NUR Practice questions

When asked about his or her religious affiliation, a client responds, "That's personal; why do you want to know?" The most appropriate nursing response is: 1. "You need not answer my question if you prefer not to share that information." 2. "All information you provide will be kept in strict confidence." 3. "By knowing your religious preferences, I can best meet your spiritual needs." 4. "I did not mean to offend you; we ask that question of all our new admissions."

"By knowing your religious preferences, I can best meet your spiritual needs."

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse? 1. "I will be sure to put non-skid slippers on the patient before getting him up to ambulate." 2. "I use the under-axilla technique to get him up and then use the gait belt to walk him." 3. "Rocking the heavier patient into a standing position seems to work really well for me." 4. "The patient has a weak left side from a stroke. I'll position myself on that side for more support."

"I use the under-axilla technique to get him up and then use the gait belt to walk him."

The nurse is preparing to delegate the application of an SCD to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse? 1. "I will check the tubing frequently for kinking or bending." 2. "I will remove the SCD before ambulating the patient." 3. "I will tell you if I see any signs of itching, redness, or irritation on the patient's legs." 4. "I will measure the patient's legs to determine what size of SCD to apply."

"I will measure the patient's legs to determine what size of SCD to apply."

Which of the following statements made by ancillary staff assigned with the responsibility of performing range-of-motion exercises on an older adult patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding his intervention? 1. "I'll let you know if I need your help with exercising her." 2. "Do you think I can wait until I bathe her to do the exercises?" 3. "She complained of a little pain when I flexed her chin toward her chest." 4. "Do you think that repeating the exercise on each joint five times is sufficient?"

"She complained of a little pain when I flexed her chin toward her chest."

The client experienced a near-death experience and was successfully resuscitated. The nurse wants to provide the opportunity for the client to discuss the near-death experience. The most appropriate response by the nurse is: 1. "This is a common experience that is easily explained." 2. "That must have been a very awful experience for you." 3. "Have you ever heard of other persons having a near-death experience?" 4. "What was your experience like, and how did it make you feel?"

"What was your experience like, and how did it make you feel?"

How does the nurse support a culture of safety? (Select all that apply.) 1 Completing incident reports when appropriate 2 Completing incident reports for a near miss 3 Communicating product concerns to an immediate supervisor 4 Identifying the person responsible for an incident

1 Completing incident reports when appropriate 2 Completing incident reports for a near miss 3 Communicating product concerns to an immediate supervisor

The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? (Select all that apply.) 1 Avoid cleaning the feet until an order from the health care provider is received. 2 Wash the feet with lukewarm water and then dry well. 3 Apply moisturizing lotion to the feet, especially between the toes. 4 File the toenails straight across.

2 Wash the feet with lukewarm water and then dry well. 4 File the toenails straight across.

Which of the following patient transfers using a hydraulic lift should not be assigned to ancillary staff without supervision by a nurse? 1. 47-year-old patient in the terminal stage of renal failure 2. 66-year-old comatose patient with a history of seizures 3. 26-year-old patient on the first day post-op for reduction of a fractured femur 4. 76-year-old hospice patient diagnosed with lung cancer and dementia

26-year-old patient on the first day post-op for reduction of a fractured femur

The assistive personnel may be delegated the task of transferring a patient from bed to a stretcher. Which of the following patient's transfers should the nurse delegate to assistive personnel? 1. 92-year-old hospice patient who is being transferred to a skill nursing unit 2. 35-year-old patient who has been on bedrest for 15 days as a result of a neck injury 3. 26-year-old patient who experienced a closed-head injury resulting from a fall 3 days ago 4. 63-year-old patient who will be transferred for the first time since knee replacement surgery

92-year-old hospice patient who is being transferred to a skill nursing unit

Which intervention is appropriate to include on a care plan for improving sleep in the older adult? A) Decrease fluids 2 to 4 hours before sleep B) Exercise in the evening to increase fatigue C) Allow the patient to sleep as late as possible D) Take a nap during the day to make up for lost sleep

A (Decrease fluids 2 to 4 hours before sleep) (Decreasing fluids 2 to 4 hours before sleep reduces the likelihood that the older adult's sleep will be disrupted during the night by the need to void.)

Which of the following patients should not be assigned to ancillary staff for repositioning in bed? 1. A 66-year-old patient who is 2 days postcholecystectomy. 2. A 47-year-old patient in the terminal stage of lung cancer. 3. A 16-year-old patient with a concussion resulting from a bicycle accident. 4. A 76-year-old patient who has a Foley catheter and an intravenous fluid line.

A 16-year-old patient with a concussion resulting from a bicycle accident.

While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first? 1 A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10 2 A patient who prefers a bath in the evening when his wife visits and can help him 3 A patient who is experiencing frequent incontinent diarrheal stools 4 A patient who has just returned from diagnostic testing and complains of being very fatigued

A patient who is experiencing frequent incontinent diarrheal stools

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: 1 A safe environment promotes patient activity. 2 Assessment focuses on environmental factors only. 3 Teaching home safety is difficult to do in the hospital setting. 4 Most accidents in the older adult are caused by lifestyle factors

A safe environment promotes patient activity.

The nurse is caring for a critically ill patient, who informs the nurse that there is a conflict between her spiritual beliefs and a proposed health option. What is the nurse's role in this situation? A: Assist the patient in obtaining information to make a informed decision B: The nurse has little role in this situation because it is best managed by the physician C: Provide a subjective opinion on the appropriate course of action D: The nurse should provide examples of ways other patients from various religions handle the situation.

A: Assist the patient in obtaining information to make an informed decision The nurses role in resolving conflict between spiritual beliefs and treatment is to assist the patient in obtaining information needed to make an informed decision and to support the patient's decision making.

Members of which of the following religious tradition are likely to have the most stringent restrictions and parameters placed on their medical care? A: Christian scientism B: Hinduism C: Protestantism D: Buddhism

A: Christian scientism. Rationale Christian scientism places significant restriction of the use of drugs, medical procedures, therapies, and surgeries. The scope of these restrictions greatly exceeds that dictated by Hinduism, Protestant, Christianity and Buddhism.

Which description best describes the role of a parish nurse? A: A nurse who works to reintegrate the healing tradition into the life of a faith community. B: A trained layperson who provides the spiritual needs of the congregation or parish. C: Spiritual leader, such as a minister, who is also a registered nurse. D: A nurse who provides home health services similar to a visiting nurse.

A: a nurse who works to reintegrate the healing tradition into the life of a faith community. Rationale Parish nurses and health ministry teams work to reintegrate the healing tradition into the life of the faith community. The key roles of the parish nurse and health educator, personal health counselor, referral agent, trainer of volunteers, developer of support group, integrator of faith and health, and health advocate. Parish nurses are not visiting nurses or home health nurses.

Which of the following statements about religion and spirituality is most accurate? A: religion is an organized system of spiritual beliefs and practices. B: spirituality is the behavioral manifestation of religious beliefs. C: spirituality is a recently developed alternative to traditional religious beliefs. D: religion and spirituality are synonymous.

A: religion is an organized system of spiritual practices. Rationale spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion, nor is it in recent development.

The parents of a three children ages four, seven, and 11 years are interested in fostering spiritual development in their children. A nurse informs the parents that the development of the child spirituality is best accomplished by: A: teaching through parental behaviors B: teaching the child about religion C: teaching through religious based schools D: teaching the child about God

A: teaching through parental behaviors rationale a child's parents play a key role in the development of the child's spirituality. What is important is not so much what parents teach a child about God and religion, but rather what the child learned about God, life, and self from the parents behavior.

