Week 1 Concept Questions

The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client? A) Placing the client in a private room, away from others B) Speaking to the client in a soft, calm tone C) Administering a prn medication to sedate the client D) Using short sentences when talking to the client

B) Speaking in a soft, calm manner is the first step in attempting to soothe an excited client. The nurse's tone may calm the excited client. Using short sentences is a useful approach, but in the case of an excited client, the nurse would attempt to calm the client first. Isolating the client may be necessary if the client's behavior escalates to violence, but that is not evident here and is not the first choice of action. Giving a sedative is the last resort and is used only if the client is threatening to hurt self or others.

During a health history, the nurse learns that a male client has a recent onset of erectile dysfunction (ED). Which assessment question is likely to elicit the most useful information about factors that may be contributing to the client's ED? A) "Does this occur often?" B) "For what diseases and disorders have you been treated?" C) "Are you on any medications?" D) "How does your partner feel about this problem?"

B) The client's health history can provide clues regarding the underlying cause of the erectile dysfunction (ED). The question "For what diseases and disorders have you been treated?" would most likely provide useful information as to possible causes for the recent onset of the disorder. Asking the client whether ED occurs often will not help identify the cause of the problem, nor will asking the client how his partner feels about the situation. Inquiring about the client's medication use would be useful; however, the inquiry should be phrased as an open-ended question and not a closed-ended question, as it is here.

Which of the following conflict-related communication styles involves attempting to satisfy the concerns of others while neglecting the self? A) Compromising B) Accommodating C) Avoiding D) Competing

B) The five main styles of conflict-related communication are competing, collaborating, compromising, avoiding, and accommodating. Accommodating involves attempting to satisfy the concerns of others while neglecting the self. In comparison, competing is an assertive, power-oriented approach where one focuses on the self; collaborating is a cooperative approach that involves gaining insight to the perspectives of others; compromising is an approach where both parties are partially satisfied; and avoiding is refusing to address a conflict.

Which of the following individuals would be included on an interdisciplinary healthcare team but not on an interprofessional healthcare team? A) Nurse practitioner B) Laboratory technologist C) Pharmacist D) Physical therapist

B) The term interprofessional usually refers to professionals from various disciplines, whereas the term interdisciplinary is often used to denote that paraprofessionals or others (such as clients or family members) are also included. Nurse practitioners, pharmacists, and physical therapists are all professionals, so they could be part of both interprofessional and interdisciplinary teams. In contrast, a laboratory technologist is considered a paraprofessional, so he or she would be part of an interdisciplinary team but not an interprofessional team.

The nurse on third shift is handing off clients to the nurse on first shift. Which of the following statements is most important for the third shift nurse to report during this handoff? A) "The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders." B) "The client in room 313 ate a full meal several hours ago and is currently sleeping peacefully." C) "The client in room 315 received an enema at 2100." D) "The client in room 311 was transferred from room 212."

A) A good change-of-shift report is concise and does not elaborate on background data or routine care, such as enema administration, meal consumption, or past client transfers. Rather, an effective change-of-shift report highlights significant changes in or concerns with a client's condition (e.g., persistent unrelieved headache), as well as any pending orders or requests for orders related to these changes or concerns.

The nurse is providing care to a client who is diagnosed with hypertension. Which response by the nurse is an appropriate example of informational confrontation with the client? A) "I noticed you rubbing your head and your eyes. Are you hurting? Let's take your blood pressure." B) "I heard raised voices when I was coming down the hall to your room. Are you upset?" C) "It is 3 p.m. and time to take your blood pressure before I give you your medication." D) "Is the blood pressure medication making your head hurt?"

A) An informational confrontation describes the visible behavior of another individual, whereas an interpretive confirmation expresses thoughts and feelings about behavior and draws inferences. Of the options provided, only the one that begins with "I noticed you rubbing your head and your eyes" is an example of an informational confrontation.

The nurse is caring for a client who was admitted to the emergency department with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. When the interpreter arrives, which action by the nurse is appropriate? A) Ask the interpreter to translate as closely as possible. B) Ask the client's family to be included in the interpreting process and exchange of information. C) Direct questions to the interpreter and not the client. D) Request that the interpreter use the same dialect as the client to promote understanding.

A) An interpreter is an individual who mediates spoken or signed communication between people who use different languages without adding, omitting, distorting meaning, or editorializing. It is not the interpreter's responsibility to determine the dialect with which the client is most familiar. The nurse should direct all questions to the client, not the interpreter. The nurse should also avoid asking the client's family, especially a child or spouse, to help interpret.

A critical nursing concept that a nurse uses with every client that allows the nurse to identify habits of health and wellness and the effects of illness and injury is A) assessment. B) collaboration. C) teaching and learning. D) advocacy.

A) As the first step in the nursing process, the nurse will use assessment with every client to identify habits of health and wellness and the effects of illness and injury. Nurses will use the concepts of collaboration, teaching and learning, and advocacy for many clients, but these concepts do not help identify healthy habits or the effects of illness and injury.

The nurse is providing care for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). In this scenario, which action by the nurse would be considered an example of therapeutic communication? A) The nurse asks appropriate questions about the client's medical history. B) The nurse closes the conversation with an anecdote about breathing. C) The nurse plans to tell the client about a COPD support group. D) The nurse bonds with the client by describing her own experiences living with COPD.

A) Attentive or "mindful" listening is a therapeutic communication technique that involves listening and absorbing the content and feeling of what an individual is conveying, without selectivity. This technique requires paying attention to the client's total message, both verbal and nonverbal, and noting whether these communications are congruent. During attentive listening, the nurse focuses not on the nurse's own needs but rather on the client's needs. By asking appropriate questions about the client's medical history and carefully noting the client's responses, the nurse is engaging in attentive listening and thus in therapeutic communication.

Reducing the risk of functional decline in older adults can help prevent which complication? A) Pressure ulcers B) Macular degeneration C) Hyperglycemia D) Hearing loss

A) By reducing the risk of functional decline, nurses and independent older adults can help prevent complications such as pressure ulcers, delirium and depression, decreased mobility, loss of independence, and incontinence. Macular degeneration, hearing loss, and hyperglycemia are not complications that occur as a result of functional decline.

For a client with chronic obstructive pulmonary disease (COPD), the nurse may provide health promotion teaching about what other major health concept? A) Safety B) Elimination C) Immunity D) Development

A) COPD often develops as a result of years of smoking, and one common therapy is oxygen administration. The combination of smoking and oxygen increases the client's risk for safety related to fire hazards. COPD does not commonly cause changes in elimination, immunity, or development.

) Which of the following is an advocacy intervention that a nurse may perform? A) Ensuring that clients and their families understand their legal rights. B) Deciding whether clients need to know information regarding their care. C) Following organizational policies and procedures in all cases without question. D) Leaving monitoring of clients' care to the clients themselves.

A) Educating clients and their families about their legal rights regarding informed decision-making is a specific advocacy intervention a nurse may make. Nurses should ensure that clients have all the information they need to give informed consent. They should review organizational policies and procedures to ensure protection of client rights, and they should monitor client care to ensure client rights.

A client is complaining of pain in the lower-left quadrant of his abdomen. The nurse prepares to auscultate the lower abdomen and notes that the client has a great deal of hair there. Which action by the nurse is appropriate prior to auscultating the client's abdomen? A) Moistening the abdominal hair B) Documenting that the client has hirsutism C) Cutting the client's hair over the entire abdomen D) Discontinuing the use of auscultation and palpating the abdomen only

A) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for auscultation. The client complains of abdominal pain, so auscultation would be a necessary part of a thorough examination because the nurse would need to listen to bowel sounds. Hirsutism includes excess hair all over the entire body, not just the abdomen.

A nurse is explaining the need to obtain laboratory tests on a client who has an infection and is of a cultural group different from the nurse's. During the interview, the client avoids eye contact and refrains from answering questions for long periods of time. Which does this behavior indicate to the nurse? A) In this client's culture, direct eye contact may show disrespect. B) The nurse should come back at a different time when the client is feeling more communicative. C) The nurse should have another nurse finish the interview who might be more culturally aware of this group's customs. D) Leave the room and come back after having learned more about this particular culture.

A) Nonverbal communication includes silence, touch, eye movement, facial expressions, and body posture. In some cultures, direct eye contact may indicate disrespect. In addition, some cultures are quite comfortable with long periods of silence. Before assigning meaning to nonverbal behavior, the nurse must consider the possibility that the behavior may have a different meaning for the client and family. The nurse should not leave to come back later or try to find another nurse to take over this client's care; nurses should be able to communicate with clients from a diversity of backgrounds.

The nurse in an urgent care center is assessing an adult client who is diagnosed with the flu. The nurse discusses the need for flu shots with the client, who states, "I cannot afford the shots. I do not have health insurance." Which suggestion by the nurse is most appropriate? A) Seek preventive care at the local health department. B) Find a primary care physician who will give free care. C) Obtain the flu shot at a local pharmacy. D) Get the shot every year in the emergency department.

A) Public health organizations, such as local health departments, are available for those who are uninsured or underinsured. This provides the client with health promotion and preventive measures as well as treatment when the client is ill. Using the emergency department for preventive care is part of the increased cost of healthcare. The nurse should not give the client a vague message that he or she needs need to find a care provider who gives free care. Rather, the nurse would refer the client to a specific place that can meet the client's needs. Flu shots at pharmacies require payment by the client and are not the solution for those with a low income and no insurance.

