/ the name of the med on the HCP's order. At the bedside the RN checks the Pt's name against the med order as well. The RN is following which critical thinking attitude: a. Responsible b. Complete c. Accurate d. Broad

A (The nurse is demonstrating responsibility for correct medication and patient identification. The other three choices are critical thinking intellectual standards.)

The RN is caring for a patient with a nasogastric feeding tube who is receiving a cont. tube feed @ rate of 45 mL per hour. The RN enters the Pt assessment data & which includes a bed elevation of 20 degrees. An alert appears on the screen, warning that this Pt is at elevated risk for aspiration bc the head of the bed is not adequately elevated... This warning is known as which type of system? a. Electronic health record. b. Clinical documentation. c. Clinical decision support system. d. Computerized physician order entry

A (This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.)

When developing an appropriate outcome for a 15-year-old girl, the RN considers that a primary developmental task of adolescence is to: a. Form a sense of identity. b. Create intimate relationships. c. Separate from parents and live independently. d. Achieve positive self-esteem through experimentation.

A (Understanding developmental tasks across the life span is essential in designing nursing care. Adolescents are focused on establishing their identity outside the family and should be supported in meeting this developmental task.)

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year-old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. What is the correct order for the nurse's discussion with the parents? 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4. "Let me help you two calm down a bit so I can take you to your daughter." A. 2, 4, 3, 1 B. 4, 2, 1, 3 C. 3, 1, 4, 2 D. 2, 3, 4, 1

A (First and most important the parents need to know the immediate status of their daughter. Letting them know the situation will help to relieve their immediate stress. Second, helping the parents calm down and reduce their stress will allow them to see their daughter without increasing the 10-year-old's anxiety. Third, let the parents know you recognize their need to talk to the doctor as soon as possible and you will act as their advocate to get that accomplished. Last, but important, you want to ask if there is anyone you can call to help. There may be children who need to be picked up from camp/day care, and a neighbor or grandparent may be able to assist.)

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? a. Results in neurophysiological response b. Reduces body temperature c. Causes a person to be hypervigilant d. Reduces level of consciousness to conserve energy.

A (Negative feedback senses an abnormal state such as lowered body temperature and makes an adaptive response such as shivering to generate body heat to return the body to hormonal homeostasis.)

An adult woman is recovering from a mastectomy for breast cancer & is frequently tearful when left alone. The RN's approach should be based on an understanding of which of the following? a. Patients need support in dealing with the loss of a body part. b. The patient's family should take the lead role in providing support. c. The nurse should explain that breast tissue is not essential to life. d. The patient should focus on the cure of the cancer rather than loss of the breast. (X)

A (The nurse should encourage the patient to talk about the threats to body image, including the meaning of the loss, the reactions of others, and the ways in which the patient is grieving.)

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, has increased by saying, "You're wrong. My blood sugar has been excellent for the last 6 months." Which defense mechanism is the patient using? a. Denial. b. Conversion c. Dissociation d. Displacement.

A (Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars.)

On the basis of knowledge of the developmental tasks of Erikson's Industry versus Inferiority, the RN emphasizes proper technique for use of an inhaler w/ a 10-year-old boy so he will: a. Increase his self-esteem w/ mastery of a new skill. b. Accept changes in his appearance & physical endurance. c. Experience success in role transitions and increased responsibilities. (X) d. Appreciate his body appearance & function.

A (The developmental stage of Industry versus Inferiority (ages 8 to 12) is focused on incorporating feedback from peers and teachers, increasing self-esteem with new skill mastery, and promoting awareness of strengths and limitations.)

A 20-year-old Pt diagnosed w/ an eating disorder has a RN Dx of Situational Low Self-Esteem. Which of the following RN interventions would be appropriate to address self-esteem? (Pick 2 that apply.) a. Offer independent decision-making opportunities. b. Review previously successful coping strategies. c. Provide a quiet environment with minimal stimuli. d. Support a dependent role throughout treatment. (X) e. Increase calorie intake to promote weight stabilization.

A & B (Offering opportunities for decision making promotes a sense of control, which is essential for promoting independence and enhancing self-esteem. Reviewing successful coping strategies is also a priority intervention to signal previous mastery and promote effective coping in an individual with self-esteem issues. Promoting independence is an important part of treatment. Although weight stabilization may be needed, it will likely have a negative effect on self-esteem early in treatment.)