Upon assessment, the nurse is addressing the beliefs of a newly admitted man who reports practicing the Adventist religion. Based on the nurses familiarity with his religion, she appropriately asks the patient: A: what are your beliefs about the use of narcotics for pain? B: is that acceptable for the healthcare team to remove undergarments in an emergency? C: what are your beliefs about blood transfusions? D: do you receive care from a medicine man or woman?

A: what are your beliefs about the use of narcotics for pain? Rationale the Adventist religion prohibits the taking of narcotics and stimulant because the body the Temple. Jehovah witnesses prohibits blood transfusions because it violates God's law. Native American religions incorporate medicine men or women healthcare needs. Members of the Church of Jesus Christ of Latter Day Saints are required to wear special undergarments that should be removed only an emergency.

A dying patient request that the nurse pray with him. The nurse is not accustomed to praying out loud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this patient? A: the nurse should select a formal prayer or Bible passage to use to pray out loud. B: the nurse should defer to the patient's request to pray. C: the nurse should inform the patient that she pray for the patient but not with him. D: the nurse had asked the patient's roommate to pray with the patient

A; the nurse should a formal prayer or Bible passage to use to pray out loud. Rationale a nurse unaccustomed to praying out loud or in public may find it helpful to have a Bible passage or formal prayer readily available for praying. If the nurse is not the praying the patient, she should call the hospital chaplain or find another individual who is comfortable.

A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit smoking. When approached by the nurse, he states that he would be "better off dead." He states that he has always supported his family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse should a. Develop a plan of care for the family. b. Contact psychiatric services. c. Assure the patient that things will work out. d. Focus the plan of care on maximizing patient function.

ANS: A Because of the effects of illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable.

Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. An example of an internal variable would be a. Perception of functioning. b. Family practices. c. Socioeconomic factors. d. Cultural background.

ANS: A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient who says that she wants to be "detoxified." It is important for the nurse to a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Instruct the patient that she will have to change her lifestyle. d. Instruct the patient that relapses are not tolerated.

ANS: A Processes of change, or nursing interventions, should be appropriately chosen to match the stage of change. Most behavior change programs are designed for those people who are ready to take action regarding their health behavior problems. Only a minority of people are actually in this action stage. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

The nurse is preparing a smoking cessation class and is amazed at how many people still smoke even with the information on lung cancer so readily available. She believes that her class will convert many smokers to nonsmokers once they get all the latest information. The nurse is a believer in which of the following health care models? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: A The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model is more complex than the Health Belief Model in that it notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. Education is important but is not the sole determinant of change.

Models of health offer a perspective by which to understand the relationships between the concepts of health, wellness, and illness. Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health because nurses (Select all that apply.) a. Understand the challenges of today's health care system. b. Identify actual and potential risk factors. c. Have coined the term "illness behavior." d. Can minimize the effects of illness and assist to the return of optimal health

ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system and embrace the opportunity to use wellness activities to promote health and wellness and to prevent illness. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Medical sociologists call the reaction to illness "illness behavior."

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. What level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle. The presence of any of these risk factors means that a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. The disease is guaranteed not to develop if the risk factor is controlled. d. Risk modification will have no effect on disease prevention.

ANS: B The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor identification assists patients in visualizing those areas in life that can be modified or even eliminated to promote wellness and prevent illness.

The patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. She is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. The nurse recognizes that the patient is in which stage of the change process? a. Precontemplation b. Contemplation c. Preparation d. Action

ANS: B These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). This patient is planning to make the change within the next 6 months and is in the contemplation stage.

The nurse is caring for a patient who has been trying to quit smoking. She has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and never will quit smoking. b. The patient will return to the contemplation or precontemplation phase. c. The patient will need to adopt a new lifestyle for change to be effective. d. The patient must pick up her attempt right where she left off.

ANS: B When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up her attempt where she left off. It is believed that change involves movement through a series of stages. These stages range from no intention to change (precontemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintenance. The action phase indicates a desire to change and a potential to do so. Changes will be maintained over time only if they are integrated into an individual's overall lifestyle.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses, and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

The health care model that utilizes Maslow's hierarchy as its base is the _____ Model. a. Health Belief b. Health Promotion c. Basic Human Needs d. Holistic Health

ANS: C The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy

MULTIPLE RESPONSE 1. Just as health and health behavior are affected by internal and external variables, so are illness and illness behavior. Which external variables can affect illness and behavior? (Select all that apply.) a. Perception of the seriousness of the illness b. Patient's coping skills c. Cultural background d. Social support e. Socioeconomic status

ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. In doing so, the nurse is fostering the concept of a. Illness prevention. b. Active health promotion. c. Wellness education. d. Passive health promotion.

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

The patient is describing moderate incisional pain that was not relieved by the last dose of hydromorphone (Dilaudid) given 90 minutes earlier. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music she likes, and puts on the music channel on the television, setting it to play that type of music. The nurse is attempting to utilize which health care model? a. Health Belief Model b. Health Promotion Model c. Basic Human Needs Model d. Holistic Health Model

ANS: D The Holistic Health Model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The Health Belief Model addresses the relationship between a person's beliefs and behaviors. The Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The Basic Human Needs Model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

The patient has quit smoking and has been smoke free for the past 2 years. Of the following stages, which best fits her current stage of change? a. Contemplation b. Preparation c. Action d. Maintenance

ANS: D These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). Because she has been smoke free for 2 years, she is in the maintenance stage

Karen Johnson is a single mother of a school-age daughter. Linda Brown is also a single mother of two teenage daughters. Karen and Linda are active professionals, have busy social lives, and date occasionally. Three years ago they decided to share a house and share housing costs, living expenses, and child care responsibilities. The children consider one another as their family. This family form is considered a(n): 1. Diverse family relationship 2. Blended family relationship 3. Extended family relationship 4. Alternative pattern of relationship

Alternative pattern of relationship

When preparing to delegate the transfer of a client from bed to stretcher to assistive personnel, the nurse must first: 1. Observe the assistive personnel while making the transfer. 2. Determine the most appropriate time for the assistive personnel to transfer the client. 3. Assess the assistive personnel's understanding of the proper technique for this task. 4. Inform the

Assess the assistive personnel's understanding of the proper technique for this task.

When preparing to safely transfer a patient using a hydraulic lift, the nurse should first: 1. Assess the patient for IV or catheter tubing. 2. Arrange for the appropriate number of staff to assist. 3. Inquire as to whether the patient agrees to the intervention. 4. Arrange for the equipment to be available at the agreed upon time.

Assess the patient for IV or catheter tubing.

The nurse may incorporate similarities of nutritional needs into the plan of care for clients who are Mormon and Buddhist. Members of these religions both: 1. Fast on Fridays 2. Follow vegetarian diets 3. Avoid alcohol and tobacco 4. Avoid mixing dairy and meat products

Avoid alcohol and tobacco

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? A) Have patient follow hospital routines B) Avoid awakening patient for nonessential tasks C) Give prescribed sleeping medications at dinner D) Turn television on low to late-night programming.

B (Avoid awakening patient for nonessential tasks) (Avoiding awakening patient for nonessential tasks promotes sleep. Cluster activities and allow the patient time to sleep. Do not perform tasks such as laboratory draws and bathing during the night unless absolutely essential. Patients should try to follow home routines related to sleep habits. The other tasks do not promote sleep.)

Which of the following recommendations should a nurse give to a client to promote sleep and rest? (Select all that apply.) A. Avoid all caffeinated beverages. B. Participate in regular exercise each morning. C. Take an afternoon nap. D. Practice relaxation exercises before bedtime. E. Limit fluid intake at least 2 hr before bedtime.