The nurse is participating in a quality improvement process related to improving care for clients at risk for skin breakdown. Which best describes the purpose of this process? A) To improve client outcomes B) To advance the nurse's career C) To fulfill legal requirements D) To maintain accreditation

A) Quality improvement is the name for the processes used by an agency to measure and improve aspects of client care, including overall outcomes. Participation may help the nurse advance in his or career, but that is usually accomplished by returning to school for a higher degree. Nurses are encouraged to participate in quality improvement programs but are not legally required to do so. Although maintaining accreditation is important, it is not the primary reason for engaging in quality improvement processes.

Which statement correctly describes quality management? A) Quality management compares nursing processes to accepted standards to prevent errors in treatment. B) Quality management refers to systematic actions that lead to improvements in healthcare services. C) Quality management is the degree to which health services increase the likelihood of desired health outcomes. D) Quality management provides clients with appropriate service in a technically competent manner.

A) Quality management includes evaluation of medical and nursing processes for quality and effectiveness compared to accepted standards in order to correct problems before they harm clients and to prevent errors in treatment. Quality improvement refers to systematic actions that lead to improvements in healthcare services. Quality is the degree to which health services increase the likelihood of desired health outcomes. High-quality care provides clients with appropriate service in a technically competent manner.

The nurse is assessing an older adult client who is confused. The client is accompanied by his adult son. Who can the nurse employ as a primary source of data when assessing this client? A) The client himself B) The client's adult son C) A nurse who cares for the client at the retirement home D) The client's primary healthcare provider

A) The client is the only person who is considered a primary source of data. Family members, other support people, health professionals, medical records, laboratory and diagnostic reports, and any other information sources beyond the client himself are considered secondary sources of data.

A female client, from a male-dominated culture, is being discharged after a lengthy hospitalization. Which action by the nurse prior to providing discharge instructions is appropriate? A) Assess who the decision maker is in the family. B) Ensure that the healthcare provider gives the instructions. C) Make sure instructions are understood by the client. D) Ask the client when the best time for teaching would be.

A) The nurse needs to identify who has the "authority" to make decisions in a client's family. If the decision maker is someone other than the client, the nurse needs to include that individual in healthcare discussions. Nurses need an awareness of cultural variations of gender because they will be caring for diverse client needs. What might be considered sexism by one culture may not be in another. Regardless of who is present during the teaching, it is always necessary to make sure that the instructions are understood, but it is difficult to do that before instructions are given. Asking the client when the best time for teaching would be does not address the need for the decision maker of the family to be present. The nurse should not simply leave giving instructions to the healthcare provider.

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. Which of the following is the best example of this problem for the educator to share with the students? A) "Delays of diagnoses lead to higher mortality and morbidity rates." B) "Delays in health coverage for children put the health provider at risk for litigation." C) "Immunizations are free for children at public health clinics." D) "Older adults are less likely to be treated for falls."

A) Those who are not insured, or are underinsured, often do not seek treatment in a timely manner due to finances. As a result, diagnosis is made in the later stages of the disease, resulting in decreased chance of survival and an increased cost of treatment. The exposure of healthcare providers to litigation is not an aspect of this issue. Children with healthcare coverage receive preventive care such as immunizations and are more likely to stay healthy and do well in school. Adults age 65 and older are eligible for Medicare and have access to healthcare for falls and other medical problems.

The clinic nurse is caring for an infant during a routine wellness exam. The parents and infant immigrated to the United States 6 months ago. The mother explains that she believes that an herbal remedy is the best way to treat the infant's colic. Which action by the nurse is appropriate? A) Ask the mother what the ingredients are in the remedy. B) Give the mother an alternate remedy for colic. C) Explain how herbal ingredients may be harmful to the infant. D) Tell the mother not to use the remedy because there is no way to know what the ingredients' scientific effect may be.

A) To recognize cultural practices, the nurse must acknowledge that use of old and home remedies is part of caregiving practices. Asking the mother what ingredients are in the herbal remedy allows the nurse to best evaluate what the mother is using, and then a determination of the benefit or detriment to the infant can be made in a nonjudgmental manner. Telling the mother not to use the remedy, giving an alternative, or making a judgment that any herbal ingredient is harmful does not recognize this cultural practice and shows insensitivity on the part of the nurse.

) A nurse is planning a community health fair at a local community center. Which goals regarding health promotion does the nurse plan to highlight at the event? Select all that apply. A) The ability to change and modify goals as health needs change B) The ability for clients to be able to assess and evaluate their health needs C) The ability for the client to promote health in other individuals D) The ability to promote cost-saving techniques to healthcare providers E) The ability to prevent disease by imitating nursing techniques

A, B A) The nurse has an integral role in health promotion. The nurse's aim should be to teach clients how to remain healthy, thus preserving wellness. The overarching goal is to ensure that clients understand the importance of setting health goals for themselves and their children, and that clients are able to assess, implement, evaluate and, as their health needs change, modify them. This does not include teaching clients to promote health in others, saving costs to healthcare providers, or actively preventing disease by imitating nursing techniques. B) The nurse has an integral role in health promotion. The nurse's aim should be to teach clients how to remain healthy, thus preserving wellness. The overarching goal is to ensure that clients understand the importance of setting health goals for themselves and their children, and that clients are able to assess, implement, evaluate and, as their health needs change, modify them. This does not include teaching clients to promote health in others, saving costs to healthcare providers, or actively preventing disease by imitating nursing techniques.

A nurse has just been hired as a medical information system (MIS) trainer at a hospital where an electronic medical record system is being installed. The nurse has been asked to assess the security of clients' medical records. According to HIPAA's Security Rule, which recommendations by the nurse will enhance security? Select all that apply. A) Assign each staff member a unique username and password. B) Install a firewall. C) Store computer-generated worksheets in a locked vault. D) Turn monitors away from view when unattended. E) Assign each unit unique passwords.

A, B A) To comply with HIPAA's Security Rule, institutions should assign individual passwords to each staff member for logging on and off computer files. Firewalls should be installed to enhance the security of client records. Client information should not be displayed on unattended terminals, regardless of which direction the monitor faces, and computer-generated worksheets should be shredded when no longer needed. B) To comply with HIPAA's Security Rule, institutions should assign individual passwords to each staff member for logging on and off computer files. Firewalls should be installed to enhance the security of client records. Client information should not be displayed on unattended terminals, regardless of which direction the monitor faces, and computer-generated worksheets should be shredded when no longer needed.

A nurse is preparing a workshop on the topics that are new to Healthy People 2020. Which of the topic areas should the nurse plan to address? Select all that apply. A) Adolescent Health B) Genomics C) Lesbian, Gay, Bisexual, and Transgender Health D) Mental Health and Mental Disorders E) Healthcare-Associated Infections

A, B, C, E

An occupational health nurse for a large corporation is planning programs to address health problems identified in the Healthy People 2020 report. Which programs should the nurse include for the company employees at the worksite? Select all that apply. A) A blood disorder and blood safety education program B) A seminar about the components of wellness C) A cultural competence program related to LGBT health D) An informational program about genomics E) An education program about the importance of sleep health

A, B, C, E A) Healthy People 2020 identifies a variety of programs that can be used to promote health at the worksite. Specific programs should address components that may affect work productivity, safety, and cohesion among workers, and may include blood disorders, wellness, LGBT health, and sleep health, among many others. Information about genomics is not relevant to the worksite. B) Healthy People 2020 identifies a variety of programs that can be used to promote health at the worksite. Specific programs should address components that may affect work productivity, safety, and cohesion among workers, and may include blood disorders, wellness, LGBT health, and sleep health, among many others. Information about genomics is not relevant to the worksite. C) Healthy People 2020 identifies a variety of programs that can be used to promote health at the worksite. Specific programs should address components that may affect work productivity, safety, and cohesion among workers, and may include blood disorders, wellness, LGBT health, and sleep health, among many others. Information about genomics is not relevant to the worksite. E) Healthy People 2020 identifies a variety of programs that can be used to promote health at the worksite. Specific programs should address components that may affect work productivity, safety, and cohesion among workers, and may include blood disorders, wellness, LGBT health, and sleep health, among many others. Information about genomics is not relevant to the worksite.

A nurse identifies the seven components of wellness as a useful tool in assessing health. Which are some of the components of wellness? Select all that apply. A) Physical B) Environmental C) Emotional D) Financial E) Spiritual

A, B, C, E A) The physical component is the ability to carry out daily tasks, achieve fitness, and generally practice positive lifestyle habits. The environmental component includes influences such as food, water, and air. The emotional component is the ability to manage stress and to express emotions appropriately. Finances are not one of the seven components of health. The spiritual component is the belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life. B) The physical component is the ability to carry out daily tasks, achieve fitness, and generally practice positive lifestyle habits. The environmental component includes influences such as food, water, and air. The emotional component is the ability to manage stress and to express emotions appropriately. Finances are not one of the seven components of health. The spiritual component is the belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life. C) The physical component is the ability to carry out daily tasks, achieve fitness, and generally practice positive lifestyle habits. The environmental component includes influences such as food, water, and air. The emotional component is the ability to manage stress and to express emotions appropriately. Finances are not one of the seven components of health. The spiritual component is the belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life. E) The physical component is the ability to carry out daily tasks, achieve fitness, and generally practice positive lifestyle habits. The environmental component includes influences such as food, water, and air. The emotional component is the ability to manage stress and to express emotions appropriately. Finances are not one of the seven components of health. The spiritual component is the belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life.

