nur1023 custom quiz 1 & 2 eaq

which situation would the nurse address to meet the safety and security needs of the client according to Maslow's hierarchy of needs?

"I fear my house may be broken into and I might lose my things." rationale The nurse would attend to the safety and security needs of the client by addressing the client's fear of losing things due to a home break in. When the client says that they are on liquid diet, the nurse would consider this as a possible lack of nutrition. This is a physiological need. When the client says that the blood pressure level fluctuates, the nurse would consider this as an example of physiological needs. When the client says that family members "avoid me," the nurse would understand this to be a love and belonging need.

Which statement made by the client illustrates the love and belonging need based on Maslow's hierarchy of needs?

"I hardly speak to my children because they live in different countries."

Which parental statement would the nurse recognize as indicating that a child is at risk of muscle injury from overuse?

"I make my child exercise 2 hours per day."

Which nursing-sensitive indicator would the nurse manager use to evaluate the process of nursing care?

Nurse job satisfaction

Which action by the nurse leader signifies the implementation phase of the nursing process as it relates to client teaching?

Sequence different tasks

Which definition is correct to explain the nursing process?

Sequence of steps used to meet the client's needs rationale The nursing process is a step-by-step method that scientifically provides for a clients nursing needs.

Which level of Maslow's hierarchy of needs would the nurse need to follow for a client brought to the emergency department with severe breathing difficulty?

first level

Which step in the research process is similar to the assessment step of the nursing process?

identifying the problem

Which step in the nursing process would involve promoting a safe environment for the client?

implementation

When the health care facility uses cardiac telemetry for a client, to which Quality and Safety Education for Nurses (QSEN) competency would this intervention adhere?

informatics

Which needs would the nurse address using Maslow's hierarchy of needs when caring for an emancipated minor reporting improper nutrition?

physiological rationale In the given scenario, the client reports improper nutrition, so the nurse would address the physiological need of the client first.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

planning

The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective?

Observe the mother feeding the infant. Rationale A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother's readiness to learn is part of planning in the nursing process, not evaluating.

Which parental statement would the nurse recognize as indicating a need for further education about the importance of play in the development of their preschool-age child? Select all that apply. One, some, or all responses may be correct.

"We should eliminate all television, electronic games, and computer programs." "If the child fantasizes about imaginary playmates, we should bring him or her back to reality."

Which scenario would the nursing consider an example of the feedback component of the nursing process? Select all that apply. One, some, or all responses may be correct.

-"The nurse notices that the client's pain has decreased after giving a back massage." -"The caregiver says the client's body temperature has decreased after administering the prescribed medication." -"The nurse finds the client has developed breathing issues after administering a medication through the central venous access device."

Which example mentioned by the nurse belongs to the fifth level of Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct.

"A client wishes to become the best swimmer in the whole world." "A client tells the nurse that he or she wishes to become a successful engineer despite having dyslexia." "A client who is bedridden requests a physical therapist consultation to achieve maximum mobility." rationale According to Maslow's hierarchy of needs, the fifth level of needs include self-actualization needs. At this level, the individual wishes to reach his or her maximum potential while coping realistically with the situations of life. A client who wants to become the best swimmer in the world, become a successful engineer, or achieve maximum mobility after being bedridden is displaying self-actualization needs. Feeling the urge to urinate every 10 minutes is a physiological health problem that belongs to the first level of needs. A client who feels like a failure for not being able to complete college education may have a lack of self-worth and achievement. This situation belongs to the fourth level of needs.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation?

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

which feature distinguishes nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct.

-nursing diagnoses involve the client when possible. -nursing diagnoses involve the sorting of health problems within the nursing domain. -nursing diagnoses involve clinical judgment about the client's response to health problems. rationale Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.

In which order would the nursing student arrange the scenarios, from the highest to the lowest level of needs based on Maslow hierarchy.

1. "I want to maintain good health because I intend to be the best soccer player on my team." 2. "I do not have any skills that will help me be an achiever in life." 3. "I have been feeling depressed ever since my sibling stopped speaking to me." 4. "It is hard to catch my breath when I have an asthma attack." rationale According to Maslow's hierarchy of needs, self-actualization is the highest level of need for an individual. If the client intends to reach their full potential as a human being, this statement indicates the need to achieve self-actualization. The next level of need is self-esteem. The client displays a lack of self-esteem by conveying to the nurse that they lack the skills to achieve anything in life. The next need is love and belonging. The client's statement about the cessation of contact with a sibling illustrates this need. The lowest level of need is physiological need. A client who voices it is hard to catch my breath is evidence of a physiological need, oxygen.

which activity would the nurse perform under the practice of implementation after learning about about the standards of nursing practice? Select all that apply.

educating pt for health awareness using therapeutic produces for pt care providing consultation to enhance pt care rationale implementation is the practice in which the nurse actually uses and performs a particular action or puts a strategy into use. The nurse implements the health awareness plan by educating patients about disease prevention and health promotion. The nurse uses medical and therapeutic knowledge and implements therapeutic procedures for patient care. The nurse implements the plan of care by providing consultation to enhance patient care. Developing strategies for patient care is a part of planning in nursing practice. Analyzing the assessment data for diagnosis is a part of diagnosis in nursing practice.

The nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says: "It is the nurses' responsibility to discourage these people from bringing all that alternative medicine stuff to their family members." Which response by the primary nurse is correct?

"Nontraditional approaches to health care can be beneficial."

The nursing student is learning how to educate a client who is having trouble adapting to a new illness. Which statement made by the nursing student indicates the need for further education?

"I should assume that the family is involved."

The nurse is educating a parent about language and psychosocial development in toddlers. Which statement made by the parent indicates a need for further teaching?

"I should use the television for language and knowledge development."

Which parental statement indicates the need for further education related to bicycle safety for the school-aged client?

"My child should keep as far from the curb as possible when in the street."

Which statements by the student nurse indicate an understanding of caring for clients of various cultures? Select all that apply. One, some, or all responses may be correct.

"The focus is on understanding the traditions, beliefs, and values of the client's culture." "I will be aware of my own cultural background and beliefs when attending to clients who belong to different cultures."

Which nurse statement reflects positive cultural sensitivity to help reduce potential health disparities?

"Which type of food do you usually eat at home?"

The nurse caring for a client postsurgery takes necessary steps to achieve quality client care. Which nursing action satisfies the Quality and Safety Education for Nurses (QSEN) competency called informatics? Select all that apply. One, some, or all responses may be correct.

-Documenting in the electronic health record (EHR) after performing wound debridement -Locking the electronic health record (EHR) after every entrance of necessary information -Using a computer-assisted instruction (CAI) program to provide better quality of care to the client

Which scenario would the nurse label as the "input" component of the nursing process? Select all that apply. One, some, or all responses may be correct.

-The nurse checks the client's health history for allergy to iodine before inserting a urinary catheter. -The nurse checks for whether the client has a history of substance abuse before administering nasal medications. -Before placing an internal fecal catheter, the nurse checks the client's medical records for any rectal surgery within the past year.

In which order would the nurse arrange the human needs of Maslow's hierarchy? Arrange from the top priority need to the lowest priority need.

1. physiological 2. safety 3. social 4. esteem 5. self actualization

Which scenario would contribute to health disparities?

An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

Who would the nurse use as an interpreter to explain a consent form for a foreign-language speaking client who needs to undergo chemotherapy?

An official interpreter

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)?

Center for Medicare and Medicaid Services (CMS)

Which situation would the nurse address first according to Maslow's hierarchy?

Complains of sleeplessness due to pain postsurgery

A Spanish-speaking client is being cared for by English- speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client?

Contact an interpreter provided by the hospital.

When teaching the staff about how the health care provider strives to work effectively within the cultural context of a client, which cultural principle is the nurse leader explaining?

Cultural competence rationale Cultural competence is the process in which the health care provider strives to achieve the ability to work effectively within the cultural context of a client, individual, family, or community. Cultural diversity describes a vast range of cultural differences among individuals or groups. Cultural sensitivity describes the affective behaviors in individuals such as the capacity to feel, convey, and react to ideas, habits, and customs or traditions unique to a group of people. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for various reasons.

The nurse working in a cardiac center is preparing to enter client data using health information technology. The nurse needs to refer to these data during subsequent follow-up client visits. Which type of record would the nurse use to enter the client's data?

Electronic medical record (EMR)

Which nursing intervention is an example of the nurse as a caregiver? Select all that apply. One, some, or all responses may be correct.

Encouraging the client to exercise daily Setting goals for the client to reduce weight Arranging for the client to meet a spiritual advisor rationale The nurse acts as a caregiver by encouraging the client to exercise daily. The nurse's role as a caregiver involves helping the client maintain and regain health. As a caregiver, the nurse also sets goals and helps the client and family achieve them. The duties of a caregiver involve restoring a client's emotional, spiritual, and social well-being. The nurse arranges for the client to meet a spiritual advisor to meet the client's spiritual needs. The nurse as an educator evaluates the client's understanding of prescribed diet.

When the nurse labeled an African-American client as a drug abuser for requesting pain medication, which behavior did the nurse demonstrate?

Ethnocentrism rationale Ethnocentrism is the tendency of a person to hold their own beliefs superior to those of other people. Ethnocentrism causes biases and prejudices in regard to people from other groups. This practice is transmitted by cultural groups from one generation to another. In multiculturalism, two cultures coexist and are accepted by the individual. In a cultural encounter, part of cultural competence, the nurse engages in cross-cultural interactions for effective communication. Cultural imposition occurs when the nurse or health care provider ignores the differences between his or her own culture and others, imposing his or her beliefs on people of other cultures.

Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs?

Has multiple fainting episodes due to lack of proper nutrition.

Which component of the nursing process includes tasks that can be delegated?

Implementation

The nurse starts a new job and recognizes that the client population is very diverse. Which action will help the nurse provide culturally competent care?

Increase self-awareness of cultural identity, cultural knowledge, and potential biases.

Which results are the benefits of providing culturally competent care? Select all that apply. One, some, or all responses may be correct.

Increased client safety Reduced health disparities Increased client satisfaction

Which nursing action(s) reflect(s) the evaluation phase of the critical thinking process? Select all that apply. One, some, or all responses may be correct.

Looking at all the situations objectively Using several criteria to determine the effectiveness of a nursing intervention rationale During the evaluation phase of the critical thinking process, the nurse would look at the situations objectively to identify the client's response to interventions. The results of the nursing actions should be evaluated using criteria such as expected outcomes, pain characteristics, and learning objectives. The nurse demonstrates interpretation skills by collecting all the data in order. Supporting one's findings and drawing conclusions reflects the explanation aspect of the critical thinking process. The nurse would be open-minded while looking at the information about the client to help in accurate analysis.

Which Quality and Safety Education for Nurses (QSEN) competency does the nurse comply with when asking a client from another country about health care traditions?

Patient-centered care rationale The nurse who provides compassionate and coordinated care to clients based on their preferences, values, and needs is providing patient-centered care. Asking about the health care traditions followed in the client's country is an example of patient-centered care.

Which is the first action of the nurse when a parent expresses concern about a child's diet?

Perform a nutritional assessment.

The nurse manager works on a unit where the nursing staff members are uncomfortable providing care for clients from cultures different from their own. Which action would the nurse manager take to address this problem?

Plan a workshop offering opportunities to learn about the cultures the nurses might encounter while at work rationale A workshop provides an opportunity to discuss cultural diversity; this should include identification of one's own feelings. Also, the workshop provides an opportunity for participants to ask questions. Although articles provide information, they do not promote a discussion about the topic. Relocation is not feasible or desirable; clients from other cultures are found in all settings. Rotating the nurses' assignments probably will prob increase tension

The nurse finds that a child has developed the qualities of independence, self-control, and self-governance. Which type of development would the nurse anticipate in the toddler?

Psychosocial development

Which social development tasks would the nurse anticipate when assessing a toddler-age client during a health maintenance visit? Select all that apply. One, some, or all responses may be correct.

Separation Individuation rationale Separation and individuation are two social development tasks the nurse anticipates for the toddler-age client. Parallel play, irreversibility, and temper tantrums are also expected during the toddler stage of development; however, these are not social development tasks.

Which information regarding developmental safety risks for toddlers would the nurse include in a parent education session? Select all that apply. One, some, or all responses may be correct.

Store matches and lighters out of reach. Install childproof safety locks on cabinets. Ensure the use of safety equipment when riding bicycles. Provide constant supervision around pools and during bath time. Identify and address any potential sources of lead in the child's environment.

Which behavior of a 3-year-old child indicates delayed development? Select all that apply. One, some, or all responses may be correct.

The child is unable to feed themself. The child is unable to climb the stairs.

Which major gross motor development skills would the nurse expect to see demonstrated during a teaching session with a parent of a 12-month-old child?

Walking alone rationale A major gross motor development the nurse would include in the teaching session with the parent of a 12-month-old client is walking alone. Drawing a stick figure person is a fine motor skill that is not developed until the preschool stage of development. Showing interest in cooperative play does not occur until late in the preschool stage of development. Object permanence occurs during infancy.

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client?

assessment

The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in this situation?

assessment

Which step of the nursing process involves the nurse interviewing a client about a current health problem and obtaining the client's vital signs?

assessment

The nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent?

delegation rationale Delegation is the assignment of a nursing task to someone else who is able or qualified to perform the task.

A registered nurse notices that the insertion site of a client receiving intravenous medication is swollen. The nurse takes appropriate measures to treat the area and takes a photo of the insertion site and saves it in the client's electronic health record. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse following?

safety

Which consideration would the nurse emphasize to the parent of a toddler-age client when selecting toys?

safety

Which basic human need belongs to the fourth level of Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct.

self worth achievement rationale The fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

Which topic will the nurse include when educating adolescents about injury prevention? Select all that apply. One, some, or all responses may be correct.

suicide seat belt use firearm safety rationale Education about injury prevention for adolescents will include suicide, seat belt use, and firearm safety. Depression should be addressed when assessing mental health. Contraception should be included in discussions about sexuality.

The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client's temperature. Which action is the nurse taking?

validation rationale The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data; it involves clarifying vague or unclear data.