B, D, E (Establishing a regular exercise routine helps promote sleep and should be completed at least 2 hr prior to sleep. Relaxation exercises can decrease stress and tension and thereby promote rest. Fluid should be limited 2 to 4 hr before bedtime to prevent nocturia. It is not necessary to avoid all caffeinated beverages but to limit consumption of these after dinner. An afternoon nap disrupts nighttime sleep.)

The nurse is providing health teaching for a patient using herbal compounds such as melatonin for sleep. Which points need to be included? (Select all that apply.) A) Can cause urinary retention B) Should not be used indefinitely C) May cause diarrhea and anxiety D) May interfere with prescribed medications E) Can lead to further sleep problems over time F) Are not regulated by the U.S. Food and Drug Administration (FDA)

B, D, F (Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and promote sleep. Short-term use of melatonin has been found to be safe, with mild side effects of nausea, headache, and dizziness occurring infrequently. Caution patients about the dosage and use of herbal compounds because the FDA does not regulate them. Herbal compounds may create interactions with prescribed medication, and patients need to avoid using these together.)

An 80-year-old woman who identifies herself as a devout Catholic has recently relocated to an assisted living facility. The woman is pleased with most aspects of her new living situation, but laments the fact that she is no longer close to the church where she was in the Habit of attending daily mass each morning. What nursing diagnosis may apply to this problem that the woman has identified? A: hopelessness B: impaired religiosity C: spiritual pain D: spiritual distress

B: impaired religiosity rationale the nursing diagnosis of impaired religiosity encompass the inability to participate in rituals of particular faith tradition. Spiritual distress involves the inability to integrate meaning and purpose in life, while spiritual pain involves angst over the nature and actions of higher power. The woman's statements do not directly reflect an outlook of hopelessness.

Upon assessment, patient report does not belong to organized religion. The nurse is correct interpret this statement of which of the following? A: the patient spiritual needs are met B: the patient is not affiliated with a specific system of belief regarding a higher power C: the patient will experience conflict between religious beliefs and healthcare option. D: the patient will not request to see the hospital chaplain or seek spiritual counseling.

B: the patient is not affiliated with a specific system of belief regarding a higher power. Rationale the nurse should not interpret the fact that the patient does not belong to an organized religion to mean that the patient has no spiritual need; a person may be highly spiritual yet not profess a religion. The patient may seek spiritual counseling during hospitalization related to spiritual needs.

The nurse has applied an SCD to a postoperative patient. The most appropriate way for the nurse to determine proper fit is to: 1. Ask the patient if the device is causing him any pain. 2. Be able to slip two fingers between the patient's leg and the device. 3. Follow the manufacture's instruction for the application of the device. 4. Ask another nurse to check the patient for proper application of the device.

Be able to slip two fingers between the patient's leg and the device.

The Collins family (in question 1), which includes a mother, Jean;Stepfather, Adam; two teenage biological daughters of the mother, Lisa and Laura; and a biological daughter of the father, 25-year-old Stacey is an example of a(n): 1. Nuclear Family 2. Blended Family 3. Extended Family 4. Alternative Family

Blended Family

A nurse is caring for an older adult client who has been bathing in the morning following the facility's routine. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following interventions should the nurse take first? A. Rub her back for 15 min before bedtime. B. Offer her warm milk and crackers at 2100. C. Allow her to take a bath in the evening. D. Ask her provider for a sleeping medication.

C (Allow her to take a bath in the evening. ) (The least restrictive action is to allow the client to follow her usual bedtime routine to promote sleep. Rubbing her back, offering warm milk and crackers, and requesting a sleeping medication may be necessary if this intervention is unsuccessful.)

The nurse teaches a patient taking a benzodiazepine that this group of medications causes which symptom of a sleep problem? A) Nocturia B) Hyperactivity C) Grogginess and feeling hung over D) Increased sleep time

C (Grogginess and feeling hung over) (Benzodiazepines cause a hangover effect and rebound insomnia. The other sleep problems are not related to benzodiazepines.)

A nurse who provides care on a palliative unit of a hospital is aware of the importance of spiritual assessment and the integration of spirituality into patient's care. What assessment questions should the nurse use in an effort to determine the patient's spiritual beliefs? A: Do you hold a belief in the afterlife? B: what church do you normally attend? C: are there any spiritual or religious beliefs or practices that are important to you? D: if you had to identify yourself as either a religious person or spiritual person, which would you choose?

C: are there any spiritual or religious beliefs or practices that are important to you? Rationale an open ended yet clear question about a person spiritual beliefs is most likely to elicit information about the patient in a thoughtful manner. Asking the patient to choose between identifying as religious or spiritual is not an accurate dichotomy, while asking about the afterlife is not a direct way of assessing religion and spirituality. Not every religious or spiritual group situates their practices in a church.

The son of a dying patient surprised at his mother's adamant request to meet with hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation? A: perform a detailed spiritual assessment of the patient B: organize a meeting between the chaplain, the son, and the patient to achieve a resolution. C; contact the chaplain to arrange a visit with the patient D: document the patient's request and wait to see if she reiterates request.

C: contact the chaplain to arrange a visit with the patient rationale The nurses primary duty is to honor the patient's request for a meeting with a spiritual advisor.

Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy? 1 Checking frequently for soiling 2 Washing the perineal area with strong soap and water 3 Placing the call light within easy reach 4 Keeping a pad under the patient

Checking frequently for soiling

The primary purpose for the nurse to assess a patient's mental and cognitive status upon admission to a residential care unit is to: 1. Ensure quality care regardless of mental or cognitive deficiency. 2. Identify patient behaviors resulting from mental and cognitive deficiency. 3. Create a safe environment that is free of chemical and physical restraints. 4. Determine potential for risk of injury related to behaviors resulting in self-injury.

Create a safe environment that is free of chemical and physical restraints.

The nurse is preparing to apply an SCD to the legs of a postoperative patient. The nurse realizes that which of the following assessment observations would contraindicate the application of these devices? 1. Low-grade fever 2. Prescribed anticoagulant 3. Dermatitis on patient's legs 4. Presence of elastic stockings 3. The nurse has applied an SCD

Dermatitis on patient's legs

A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP: 1 Used clean gloves. 2 Did not retract the foreskin before cleansing. 3 Used the clean portion of washcloth for each cleansing wipe. 4 Used a circular motion to cleanse from urinary meatus outward.

Did not retract the foreskin before cleansing.

The charge nurse of a unit tries, as a rule, to admit Hispanic clients to a room at the end of the hall so that "the noise from the family will not disturb others." This nurse is exhibiting a. Racism b. Prejudice c. Discrimination d. Sexism

Discrimination

A family's access to adequate health care, opportunity for education, sound nutrition, and decreased stress is increased by: 1. Development 2. Family function 3. Family structure 4. Economic stability

Economic stability

You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? 1 Explain to the patient that, because of her symptoms, you need to observe the perineal area. 2 Insist that you are supposed to complete the care. 3 Honor the patient's request to complete her own perineal care to avoid any embarrassment. 4 Ask the patient if a family member can complete the care instead.

Explain to the patient that, because of her symptoms, you need to observe the perineal area.

The nurse is conferring with the nutritionist about the needs of a Native American. The nurse anticipates that the client will: 1. Follow a strict vegetarian diet 2. Avoid the use of alcohol and tobacco 3. Expect to avoid pork-related products 4. Follow a diet according to individual tribal beliefs

Follow a diet according to individual tribal beliefs

During bathing, your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to: 1 Trendelenburg's. 2 Reverse Trendelenburg's. 3 Fowler's. (45 degrees) 4 Semi-Fowler's.

Fowler's. (45 degrees)

Communication among family members is an example of family: 1. Goals 2. Function 3. Structure 4. Development

Goals

The nurse realizes that precautions should be taken in order to minimize the risk of injury to those involved in the transfer. Which of the following apply? 1. Medicate the uncooperative patient before attempting the transfer. 2. Encourage the patient to help with the transfer as such as possible. 3. Have enough available staff members to assist with the patient transfer. 4. Transfer the patient when he or she is most willing to cooperate with staff.