An RN is supervising a new RN student & allows the student to complete documentation of Pt while observing... Which action would be considered innappropriate for the RN student, & requires intervention by the supervising RN? (Select 2 that apply.) a. Documents a medication given by another nursing student. b. Includes the date and time of the entry into the medical record. c. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. d. Leaves a slip of paper with her user name and password in the patient's room. e. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

A & D (Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed. Personal passwords used to access an electronic medical record need to be kept secure to provide for safety and confidentiality of patient information. All of the other actions are appropriate for documentation.)

Match each line of documentation with the appropriate SOAP category... The RN documents information as "Acute pain related to tissue injury from surgical incision." This type of information belongs in which area of the SOAP note

A (Assessment)

The RN can increase a Pt's self-awareness through which of the following actions? (Select 3 that apply.) a. Helping the patient define her problems clearly b. Allowing the patient to openly explore thoughts and feelings c. Reframing the patient's thoughts and feelings in a more positive way d. Having family members assume more responsibility during times of stress e. Recommending self-help reading materials

A B & C (Helping a patient define problems clearly, allowing him or her to openly explore thoughts and feelings, and reframing his or her thoughts and feelings in a more positive way are designed to promote self-awareness and a positive self-concept. Having the family assume more responsibility does not help a patient achieve self-awareness; instead it is important to encourage the patient to assume more self-responsibility. The nurse should refrain from offering self-help reading materials unless directly asked; the nurse should then provide numerous options.)

A RN on a busy medicine unit is assigned to four Pt's. It is 10 am. 2 Pt's have meds due & one of those has a specimen of urine to be collected. One Pt is having complications from surgery & is being prepared to return to the operating room. The 4th Pt requires instructions about activity restrictions before going home this afternoon. Which of the following should the RN use in making clinical decisions appropriate for the Pt group? (Select 3 that apply) A. Consider availability of assistive personnel to obtain the specimen B. Combine activities to resolve more than one patient problem C. Analyze the diagnoses/problems and decide which are most urgent based on patients' needs D. Plan a family conference for tomorrow to make decisions about resources the patient will need to go home (X) E. Identify the nursing diagnoses for the patient going home

A B & C (Analyzing urgency of problems helps in prioritization as does considering the resources that are available (such as assistive personnel) to complete patient care activities. Deciding on how to combine activities is good time management. Holding a family conference is a good idea but in this case would be too late to be beneficial to the patient. The nurse must identify nursing diagnoses for all patients in order to determine priorities.)

In which of the following examples, is an RN applying critical thinking skills in practice? (Pick 3 that apply.) a. The nurse thinks back about a personal experience before administering a medication subcutaneously. b. The nurse uses a pain-rating scale to measure a patient's pain. c. The nurse explains a procedure step by step for giving an enema to a patient care technician. d. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. e. A nurse offers support to a colleague who has witnessed a stressful event. (X)

A B & D (Reflection, using a pain rating scale to be precise and specific, and nursing assessment (the first step of the nursing process) are examples of critical thinking skills. Explaining a procedure based on policy is not critical thinking - however performing a procedure following policy is basic critical thinking. Offering support to a colleague is an important way to assist another in managing stress but is not a critical thinking skill.)

A staff RN is talking with the RN supervisor about the stress that she feels on the job. Which of the following are true about work-related stress? (Select all that apply.) a. Job-related stress can affect the quality of patient care. b. Stress can affect nurses' efficiency and decision making. c. Nurses who talk about feeling stress are unprofessional and should calm down. d. Nurses frequently experience stress with the rapid changes in health care technology. e. Nurses cannot resolve job-related stress.

A B & D (Nurses frequently experience stress with the rapid changes in health care and when the situation seems out of their personal control. When job stress remains unresolved, patient care and clinical decision making can be affected because the stress is perceived as uncontrolled and all consuming.)

During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which of the following questions provide information about the impact of this crisis? (Select all that apply.) a. With whom do you talk on a routine basis? b. What do you do when you feel lonely? c. How is having diabetes affecting your life? d. I know this must be hard for you. Let me tell you what might help. e. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

A B & E (A developmental crisis occurs as a person moves through the stages of life, including widowhood. It is important to gather information about how this crisis affects her interactions, coping with loneliness, and any changes in lifestyle habits. Although stress can affect diabetes, there is nothing in this situation that states that the woman has diabetes. Saying, "I know this must be hard for you. Let me tell you what might help" is unacceptable, because the whole purpose of assessment is to gather data and let the patient tell his or her story.)

