Wellness Exam 3

A nurse has determined that many of her home care clients and their families have not been vaccinated against the flu. Several community members point to difficulties with public transportation and the lack of after-hours clinics. What Nursing diagnosis is most applicable to this situation? a. Inadequate community resources b. Impaired health maintenance c. Powerlessness d. Social isolation

a

When a patient reports having dyspareunia, which question is it most appropriate for the nurse to ask? a. "Have you talked with your partner about this discomfort?" b. "Have you had these spasms since you became sexually active?" c. "Does the bleeding continue longer than 5 days?" d. "Do your breasts swell up large enough for you to need a larger bra?"

A Dyspareunia is painful intercourse, and the sexual partner should be made aware of this to foster understanding and adjustment of sexual practices. Spasms, bleeding, and breast swelling are not associated with this condition.

Before Jay delegates tasks, he must make sure that he is delegating in accordance with a registered nurse's legal scope of practice. Rank in order the five rights of delegation Jay must follow. A. Right supervision/evaluation B. Right person C. Right task D. Right circumstances E. Right direction/communication

Answer: C, D, B, E, A Rationale: The five rights of delegation are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.

Ms. Ruiz has tuberculosis. Because of this, like other community nurses, Michelle will also serve in the role of _____________ in an effort to promote health teaching about tuberculosis to Ms. Ruiz and track incident rates of the illness.

Answer: Epidemiologist Rationale: Community nurses apply principles of epidemiology by being involved in case findings and health teaching and tracking incident rates of an illness.

Michelle sits in on a counseling session with her nursing mentor and a childless couple. The choices for infertile couples include which of the following? (Select all that apply.) A. Pursuing adoption B. Remaining childless C. Undergoing fertilization treatment D. Medicating with St. John's wort

A, B, C Choices for the infertile couple include pursuit of adoption, medical assistance with fertilization, or adapting to the probability of remaining childless. St. John's wort is an herbal treatment used for depression management.

Mrs. Brown asks Cody if she can look at her husband's medical record. On what legislation would Cody base his answer?

Answer: HIPAA Rationale: HIPAA is a federal law that protects the privacy of health care information. For Mrs. Brown to view Mr. Brown's medical record, her husband would have to give permission.

Ms. Ruiz is considered a vulnerable patient. Vulnerable populations are groups of patients who are more likely to develop health problems as a result of excess health risks, who are limited in access to health care services, or who depend on _______ for care.

Answer: Others Rationale: Vulnerable populations depend on others for care and include those in poverty, older adults, the homeless, immigrants, those in abusive relationships, substance abusers, and people with severe mental illness.

What consequences may a nurse experience if the nurse is convicted of a crime? (Select all that apply.) a. Loss of nursing licensure b. Employment affirmation c. Monetary penalty d. Imprisonment e. Promotion

A, C, D Nurses who are convicted of a crime may have their nursing licenses revoked, be required to pay fines or pay restitution to patients or their families for damages, and be incarcerated for various periods, depending on the severity of the crime. Nurses who commit crimes are most often placed on probation pending the outcome of court proceedings or dismissed from their employment, not affirmed or promoted.

Which behaviors are expected of the nurse at the experienced informatics competency level? (Select all that apply.) a. Collect accurate assessment data. b. Conduct informatics research. c. Group assessment data. d. Document data appropriately on the electronic health record (EHR). e. Integrate information science, computer science, and nursing science.

A, C, D The nurse at the intermediate level of informatics competency can see data relationships and is able to collect and group data. The nurse is skilled in the use of computer technology and can document in the EHR. Conducting informatics research and integration of the sciences is the advanced level of informatics competency.

When interviewing Ms. Ruiz, it is okay to have Mr. Ruiz present as long as he understands that he may not be abusive during the interview. A. True B. False

Answer: B Rationale: It is important to provide protection to abused victims. Therefore, interview the patient in private and at a time that the abuser is not present.