The nurse is preparing an educational brochure to teach clients how to determine the validity of content obtained from health-related internet websites. Which information should the nurse plan to include in this teaching tool? Select all that apply. A) Source for the information B) Sponsor of the website C) Ways to identify if the site is selling a product D) Number of visitors to the website E) Date the content was last reviewed

A, B, C,E A) When analyzing online information, the source of the information should be validated. The sponsor of the website should be clearly identified. The site should be studied to see if a product is being sold. A date when the data was last reviewed or updated should be visible. It is not necessary to locate the number of visitors to the website. B) When analyzing online information, the source of the information should be validated. The sponsor of the website should be clearly identified. The site should be studied to see if a product is being sold. A date when the data was last reviewed or updated should be visible. It is not necessary to locate the number of visitors to the website. C) When analyzing online information, the source of the information should be validated. The sponsor of the website should be clearly identified. The site should be studied to see if a product is being sold. A date when the data was last reviewed or updated should be visible. It is not necessary to locate the number of visitors to the website. E) When analyzing online information, the source of the information should be validated. The sponsor of the website should be clearly identified. The site should be studied to see if a product is being sold. A date when the data was last reviewed or updated should be visible. It is not necessary to locate the number of visitors to the website.

An experienced nurse is delivering a presentation to a group of nursing students about the importance of collaboration in the healthcare environment. The nurse wants to use evidence from the literature to support her argument. Which of the following are documented benefits of collaboration that the nurse should discuss in her presentation? Select all that apply. A) Improved client outcomes B) Reduction in duplication of healthcare services C) Increased overall cost of healthcare services D) Decreased client morbidity and mortality E) Higher level of job satisfaction

A, B, D, E A) Research findings suggest that collaboration in healthcare among clients, family members, caregivers, and communities leads to improved client outcomes, a reduction in the duplication of healthcare services, and a decrease in client morbidity and mortality. Collaborative efforts have also been found to decrease, rather than increase, the overall cost of healthcare services, and to contribute to an enhanced sense of autonomy. This increase in sense of autonomy has been linked to greater job satisfaction among nurses. B) Research findings suggest that collaboration in healthcare among clients, family members, caregivers, and communities leads to improved client outcomes, a reduction in the duplication of healthcare services, and a decrease in client morbidity and mortality. Collaborative efforts have also been found to decrease, rather than increase, the overall cost of healthcare services, and to contribute to an enhanced sense of autonomy. This increase in sense of autonomy has been linked to greater job satisfaction among nurses. D) Research findings suggest that collaboration in healthcare among clients, family members, caregivers, and communities leads to improved client outcomes, a reduction in the duplication of healthcare services, and a decrease in client morbidity and mortality. Collaborative efforts have also been found to decrease, rather than increase, the overall cost of healthcare services, and to contribute to an enhanced sense of autonomy. This increase in sense of autonomy has been linked to greater job satisfaction among nurses. E) Research findings suggest that collaboration in healthcare among clients, family members, caregivers, and communities leads to improved client outcomes, a reduction in the duplication of healthcare services, and a decrease in client morbidity and mortality. Collaborative efforts have also been found to decrease, rather than increase, the overall cost of healthcare services, and to contribute to an enhanced sense of autonomy. This increase in sense of autonomy has been linked to greater job satisfaction among nurses.

The nurse is part of the clinical information system committee at a major healthcare organization. When designing a plan to ensure the protection of client information, which approaches should the nurse suggest this committee include in the implementation plan? Select all that apply. A) Design policies to address password protection and login information. B) Determine how to handle clients who desire to "friend" staff through social media. C) Identify applications that interface with smartphones. D) Create interfaces so that health data can be inputted by the client. E) Teach users to not leave protected health information unattended.

A, B, E A) The committee is creating a plan to ensure the protection of client information. The committee needs to design polices for password protection and login information, determine mechanisms to handle clients and staff who communicate through social media, and teach users to not leave protected health information unattended. Identifying applications that interface with smartphones and creating interfaces so that clients can input health data are not approaches to ensure the protection of client information. B) The committee is creating a plan to ensure the protection of client information. The committee needs to design polices for password protection and login information, determine mechanisms to handle clients and staff who communicate through social media, and teach users to not leave protected health information unattended. Identifying applications that interface with smartphones and creating interfaces so that clients can input health data are not approaches to ensure the protection of client information. E) The committee is creating a plan to ensure the protection of client information. The committee needs to design polices for password protection and login information, determine mechanisms to handle clients and staff who communicate through social media, and teach users to not leave protected health information unattended. Identifying applications that interface with smartphones and creating interfaces so that clients can input health data are not approaches to ensure the protection of client information.

The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply. A) Client fell getting out of bed because the call light was not used. B) Client name band was checked prior to providing all medications. C) Client's morning medications were administered in the early afternoon. D) Client states not understanding activity restrictions and wound eviscerated. E) Client documentation did not include appearance of infiltrated IV site.

A, C, D, E A) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care. C) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care. D) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care. E) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client's healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care.

A community health nurse is educating a group of clients on the difference between illness and disease. Which statements are appropriate for the nurse to include in the educational session? Select all that apply. A) "An individual can have a disease and not feel ill." B) "Illness is synonymous with disease." C) "Illness is an alteration in body function, where disease is highly subjective." D) "An individual can feel ill without disease." E) "Illness and disease are never related to one another."

A, D A) Illness is a highly personal state in which the individual's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished. It is not synonymous with disease and may or may not be related to disease. One individual can have a disease, such as a growth in the stomach, and not feel ill. Another individual can feel ill-that is, feel uncomfortable-and yet have no discernible disease. Disease can be described as an alteration in body functions that reduces the capacities or shortens the normal lifespan. D) Illness is a highly personal state in which the individual's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished. It is not synonymous with disease and may or may not be related to disease. One individual can have a disease, such as a growth in the stomach, and not feel ill. Another individual can feel ill-that is, feel uncomfortable-and yet have no discernible disease. Disease can be described as an alteration in body functions that reduces the capacities or shortens the normal lifespan.

The nurse is preparing to document care provided to a client during the day shift. The nurse notes that the client experienced an increased pain level while ambulating and thus required an extra dose of pain medication; took a shower; visited with family; and ate a small lunch. Which information is important to include during the oral end-of-shift reporting? Select all that apply. A) The extra dose of pain medication B) The client's visit with family C) The client's response to ambulation D) The last antibiotics given E) The client's taking a shower

A,C A) To best provide for the client's safety, the nurse should pass on information about the client's response to ambulation so that the oncoming staff can take fall precautions. The nurse should also report any as-needed medications that were given and when they were last administered. The client's visit with family need not be mentioned at change of shift but should be documented. Likewise, taking a shower does not need to be reported, only documented. Antibiotic administration would be reflected on the medication administration record (MAR). C) To best provide for the client's safety, the nurse should pass on information about the client's response to ambulation so that the oncoming staff can take fall precautions. The nurse should also report any as-needed medications that were given and when they were last administered. The client's visit with family need not be mentioned at change of shift but should be documented. Likewise, taking a shower does not need to be reported, only documented. Antibiotic administration would be reflected on the medication administration record (MAR).

A home health nurse is planning care for an adult client who is being discharged from the hospital after experiencing complications of diabetes mellitus. The client requires an extensive dressing change twice per day, help with activities of daily living, and comprehensive education. To ensure these needs are met, the nurse is coordinating home visits from aides and therapists. Which role is the nurse assuming by coordinating this client's care? A) Health educator B) Case manager C) Client advocate D) Health promoter

B) A case manager is responsible for ensuring that clients receive fiscally sound, appropriate care in the best setting. Part of the case manager's duties include identifying which services a client will require postdischarge, locating providers of these services, and coordinating visits from these providers. In this scenario, the home health nurse is assuming the role of case manager. Although the client requires education, the home health nurse's primary role is not that of health educator. Similarly, although case managers often engage in client advocacy and health promotion activities, these tasks account for just a portion of the nurse's duties in this scenario.

The nurse is conducting a health history on a client who is being admitted to a medical-surgical unit for the treatment of chronic pain. The client is concerned about privacy and asks why it is necessary for the nurse to ask for private information and then document it in the medical record. Which response by the nurse is most appropriate? A) "You will be able to read the record and review your care." B) "Documentation decreases the likelihood that you will have to repeat this information to others who will care for you." C) "Your family can review the record and ensure that your care is appropriate." D) "A record ensures there are no breaches of confidentiality."

B) A client's record serves as a vehicle by which different health professionals who interact with the client communicate with one another. This prevents fragmentation, repetition, and delays in client care, and it relieves the client from having to repeat information to each provider offering care. The client can read the record, but that is not a reason to keep one. The client's family does not have access to the record. Recordkeeping does not prevent breaches of confidentiality.

After conducting a physical assessment for an adult client, the nurse discusses the assessment with a coworker and states that the client's beliefs and actions regarding common health practices are unfamiliar to her. Based on this data, which action by the nurse is the most appropriate? A) Repeat the assessment later in the day. B) Determine the culture with which the client identifies. C) Write a nursing diagnosis to address the unfamiliar beliefs and actions. D) Communicate the findings to the healthcare team.