Have enough available staff members to assist with the patient transfer.

A client with diabetes is being cared for in the home, with the assistance of a home health nurse and a family member. The client asks you if eating a vegetarian diet will conflict with the disease. The nurse anticipates that the client will follow a vegetarian diet because he is a member of which of the following religions? 1. Hinduism 2. Judaism 3. Islam 4. Sikhism

Hinduism

The nurse has identified the following nursing diagnoses for his assigned clients. Of the following diagnoses, which one indicates the greatest potential need to plan for the client's spiritual needs? 1. Altered health maintenance 2. Ineffective individual coping 3. Impaired long-term memory 4. Decreased adaptive capacity

Ineffective individual coping

The most common reason grandparents are called on to raise their grandchildren is due to: 1. Single parenthood 2. Legal interventions 3. Dual-income families 4. Increased divorce rate

Legal interventions

A tool that may be used effectively with clients who have terminal diseases is hope. Hope provides a: 1. Relationship with a divinity 2. System of organized beliefs 3. Cultural connectedness 4. Meaning and purpose

Meaning and purpose

The nurse is preparing to transfer a patient from her bed to a stretcher for transport to radiology for testing. The nurse realizes that a primary concern regarding patient safety is to: 1. Assess the patient's ability to actively participate in the actual transfer. 2. Minimize the risk of falls or other injury during the transfer procedure. 3. Assure the patient that the transfer will cause her as little pain as possible. 4. Reassure the patient that she will be safely transported to the radiology department.

Minimize the risk of falls or other injury during the transfer procedure.

The nurse is working in the labor and delivery area with parents who are members of the Shinto and Buddhist religions. The nurse expects that after the birth of the child: 1. Baptism will be performed immediately 2. Special prayers will be said over the child 3. Special preparations will be made for the umbilical cord and placenta 4. No particular rituals will usually be performed in the postpartum period

No particular rituals will usually be performed in the postpartum period

If a client is identified as following the traditional health care beliefs of Judaism, the nurse should prepare to incorporate the following into care: 1. Faith healing 2. Regular fasting 3. Ongoing group prayer 4. Observance of the Sabbath

Observance of the Sabbath

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1 Place a bed alarm device on the bed. 2 Place the patient in a belt restraint. 3 Provide one-on-one observation of the patient. 4 Apply wrist restraints.

Place a bed alarm device on the bed.

A comatose patient who weighs 201 pounds requires repositioning in the bed. Which of the following actions is most likely to ensure that the client and staff will be safe during the move? 1. Accomplish the move in two or three small moves instead of one big move. 2. Place a repositioning aid (such as a lift sheet) from his shoulders to his thighs. 3. Enlist the help of two assistants since the patient weighs more than 200 pounds. 4. Assume a wide stance with the foot closest to the head of the bed behind the other.

Place a repositioning aid (such as a lift sheet) from his shoulders to his thighs.

At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? 1 Prepare for an influx of patients 2 Contract the American Red Cross 3 Determine how to restore essential services 4 Evacuate patients per the disaster plan

Prepare for an influx of patients

What is the priority concern when providing oral hygiene for a patient who is unconscious? 1 Thoroughly brushing all tooth and oral surfaces 2 Preventing aspiration 3 Controlling mouth odor 4 Applying local antiseptic such as chlorhexidine

Preventing aspiration

1. A nurse should be aware that adolescent clients who are discussing spirituality often: 1. Have a good concept of a supreme being 2. Question religious practices and/or values 3. Fully accept the higher meaning of their faith 4. Often give themselves over to spiritual tasks

Question religious practices and/or values

The nurse is preparing to initiate ambulation for a patient who has been on bedrest for several weeks. To minimize the risk of the patient experiencing dizziness, the nurse first: 1. Raises the head of the patient's bed to 90 degrees. 2. Assists the patient into a sitting position on the side of the bed. 3. Asks the patient if he has felt dizzy when moving in the bed. 4. Assesses the patient's blood pressure before attempting to ambulate.

Raises the head of the patient's bed to 90 degrees

The Collins family includes a mother, Jean; Stepfather, Adam; two teenage biological daughters of the mother, Lisa and Laura; and a biological daughter of the father, 25-year-old Stacey. Stacey just moved home following the loss of her job in another city. The family is converting a study into Stacey's bedroom and is in the process of distributing household chores. When you talk to members of the family, they all feel that their family can adjust to lifestyle changes. This is an example of family: 1. Diversity 2. Durability 3. Resiliency 4. Configuration

Resiliency

When preparing to safely perform passive range-of-motion exercises, the nurse should first: 1. Review the physician's order prescribing the intervention. 2. Inquire as to whether the patient agrees to the intervention. 3. Agree upon a time for the performance of the intervention. 4. Examine the joints for inflammation, edema, or skin breakdown.

Review the physician's order prescribing the intervention.

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1 Activity intolerance 2 Impaired bed mobility 3 Acute pain 4 Risk for falls 4 A couple is with their

Risk for falls

The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to: 1. Move the family into the unit's sunroom for the ritual 2. Ask the client and her family to be allowed to pray with the group 3. Offer to arrange for the facility's chaplain to attend the prayer session 4. Schedule the client's physical therapy treatments to avoid being an interruption

Schedule the client's physical therapy treatments to avoid being an interruption

The nurse anticipates the gender-related needs of the clients and tries to accommodate those needs whenever possible. A female nurse is arranged for the female client who practices: 1. Sikhism 2. Judaism 3. Hinduism 4. Buddhism

Sikhism

A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to: 1 Decrease the chance of infection. 2 Help remove dry, flaky skin. 3 Prevent skin trauma. 4 Stimulate venous return.

Stimulate venous return.

The primary purpose for the nurse to apply a physical restraint is to: 1. Ensure quality nursing care to the patient who is mentally or cognitively impaired or physically aggressive. 2. Temporarily provide a safe patient environment when other interventions have proven ineffective. 3. Control patient behaviors that might result in the risk of self-inflicted injury. 4. Control patient behaviors that might result in the risk of injury to others.

Temporarily provide a safe patient environment when other interventions have proven ineffective.

A client who has been severely burned has been taught meditation techniques to help manage the stress of his recovery period. The nurse recognizes which of the following assessment findings as most conclusive of the effectiveness of the intervention? 1. The client stating, "I like to meditate" 2. Observing the client in a meditative pose 3. The client heard telling his son that he has learned to meditate 4. A 10-point drop in the client's systolic blood pressure after meditation

The client stating, "I like to meditate"

The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, "I should: 1 Bathe twice a week. 2 Rinse well after using soap. 3 Use hot water for bathing. 4 Drink plenty of fluids.

Use hot water for bathing.

The nurse has applied a gait belt to a post-operative patient to facilitate ambulation. Within a few feet of his bed the patient begins to complain of dizziness and leans heavily on the nurse. The nurse's initial response is to: 1. Use the gait belt to help slowly lower the patient to the floor. 2. Attempt to sit the patient down on a chair just a few steps away. 3. Ask the patient's roommate to use her call bell to alert additional staff. 4. Inform the staff that help is needed by calling out in a loud but calm voice.

Use the gait belt to help slowly lower the patient to the floor.

Which of the following nursing interventions would be effective when dealing with the family members of a critically ill client? a. Involve the family members in care conferences about the client's care b. Complete all of the client's care so the family is not inconvenienced

a. Involve the family members in care conferences about the client's care

The nurse notes that the client's grandmother is looked to for input whenever questions arise about the client's care choices. Which cultural specific will guide the nurse's plan of care? a. Communication b. Social organization c. Environmental control d. Biologic variations

b. Social organization

According to structural-functional theory, families function differently in the various stages of the family life cycle. a.True b.False

b.False Structural-functional theories present concepts related to family roles and interactions as they relate to family functioning.

