Taylor Chapter 1

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment. School-age children in the 7th grade are physically active, which makes them prone to play-related injuries. Therefore, protective sporting equipment should be used. Information about not texting while driving is more appropriate for teenagers and adults who drive. Using caution around electrical outlets and stairs is more appropriate for parents of toddlers.

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding." Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chin strap should fit snuggly, not loosely. Young children who are secured in a bicycle passenger seat must also wear a helmet.

A 48-year-old client was just diagnosed with type 2 diabetes mellitus. The client has a body mass index of 35 and leads a sedentary lifestyle. The nurse informs the client of risk factors for the diagnosis and the need to change diet and exercise behavior. Which client statement indicates a need for further teaching?

"There is nothing that can be done anyway; chronic diseases cannot be prevented." The major causes of chronic diseases are known, and if these risk factors were eliminated, over 80% of cases of heart disease, stroke, and type 2 diabetes would be prevented and over 40% of cases of cancer would be prevented. Of the ten leading causes of death in the United States, seven are chronic illnesses. The statement that the client should start slow on an exercise program approved by the client's healthcare provider is true.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant?

"We place our baby in a rear-facing car seat in the back seat of the car." Children from birth to 2 years of age should remain in a rear-facing infant seat in the back seat of the car until they reach the maximum height and weight for a front-facing child car seat.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler. The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply.

Communicator Counselor Teacher The roles and functions of the nurse are many and include caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are not the roles of the nurse.

Which nursing action best exemplifies the nurse's role in promoting health?

encouraging a group of junior high school students to engage in regular physical activity Health promotion involves encouraging individuals to be proactive in taking measures to foster their well-being and maximize optimal functioning. Exercise is one of the most common and accessible activities that can help achieve this. Facilitating support groups promotes coping with an existing condition. Treating hypertension pharmacologically and removing secretions that can threaten oxygenation help to restore health and prevent illness.

The nurse is providing discharge information to the mother of a 4-year-old who was just diagnosed with influenza A. Which comments, made by the mother, indicate a potential problem in this child's future care? Select all that apply.

"How much does this antibiotic cost?" "I have already missed two day's work because I was sick." Asking about the cost of an antibiotic may indicate an issue with finances. The statement about missing work may indicate that the mother has a childcare issue. Staying with grandma indicates a plan for the child's care. The nurse would educate the mother about flu immunizations, but the statement does not indicate a problem. The statement about missing the movies indicates the mother has knowledge of the need for rest and avoiding the spread of the virus to others.

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include?

Adjustment to retirement Developmental tasks for families with adolescents and young adults include balancing teenagers' freedom with responsibility, maintaining supportive home base, and strengthening marital relationships. Adjusting to retirement is a developmental task for families with older adults.

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined.

The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?

Educator Under the overall umbrella of nursing process, the nurse in this situation is performing the the implementation of the care plan interventions.The nurse is acting in the role of educator by explaining each step at a level, and to a degree that the client can process, ask questions if necessary, and understand. The act of changing the dressing is an aspect of the caregiver role. Once the nurse moves beyond the care plan interventions, it may become necessary to make a decision or advocate for the client as a result of the assessment of wound and client learning during the teaching of wound care occurring.

What is the best nursing intervention to promote health in a client at risk for heart disease?

Emphasizing a client's strengths to encourage weight loss

Which is the most accurate definition of health?

Health is a state of complete physical, mental, and social well-being.

A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?

It is the role of nursing to provide a caring relationship that facilitates health and healing. The American Nurses Association (ANA) defines nursing as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" (ANA, 2010). The ANA does not see nursing as dependent upon medicine. The ANA sees one of the roles of the nurse as assisting clients in understanding their health problems. The ANA does not address essential components of professional nursing care with terms such as strength, endurance, and cure.

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher. The occupations of the parents provide financial support for the family and contribute to the socioeconomic status of the family. Affiliation with a religious organization can be a source of social support during stressful times, which can promote adaptive coping for the family. Cultural and religious activities of the family define values and beliefs important to family members. Recreational activities, such as vacationing together, promote interaction of family members.

The nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care?

"What can we do to help you meet any religious needs you may have?" The nurse should always respect the client's religious beliefs and ask whether the client has any religious needs that may affect health care. Comparing the client's beliefs with those of the nurse is inappropriate. Asking general questions about the client's religion would not identify other aspects of religion that might affect health care. A too-narrow focus on only dietary restrictions or specific medical treatments will not give the nurse enough information to develop an inclusive plan of care.