B) A thorough assessment that includes assessment of cultural beliefs and practices is needed before proceeding with other steps of the nursing process. Behavior that is considered uncommon in one cultural context may be considered desirable in another. Repeating the assessment will most likely result in the same incomplete data. Writing a nursing diagnosis or communicating findings before investigating the client's culture would be premature.

The nurse is preparing to assess a client who is experiencing difficulty breathing. Before palpating the client's abdomen, which nursing action is appropriate? A) Administering 10 L of oxygen to the client B) Having the client remain upright C) Placing the client in a modified Sims position D) Asking the client to bend over a table

B) Abdomen palpation is usually done in the supine position, but a client with difficulty breathing would not tolerate that position well. Instead, the nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in a modified Sims position could compromise the client's ability to breathe effectively. A client who is experiencing dyspnea would not be asked to bend over a table. Depending on the client's underlying condition, administering 10 L of oxygen may be excessive.

The nurse in the clinic is assessing an adult client who has signs and symptoms of heart failure. Which of the following lifestyle habits would be useful for the nurse to assess before developing the client teaching plan? A) The client's occupation B) The client's diet C) The client's usual sleep schedule D) The client's marital status

B) For clients who have heart failure, the nurse should ask questions aimed at obtaining information about lifestyle habits that may be contributing to the heart failure, such as smoking and diet. Although sleep schedule is a lifestyle habit about which the nurse should inquire, it is less likely than diet to be a contributing factor to heart failure. Gathering psychosocial information such as the client's marital status and occupation is also important, but in this case, it is not directly related to the client's current problem and teaching needs.

For many clients, health promotion requires nursing assessment of and implementation of changes in A) culture. B) lifestyle. C) spiritual beliefs. D) socioeconomic status.

B) Health promotion involves nursing assessment of a client's lifestyle and implementation of needed changes to that lifestyle. Examples include assessing and implementing changes in habits related to smoking, diet, and exercise. The nurse is responsible for assessing culture, spiritual beliefs, and socioeconomic status and how those factors influence health promotion, but the nurse is not responsible for promoting changes to those factors.

The nurse is caring for a client who is reporting a pain level of 8 on a 0-to-10 numeric pain scale. The nurse administers the prescribed pain medication. When the nurse re-evaluates the client 1 hour later, the client is still reporting a pain level of 8. Which action by the nurse is appropriate at this time? A) Wait for the healthcare provider to make rounds to report the problem. B) Report to the healthcare provider by telephone. C) Increase the dosage of the medication. D) Include an entry in the nursing report indicating that the medication is ineffective.

B) In this case, reporting to the healthcare provider by telephone is appropriate. The nurse would address the client's distress immediately and later include the event in the end-of-shift report to the oncoming nurse. The nurse cannot alter the dose of medication. Waiting for the provider to arrive could cause the client to experience a great deal of pain in the interim.

The nurse is caring for a 43-year-old client. What education should the nurse implement to best address the overall health promotion needs of someone in this age group? A) Teach the client about ergonomic aids for computer use B) Teach the client about age-appropriate medical screenings C) Tell the client to seek medical help for injuries D) Encourage the client to not drive while distracted

B) The nurse can provide education in many areas related to disease prevention, including teaching about age-appropriate medical screenings. Teaching the client about ergonomic aids for computer use, telling the client to seek medical help for injuries, and encouraging the client to not drive while distracted are all methods to prevent injury, not disease.

The nurse is caring for a client who is actively engaged in an organized religion. Based on this statement, the nurse knows that which of the following statements is most likely true? A) The client believes in the presence of only one god. B) The client knows other individuals from the same religion who may be available to offer emotional and spiritual support. C) The client lives by the moral code of the Ten Commandments. D) The client will require time set aside for prayer several times each day, and the nurse will need to work around this schedule.

B) Individuals who are actively engaged in a specific religion are usually part of a religious community. Members of this community are often called upon for emotional and spiritual support, especially during times of hardship or illness. Without knowing the client's specific religion, the nurse cannot assume that the client believes in the presence of only one god, that the client will need to set aside specific times each day for prayer, or that the client lives by the moral code of the Ten Commandments.

A novice nurse asks the preceptor why the staff spends time talking about clients between shifts when the oncoming nurses can read the clients' charts instead. Which is the best response by the preceptor? A) "Maybe we should suggest primary nursing as an alternative." B) "Change-of-shift reporting ensures that oncoming staff know the most critical information about the clients they'll be caring for." C) "Shift changes have always been done this way." D) "You're right. Talking about clients during shift changes is a waste of time."

B) Nurses often do not have time to read clients' charts prior to assuming care, which could result in errors and assumptions. By participating in change-of-shift reports, outgoing nurses can ensure that oncoming staff are aware of critical information. The preceptor should not tell the new nurse that change-of-shift reports are a waste of time because these reports allow for communication of valuable client data. Stating that shift changes have always been done a certain way does not help the novice nurse understand why a change-of-shift report is necessary. Primary nursing promotes continuity of care, but even the primary nurse would need to be informed of client changes that occurred during his or her absence.

The nurse is documenting in the electronic medical record (EMR) after providing care in the client's room. The client asks the nurse why a computer is being used. Which response by the nurse is appropriate? A) "The information that is uploaded is available for anyone to view." B) "Computers improve client care because information is readily available." C) "The computer decreases documentation time for nurses." D) "Computers allow you access to your medical record."

B) Nursing informatics is the science of using computers in nursing practice to improve client care by making client information easily accessible for the client and other healthcare workers who are participating in the client's care. Documenting client information by computer does not necessarily reduce charting time, depending on the system used. The client's information is protected by privacy laws. Clients have the right to access their medical records regardless of whether they are paper or electronic.

Which of the following is a primary barrier to effective nurse-physician collaboration that has persisted over time? A) The view among the general population that nurses' contributions to client care are less important to health and well-being than physicians' contributions B) Nurses' and physicians' perceptions of inequity in their roles, with nurses assuming a subservient role and physicians assuming leadership and a superior role in healthcare settings C) A general lack of education among health professionals about the ways in which nurse—physician collaboration improves healthcare quality D) A lack of published evidence regarding the effectiveness of collaborative efforts among and between nurses and physicians E) A lack of support at the federal level for efforts to improve healthcare among the general population through increased nurse-physician-client collaboration

B) Over the years, a primary barrier to effective nurse-physician collaboration has been nurses' and physicians' perceptions of inequity in their roles, with nurses assuming a subservient role and medical providers perceiving their role to be superior in the provision of healthcare services. Evidence does not suggest that the general population views nurses' contributions to client care as less important than physicians' contributions; thus, this is not a primary barrier to nurse-physician collaboration. Likewise, because health professionals are in fact educated about the benefits of collaborative practice and published evidence has documented the effectiveness of collaboration in improving client outcomes, these are not barriers to collaboration. In addition, the federal government, as evidenced in particular by the Healthy People initiative, has promoted collaborative efforts among clients, nurses, physicians, other healthcare providers, and the larger community to improve the overall health of the U.S. population.

A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation? A) Ask a staff nurse to question the client about the situation. B) Discuss the situation with the client in a private setting. C) Ask the other staff members if abuse is involved. D) Ignore the situation until the client shows a willingness to talk.

B) The charge nurse should discuss the situation with the client in private and offer options of help. The charge nurse should not ignore the situation and should advocate for the client. The charge nurse herself should address this situation. The nurse should speak to the client first, not the staff, and not assume abuse until the client has given her version of events.

A client with type 1 diabetes mellitus has developed an open sore on the shin and is having trouble meeting daily goals for exercise. The client is scheduled for discharge in a couple of days. When planning for this client's continued care, who will the nurse notify regarding the client's postdischarge needs? A) The pharmacy B) The case manager C) The occupational therapist D) The physical therapist

B) The client's needs and progress have changed, so the nurse should contact the case manager to coordinate appropriate modifications in the client's postdischarge care plan. A physical therapist may be needed, but the nurse would best coordinate care by notifying the case manager. Based on the information presented, the pharmacy would not be a necessary part of the care team at this time. An occupational therapist mainly deals with upper body areas that require rehabilitation, and the client currently does not require such assistance.

The nurse is caring for a young adult client after a cervical biopsy. The client has expressed anxiety about the results. The healthcare provider peeks into the client's room and says, "The biopsy is negative." The nurse later finds the client sobbing. Which response by the nurse is most appropriate? A) "What did the healthcare provider tell you about the biopsy?" B) "You seem upset. Do you want to talk to me about the test results?" C) "Why are you crying after getting such good news?" D) "In this case, the term 'negative' is good!"

B) The nurse does not know specifically what the client is upset about and should ask the client an open-ended question so she can talk. The healthcare provider, in delivering important news to the client, should have taken time to sit with her and discuss the test results. In telling the client that the test was negative, the provider did not clarify what "negative" actually meant. Using medical jargon without explanation can lead to misinterpretation by the client. Asking the client why she is crying about good news does not allow the client to express concern regarding the results. Asking the client what the provider told her assumes that she is crying because of what the provider said and does not allow her to express her concern in an open-ended manner. Saying that the test results are good in this case assumes that the client has misunderstood the results, which may be true but does not allow the client to express her concerns.

By providing volunteer client care to an inadequately insured population, the nurse is demonstrating which value of client advocacy? A) The client has the right to make choices and decisions. B) The nurse has the responsibility to ensure the client has access to healthcare services. C) The client has the right to expect a nurse-client relationship based on shared respect. D) The nurse has the responsibility to make choices and decisions.