It would be most important for the nurse to instruct the NAP to assist clients of which faith to wash their hands before meals? a. Christian b. Jewish c. Mormon d. Muslim

d. Muslim

It is important for the nurse to understand the structure of the client's family so that he/she a. Can address the various family members correctly b. Can tailor visiting hours to the family's needs c. Can avoid embarrassing moments during client interventions d.Can develop a holistic plan that includes the whole family

d.Can develop a holistic plan that includes the whole family

The most important concept about vulnerable subcultures guiding nursing care is that persons belonging to these groups a.Receive different health care b.Have difficulty complying with their therapy c.Never have insurance d.Often have limited access to health care

d.Often have limited access to health care

When preparing to move or position a patient, the nurse should first: 1. Assemble adequate help to facilitate the change. 2. Assess the patient's ability to assist with the change. 3. Determine the effect of the patient's weight on the change. 4. Decide upon the most effective method to facilitate the change.

Assess the patient's ability to assist with the change.

When preparing to safely transfer a patient from a bed to a wheelchair, the nurse should first: 1. Determine the patient's arm strength. 2. Assess the patient's weight-bearing ability. 3. Assess the patient's willingness to cooperate. 4. Decide upon the most appropriate transfer method.

Assess the patient's willingness to cooperate.

Which of the following patient transfers should not be assigned to ancillary staff without supervision by a registered nurse? 1. 66-year-old patient receiving cancer radiation treatments 2. 47-year-old patient in the terminal stage of renal failure 3. 26-year-old patient who is 8 hours post- cesarean section 4. 76-year-old patient who has an intravenous fluid line in place

26-year-old patient who is 8 hours post- cesarean section

Passive range-of-motion on which of the following clients should not be assigned to ancillary staff? 1. 47-year-old patient in the terminal stage of renal failure 2. 66-year-old comatose patient with a history of seizures 3. 26-year-old patient with multiple fractures resulting from a fall

26-year-old patient with multiple fractures resulting from a fall

Which of the following statements made by ancillary staff assigned to position an immobile patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding this intervention? 1. "I'll let you know if I need your help with her positioning." 2. "Do you think she will be ready to be positioned before lunch?" 3. "I noticed a small reddened area on her left hip when I turned her." 4. "Do you think I should use the mechanical lift when moving her?"

"I noticed a small reddened area on her left hip when I turned her."

Which of the following statements made by a nurse regarding spiritual support provided displays an inappropriate intervention or attitude? 1. "I offer to pray with my clients as I prepare them for transport to surgery." 2. "I always try to tell my Catholic clients when Mass is being held in the chapel." 3. "When caring for a client for the first time, I always check to see their religious affiliation." 4. "I'm not very comfortable interviewing a client concerning their religious beliefs or practices."

"I offer to pray with my clients as I prepare them for transport to surgery."

Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of promoting a safe environment for a patient diagnosed with Alzheimer disease who has a history of falls? 1. "He is a large man, so let me know how many people you needed to transfer him." 2. "He gets uncooperative, so let me know if he refuses to allow you to bathe him." 3. "Be sure to let me know if he is tugging at his Foley catheter tubing." 4. "He has reported being dizzy and lightheaded, so be aware of that."

"Be sure to let me know if he is tugging at his Foley catheter tubing."

Which of the following statements made by ancillary staff assigned the responsibility of promoting a safe environment for an elderly patient who required the temporary use of wrist restraints reflects the best understanding regarding the patient's risk for injury? 1. "I checked the pulse and warmth of her hands every 30 minutes." 2. "I needed someone to help me walk her to the bathroom to toilet." 3. "She drank a cup of coffee and a glass of juice while in restraints." 4. "She fell asleep about 10 minutes after the restraints were applied."

"I checked the pulse and warmth of her hands every 30 minutes."

A 76-year-old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the client's spiritual needs and responds best by saying: 1. "I notice you have a Bible; is that a source of spiritual strength to you?" 2. "What do you believe will happen to your personal spirit when you die?" 3. "We would allow members of your church to visit you whenever you desire." 4. "Has hearing about your terminal condition made you lose your faith or beliefs?"

"I notice you have a Bible; is that a source of spiritual strength to you?"

Which of the following nursing statements about a patient currently in wrist restraints has priority when providing ancillary staff with instructions regarding patient outcomes that should be immediately reported to the nurse? 1. "If she is tugging on the restraints, check her radial pulses every 15 minutes." 2. "Wrist restraints can cause friction damage to the skin, so check often." 3. "I want to know if she gets increasingly more agitated or confused."

"I want to know if she gets increasingly more agitated or confused."

The nurse is preparing to delegate the transfer of a client from bed to a stretcher for transport to the physical therapy (PT) department to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse? 1. "I'll use gloves for the transfer if the bed sheets have been soiled." 2. "She said her daughter was going to PT with her. I'll see if she's here." 3. "I noticed some red areas on her back, so I'll be extra careful to position her on her side." 4. "The PT department is chilly, I'll be sure to send an extra blanket with the client."

"I'll use gloves for the transfer if the bed sheets have been soiled."

The wife of a client diagnosed with Alzheimer's disease shares with the home health nurse that, "We always went to church on Wednesday evenings. I miss that a lot." Which of the following statements made by the nurse has the greatest therapeutic value at this time? 1. "Was religion as important to your husband as well?" 2. "Please tell me more about the role religion plays in your lives." 3. "May I help arrange for a sitter so you can attend church services again?' 4. "Attending church services has always been very important to me as well."

"May I help arrange for a sitter so you can attend church services again?'

Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of promoting a safe environment for a patient diagnosed with Alzheimer disease who has a temporary belt restraint applied? 1. "This is designed to keep him from falling out of the chair until his sitter arrives." 2. "Remember to keep reminding him that he is to stay in the chair so he won't fall." 3. "Move his chair into the dayroom so we all can keep an eye on him." 4. "He needs to be ambulated to the bathroom at least every 2 hours."

"Move his chair into the dayroom so we all can keep an eye on him."

Which of the following statements made by a client diagnosed with terminal renal failure best expresses the client's sense of hope? 1. "My father lived for years with this disease." 2. "I've had a good life, and I'll live each day as it comes." 3. "Research is always coming up with new treatments and cures." 4. "My daughter is getting married in 4 months, and I'm going to walk her down the aisle."

"My daughter is getting married in 4 months, and I'm going to walk her down the aisle."

Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned passive range-of-motion exercises on a patient on how to best perform this intervention? 1. "Let me know if you need my help." 2. "Stop if the patient complains of pain." 3. "Be aware that the patient has moderate arthritis in her wrists and fingers bilaterally." 4. "Please be sure to support each joint as you slowly put it through its range of motion."

"Please be sure to support each joint as you slowly put it through its range of motion."

It has been determined that a patient is capable of assisting with her own repositioning toward the head of the bed. Which of the following statements made by the nurse will be most effective in instructing the patient on how to best facilitate the move? 1. "When I count to 3, please push off with your feet." 2. "Please help by folding your arms across your chest." 3. "Please bend your knees so your feet are flat on the bed." 4. "Please let me know how I can best help you with this move."

"Please bend your knees so your feet are flat on the bed."

It has been determined that a patient is capable and willing to assist with her own transfer from the bed to the chair. Which of the following statements made by the nurse will be most effective in instructing the patient on how to best facilitate the move? 1. "When I count to three, please rock yourself into a standing position." 2. "Please help me by holding onto my waist while I help you stand." 3. "Please let me know how I can best help you get up off the bed and stand up." 4. "Please push down onto the mattress with both hands and stand when I count to three."