A client will be hospitalized for at least three weeks following a serious automobile accident. How can the nurse best support this client's love and belonging needs during this hospitalization? Select all that apply.

1. Allow a family member to stay at the bedside as much as possible. 2. Be caring in the provision and planning of care. Including family in the client's care and caring for the client are ways to support love and belonging needs. Encouraging goal setting that is achievable helps to support self-esteem needs. Teaching that will help the client overcome physical disabilities helps to support self-actualization. Providing medications to allow for sleep supports physiological needs.

What are the best examples of the role of the nurse as a communicator? Select all that apply.

1. Telling a client their blood pressure 2. Calling a physician about a client's blood pressure 3. Informing the physical therapist that the client's therapy was discontinued 4. Discussing laboratory values with a client When acting in the role of communicator, the nurse is using effective interpersonal and therapeutic communication skills to establish and maintain helping relationships. Examples include telling a client their blood pressure, calling a physician regarding a client condition, reviewing laboratory values with the client, and relaying pertinent information with members of the multidisciplinary team, such as the physical therapist. Telling a friend something that happened to a client that day is not the role of the nurse as communicator; in fact, it may be a violation of the client's privacy and confidentiality.

Health is a state of complete well-being.

A classic definition of health is that health is a state of complete physical, mental, and social well-being, not merely the absence of disease or physical symptoms. Health encompasses a state of mind and not just how a client feels.

The nurse is evaluating client health. Which client should the nurse determine to be exhibiting the most signs of health?

A client with a leg amputation who performs activities of daily living with a prosthesis As defined by the World Health Organization, one's health includes physical, social, and mental components and is not merely the absence of disease or infirmity. Health is often a subjective state—a person may be medically diagnosed with an illness, but still consider himself or herself healthy. The client with an amputation is performing activities of daily living, thereby demonstrating healthy behaviors. A client with diabetes who is refusing to take insulin is in denial of the illness. A client in acute emotional distress related to the spouse's death is experiencing a normal pattern but not demonstrating a healthy behavior. A client with depression who will not get out of bed is also experiencing denial as opposed to a healthy behavior and coping.

Which client would most benefit from the nurse including in the plan of care interventions addressing the client's social health?

A spouse and parent who is angry about no longer being able to work due to a spinal cord injury A spouse and parent who is angry about no longer being able to work due to a spinal cord injury has had a drastic role change, which can can cause a feeling of powerlessness and feelings that the client is no longer useful to the family. This is an alteration in the client's social health. Social health is an outcome of feeling accepted and useful. Nursing interventions that allow the client to feel useful or express feelings about the role change can enhance social health. A client with a sexually transmitted infection has a physical health problem. A stressed client who is learning to using guided imagery for relaxation is adapting to an alteration in their emotional health. A new mother cradling her infant is displaying appropriate bonding.

A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important?

Emphasizing the client's strengths. To help meet a client's self-actualization needs, the nurse focuses on the person's strengths and possibilities rather than on problems. Reducing fear would assist in meeting the client's safety and security needs. Promoting socialization would aid in meeting the client's love and belonging needs.

Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor?

Environmental risk factor Working and living environments may contribute to disease. Working with cancer-causing chemicals is an example of an environmental risk factor for illness. Physiologic risk factors are those relating to an individual's body or biology. Lifestyle risk factors are habits or behaviors people choose to engage in. A health habit risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury.

A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?

Facilitating coping This client's care in the coming weeks or months will likely encompass all of the four foundational roles of the nurse. However, because the client has just recently received bad news and is emotionally distraught, helping the client cope is an appropriate priority in immediate care. Preventing illness is focused on preventing an infection or disease from occuring such as through immunizations, hand hygiene, exercising and diet. Restoring health would more appropirately occur after the client has accepted the disease and would involve taking medication and working to get back to baseline with the disease. Health promotion is the process of enabling people to increase control over, and to improve, their health.

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area?

Health promotion Health promotion is the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability. Self-concept incorporates both how people feel about themselves (self-esteem) and the way they perceive their physical self (body image). Diagnosis of disease involves a medical aspect such that a disease is traditionally diagnosed—and treatment is prescribed—by a physician or advanced practice nurse, whereas nurses focus on the person with an illness.

The nurse is assessing a family parented by a 60-year-old grandmother and three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families?

Increased financial concerns Many single-parent families are headed by women. Single parents often have special problems and needs, including financial concerns and role shifts (i.e., having the roles of both parents). Single-parent families are not less knowledgeable about child safety than other family types, nor is there a higher incidence of child abuse, neglect, or conflict among family members.