B) The nurse has the responsibility to ensure the client has access to healthcare services that meet health needs. Although the client does have the right to make choices and decisions, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. Although the client does have the right to expect a nurse-client relationship based on shared respect, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. The nurse's responsibility to make choices and decisions is not one of the values basic to client advocacy.

The nurse is conducting a health history as part of a nursing assessment. The client says to the nurse, "I am allergic to penicillin." Which assessment question would best help the nurse learn more about the client's allergy? A) "Where did you experience the reaction?" B) "What type of reaction occurred?" C) "How long did your symptoms last?" D) "Do any other family members have this same allergy?"

B) The nurse should ask the client to provide more information about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important, but the priority is determining the type of reaction the client experienced. Asking whether any other family members have the same allergy will not provide the nurse with useful information.

A female nurse is caring for a 21-year-old male client with a questionable gastrointestinal blockage. The healthcare provider prescribes an enema. Which reaction by the client would the nurse anticipate when planning care? A) "May I have a visitor in the room with me for support during the procedure?" B) "I would rather have my doctor perform this procedure." C) "I don't know what an enema is." D) "I am afraid of having an enema."

B) The nurse would anticipate that most young adult clients will be embarrassed by this procedure when the nurse and client are of different genders. When the client states that he would rather have his doctor perform the enema, he is probably motivated by embarrassment and acting on the assumption that the doctor is male. The nurse should approach the client beforehand to address the issue. Most clients would only experience annoyance, not fear, in relation to this procedure. Most clients in this age group would also be familiar with what an enema is, even if they have not had an enema themselves. The nurse would definitely not expect the client to request the presence of another individual in the room for this procedure.

The nurse is caring for a client on a mental health unit who is yelling at other clients and some of the staff. Which verbal intervention by the nurse is most consistent with the concept of advocacy? A) "You should be ashamed of your behavior. No wonder you ended up on a mental health unit." B) "You seem upset. Can you tell me what you think might help to calm you down?" C) "You need to behave. If this doesn't stop you are going to be placed in restraints." D) "You are out of control. You have no choice but to take more medication."

B) The nurse's role is to advocate for the rights of the individual with mental illness or disability. The nurse should validate the meaning of the behavior and encourage safe coping methods. Disparaging the client or threatening to restrain them or sedate them is inconsistent with client rights.

What is the primary advantage of electronic reminders in the electronic health record? A) They help nurses decrease the length of stay. B) They help nurses increase client safety. C) They help nurses document assessments. D) They help nurses track quality metrics.

B) The primary direct advantage of electronic reminders is that they help improve client safety, often by reminding nurses to use certain screening tools or complete certain assessments. By increasing safety, these reminders can indirectly reduce length of stay. Note, however, that electronic reminders don't actually help nurses document assessments, nor do they track quality metrics.

Several nurses are discussing the Joint Commission's 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients correctly? A) Labeling all medications with the client's name B) Consistently using two methods to identify the client C) Asking the client's name before conducting assessments D) Marking the intended surgical site on the client

B) Two elements of performance that accompany the goal to identify clients correctly include consistently using two methods to identify the client and ensuring that clients receiving blood transfusions are correctly identified prior to transfusion. Labeling medications with the medication information helps prevent medication errors, and marking the intended surgical site on the client helps prevent surgical errors. Asking the client's name before conducting assessments is not associated with a National Patient Safety Goal.

Which nursing intervention exemplifies the nurse working in a health promotion role? Select all that apply. A) Administering a prescribed antibiotic B) Reinforcing desirable changes to the client's lifestyle C) Administering vaccines to a well child D) Administering an inhaler to a client with asthma E) Obtaining a blood glucose sample on a client with hypoglycemia

B, C B) The nurse acting in a health promotion role is performing interventions to prevent disease. Reinforcing desirable changes to the client's lifestyle and administering vaccines to a well child exemplify health promotion. Administering an ordered antibiotic or inhaler to a client and obtaining a blood glucose sample from a symptomatic client exemplify nursing interventions that are in response to disease or illness. C) The nurse acting in a health promotion role is performing interventions to prevent disease. Reinforcing desirable changes to the client's lifestyle and administering vaccines to a well child exemplify health promotion. Administering an ordered antibiotic or inhaler to a client and obtaining a blood glucose sample from a symptomatic client exemplify nursing interventions that are in response to disease or illness.

The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care? Select all that apply. A) Apply physical restraints if the client gets out of bed. B) Assess the client's vision and make sure he is using any prescribed eyewear. C) Use side rails on client beds. D) Keep frequently used items within easy reach. E) Provide slippers for the client to wear while ambulating.

B, C, D B) Assessing the client's vision and making sure he is using any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Using side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if the client gets out of bed. The nurse should ensure that the client wears shoes with adequate traction while ambulating. Slippers may increase the risk for falls. C) Assessing the client's vision and making sure he is using any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Using side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if the client gets out of bed. The nurse should ensure that the client wears shoes with adequate traction while ambulating. Slippers may increase the risk for falls. D) Assessing the client's vision and making sure he is using any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Using side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if the client gets out of bed. The nurse should ensure that the client wears shoes with adequate traction while ambulating. Slippers may increase the risk for falls.

) A nurse is providing care for a client who has vocal cord damage and wants to implement strategies that will promote communication with this client. Which interventions would be appropriate? Select all that apply. A) Facing the client when speaking B) Having pen and paper on hand for the client C) Making sure that the language spoken is the client's dominant language D) Using a picture board to facilitate communication E) Employing an interpreter

B, D B) The client who is nonverbal would respond best to use of a picture board or pen and paper. Because the client cannot communicate verbally, facing the client when talking, using an interpreter, or using the client's dominant language would not address the client's inability to communicate. D) The client who is nonverbal would respond best to use of a picture board or pen and paper. Because the client cannot communicate verbally, facing the client when talking, using an interpreter, or using the client's dominant language would not address the client's inability to communicate.

A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply. A) "Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart." B) "Use standard precautions during the history and physical examination process." C) "Perform invasive procedures like pharyngeal and otic exams at the end of the assessment." D) "Use age-appropriate terminology for explaining procedures and actions." E) "Use the assessment process to teach about exam procedures and findings."

B, D, E B) Following standard precautions, employing age-appropriate terminology, and using the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducting a cardiovascular assessment during sleep is appropriate for some pediatric clients, but it would be considered an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for pediatric clients but not necessary for adult clients. D) Following standard precautions, employing age-appropriate terminology, and using the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducting a cardiovascular assessment during sleep is appropriate for some pediatric clients, but it would be considered an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for pediatric clients but not necessary for adult clients. E) Following standard precautions, employing age-appropriate terminology, and using the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducting a cardiovascular assessment during sleep is appropriate for some pediatric clients, but it would be considered an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for pediatric clients but not necessary for adult clients.

An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate? A) Ask the spouse for more information. B) Assess for pedal edema. C) Assess skin turgor. D) Repeat the temperature measurement.

C) A client who presents with hyperthermia, vomiting, diarrhea, and pale, dry mucous membranes is likely dehydrated and requires assessment to confirm this suspicion. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support for a diagnosis of dehydration. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. Only measurements that are extremely abnormal need to be repeated in stable clients.

What is the first phase in the therapeutic nurse-client relationship? A) Introductory phase B) Working phase C) Preinteraction phase D) Anticipatory phase

C) The therapeutic nurse-client relationship can be described in terms of four sequential phases: the preinteraction phase, introductory phase, working (maintaining) phase, and termination phase. During the preinteraction phase, the nurse plans for the initial face-to-face meeting with the client.

A student nurse administers a medication to the wrong client while the instructor is with another student. Which statement by the instructor is most appropriate in this situation? A) "You have placed the nursing student program in danger." B) "You may be sued by the hospital for the extra care cost to the client." C) "You are expected to practice like a licensed nurse." D) "You have set a bad example for the other students."

C) A nursing student is held to the standard of conduct of an experienced, licensed professional nurse. Students are required to know the standards and to follow them. Hospitals do not generally sue nurses to recover money for extended care due to an error. It is not likely that the teaching program is in danger, as people do make mistakes and hospitals do rely on nursing schools to help provide care to clients. It is not likely that the other students are apt to follow the example of a student who fails to follow policy.

A female client tells the nurse she is having difficulty with sexual relations because of a recent weight gain. When planning this client's care, the nurse should prioritize interventions related to which of the following areas? A) Sexual self-concept B) Gender identity C) Body image D) Gender-role behavior

C) An individual's body image is constantly changing. How people feel about their bodies is related to sexuality, and people who have a poor body image may respond negatively to sexual arousal. This is what the client is experiencing. Sexual self-concept determines the gender and kinds of individuals to whom the person is attracted; the individual's values about when, where, how, and with whom he or she expresses his or her sexuality; and the individual's ability to freely choose sexual partners. Gender identity refers to an individual's self-image as a male, female, or transgender person. Gender-role behavior is the outward expression of an individual's sense of maleness or femaleness, as well as the expression of what is perceived as gender-appropriate behavior.