"Please push down onto the mattress with both hands and stand when I count to three."

Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the transfer of a patient using a hydraulic lift on how to best perform this intervention? 1. "Let me know if you need my help with the transfer." 2. "This patient can become agitated when she's anxious" 3. "Remember to position the horseshoe under the bed with its legs wide open." 4. "Be sure to put the wheelchair near the bed, but leave space to maneuver the lift."

"Remember to position the horseshoe under the bed with its legs wide open."

Which of the following statements made by ancillary staff assigned with the transfer of a mobility-impaired patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding this intervention? 1. "I'll let you know if I need your help with her transfer." 2. "Do you think she will enjoy eating lunch in her chair?" 3. "Has she been complaining of pain or dizziness today?" 4. "She is less able to help with the transfer than she was yesterday."

"She is less able to help with the transfer than she was yesterday."

Which of the following statements made by ancillary staff assigned the responsibility of promoting a safe environment for a newly admitted elderly patient reflects the best understanding regarding the patient's risk for injury? 1. "She is unable to bear weight on her left leg, so her balance is unstable." 2. "You need the assistance of two to walk her into the bathroom to toilet." 3. "Nice lady but a bit confused when it comes to time and place." 4. "If you toilet her often, she is less likely to try to get out of bed."

"She is unable to bear weight on her left leg, so her balance is unstable."

Which of the following statements made by the nurse will be most effective in instructing ancillary staff in the most effective means of minimizing patient discomfort when applying elastic stockings? 1. "Please be sure that you smooth out any wrinkles in the stockings." 2. "It's easier to put them on if you turn them inside out up to the heels." 3. "She isn't allergic, so apply a little powder to the legs and feet before you start." 4. "There is a clean pair of stockings in her bedside stand; her family brought them."

"She isn't allergic, so apply a little powder to the legs and feet before you start."

A client who recently required advanced cardiac life support after experiencing a myocardial infarction shares with the nurse that, "I could hear voices talking about me dying and then there was this brightly lighted tunnel." Which of the following statements made by the nurse shows the best understanding of therapeutic communication regarding a client's near-death experience? 1. "Tell me more about what you saw and heard." 2. "What you are describing is called a near-death experience." 3. "Many clients who have been clinically dead have those types of memories." 4. "What you are describing is most likely a result of the drugs you were given."

"Tell me more about what you saw and heard."

Which of the following statements made by ancillary staff assigned with the responsibility of transferring an elderly patient using a hydraulic lift reflects the best understanding of the importance of appropriately communicating with the nurse regarding this intervention? 1. "Do you think I really need the hydraulic lift to transfer her?" 2. "I'll let you know if I need your help with working the hydraulic lift." 3. "Do you think that she will be as anxious about the transfer as she was the first time?" 4. "The patient was really much stronger today than she was last time I transferred her."

"The patient was really much stronger today than she was last time I transferred her."

Which of the following interview questions will best determine a client's readiness for enhanced spiritual well-being? 1. "Are you a religious person?" 2. "Are you satisfied with your life?" 3. "To whom do you turn when you have a problem to deal with?" 4. "Do you tend to rely on prayer during times of personal stress?"

"To whom do you turn when you have a problem to deal with?"

The nurse is discussing a cognitively impaired patient's risk for falling with a family member. Which of the following nursing statements is most therapeutic in response to the daughter's stated concern of, "I don't like the idea of tying him down in the bed?" 1. "I'm sure you don't want him to fall again." 2. "What would you prefer we do to keep him safe?" 3. "What did you do to prevent him from falling when he was at home?" 4. "We will try all of the other alternatives before using physical restraints."

"We will try all of the other alternatives before using physical restraints."

A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.) 1 Allow the patient to perform as much of the care as possible. 2 Start by washing the face. 3 Try an alternative to traditional bathing such as the "bag bath." 4 Use restraints to prevent the patient from injuring self or the nurse.

1 Allow the patient to perform as much of the care as possible. 3 Try an alternative to traditional bathing such as the "bag bath."

A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is(are) appropriate actions? (Select all that apply.) 1 Finding a female nurse to help the patient 2 Convincing the patient that he will work quickly and provide as much privacy as possible 3 Skipping hygiene care for the day except for the parts that the patient can complete independently 4 Asking the patient if she prefers a family member assist with the care

1. Finding a female nurse to help the patient 4. Asking the patient if she prefers a family member assist with the care

Your patient wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in a teaching plan for denture care? (Select all that apply.) 1 Remove dentures overnight once a week while they soak in a cleansing bath. 2 Do not wear damaged or poorly fitting dentures. 3 Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. 4 See dentist regularly. 5 Rinse dentures after meals. 6 Clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime.

2 Do not wear damaged or poorly fitting dentures. 3 Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. 4 See dentist regularly. 5 Rinse dentures after meals.

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) 1 Insert a urinary catheter. 2 Leave a night light on in the bathroom. 3 Ask the physician to order a restraint. 4 Keep the bed in low position with upper and lower side rails up. 5 Assign a staff member to stay with the patient. 6 Provide scheduled toileting during the night shift. 7 Keep the pathway from the bed to the bathroom clear.

2 Leave a night light on in the bathroom. 6 Provide scheduled toileting during the night shift. 7 Keep the pathway from the bed to the bathroom clear

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1 Contact the nursing supervisor. 2 Restrict the family's visiting privileges. 3 Ask the family to stay with the patient if possible. 4 Inform the family of the risks associated with side-rail use. 5 Thank the family for being conscientious and put the four rails up. 6 Discuss alternatives with the family that are appropriate for this patient.

3 Ask the family to stay with the patient if possible. 4 Inform the family of the risks associated with side-rail use. 6 Discuss alternatives with the family that are appropriate for this patient.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) 1 Smokes a pack a day 2 Used a cane to walk at home 3 Takes antihypertensive and diuretics 4 History of recent fall 5 Neglect, spatial and perceptual abilities, impulsive 6 Requires assistance with activity, unsteady gait 7 IV line, urinary catheter

3 Takes antihypertensive and diuretics 4 History of recent fall 5 Neglect, spatial and perceptual abilities, impulsive 6 Requires assistance with activity, unsteady gait 7 IV line, urinary catheter

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A) I always feel tired when I wake up in the morning. B) I go to bed at the same time each night. C) It takes me about 15 minutes to fall asleep. D) Sometimes I have to get up during the night to urinate.

A ( I always feel tired when I wake up in the morning.) (This statement indicates that the patient is not experiencing quality sleep and should be followed up with more extensive questions and assessment of the problem. Patients are the best resource for describing sleep problems and how these problems are a change from their usual sleep and waking patterns. A general description of the problem followed by more focused questions usually reveals specific characteristics that are useful in planning therapies. To begin you need to understand the nature of the sleep problem, its signs and symptoms, its onset and duration, its severity, any predisposing factors or causes, and the overall effect on the patient. Ask specific questions related to the sleep problem.)

The patient reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs during which sleep phase? A) REM sleep B) Stage 1 NREM sleep C) Stage 4 NREM sleep D) Transition period from NREM to REM sleep

A (REM Sleep) (Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe they are functionally important to learning, memory processing, and adaptation to stress.)

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a nonjudgmental attitude. Why does the nurse do this? a. Noncompliant patients thrive on the disapproval of authority figures. b. External variables have little effect on compliance. c. A person's compliance is affected by economic status. d. Employment status is an internal variable that impacts compliance.

ANS: C A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices. Internal and external variables influence how a person thinks and acts toward health care. Employment status is an external variable, not an internal variable.