The RN is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a RN who works at that facility & who will be receiving the Pt. In documenting this call, the RN begins w/ date & time the report was given & the name of the RN taking the report. Which of the following pieces of information does the RN include in the documentation of this telephone call? (Select all that apply.) a. The patient's name, age, and admitting diagnoses b. The discussion of any allergies to food and medications that the patient has c. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" d. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol e. Description of any unresolved problems and current interventions in place

A B D & E (During transfer to another institution, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.)

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

A C & D (The stressors for this parent are her child's illness, missing school, and loss of disability payments. Obtaining resources to resolve these stressors will reduce the mother's stress load and allow her to focus on helping her child improve and preventing another respiratory tract infection. Discharging the child in 72 hours with a return to school may not be best for the child's physical condition and may make the situation worse. Giving the mom a 6-week time frame is unrealistic because everyone's time frame is different. The mom may also need to adjust to a "new normal.")

this term is defined as "willful infliction of physical injury or mental anguish and the deprivation of essential services."

Abuse

Several staff members complain about an adult Pt's constant Q's such as, "Should I have a cup of coffee or a cup of tea?" & "Should I take a shower now or wait until later?" Which interpretation of the Pt's behavior helps the RN provide optimal care? a. Asking questions is attention-seeking behavior. (X) b. Inability to make decisions reflects a self-concept issue. c. Dependence on staff must be stopped immediately. d. Indecisiveness is aimed at testing how the staff reacts.

B (Patients with deficits in self-concept often have difficulty making decisions. It is essential for the nurse to remain accepting of the patient and to support him or her in decision making.)

When an RN asks the patient, "How do you FEEL about yourself?" The RN is assessing which information about the Pt... a. Identity. b. Self-esteem. c. Body image. d. Role performance.

B (Self-esteem is how a person feels about himself or herself. Asking open-ended questions about self-esteem is important during the nursing assessment.)

What is an appropriate RN Dx for an individual who experiences confusion in the mental picture of his physical appearance? a. Acute Confusion. b. Disturbed Body Image. c. Chronic Low Self-Esteem. d. Situational Low Self-Esteem.

B (Body image involves attitudes related to the body, including physical appearance, structure, or function. Disturbed Body Image would be an appropriate nursing diagnosis.)

Two Pt deaths have occurred on a med unit in the last mos. The staff notices that everyone feels pressured and team members are getting into more arguments. As an RN on the unit, what will best help you manage this stress? a. Keep a journal. b. Participate in a unit meeting to discuss feelings about the patient deaths. c. Ask the nurse manager to assign you to less difficult patients. d. Review the policy and procedure manual on proper care of patients after death

B (By connecting & meeting with staff colleagues, the nurse can talk about the experiences of caring for dying patients and learn that her feelings are likely shared by others. A journal is helpful but not the best way to relieve stress. A policy and procedure manual will not help the nurse examine and understand the nature of the stress. Asking for a different assignment is no guarantee that another stressful experience will develop.)

In planning RN care for an 85-year-old male, what is the most important BASIC NEED that MUST be met? a. Assurance of sexual intimacy (X) b. Preservation of self-esteem c. Expanded socialization d. Increase in monthly income

B Self-esteem is essential for physical and psychological health across the life span.

While reviewing the pulmonary assessment entered by a RN in a Pt's electronic medical record (EMR), a HCP notices that the only information documented in that section is "WDL" (within defined limits). The HCP also is not able to find a narrative description of the Pt's respiratory status in the RN's progress notes. What is the most likely reason for this? a. The nurse caring for the patient forgot to document on the pulmonary system. b. The EMR uses a charting-by-exception format. c. The computer shut down unexpectedly when the nurse was documenting the assessment. d. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

B (Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.)

A Pt states, "I would like to see what is written in my medical record." What is the nurse's best response? a. "Only your family can read your medical record." b. "You have the right to read your record." c. "Patients are not allowed to read their records." d. "Only health care workers have access to patient records."

B (Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.)

Which of the following assessment findings suggest an altered self-concept? (Select all that apply.) a. Uneven gait b. Slumped posture and poor personal hygiene c. Avoidance of eye contact when answering a question d. Requests for visits from the chaplain e. Frequent use of the call light

B & C (Common assessment findings for an individual with altered self-concept can mirror depressive symptoms such as slumped posture, poor hygiene, and avoiding intermittent eye contact. An individual with an unsteady or uneven gait may have successfully adjusted to an underlying condition. Requests for spiritual support and nursing care should be honored and may have nothing to do with an altered self-concept.)