A client was recently diagnosed with alcoholic liver cirrhosis. During a regular checkup, the client tells the nurse, "This is God's punishment for all those parties I went to when I was younger." The nurse should recognize that this religious view could have a negative effect on what other nursing concept? A) Addiction B) Legal Issues C) Stress and Coping D) Digestion

C) Clients can use religion as either a positive or a negative coping strategy. Negative expressions of religious coping include statements like "God is punishing me." If the client is addicted to alcohol, the diagnosis and religious belief may stimulate the client to give up alcohol, which would not be a negative effect. There are no legal issues present due to this client's statement. This religious view is unlikely to affect the client's digestive processes, although the disease itself may reduce metabolism associated with digestion.

A hospital has created a culture of safety by providing organizational support for safety initiatives and by training and encouraging healthcare employees in the area of safety. What other step is needed to promote safety for everyone in the healthcare environment? A) Keep a mindset for quality of safe practice B) Post signs related to safety on the walls C) Engage clients in their own safety D) Be a safety advocate for others

C) Healthcare facilities should use a three-pronged approach to quality and safety for everyone, including organizational support for keeping safety a priority, encouraging employees to consistently choose to follow health safety rules and standards, and actively engaging clients in every aspect of their care, including safety. Keeping a mindset for quality of safe practice and posting signs related to safety relates to the organizational support for safety. Being a safety advocate for others is related to employees maintaining safety standards.

What major nursing concept has the strongest relationship to the identification of areas for quality improvement, such as tracking data on healthcare-associated infections? A) Ethics B) Safety C) Informatics D) Evidence-based practice

C) Informatics can be used to identify areas for improvement, such as tracking healthcare-associated infections. Without informatics, tracking adverse outcomes would be time-consuming and potentially cost-prohibitive. With the advent of technology and informatics, statistics and client outcomes are easier to track, making quality improvement more efficient. Ethics, safety, and evidence-based practice can all contribute to quality improvement, but not by easily tracking poor client outcomes.

The nurse is preparing for the discharge of a client who will require physical therapy (PT) for rehabilitation following a total knee replacement. After reading the healthcare provider's order for PT, what should the nurse do next? A) Set up outpatient appointments for the client with the hospital's PT department B) Call home health and schedule a therapist to visit the client's home for PT C) Inform the client about the settings in which PT may occur and have the client choose the venue D) Teach the client's family the exercises that will be included in the client's PT regimen

C) Major objectives of interdisciplinary collaborative practice include providing client-directed, client-centered care; improving client and family satisfaction with care; and promoting mutual respect, communication, and understanding between the client and members of the healthcare team. Of the choices listed here, the option that best supports achievement of these objectives is informing the client about the settings in which PT may occur and having the client choose the desired venue. The nurse would not refer the client for outpatient therapy or schedule home PT unless the client specifically requested either form of therapy. Also, because the client requires therapy that must be performed by a professional physical therapist, providing teaching about exercises that will be included in the client's PT regimen encroaches on the expertise of another healthcare professional.

The nurse is discussing follow-up care with a client who is being discharged. The client and his family cross their arms and state angrily that the care team's suggestions are not acceptable. Which response by the nurse is appropriate? A) "We will leave you alone to discuss your options." B) "We only want what's best for you." C) "Let's discuss other options that might work well for you and your family." D) "Perhaps you did not understand the recommendations."

C) Major objectives of interdisciplinary collaborative practice include providing client-directed, client-centered care; improving client and family satisfaction with care; and promoting mutual respect, communication, and understanding between the client and members of the healthcare team. Of the choices listed here, the response that best supports achievement of these objectives is "Let's discuss other options that might work well for you and your family." Leaving the room might lead the client and family to feel abandoned by the healthcare team. Stating that the team "only wants what is best" sends the message that the client does not know what is best, when, in fact, a well-informed client does know what is best and should be able to make the correct choice. Suggesting that the client and family do not understand the recommendations may be interpreted as demeaning, even if it is true.

The nurse is caring for a client who just had abdominal surgery. The client's nonverbal cues indicate pain, but the client denies the need for the pain medication prescribed by the healthcare provider. The nurse recognizes that this client is from a culture that feels it is inappropriate to complain about pain. Which action by the nurse is appropriate? A) Seek out a family member to convince the client to take the medication. B) Consult with the healthcare provider about providing pain medication without the client's knowledge. C) Offer the pain medication to the client again, stating that providing comfort is the nurse's most important responsibility. D) Allow the client to suffer in silence.

C) Members of some cultures will typically not complain of pain or physical problems because they are taught self-restraint and the priority of the group over individual needs. Many people from these cultures will consider refusal of something offered as a gesture of courtesy. The nurse should take this into account when offering the pain medication to the client in a culturally sensitive way. Seeking out the intervention of a family member of the client, trying to administer the medication without the client's knowledge or simply allowing the client to suffer in silence are not appropriate actions.

________ occurs when two or more individuals show or feel honor or esteem toward one another, and it is an important element of successful collaborative practice. A) Trust B) Conflict management C) Mutual respect D) Effective communication

C) Mutual respect, trust, conflict management, and effective communication are all important elements of successful collaborative practice. Mutual respect occurs when two or more individuals show or feel honor or esteem toward one another. Trust occurs when an individual is confident in the actions of another individual. Conflict management involves addressing, containing, and resolving disagreements among team members in a constructive way. Effective communication involves sharing information and ideas both clearly and in a way that demonstrates respect and appreciation for other team members.

The nurse is assessing a 24-year-old woman who recently found out she is pregnant. Which factor would the nurse identify as the most likely source of a barrier to health promotion in this client? A) Age of the client B) Presence of the client's mother during the appointment C) Pregnancy occurred as a result of rape D) First pregnancy (primigravida)

C) The age of the mother, presence of the client's mother, and gravidity could all be factors that promote a desire for health or cause the client to make unhealthy choices, depending on the client's situation. However, most clients who are pregnant as a result of rape will have both physical and emotional barriers to health promotion.

The nurse notices that a client, who is from another country, appears uncomfortable when the nurse asks to look at the client's abdominal incision from a recent surgery. Which nursing action is the most culturally competent? A) Close the client's curtain to maintain privacy. B) Ask the client to explain why she is uncomfortable. C) Explain the reason for the intervention using lay terms. D) Wait until the next assessment time to observe the incision.

C) The most culturally competent intervention is to explain to the client the reason for the intervention using lay terms. The nurse should close the client's curtain to maintain privacy for all clients; this is not necessarily just a culturally competent action. Asking the client why she is uncomfortable is confronting the client and is not culturally competent. Waiting until the next assessment time to observe the incision is inappropriate, as this can lead to missing important assessment findings regarding the state of the client's incision.

The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client? A) Facilitating and taking action when needed B) Maintaining a proper social distance when speaking with the client C) Leaning toward the client during conversation D) Being concrete about actions that need to be taken during client care

C) The nurse best conveys physical attending by leaning toward the client, which communicates involvement. Facilitating and taking action and maintaining social distance do not convey physical attending. Being concrete is a method of communicating information to the client, not a method of conveying physical attending.

The nurse is providing care to a client diagnosed with type 2 diabetes mellitus. The client wishes to take Communion but must fast for 1 hour prior to receiving it. Which action by the nurse is most appropriate? A) Contact the healthcare provider to suggest an alternative form of nutrition because the client is refusing to eat or drink. B) Provide the client with breakfast and morning medication and encourage the client to eat and take Communion some other time. C) Find out when the hospital clergy will be distributing Communion and adjust the client's medications and breakfast accordingly. D) Suggest that because the client is hospitalized, eating and drinking will not affect the Communion.

C) The nurse should follow the client's expressed wishes regarding spiritual care and should not pressure them to relinquish any of their beliefs or practices. To support the client's spiritual needs, the nurse should find out when Communion will be distributed and adjust the medications and breakfast accordingly. The nurse should not suggest that eating and drinking will not affect Communion. The nurse should not ignore the client's needs by providing medication and breakfast. The nurse should also not contact the healthcare provider to suggest alternative forms of nutrition, because the client is not refusing to eat or drink but wants to delay eating and drinking until after Communion.

The nurse is caring for a client with a self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this client? A) Wear hypoallergenic gloves B) Wear gloves with powder C) Wash hands after taking gloves off D) Keep beta adrenergic agonists on hand

C) The nurse should wear latex-free gloves that are hypoallergenic and powderless. Not all hypoallergenic gloves are latex-free. Powder from the gloves can absorb the latex and be transferred to clients through touch or through the air. Therefore, it is important to wash hands after removing gloves, especially gloves with powder. Beta adrenergic agonists are used for the treatment of asthma, which may develop with chronic latex exposure in a sensitive individual, but it will not affect the early symptoms of latex allergy.

The nurse managers in a community hospital have been charged with reviewing the job descriptions of unlicensed assistive personnel (UAP), and they have questions about the delegation of certain client care activities to UAP by nurses. To which group, organization, or individual would the committee members direct their questions to obtain definitive answers about the parameters of nurse delegation to UAP? A) The hospital's Chief Nursing Officer B) The hospital's Chief Executive Officer C) The state board of nursing D) The American Nurses Association

C) The parameters of nurse delegation to UAP are delineated by state boards of nursing and statutes contained in state administrative codes.

A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy? A) "I wouldn't be afraid if I were you." B) "You shouldn't have done it that way." C) "You seem to be frightened by the procedure. Tell me how you are feeling." D) "I know just how you feel, because my mother has the same illness."