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which points should be included in the education? (Select all that apply.) A) Do not study in your bed. B) Go to sleep each night whenever you feel tired. C) Turn off your cell phone at bedtime. D) Avoid drinking coffee or soda before bedtime. E) Turn on the television to help you fall asleep.

A, C, D (Adolescents need to practice good sleep hygiene practices. Beds should be used for sleeping only. Activities other than sleep should not be done in bed. A person should try to go to bed at the same time each night. Create an environment that is quiet and free of distractions. Turning off cell phones prevents sleep disruptions. Coffee or soda contains caffeine. Caffeine acts as a stimulant, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.)

A nurse is caring for a client who presents to the clinic reporting fatigue and an inability to sleep at night. Which of the following questions should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply.) A) Does your lack of sleep interfere with your ability to function during the day? B) Do you experience confusion in the late afternoon? C) Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day? D) Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? E) Tell me about any personal stress you are experiencing.

A, C, D, E (People with severe nighttime sleep problems often have difficulty concentrating during the day. Caffeinated drinks act as a stimulant and may interfere with sleep. A person who has periods of apnea may need to be referred for diagnostic studies. Personal stress may be the cause of insomnia. Confusion is not an expected finding with insomnia.)

The nurse is gathering a sleep history from a patient who is being evaluated for obstructive sleep apnea. Which common symptoms does the patient most likely report? (Select all that apply.) A) Headache B) Early wakening C) Excessive daytime sleepiness D) Difficulty falling asleep E) Snoring

A, C, E (Common symptoms for obstructive sleep apnea include headache, snoring, and excessive daytime sleepiness caused by poor sleep during the night. The other symptoms are not related to obstructive sleep apnea.)

The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to provide a. Primary prevention. b. Secondary prevention. c. Tertiary prevention. d. Diagnosis and prompt intervention.

ANS: A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and his wife refuse to talk about it and refuse to be taught about how to care for it. The nurse realizes that the patient and his wife are in which stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

ANS: B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment when they accept the loss, and rehabilitation when the patient is ready to learn how to adapt.

According to the World Health Organization, what is the best definition for "health"? a. Simply the absence of disease b. Involving the total person and environment c. Strictly personal in nature d. Status of pathological state

ANS: B Nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not equally healthy. Views of health have broadened to include mental, social, and spiritual well-being, as well as a focus on health at family and community levels. Conditions of life, rather than pathological states, are what define health.

To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is a. Allowing people to continue current behaviors to reduce the stress of change. b. Focusing only on individual health changes that will lead to better communities. c. Creating social and physical environments that promote good health. d. Focusing on illness treatment to provide fast recuperation.

ANS: C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The other three include (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; and (3) promote quality of life, healthy development, and healthy behaviors across all life stages.

An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2020 goal of a. Increasing quality of life in America. b. Prolonging healthy life in America. c. Eliminating health disparities in America. d. Promoting healthy behaviors.

ANS: C Healthy People 2020 promotes a society in which all people live long, healthy lives. This program has four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages. Providing health care to all would eliminate disparities in health care by ensuring access. Perhaps the best way to increase quality and years of healthy life is to promote healthy behaviors. However, providing access to health care would not guarantee changes in behaviors, increased quality of life, or prolonged healthy life.

Which statement made by the patient indicates a need for further teaching on sleep hygiene? A) “I’ m going to do my exercises before I eat dinner.” B) “I’ll have a glass of wine at bedtime to relax.” C) “I set my alarm to get up at the same time every morning.” D) “I moved my computer to the den to do my work.”

B (“I’ll have a glass of wine at bedtime to relax.”) (Drinking alcohol before bed in an effort to relax indicates a need for further teaching. Alcohol should be avoided before bed because it speeds onset of sleep, reduces REM sleep, awakens the person during the night, and causes difficulty returning to sleep.)

A college foreign-exchange student is living with a family in England and is confused about the daily Catholic prayers and rituals of the family. The student longs for the comfort of her fundamentalist Protestant practices and reports to the campus nurse the direction. The nurse recognizes the student is experiencing which type of spiritual distress? A: spiritual anger B; spiritual alienation C: spiritual guilt D: spiritual loss

B: spiritual alienation rationale spiritual alienation occurs when an individual is separated from his/her a community. Spiritual guilt is the failure to live according to religious rules. Their anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.

What preparing a spiritual counselor to visit a hospitalized patient, the nurse should: A: ask spiritual counselor to summarize the visit in the patient's medical record. B: take measures to ensure privacy during the counselors visit. C: ensure that the counselor is approved by the hospital administration. D: asked to be present during a visit in order to explain any medical information or answer questions about the patient's care.

B: take measures to ensure privacy during the counselors visit. Rationale Visits between a patient and a spiritual counselor require privacy. The details of the meeting are not typically documented in the patient's chart, though the fact that the visit took place often noted. The nurse may be present during the meeting, but they should take place at the patient's request. Spiritual counselers do not require administrative approval; patient and families are normally able to seek spiritual help from whoever they prefer.

The following factors should be the primary factor in a nurse's decision whether to pray with a patient? A: the nature and course of the patient's current diagnosis B: the patient's openness to being prayed for C: the nurses familiarity with a prayer traditions of different faiths D: the availability of a hospital chaplain or other spiritual counselor.

B: the patient's openness to being prayed for rationale Many factors influence the nurse's decision to pray with the patient. Central among theses, however, is the question of whether the patient is open to this possibility. This factor is more important than the nurses familiarity with specific prayer tradition, the patient's medical condition, or the presence or absence of a chaplain.

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching? A) "I won't put the baby to bed with a bottle." B) "For the first few weeks we're putting the cradle in our room." C) "My grandmother told me that babies sleep better on their stomachs." D) "I know I'll have to get up during the night to feed the baby when he wakes up."

C ("My grandmother told me that babies sleep better on their stomachs.") (Thinking that babies will sleep better on their stomachs indicates that the mother needs further teaching. She needs to be educated on the "back to bed" concept for infant sleeping. Infants' beds need to be safe. Parents should place infants on their back to prevent suffocation and decrease the risk of sudden infant death syndrome "SIDS")

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? A) “I’ll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear.” B) “Sleep medicines won’t cause any sleep problems once I stop taking them.” C) “I’ll talk to my health care provider before I use an over the- counter sleep medication.” D) “I’ll contact my health care provider if I feel extreme sleepy in the mornings.”

C (“I’ll talk to my health care provider before I use an over the- counter sleep medication.”) (Talking to a health care provider before using an over-the-counter sleep medication shows an understanding of the risks of over-the-counter sleep medications. The use of nonprescription sleep medications is not advisable. Over the long term these drugs lead to further sleep disruption, even when they initially seemed to be effective. Caution older adults about using over-the-counter antihistamines because of their long duration of action, which can cause confusion, constipation, urinary retention, and increased risk of falls.)

Which of the following patients statement is most clearly suggests the potential for a nursing diagnosis of spiritual anxiety? A: "I always try to do the right pain, so' I don't understand why I have to suffer so much now" B: "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable." C: "Now that I am nearing the end, I'm worried that God wont think I lived a good enough life" D; "I guess I should have taken a lot more time to go to church when I was younger"

C: "now that I'm nearing the end, I'm worried that God wont think I lived a good enough life" rationale worry about one spiritual condition it indicative of the nursing diagnosis of spiritual anxiety. Unfamiliarity with the religious character of a care setting suggests spiritual alienation, while questions of suffering often indicate spiritual pain or spiritual despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of spiritual guilt.