A Pt with DM type 2 is experiencing a lot of work-related stress & is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevating, & his HCP wants him to attend some stress-management classes. He says, "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? (Select 3 that apply.) A. Increases in antidiuretic hormone (ADH) B. Increases in cortisol C. Increases in aldosterone D. Increases in adrenocorticotropic hormone (ACTH) E. Increases in epinephrine

B D & E (With stress the general adaptation syndrome is present. Glucose levels rise because ACTH stimulates cortisol, and gluconeogenesis occurs; the body creates new glucose from nonglucose sources (proteins and fats); cortisol alone increases gluconeogenesis; the sympathetic nervous system causes increased epinephrine, which elevates blood glucose. In the person with diabetes, these physiological responses can cause blood glucose levels to elevate beyond normal. ADH and aldosterone affect sodium and/or water balance and do not affect blood glucose.)

This can be either physical, psychological or sexual. It is defined as... behavior exhibited by the abuser to the victim, a criminal act.

Battering

When an RN tries to understand a Pt's & family caregiver's perspective of why a Pt is falling at home, the RN applies the intellectual standard of ____________ to understand all viewpoints

Broad (The intellectual standard of 'broad' covers multiple viewpoints.)

The RN is caring for a Pt w/ a nasogastric feeding tube who is receiving a continuous tube feeding @ a rate of 45 mL per hour. The RN enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? a. Electronic health record b. Clinical documentation c. Clinical decision support system d. Computerized physician order entry

C (A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.)

By using known criteria in conducting an assessment such as reviewing with a Pt the typical characteristics of pain, a RN is demonstrating which critical thinking attitude? a. Curiosity b. Adequacy c. Discipline d. Thinking independently

C (Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline.)

A preceptor observes a new grad RN discussing changes in a Pt's condition with a HCP over the phone. The new grad RN accepts a phone order for new meds + additional lab tests per the HCP. During the conversation, the new grad writes med orders down on paper & plans to enter them into the EMR when a computer is available. At this hospital, (new) med orders in the MREC can be viewed immediately by hospital pharmacists, & policy states, "all new meds must be reviewed by a pharmacist before being administered to Pt's." The supervising RN will have to intervene if the new RN grad completes which action... a. Read the orders back to the HCP to verify accuracy of transcribing the orders after receiving them over the phone b. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. c. Gives a newly ordered medication before entering the order in the patient's medical record. d. Asks the preceptor to listen in on the phone conversation.

C (When provider orders for new medication(s) are entered into an electronic medical record, the new orders are available to pharmacists using the same electronic system within the hospital. To improve patient safety, many hospitals have a policy that new medications are not to be administered (unless in an emergency) until a pharmacist reviews the new order(s), and verifies that there is no document allergies to the medications, the ordered dose(s) are appropriate, and that there are no potential medication interactions with medications already ordered for a patient. Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.)

The RN is reviewing the HIPAA regulations w/ the patient during the admission process. The Pt states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? a. HIPAA allows all hospital staff access to your medical record. b. HIPAA limits the information that is documented in your medical record. c. HIPAA provides you with greater protection of your personal health information. d. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C (HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.)

An aspect of clinical decision making is knowing the Pt. Which of the following is the most critical aspect of developing the ability to know the Pt? a. Working in multiple health care settings b. Learning good communication skills c. Spending time establishing relationships with patients d. Relying on evidence in practice

C (Knowing the patient relates to a nurse's experience with caring for patients, time spent in a specific clinical area and having a sense of closeness with them. However, a critical aspect to knowing the patient and thus being able to make timely and appropriate decisions is spending time establishing relationships with patients.)

What is the appropriate way for a RN to dispose of information printed out from a patient's EHR? a. Rip the papers up into small pieces and place the pieces into a standard trash can b. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit c. Place papers with patient information in a secure canister marked for shredding d. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

C (Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.)

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: a. A situational crisis. b. A maturational crisis. c. An adventitious crisis. d. A developmental crisis.

C (An adventitious crisis is a type of crisis resulting from a natural disaster such as a tsunami.)