C) To be able to empathize with patients, the nurse must be able to understand and acknowledge the ideas that the patient is expressing or that the patient feels are important to the situation. By stating that the client seems frightened and asking the client to describe his or her feelings, the nurse is demonstrating empathy. The nurse should not say he or she knows how the client feels; such a statement will likely be met with disbelief, because one individual never knows how another individual is feeling unless that individual tells them. Telling the client not to be afraid is demeaning; instead, the nurse should ascertain the source of the client's fear and provide appropriate teaching. Saying the client should not have done something is passing judgment and inappropriate.

Which statements best describe how a quality improvement process can contain healthcare costs? Select all that apply. A) "Promoting safety increases the cost of care." B) "Medication errors decrease the cost of care." C) "High nurse-to-client ratios result in decreased readmission rates." D) "Increased nursing staff has been linked to decreased infection rates." E) "Use of computers increases the number of lawsuits."

C, D C) Studies have shown that increasing the nurse-to-client ratio can decrease overall cost because readmission rates and infection rates, as well as client mortality, are reduced with RN care. Medication errors increase cost due to harm to the client and increased length of stay. Promoting safety is a cost-containment measure because it decreases injury to the client and the consequent risk of lawsuits. Computers increase efficiency and reduce cost as a result. Lawsuits do not increase because of computer use; they increase when computers are used improperly. D) Studies have shown that increasing the nurse-to-client ratio can decrease overall cost because readmission rates and infection rates, as well as client mortality, are reduced with RN care. Medication errors increase cost due to harm to the client and increased length of stay. Promoting safety is a cost-containment measure because it decreases injury to the client and the consequent risk of lawsuits. Computers increase efficiency and reduce cost as a result. Lawsuits do not increase because of computer use; they increase when computers are used improperly.

A nurse educator is teaching a group of students about managed care. The educator knows that the students have understood the concept when they state that managed care has which emphasis? Select all that apply. A) Bringing services of multiple providers to the client B) Organizing healthcare services around the stated needs of the client C) Cost-effective care D) Preventive services E) Health promotion

C, D, E C) Managed care describes a healthcare system that emphasizes cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Managed care clinics will emphasize cost-effective care by offering preventive services and health promotion activities. Case management describes a range of models for integrating and delivering healthcare services from multiple providers to the client. Client-focused care is a delivery model that organizes healthcare services around the stated needs of the client. D) Managed care describes a healthcare system that emphasizes cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Managed care clinics will emphasize cost-effective care by offering preventive services and health promotion activities. Case management describes a range of models for integrating and delivering healthcare services from multiple providers to the client. Client-focused care is a delivery model that organizes healthcare services around the stated needs of the client. E) Managed care describes a healthcare system that emphasizes cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. Managed care clinics will emphasize cost-effective care by offering preventive services and health promotion activities. Case management describes a range of models for integrating and delivering healthcare services from multiple providers to the client. Client-focused care is a delivery model that organizes healthcare services around the stated needs of the client.

A client who is scheduled for surgery wants to continue to wear a religious medallion. Which actions by the nurse support the client's religious needs? Select all that apply. A) Keep the medallion on the client but remove it once anesthesia is provided. B) Ask the client if wearing a medallion is going to ensure a successful surgery. C) Document that the medallion is being worn by the client. D) Suggest the client not wear the medallion because it will most likely be lost. E) Explain that the medallion can be safety pinned to the client's gown.

C, E C) The nurse should explain that the medallion can be safety pinned to the client's gown. This approach would ensure compliance with the client's religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medallion is being worn by the client. The nurse should not remove the medallion after anesthesia is provided. The nurse should not tell the client that the medallion will be lost if worn or confront the client by asking if the medallion is going to ensure successful surgery. E) The nurse should explain that the medallion can be safety pinned to the client's gown. This approach would ensure compliance with the client's religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medallion is being worn by the client. The nurse should not remove the medallion after anesthesia is provided. The nurse should not tell the client that the medallion will be lost if worn or confront the client by asking if the medallion is going to ensure successful surgery.

A 16-year-old client has requested that she be examined and receive counseling without her parents being present. Which response demonstrates a correct response to this request? A) The nurse asks the client's parents if this is okay with them. B) The nurse agrees but still informs the parents immediately of everything they did not witness. C) The nurse strongly urges the client to reconsider this request to receive the best possible care. D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.

D) Adolescent clients may wish to be examined or receive counseling separate from their parents. The nurse should make every effort to honor this request, though doing so may lead to confrontation with the parents. Understanding state statutes and organizational policy related to adolescent confidentially is essential when situations such as this arise. When providing confidential care to adolescents, the nurse should encourage adolescents to consider involving parents or guardians in their decision making. The nurse should make it clear that this is a suggestion and not a requirement for receiving care. The nurse should not clear this request with the parents, involve the parents anyway, or make it sound as though competent care depends on the adolescent reconsidering her request.

The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic? A) "Would you like some toys from the playroom?" B) "I'm going to go get the doctor." C) "You shouldn't cry. You are not in pain." D) "It is okay to cry. I know this is scary."

D) Assertive communication is appropriate in the group setting, but for this client, the nurse should be accepting of the client's feelings of fear. Telling the client not to cry invalidates the client's feelings. Leaving to get the doctor could be seen by the child as abandonment and would signal that the nurse is uncomfortable with the child. Distraction is not appropriate when the client is clearly upset, so the nurse should not ask whether the client wants toys. Instead, the nurse should attempt to seek more information about what the child is feeling.

A nurse is teaching a client about a dressing change that should be done three times per day. The client is from a culture that is "present oriented." Based on this data, at which times should the nurse tell the client to perform the dressing changes? A) At whatever times the client selects, as long as they are 8 hours apart B) At 9 a.m., 3 p.m., and 9 p.m. C) At whatever times the client selects, as long as the dressing is changed three times each day D) After breakfast, lunch, and dinner

D) For clients who are "present oriented," it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments, such as in the morning or after breakfast, and in the evening or before going to bed. Relating the dressing changes to regular daily activities would be a good approach for a client who is not focused on times of the day, such as 9 a.m., 3 p.m., and 9 p.m. It is not necessary for the dressing changes to be exactly 8 hours apart. Leaving it up to the client to change the dressing at any time as long as it is changed three times a day does not allow for any regularity in the dressing changes.

The nurse is evaluating the following goal: Client will select low-fat foods from a list by the end of the month. The client, who has different beliefs about food, has not been able to achieve this goal. Which action by the nurse is appropriate? A) Extend the time frame and give the client a longer period to achieve the goal. B) Select a different goal. C) Make sure that the client understands the importance of the goal. D) Modify the plan of care to be consistent with the client's beliefs regarding food.

D) If the outcomes are not achieved for a client with different beliefs, the nurse should be especially careful to consider whether the client's belief system has been adequately included as an influencing factor and modify the plan of care to be consistent with the client's belief regarding food. Extending the time frame, selecting a different goal, or checking how the client understands the importance of the goal may not be as helpful as looking at the cultural practices-including dietary ones-of the client.

Handoff communication, or the transfer of data during transitions in care, includes an opportunity to ask questions, clarify, and confirm the information being passed between sender and receiver. What is the main objective for ensuring effective communication during a client handoff? A) To avoid lawsuits B) To make sure all documentation is complete C) To facilitate quality improvement D) To ensure client safety

D) Ineffective communication is the primary cause of sentinel events, making client safety the primary objective of the handoff communication process. Handoff communication may be scrutinized during a lawsuit, but avoiding litigation is not a primary objective. Similarly, engaging in handoff communication can help a nurse determine whether all documentation related to a particular client's care is complete, but this is not a primary objective. Finally, analysis of handoff communication may be a quality improvement criterion, but it is not a primary objective.

Which of the following statements is true with regard to human sexuality? A) The term "intersex" is used to describe individuals whose gender identity and/or gender expression differs from the gender they were assigned at birth. B) Members of the medical and psychological professions believe that all transgender individuals are affected by gender dysphoria. C) Today, the terms "transgender" and "transsexual" are typically used interchangeably. D) Transgender individuals are at increased risk for violence, discrimination, poverty, and limited access to healthcare.

D) Intersex individuals are people who have contradictions among their chromosomal gender, gonadal gender, internal sex organs, and external genital appearance, whereas transgender individuals are people whose gender identity and/or expression differs from the gender they were assigned at birth. In the past, transgender individuals were often referred to as transsexual, although use of this term is now usually limited to people who have changed or seek to change their sexual anatomy through medical interventions. Some-but not all-transgender individuals are affected by a condition called gender dysphoria, which involves strong and persistent feelings of discomfort with one's assigned gender. Regardless of terminology and diagnoses, all transgender individuals are at increased risk for violence, discrimination, poverty, and limited access to healthcare.

A general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male is A) homosexual. B) transgender. C) genderqueer. D) intersex.

D) Intersex is a general term used for a variety of conditions in which an individual is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male. Homosexuality is a sexual preference for members of the same sex. Transgendered individuals do not identify with the gender assigned to their bodies. Genderqueer individuals don't identify with male or female exclusively but with both categories.

A nurse is working at a healthcare clinic serving the needs of an inner-city population that is predominantly made up of minority people groups. A neighbor says the nurse must be brave because most of "those" people have guns and are in gangs. Which response by the nurse is appropriate? A) "It's very difficult for me when you discriminate like that." B) "It's okay because I'm not a gang member, so I will be okay." C) "Hey, it's a job like any other job. All jobs have problems." D) "That's an unfortunate stereotype. Can we talk about the reality?"