A patient recently diagnosed with cancer informs the nurse that she values faith and finds comfort in her faith. The nurse is aware that faith is best defined as which of the following? A: Practice associated with all aspects of a person Iife. B: An organized belief system about a higher power C: I believe in something for which there is no proof or material of evidence D: a positive outlook even in the bleakest moment

C: a belief in something for which there is no more material evidence. Rationale Faith is a belief in something for which there is no proof or material evidence. Hope is a positive outlook even in the bleakest moments. Religion is an organized belief system about a higher power. Spiritual beliefs are practices associated with all aspects of a person's life.

The nurse caring for a patient with Parkinson's disease. The patient informs the nurse that he has been angry with God because of his worsening health, but after talking to the hospital chaplain, he is ready to return to church choir and become active again in the men's group at the church. Why is an appropriate nursing diagnosis for this patient? A: spiritual distress B: impaired religiosity C: readiness for enhanced spiritual well-being D; risk for loneliness

C: readiness for enhanced spiritual well-being Rationale The most appropriate diagnosis for this patient is readiness for enhanced spiritual well-being. The patient's desire to experience and integrate meaning and purpose in life through connectesness with self , others, art, music, literature, nature, or a power greater than himself.

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

D (Encourage patient to take one or two 20-minute naps during the day) (A person with narcolepsy has the problem of falling asleep uncontrollably at inappropriate times. Brief daytime naps no longer than 20 minutes help reduce subjective feelings of sleepiness. Other management methods that help are following a regular exercise program, practicing good sleep habits, avoiding shifts in sleep, strategically timing daytime naps if possible, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Patients with narcolepsy need to avoid factors that increase drowsiness - e.g., alcohol; heavy meals; exhausting activities; long-distance driving; and long periods of sitting in hot, stuffy rooms)

Which action by the nursing assistant at bedtime requires the nurse to intervene? A) Giving the patient a back rub B) Turning on quiet music C) Dimming the lights in the patient's room D) Giving a patient a cup of coffee

D (Giving a patient a cup of coffee) (Encourage patients not to drink or ingest caffeine before bedtime. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.)

Older adults are cautioned about the long-term use of sedatives and hypnotics because these medications can: A) Cause headaches and nausea. B) Be expensive and difficult to obtain. C) Cause severe depression and anxiety. D) Lead to sleep disruption.

D (Lead to sleep disruption) (Long-term use of sleeping medications in older adults can lead to sleep disruption. Because of slower metabolism and excretion of sleep medications, the potential for sleep impairment occurs. If sleep medications are needed, the lowest dose possible should be used short term.)

Which nursing measure best promotes sleep in a school-age child? A) Encourage evening exercise B) Offer a glass of hot chocolate before bedtime C) Make sure that the room is dark and quiet D) Use quiet activities consistently before bedtime

D (Use quiet activities consistently before bedtime) (A bedtime routine "e.g., same hour for bedtime, snack, or quiet activity" used consistently helps young children avoid delaying sleep. Quiet activities such as reading stories, coloring, and allowing children to sit in a parent's lap while listening to music or a prayer are routines that are often associated with preparing for bed. Parents need to reinforce patterns of preparing for bedtime.)

American Muslim patient seeks care in the emergency room for dehydration related to a prolonged period of diarrhea and vomiting. The nurse manager has been contacted because the patient has requested that his health care be provided by: A: men older than himself B: Females younger than himself C: physicians only D: members of the black community

D: members of the black community Rationale American Muslims are encouraged to obtain healthcare provided by members of the black community.

The nurse, while working with a client to support and assess spirituality should first: 1. Refer the client to the agency chaplain 2. Assist the client to use faith to get well 3. Provide a variety of religious literature 4. Determine the client's personal belief system

Determine the client's personal belief system

The nurse is conducting a home care interview when the patient's daughter states, "Dad has fallen twice trying to get to the bathroom after we have all gone to bed." Which of the following questions will be most informative regarding the cause of these falls? 1. "Has he been hurt when he fell?" 2. "When did this behavior first start?" 3. "Does your father have vision problems?" 4. "Do you think he gets confused when it's dark?"

Does your father have vision problems?"

When nurses view the family as client, their primary focus is on the: 1. Family within a system 2. Family process and relationships 3. Family relational and transactional concepts 4. Family health and development of an individual member

Family process and relationships

Which of the following actions should have priority to best ensure that the patient will not fall while being transferred to the chair using a transfer belt? 1. Place skid-resistant shoes or slippers on the patient's feet. 2. Have the patient sit on the side of the bed with legs dangling for several minutes. 3. Apply the transfer belt snugly over outer clothing while not impairing breathing. 4. Position the chair so that the move will be toward the patient's stronger side.

Have the patient sit on the side of the bed with legs dangling for several minutes.

The nurse knows that the primary reason for the application of a sequential compression device (SCD) on the legs of an immobile patient is to: 1. Stimulate circulation in the deep arterial vascular system. 2. Help prevent the formation of deep vein thrombosis (DVT). 3. Aid in peripheral circulation to minimize the risk of skin breakdown. 4. Assist in passive range-of-motion exercises of the patient's lower extremities.

Help prevent the formation of deep vein thrombosis (DVT).

The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response? 1 Finish the bath quickly 2 Help the patient return to bed 3 Leave the patient alone to rest in the chair at the sink for a few minutes 4 Instruct the patient to take deep breaths and try to relax

Help the patient return to bed

Which of the following nursing interventions is most therapeutic in response to a cognitively impaired patient who states, "I need to know what day my daughter will be coming to visit"? 1. Marking the day of the visit on the patient's wall calendar 2. Evaluating the patient's understanding of the concept of time and days 3. Responding by stating, "I'll let you know when you can expect to see her." 4. Calling the daughter to suggest that she call her parent to reinforce the day of her visit

Marking the day of the visit on the patient's wall calendar

When initially preparing to apply elastic stockings, the nurse must first: 1. Measure the patient's legs. 2. Select the appropriate size stockings. 3. Determining the patient's sensitivity to talcum powder. 4. Place the patient in a comfortable sitting position in the bed.

Measure the patient's legs.

The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the child's birth for the clients who are: 1. Catholic 2. Navajo 3. Shinto 4. Hindu

Navajo

Which of the following actions should have priority to best ensure that the patient will not experience unnecessary pain during passive range-of-motion exercises? 1. Stop the intervention if the patient expresses or displays physical signs of pain. 2. Be careful to support each joints as it is moved slowly through its range of motion. 3. Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed. 4. Postpone the intervention if the joints appear inflamed or edematous, or if the skin is bruised or broken.

Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed.

Which of the following actions should have priority in order to best ensure that the patient will not experience unnecessary pain during a transfer facilitated with a hydraulic lift? 1. Stop the intervention if the patient expresses or displays physical signs of pain. 2. Explain the intervention to the patient before starting the transfer process. 3. Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed. 4. Postpone the intervention

Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed. 4. Postpone the intervention

When preparing to delegate the application of an SCD to assistive personnel, the nurse must first: 1. Have the personnel demonstrate the proper application of the SCD. 2. Review the steps for the proper application of the SCD with the personnel. 3. Determine the need for the application of the SCD for this particular patient. 4. Evaluate the personnel's ability to recognize the early signs of impaired circulation.

Review the steps for the proper application of the SCD with the personnel.

The nurse is ambulating a patient with a gait belt. Which of the following events warrants returning the patient to bed immediately? 1. She complains of "feeling nauseous." 2. Her son arrives for a much awaited visit. 3. She states, "I don't want to get too tired." 4. The hospital chaplain responds to a referral.

She complains of "feeling nauseous."

The nurse notes on the admission form that the client has indicated "no religious preference." He understands that a. The client does not follow the tenets of a specific faith b. The client is in denial about his religious beliefs c. The client does not believe in God or a "higher power" d. The client will not want to pray or visit with the chaplain

a. The client does not follow the tenets of a specific faith