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, & mild confusion. One of the 1rst assessments includes which of the following? a. The amount of family support b. A 3-day diet recall c. A thorough physical assessment d. Threats to safety in her home

C (Stress often causes symptoms similar to physical illnesses. Physical causes for problems need to be investigated and treated before treatment for stress-related symptoms can be initiated.)

A 30-year-old Pt diagnosed w/ major depressive disorder has a RN Dx: Chronic Low Self-Esteem, related to negative view of self. Which of the following would be appropriate interventions by the RN? (Select all that apply.) a. Encourage reconnecting with high school friends b. Role play to increase assertiveness skills (X) c. Focus on identifying strengths and accomplishments d. Provide time for journaling to explore underlying thoughts and feelings e. Explore new job opportunities

C & D (Focusing on strengths and accomplishments to minimize the emphasis on failures helps the patient to alter distorted and negative thinking. Journaling can allow a patient to explore thoughts and feelings that can promote insight and eventual behavioral change. The other interventions represent the nurse imposing ideas on what needs to occur for the patient to be healthier; allowing the patient to direct the change process is important.)

An RN changed a Pt's surgical wound dressing the day before & now prepares for another dressing change. The RN had difficulty removing the gauze from the wound bed yesterday, causing the Pt discomfort. Today he gave the Pt an analgesic 30 mins before the dressing change. The RN adds some sterile saline to loosen the gauze before removing it. The Pt reports the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (Pick 2 that apply.) A. Clinical inference B. Basic critical thinking C. Complex critical thinking D. Experience E. Reflection

C & D (The nurse relies on experience and the ability to adapt a procedure such as a dressing change (complex critical thinking) to make it successful.)

The RN is interviewing a Pt @ the free community clinic & gathers information: The Pt is a homeless, single mom of 2 children w/ developmental delays. She is suffering from chronic asthma. She does not laugh or smile, doesn't volunteer any information, & @ times appears close to tears. She has no support system & or job. She is experiencing an allostatic load. As a result, which of the following would be present during complete Pt assessment? (Select 2 that apply.) A. Posttraumatic stress disorder B. Rising hormone levels C. Chronic illness D. Return of vital signs to normal E. Depression

C & E (An increased allopathic load can result in long-term physiological and psychological problems such as chronic illness and depression. Post-traumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage. Vital signs return to normal in the resistance stage.)

The RN is evaluating the coping success of a Pt experiencing stress from being newly diagnosed w/ multiple sclerosis & psychomotor impairment. Which of the following statements indicate that the Pt is beginning to cope with the diagnosis? (Select 2 that apply.) A. "I'm going to learn to drive a car so I can be more independent." B. "My sister says she feels better when she goes shopping, so I'll go shopping." C. "I'm going to let the occupational therapist assess my home to improve efficiency." D. "I've always felt better when I go for a long walk. I'll do that when I get home." E. "I'm going to attend a support group to learn more about multiple sclerosis."

C & E (Inviting the occupational therapist into the patient's home and attending support groups are early indicators that the patient is recognizing some of the challenges of the disease and participating in positive realistic activities to cope with the stressors related to changes in physical functioning. The other options relate to independence and other coping strategies but do not address coping with the specific challenges of the disease.)

A RN prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the RN positions the patient supine w/ knees flexed as the manual recommends and begins to insert the catheter. This is an example of: A. Accuracy. B. Reflection. C. Risk taking. D. Basic critical thinking.

D (Basic critical thinking is concrete and based on a set of rules or principles, such as the guidelines in a hospital procedure manual. The nurse's approach is not accurate, as accuracy requires use of all of the facts (e.g. the patient's discomfort). A critical thinker is willing to take risks in trying different ways to solve problems; following one basic approach is not risk taking. This is also not an example of reflection.)

A manager is reviewing the RN documentation entered by a staff RN in a Pt's EMR & finds the following entry, "Pt is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is more appropriate for the manager to make to the staff RN who entered this information? a. "Avoid rushing when documenting an entry in the medical record." b. Use correction fluid to remove the entry." c. "Draw a single line through the statement and initial it." d. Enter only objective and factual information about a patient in the medical record.

D (Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.)

When caring for an 87-year-old Pt, the RN needs to understand that which of the following most directly influences the Pt's current self-concept? a. Attitude and behaviors of relatives providing care b. Caring behaviors of the nurse and health care team c. Level of education, economic status, and living conditions d. Adjustment to role change, loss of loved ones, and physical energy

D (Older adults experience significant challenges to self-concept, including mental and physical changes associated with aging and changes in identity and role following retirement and/ or loss of significant others. The adjustment to stressors is most important. The other influences are important but to a lesser degree.)