D) It is the nurse's role to promote the act of bridging, linking, or mediating between groups of people from different cultural systems to reduce conflict or produce change. Calling the neighbor's comment discriminatory may increase conflict. Rationalizing or failing to confront the neighbor's perceptions does not promote cultural brokering.

The nurse is working in a healthcare setting that has implemented Lean Six Sigma. Which of the following should the nurse anticipate with regard to this model? A) Shorter breaks B) Ordering extra supplies C) Replacing licensed with unlicensed personnel D) Decreasing staff when the census is low

D) Lean Six Sigma focuses on eliminating waste and improving process flow. Thus, when a unit's census decreases, the unit's manager would decrease the number of staff. Replacing licensed staff members with unlicensed personnel may not be safe. The unit would cut back on ordering supplies that are not needed when following this model. A shortened break time would not be considered reducing waste.

Nurses who demonstrate mindsight are able to A) focus on being "in the moment" so that they can dedicate their full attention to the events and emotions they are currently experiencing. B) predict events that will occur in the future with reasonable certainty. C) interpret events and emotions from another person's perspective. D) recognize their personal triggers to stress that result in conflict, then retrain their brain to respond differently.

D) Mindsight is a term that describes being self-aware of one's triggers to stress that can result in conflict, and purposefully "retraining" the brain to respond differently. Improving one's self-awareness is salient to growing as a leader and being able to redirect the typical response and course of action in a given situation. Taking steps to decrease or manage stress levels helps to reduce the likelihood of initiating conflict.

The nurse is caring for a client who sustained multiple injuries in an automobile accident. As a part of secondary prevention for this client, which does the nurse include in the plan of care? A) Promote wellness. B) Detect early disease. C) Restore the client to previous functioning. D) Prevent the progression of more symptoms.

D) Rehabilitation is tertiary prevention and is aimed at restoring the client to the previous level of functioning. Prevention of the progression of symptoms and early detection of disease are secondary preventions. Promoting wellness is considered primary prevention.

Which best describes the desired outcome of decreased readmission rates? A) An increased use of overtime B) A decrease in client satisfaction C) An increase in client care supplies D) A decreased cost of care

D) Research has shown that an increase in RN staff decreases a unit's readmission rate. Because readmission is reduced, cost of care is also reduced. Overtime is not necessarily reduced by an increase in staff, depending on the number of nurses available at any given time. Studies show that client satisfaction increases with an increase in RN staff. Decreasing readmission rates will likely decrease the use of client care supplies, not increase it.

The client is admitted to the hospital following a miscarriage, and she is septic. The healthcare provider orders antibiotics, which the client refuses, stating, "I don't deserve them. I lost my baby because I had sex outside of marriage." Which is the appropriate response by the nurse? A) "I'll notify your healthcare provider about your decision." B) "Do you think you should be punished because you had a miscarriage?" C) "I think you need to do what is best for you." D) "You have a serious infection and really need the medication."

D) Telling the client she needs the medication is providing the best care possible. Telling the client she needs to do what is best is inappropriate; the nurse knows she needs the medication. Calling the healthcare provider is inappropriate; the nurse knows the client needs the medication. Asking the client if she thinks she should be punished is inappropriate; she is septic and needs the medication.

The nurse conducts teaching for a client recently diagnosed with type 2 diabetes mellitus. At the conclusion of the session, which client statement indicates that teaching has been effective? A) "I will take medication for a week for this acute illness." B) "I will have to take insulin for this disease every day for the rest of my life." C) "This chronic disease will become worse and lead to death." D) "I will have to make dietary changes to manage this chronic disease."

D) The client is aware that dietary changes will be needed to manage this chronic disease, indicating that the client understands the teaching the nurse provided. Not all clients diagnosed with type 2 diabetes mellitus require medication, such as insulin, to manage the disease process. Diabetes is chronic, not acute. Depending on the client's response to the disease, the outcome may not become worse or lead to death.

The nurse is preparing discharge instructions for a client with a foot wound. How will the clinical information system support this client's learning needs? A) Improves documentation about the client's status B) Summarizes the list of charges that will appear on the client's bill C) Provides a record of all medications received while hospitalized D) Prints discharge instructions to use for teaching

D) The clinical information system provides access to client information and provides data to help the nurse execute the nursing process. This includes printing discharge instructions to use in client teaching. Although different information systems can do all of these things, only printing discharge instructions will support the client's learning needs.

An older adult client recognizes the need for help with personal care at home yet does not want to move to a nursing home or assisted living facility. Which action by the nurse would best assist this client? A) Reminding the client that his physical strength will grow weaker at home until a nursing home is required B) Suggesting that the client move in with his adult children C) Recommending to the physician that the client be admitted to a nursing home immediately D) Referring the client to a personal care assistant who can help with activities of daily living

D) The nurse needs to help strengthen this client's self-esteem. To best do this, the nurse should recommend a personal care assistant to help the client with activities of daily living. Suggesting that the client move in with children or be admitted to a nursing home does not strengthen the client's feelings of self-worth or promote a healthy self-concept. Telling the client that progressive weakness will eventually make nursing home care inevitable will harm this client's already damaged self-esteem.

A nurse is working with a number of clients at a free clinic. Which client population is at the highest risk for low levels of healthcare? A) Undocumented immigrants B) Men who have protected sex with men C) Men who have sex with women D) Teenagers

D) The term "vulnerable population" refers to groups of people in our culture who are at greater risk for diseases and reduced life span due to lack of resources and exposure to more risk factors. People may be made vulnerable by immigration status. Men or teenagers as a group are not more likely to be at risk for lower levels of healthcare.

During a sexual history, the client states, "I have always felt like a man trapped in a woman's body." The nurse should recognize that the client may identify as what? A) Bisexual B) Heterosexual C) Homosexual D) Transgender

D) The term transgender refers to individuals who do not identify with the gender assigned to their body. For example, an individual who identifies as transgender may have typical female anatomy but feel like a male and seek to become male by presenting as male and taking hormones or electing to have sex reassignment surgeries. This client's statement relates to gender identification, not to the sexuality of the client.

A client requests that surgery be delayed for several days until after a period of Holy Days has concluded. Which action by the nurse supports this client's request? A) Remind the client that one's health is more important than following Holy Days. B) Provide the client with alternative forms of treatment to replace having surgery. C) Suggest the client think about whether having the surgery is the right decision, as the client is willing to delay it now. D) Communicate the client's request to the surgeon.

D) To support the client's need to avoid surgery during Holy Days, the nurse should communicate the client's request to the surgeon. The nurse should not remind the client that health is more important than following Holy Days or suggest that the client consider not having surgery. The nurse should also not provide the client with alternative forms of treatment to replace having surgery, as this is outside the nurse's scope of practice.

The nurse is caring for a 230-lb client who needs to be repositioned every 2 hours. While repositioning the client, the nurse injured a muscle in her back. To prevent the injury and ensure safety for both the nurse and client, what should the nurse have done differently in this situation? A) She should have used proper lifting techniques. B) She should have repositioned the client only if the client requested it. C) She should have questioned the physician about the need to reposition the client. D) She should have asked for help from another nurse.

D) When moving or repositioning clients, especially larger clients, the nurse should always ask for help from another healthcare worker to prevent injury. Although using proper lifting techniques is important, they do not guarantee that injuries will not occur. In addition, there is no evidence that the nurse was not already using proper lifting techniques. The nurse should question physician orders if she is unclear about the reasoning for the order, but this is a standard best practice and would likely not require questioning. The nurse should reposition the client as ordered, not only when the client requests it.

The nurse is conducting a physical assessment of a middle-aged female client during an annual exam. What should the nurse assess that is particularly relevant to this age group? Select all that apply. A) Speech and language B) Body development and growth C) Sleeping patterns D) Ability to carry out activities of daily living (ADLs) E) Body mass index (BMI) measurement

D, E D) Areas of assessment that are relevant to middle-aged adults include BMI measurement to assess for disease risk and the ability to carry out ADLs. Speech and language, body development and growth, and sleeping patterns are more appropriate to assess in pediatric clients. E) Areas of assessment that are relevant to middle-aged adults include BMI measurement to assess for disease risk and the ability to carry out ADLs. Speech and language, body development and growth, and sleeping patterns are more appropriate to assess in pediatric clients.

A client is abstaining from meat and dairy products during Lent and refuses to select these items when making meal choices. Which actions by the nurse support the client's nutritional and religious needs? Select all that apply. A) Ask the healthcare provider to discuss the impact of the restricted diet on the client's health. B) Provide soy milk products as supplements. C) Add protein powder supplements to the client's water pitcher. D) Ask the client what foods are typically consumed during this period of time. E) Consult with a dietitian for food choices to meet the client's needs.

D, E D) The best interventions would be for the nurse to consult with a dietitian for food choices to meet the client's health and religious needs and ask the client what foods are typically consumed during this period of time. The nurse should not provide soy milk products as supplements because the client may not like them. The nurse should not ask the physician to talk about the restricted diet with the client. The nurse should also not provide protein powder supplements in the client's water pitcher. E) The best interventions would be for the nurse to consult with a dietitian for food choices to meet the client's health and religious needs and ask the client what foods are typically consumed during this period of time. The nurse should not provide soy milk products as supplements because the client may not like them. The nurse should not ask the physician to talk about the restricted diet with the client. The nurse should also not provide protein powder supplements in the client's water pitcher.