Chronic illness may be characterized by periods of remission. Remission is best defined as:

Remission is defined as the presence of a disease, but the person does not experience the symptoms. Exacerbation is the reappearance of symptoms of a disease. Disease is a pathologic change in the structure of function of the body or mind. Illness is the response of a person to a disease.

The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs?

Safety and security Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as moving and ambulating patients. Assisting the patient to ambulate ensures that the patient will not experience a fall. From the bottom of the hierarchy upwards, the needs are: physiological, safety, love and belonging, esteem and self-actualization. The third stage in Maslow's hierarchy of needs is the social stage (also known as the love and belonging stage), which includes interpersonal relationships. Human behavior is driven by needs, one of which is the need for a sense of personal importance, value or self-esteem. Self-actualization represents growth of an individual toward fulfillment of the highest needs; those for meaning in life, in particular.

A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing?

Safety and security Safety and security needs have both physical and emotional components. Physical safety and security means being protected from potential or actual harm. Emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension. Physiologic needs are the most basic in the hierarchy and the most essential to life. They must be met at least minimally to maintain life. Love and belonging needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. Self-esteem needs include the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.

A client has been admitted to the hospital for treatment of pancreatitis secondary to alcoholism. The client states that it is nearly impossible to quit drinking because of the deep entrenchment of alcohol use in the client's circle of friends and line of work. As well, the client claims to have thought that drinking only beer and foregoing hard alcohol would prevent health problems. This client is exhibiting health consequences rooted in which human dimensions?

Sociocultural and intellectual That the patient is situated in a context that normalizes heavy alcohol use is an example of the sociocultural dimension. The client's ignorance of the health consequences of drinking beer rather than spirits is a component of the intellectual dimension.

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?

Sociocultural dimension Communication is essential for interaction with others and is an example of the sociocultural dimension. The physical dimension includes physiological health and nutrition. Housing and community are examples of the environmental dimension. The emotional dimension includes fear, sadness, loneliness, and acceptance of self.

Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone?

Sociocultural needs Increased social interaction, as would be provided by visiting a senior citizen community center, would primarily address a client's sociocultural needs. Emotional needs address how the mind affects body functions and responds to body conditions. Long-term stress affects body systems, and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change the body's responses to illness. The intellectual dimension encompasses cognitive abilities, educational background, and past experiences. Spiritual beliefs and values are assessed when addressing spiritual needs.

The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?

The RN coordinates care delivery. There are 12 Standards of Practice: assessment, diagnosis, outcomes identification, planning, implementation, evaluation, ethics, culturally congruent practice, communication, collaboration, leadership, and education. The standard exemplified by the nurse is 5a, implementation via coordination of care in which the RN coordinates care delivery. Standard 5b is health teaching and health promotion in which the registered nurse employs strategies to promote health and a safe environment. Standard 3 is outcomes identification, in which the registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation. Standard 2, diagnosis, is when the registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues. Standard 1 is assessment, in which the registered nurse collects pertinent data and information relative to the health care consumer's health or the situation.

Which is the best example of a client-centered approach to care?

The nurse asks the client about health goals. Client-centered care is one of the quality and safety education requirements for nursing competencies (QSEN). The intent of client-centered care is to ensure that care is centered on the client, and not the needs of the nurse. An example of this is the nurse asking the client about personal health goals so that they can be addressed on the client's plan of care. Helping the client ambulate, asking the client what he or she would like from the menu, and drawing a blood sample are examples of client care, but are not client-centered care.

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future. Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record requires skill to document the necessarry behavior and results and allows for adapting nursing care planning; a client health record must not discuss aspects particular to the incident report or facility issues. Holding a meeting will likely be necessary or helpful, but does not replace the need to document the event in the form of an incident report.

The Standards of Practice provide nurses with:

guidelines for providing care. Standards of practice are essential because they serve as guidelines for providing and evaluating nursing care. The Standards of Practice are established by the American Nurses Association and are not legislation for health care reform or anything else. They do not provide information about potential drug interactions or measurement criteria for payment.

When educating families on fire safety, it is important to:

have a meeting place outside the home. The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet.

The primary aim of the Healthy People 2020 initiative is:

health promotion.

When chronic illnesses and disabilities are present, individuals benefit most from activities that:

help them maintain independence. Although their chronic illnesses and disabilities cannot be eliminated, adults can benefit most from activities that help them maintain independence and achieve an optimal level of health. The other answers, while beneficial, are not as helpful