As the RN enters a Pt's room, & notices the anxiety in her patient. After greeting him, he states, "I don't know what's going on; I can't get an explanation from my HCP about my test results. I want something done about this." Which is the most appropriate way to document this Pt observation? a. "The patient has a defiant attitude and is demanding test results." b. "The patient appears to be upset with the nurse because he wants his test results immediately." c. "The patient is demanding and is complaining about the doctor." d. "The patient stated feelings of frustration from the lack of information received regarding test results."

D (This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient has a defiant attitude or is demanding is judgmental, and information in the medical record should be factual and nonjudgmental. Noting that the patient appeared upset with the nurse needs to be more specific; it does not provide enough information regarding the reason for the patient's concern.)

Which of the following documentation entries is MOST accurate? a. "Patient walked up and down hallway with assistance, tolerated well." b. "Patient up, out of bed, walked down hallway and back to room, tolerated well." c. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." d. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

D (This provides the most accurate, objective information for the chart.)

The home health RN is visiting a 90-year-old man who lives with his 89-year-old wife. He is legally blind and is 3 weeks' post op for a R hip replacement. He ambulates w/ difficulty while using a walker. He describes being sad about his wife doing more for him & the inability to reciprocate it. Which of the following is the priority RN diagnosis? A. Self-Care Deficit, Toileting B. Deficient Knowledge Regarding Resources for the Visually Impaired C. Disturbed Body Image D. Risk for Situational Low Self-Esteem

D (Blindness coupled with difficulty ambulating places him at risk for situational low self-esteem. He and his wife most likely have adapted to the blindness, but his difficulty with ambulation affects many aspects of his life, including self-esteem. However, this low self-esteem is situational; as his mobility improves, his low self-esteem will also resolve. Nothing in the question suggests that the other answers are true.)

An RN enters a 72-year-old Pt's home & begins to observe her behaviors and examine her physical condition. The RN learns that the patient lives alone & notices bruising on the patient's leg. When watching the patient walk, the RN notes that she has an unsteady gait and leans to one side. The Pt admits to having fallen in the past. T he RN identifies the Pt as having the RN diagnosis of Risk for Falls. This scenario is an example of: A. Inference. B. Critical thinking. C. Evaluation. D. Diagnostic reasoning.

D (Diagnostic reasoning begins when you interact with a patient or make physical or behavioral observations. An expert nurse sees the context of a patient situation (e.g., Patient lives alone, has fallen in past, observes patterns and themes and makes a diagnostic decision.)

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? a. Loss of autonomy caused by health problems b. Physical appearance, family, friends, and school c. Self-esteem issues, changing family structure d. Search for identity with peer groups and separation from family

D (Stressors that apply to preadolescents are self-esteem issues and a changing family structure. A loss of autonomy caused by health problems applies to the older adult. Stressors that apply to children are physical appearance, family, friends, and school.)

An RN has seen many cancer Pts struggle w/ pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values & beliefs about pain control, an RN can best make clinical decisions. This is an example of: a. Creativity. b. Fairness. c. Clinical reasoning. d. Applying ethical criteria.

D (The use of ethical criteria for nursing judgment allows a nurse to focus on a patient's values and beliefs. Clinical decisions are then just, faithful to the patient's choices, and beneficial to the patient's well-being.)

A 50-year-old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little attention to her appearance. One AM the RN enters the room to see the Pt w/ her hair combed & makeup applied. Which of the following is the best response from the RN? a. "What's the special occasion?" b. "You must be feeling better today." c. "This is the first time I've seen you look this good." d. "I see that you've combed your hair and put on makeup."

D (When the nurse uses a matter-of-fact approach and acknowledges a change in the patient's behavior or appearance, it allows the patient to establish its meaning.)

A 34-year-old single father who is anxious, Fearful, & tired from caring for his 3 young children tells the RN that he feels depressed & doesn't see how he can go on much longer. Which of the following would be the RN's BEST response? a. "Are you thinking of suicide?" b. "You've been doing a good job raising your children. You can do it!" c. "Is there someone who can help you during the evenings and weekends?" d. "What do you mean when you say you can't go on any longer?"