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A A. CORRECT: By threatening the client, the AP is committing assault. Her threats could make the client become fearful and apprehensive. B. INCORRECT: Battery is actual physical contact without the client's consent. Because the AP has only verbally threatened the client, battery has not occurred. C. INCORRECT: Unless the AP restrains the client, there is no false imprisonment involved. D. INCORRECT: Invasion of privacy most often involves disclosing information about a client to an unauthorized individual.

A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly hired nurse indicates the need for further teaching? A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."

A A. CORRECT: The line of gravity should fall within the base of support, not outside, which increases the risk of falling.

A nurse is conducting a nutrition class to a group of women at a local community center. Which of the following information should the nurse include in the teaching? A. Progress toward limiting saturated fat to 7% of total daily intake. B. Good bowel function requires 35 g/day of fiber for women. C. Limit cholesterol consumption to 400 mg/day. D. Normal functioning cardiac systems depends on B‑complex vitamins.

A A. correct: The nurse should include for the client's to progress toward limiting saturated fat to 7% of total daily intake B. 25 g/day for females 38 g/day for males C. 200-300 mg/day D. nervous system depends on B-complex vitamins

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which of the following client statements indicates a need for further teaching? A. "I should select organic canned vegetables." B. "I need to read food labels when grocery shopping." C. "I will stop eating frozen dinners for lunch at work." D. "I know that deli meats are usually high in sodium." E. I can refer to the AHA's website for dietary guidelines

A A. correct: canned foods even if organic are usually high in sodium B. provides the client info about sodium content C. frozen dinners usually high in sodium = poor choice D. deli meats usually high in sodium = poor choice E. AHA recommends health association for continues client education on dietary guidelines

A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. which of the following health screenings should the nurse expect the provider to perform for this client A. testicular examination B. blood glucose C. fecal occult blood D. prostate-specific antigen

A A. correct: starting at puberty, the client should have examinations for testicular cancer along with blood pressure and body mass index and cholesterol measurements. Testicular cancer is most common in males 15-35 years of age B. begins at 45 C. begins at 50 D. begins at 50

Three weeks after delivery, a patient started a diet of 800 calories per day and began jogging 2 miles twice per day. The nurse recognizes the patient's behavior may be influenced by which motivating factor? a. Body image b. Family roles c. Illness behavior d. Chronic illness

A Body image is a self-ascribed attribute that influences a person's ability and desire to change, and it may be a motivating factor to maintain the change. Self-concept is a general and broader factor that motivates less specific responses. Family roles are not an influencing factor because this is a personal and possibly self-destructive behavior pattern for weight loss. Pregnancy is not a chronic illness.

When the nurse is establishing goals for a community health initiative, which strategy is most important to incorporate in the planning process? a. Collaboration with key stakeholders b. Help from professional interpreters c. Location of schools and businesses d. Gender of primary care providers

A Collaboration with key stakeholders is critical to effective goal planning in a community. Valuing the ideas of stakeholders increases support for initiatives and has the potential to increase participation and improve outcomes. Help from professional interpreters, the location of schools and businesses, and the gender of health care providers are factors to be considered after goals are established and interventions are being considered for a specific target population.

A famous rock star has just been admitted to Unit 12A after an automobile accident. A nurse on Unit 12B who is a fan of the musician uses the electronic health record (EHR) to find out how the patient is doing. Which is true regarding the use of a patient's EHR? a. Only staff caring for the patient should access this record. b. Permission from a supervisor is needed to read this record. c. The patient's record can be discussed with the nurse's co-worker. d. The nurse can call a friend who works at the local newspaper.

A Patient information should be accessed only by staff caring for that patient. Security codes are required for EHR access, and access of records can be monitored. Professional ethics should dictate the nurse's behavior, and only the records of patients being cared for should be accessed. A patient's record can be discussed only with those who are caring for the patient, and, because the nurse is not on the same unit, the records should not be accessed or discussed by that nurse. Health Insurance Portability and Accountability Act (HIPAA) laws prevent the discussion of private patient information with anyone outside of the team providing care.

