Nursing 221 PrepU Exam 3

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

The nurse is taking a client history. With which client is direct eye contact appropriate?

"My Russian heritage is superior to all others."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

A nurse visits a female victim of sexual assault. During the visit the client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?

"Tell me more about the aspects that make you feel as if it happened yesterday."

The nurse is caring for a client admitted with an upper respiratory infection. The client tells the nurse about following the holistic belief of hot/cold. Which food items should the nurse provide to the client based on this information?

Soup, hot tea, and toast

The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study?

Witchcraft

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?

a diet lacking in fruits and vegetables

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?"

Which is the proper way to document midnight in a client's record?

0000

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a health care provider to report a client's new onset of chest pain.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus?

"Certain vegetables can cause flatus, as they are more difficult to digest."

The nurse just attended a seminar on cultural diversity. Which statement by the nurse would require further education?

"Ethnicity and race are the same thing and are affected by cultural practice."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

Age 50 and older. A positive family history. A history of inflammatory bowel disease.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

Any abnormal occurrences with the client during the shift. Identifying demographics, including diagnosis. Current orders.

When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response?

Ask the client about personal space preferences

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline.

Which behavior by the nurse is stereotyping?

Avoiding older adult clients because their care is time consuming

A client who does not speak the dominant language is admitted to the hospital. Which cultural intervention would be most appropriate by the nurse?

Call for an interpreter who is familiar with health care.

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

Each facilitates a therapeutic nurse-client relationship except:

Closed-ended questions

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. Which is the best action for the nurse to take?

Contact a professional interpreter.

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

The emergency department nurse is caring for a client injured in a motor vehicle collision. The client recently immigrated to the country. The nurse should implement interventions aimed at addressing which issue?

Culture shock

The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse?

Discuss with the client the need for assistance during ambulation.

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response?

Document the client's request in the nursing care plan.

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply.

Education of student nurses. Reimbursement for services. Research. Education for medical students.

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

The nurse is performing digital removal of a fecal impaction. Which nursing actions follow guidelines for this procedure? Select all that apply

Gently remove impaction use non sterile gloves. Provide sitz bath (Epsom salt) after procedure. Place in side lying position.

The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication?

Identify oneself by name and title with each entry into the client's room.

Which practice should the nurse adopt when commmunicating and documenting electronically?

Include precise measurements in documentation rather than approximations

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

Interpretation of data

Which is a drawback to the type of documentation known as charting by exception?

Issues related to high-quality care should a negligence claim arise

The nurse is assisting an older adult client into position for a sigmoidoscopy. In which position will the nurse place the client?

Left lateral

A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the:

Media

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3.

A nurse is providing care to a client who is from a different culture. Which aspect about culture would be most important for the nurse to integrate into the client's care?

Not all members of the same culture act and think alike.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

The nurse will be caring a client who will soon be admitted to the medical unit. The nurse should establish a working relationship and discuss how communication will take place during what phase of the nurse-client relationship?

Orientation Phase

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

Orientation phase

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase

The nurse is administering a large-volume enema to a client as prescribed. The client reports abdominal cramping. What should the nurse do first?

Pause the administration of the enema momentarily.

A White client has requested that they not receive any care from Black nurses. This client is demonstrating what practice?

Racism

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure.

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

TCJ

The nurse is caring for several clients of different cultures. Which client situation would the nurse recognize as the client with highest risk of culture shock?

The client from Ethiopia states, "All these machines attached to me scare me and I need to get them off."

In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which principle?

The client may have a very different understanding of health promotion.

The following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse maintains eye contact with the client.

The nurse caring for a client with a new colostomy. Which assessment finding would be considered abnormal and would need to be reported to the health care provider?

The stoma is prolapsed

The nurse is talking to a client whose colostomy pouch frequently comes loose and falls off. Which interventions are appropriate suggestions? Select all that apply.

Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch. Apply a commercially available skin barrier before applying the ostomy pouch.

The client, visiting from a foreign country, arrived at the facility seeking medical assistance following an accident. The client has limited proficiency in the dominant language. An onsite certified interpreter is unavailable. To assist in interpretation, what is an appropriate nursing intervention?

Use a contracted video interpretation service

A nurse touches the client's hand while discussing the client's diagnosis. This action is:

a communication channel

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:

aggressive

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:

allow the client to set the pace

Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?

analysis

The nurse is preparing the discharge plan for a new mother and her newborn son. Which new teaching should the nurse ensure is included after noting the family is Jewish?

care following the scheduled circumcision

A student nurse studying human anatomy knows that a structure of the large intestine is the:

cecum

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline

The nurse is managing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?

emptying a client's ileostomy appliance

The use of one's culture as a cultural standard is known as:

ethnocentrism.

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

involve the child's stuffed animal in the educational session.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms:

require an individualized approach by the nurse.

The spouse of a client asks the nurse whether the spouse may bring in a cream from home to apply to the client's skin. The spouse says, "Whenever anyone gets sick, we always use this cream." The nurse interprets this as:

ritual.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

The clinic nurse is obtaining demographic data from a client. The client states, "Why do you need to know what my ethnicity is?" How should the nurse respond?

"Collecting this information allows us to develop a personalized plan of care to meet your needs."

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

A nurse is asking a colleague about a situation. Which response best demonstrates assertive communication?

"I think there is a better way to handle this."

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing."

The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client?

"It sounds as though you are most concerned about how your children will feel."

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening?

"You seem unsure. Tell me your concerns about your surgery."

A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change?

The client states, "I feel like I abandoned my religion."

The nurse is caring for a client 4 days after total hip arthroplasty and notes the client has lost weight. The unlicensed assistive personnel reports the client's food intake has decreased. Which question will the nurse ask the client to determine if cultural causes are responsible for the weight loss?

"What type of food do you like to eat at home?"

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

A client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not taken the prescribed medicines. The client believes that eating saffron will keep blood sugar under control. What is the most appropriate response by the nurse?

"What would you think about taking the medicines, too, and benefitting from both?"

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

"The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care."

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

"This test detects heme, an iron compound in blood within the stool."

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies?

"We will be having a team conference to discuss concerns that clients' relatives have raised.

The unlicensed assistive personnel reports to the nurse that the client is refusing to eat the food on the meal tray. The nurse observes the client eating the food brought in by family members. How should the nurse respond?

"What type of food did your family prepare for you, and does it have special meaning?"

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A client has been admitted to the unit for chest pain. A nurse told the family that they could not be with the client. The family became very upset, and now the client wants to leave. What is the most culturally appropriate response by the charge nurse?

"Would you feel more comfortable with your family with you?"

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

When providing culturally competent care to clients, a nurse understands that cultural competence involves which characteristics? Select all that apply.

A process that requires life-long learning. A commitment to promoting health equity. Knowledge of influences on the clients' beliefs. Awareness of one's own influences on responses

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?

A variance

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client?

Arrange for a sign language interpreter when discussing treatment.

A client's spouse has asked that the client be cared for exclusively by female nurses. How should the nurse incorporate this request into the care plan?

Document the request and make all reasonable efforts to honor it

A nurse manager of a health care provider's office is responsible for obtaining signed authorizations for releasing client information to third parties. In which situations would it not be necessary for the nurse to obtain an authorization from the client? Select all that apply.

Reporting the incidence of an infectious disease to Center for Disease Control. Releasing a medical record to the court when a nurse is being sued for negligence. Facilitating organ donation of a deceased patient. Providing statistics related to the use of a dangerous piece of equipment

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water.

An older adult has developed occasional constipation despite having no such issues during their adult years. Which developmental factor is most likely related to this change?

Weakened pelvic muscles lead to constipation.