D (You need to get information about what the gentleman means when he says he can't go on any longer. He might be thinking of turning his children over to a grandparent or seeking other child-care arrangements. Asking about suicide initially might be premature. Asking, "Are you thinking of suicide?" prematurely might shut the patient down entirely. If the patient talks about suicide, for safety reasons it is very important to further discuss his suicidal thoughts and refer to the appropriate health care professional. Asking the open-ended question provides an opportunity to understand what the person is thinking and open lines of communication.)

After a HCP has informed a Pt that he has colon cancer, the RN enters the room, to find the Pt gazing out the window in thought. Which of the following are appropriate responses or actions of the RN? (Select all that apply.) a. "I know another patient whose colon cancer was cured by surgery." b. Straighten the patient's bed and room c. "Have you thought about how you are going to tell your family?" d. "Would you like for me to sit down with you for a few minutes so you can talk about this?" e. Sit quietly with the patient

D & E (Sitting quietly or asking the patient if he would like you to sit down for a few minutes so he can talk are both effective. This provides the patient some quiet time, knowing that someone is there. Allowing the patient to talk allows the nurse to assess the patient's fears, knowledge, and perception of the situation, which is of utmost importance. The other responses are telling the patient what to do or giving reassurance, and the situation does not call for either of these.)

[4 stages of coping] during this stage, the Pt may look inward & experience negative feelings about oneself...

Defensive Retreat

This term is defined as... abuse in an intimate relationship, in order to establish and maintain power and control over another. "pattern of behavior that is chosen by a batterer in order to exercise power and control over another person. A battered partner cannot make the abuser stop being violent and/or abusive as the batterer chooses to use this behavior as a form of control."

Domestic Violence (DV)

Match each line of documentation with the appropriate SOAP category... Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

O (Objective)

[Match the concepts for a critical thinker w/ the application of the term] An RN displaying their critical thinking capabilities... while being tolerant of the Pt's views & beliefs, is applying critical thinking in which way

Open - mindedness

Match each line of documentation with the appropriate SOAP category ... Re-positioned patient on right side. Encouraged patient to use PCA device.

P (Plan)

When doing an assessment of a young woman who was a victim of a home invasion, 30 months earlier: the RN learns that the woman has vivid images of the crash whenever she hears loud yelling or a sudden noise. The RN recognizes this as a sign of ________________.

PTSD (Post-traumatic stress disorder) (PTSD originates with a person's experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The home break-in is the traumatic event that is causing intense fear and/ or flashbacks when the noises of the break-in are replicated.)

Match each line of documentation with the appropriate SOAP category... "The pain increases every time I try to turn on my left side."

S (Subjective)

[Match the concepts for a critical thinker on with the application of the term] An RN displaying their critical thinking capabilities...being objective, in ASKING Q's of a Pt is displaying an example of...

Truth seeking

Which of the following describes a RN's application of a specific knowledge base during critical thinking? (Select all that apply.) a. Initiative in reading current evidence from the literature b. Application of nursing theory c. Reviewing policy and procedure manual d. Considering holistic view of patient needs e. Previous time caring for a specific group of patients

a b & d (A nurse's specific knowledge base will vary but includes basic nursing education, continuing education courses, and additional college degrees. In addition, it includes the knowledge gained from a nurse reading the nursing literature, and acquiring information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Nurse's knowledge base also involves a different way of thinking holistically about patient problems.)

[4 stages of coping] During this stage, the Pt may reconstruct their sense of self as whole, distinct, capable person & develop new emotional skills...

acknowledgement

[4 stages of coping] during this stage, growth occurs & the Pt is aware of changes in lifestyle & develops new coping skills...

adaptation

[Match the concepts for a critical thinker on with the application of the term] An RN displaying their critical thinking capabilities who anticipates how a patient might respond to a treatment., is applying critical thinking in which way

analytically

Clinicians have reported discomfort discussing IPV, concerns for their personal safety, & apprehension about misdiagnosis. The RN understands that a specific percentage of reviewed IPV studies, included reported fear of invading privacy, (was felt by HCP's) when potentially discussing this with their patients' & did not want to risk offending them...

half

[4 stages of coping] during this stage, disorientation energy and attention are focused on responding to crisis

shock

[Match the concepts for a critical thinker on with the application of the term] An RN displaying their critical thinking capabilities... who organizes assessments on the basis of Pt priorities, is applying critical thinking in which way

systematically

The RN understands that the 6 most common barriers to proper diagnosis, reporting & screening of suspected victims of DV include inadequate amounts of

time knowledge education training follow up resources support staff