Cody is going to document in Mr. Brown's medical record. Which of the following is appropriate to document? A. Patient rates headache pain as a 6. Pain is in L temporal area and does not get better with any positioning. B. IV site looks good. C. Voiding without difficulty. D. Is pleasant to care for.

A Rationale: Documentation is to be factual, accurate, and thorough. Vague terms do not capture the intent of the reason for documentation.

Which statement is an example of the use of situational leadership? a. The emergency room manager takes a vote on holiday coverage and then responds to a Code Blue by directing orders at the nursing staff. b. The manager in surgery uses the vacation policy to grant time off and then performs a surgical count in an operating room using a checklist. c. A vice president of nursing allows the department directors to make a decision about a hospital policy on holiday time and then sides with a nurse who does not want to work the required time. d. The CEO of the hospital instructs the nursing senate to develop a dress code and then changes the dress code after determining he does not like it.

A Situational leadership adjusts leadership styles to fit the situation. In the correct option, the manager moved from a democratic to an authoritarian leadership style to fit the change in situation. The manager in surgery follows a bureaucratic style by strictly following policy and procedure. The vice president of nursing is following a laissez-faire style, because responsibility for the decision is abdicated, and he or she does not support the policy when needed. The CEO of the hospital is following an authoritarian style of leadership because input of the staff is not valued.

Which activity best illustrates use of the Health Promotion Model (HPM) by the nurse to increase the level of well-being for a patient immediately after surgery? a. Holding a pillow across his chest when coughing and deep breathing b. Encouraging the patient to eat his entire evening meal c. Changing his surgical dressing daily as ordered by the physician d. Asking his family to step out of the room during dressing changes

A The HPM describes an individual's interaction with his environment as he engages in behaviors that promote health. The patient using a pillow as a splint is interacting with his environment to prevent atelectasis and infection.

When teaching the patient mechanical barriers for birth control, the nurse would include which method? a. Diaphragm b. Transdermal patch c. Hormone injection d. Oral contraceptives

A The diaphragm is the only mechanical barrier listed for birth control. Oral contraceptives are absorbed through the gastrointestinal tract, hormones in injections, and transdermal patches are absorbed systemically.

On which ethical theory do nurses implement their care when they act on the basis of the needs of one specific patient rather than the potential consequences to other patients? a. Deontology b. Autonomy c. Utilitarianism d. Nonmaleficence

A The ethical theory of deontology focuses on the act rather than on the consequences. Autonomy is an ethical concept that values an individual's right to make personal decisions. Utilitarianism is an ethical theory that focuses on the consequences of an action and the good of many rather than of an individual. The ethical principle of nonmaleficence asserts an obligation to "do no harm."

A nurse delegates a bed bath to unlicensed assistive personnel (UAP). After lunch, the patient complains that he has not yet been cleaned up. He is very upset and angry. What should the nurse's next action be? a. Assist the patient in getting cleaned up. b. Write up the UAP for not carrying out the assignment. c. Report the UAP to the unit manager. d. Go find the UAP, and tell her to complete the bath immediately.

A The goal of delegation of any assignment is to provide efficient, patient-centered care. In this case, the patient is angry and upset, and the nurse should first see to the patient's needs and address the issue with the UAP after the situation is resolved.

Which activity by a unit nurse demonstrates information literacy? a. Researching a patient's diagnosis online b. Entering patient data into the electronic health record (EHR) c. Organizing patient data to study trends d. Learning a new electronic health record system

A The nurse is demonstrating information literacy (the ability to recognize when information is needed and to locate and use that information) when researching a patient's diagnosis online. Entering patient data into the EHR or learning a new EHR system demonstrates beginner nursing informatics competency. Organizing patient data to study trends demonstrates an experienced level of nursing informatics competency.

A nurse providing preventive care to an overweight patient with a family history of diabetes should engage in which priority care-planning activity for this patient? a. Calculating the patient's body mass index (BMI) and recommending a daily exercise routine b. Instructing the patient to perform blood glucose monitoring once daily c. Giving the patient a month's supply of insulin needles and syringes d. Participating in diabetes education classes offered at a local health facility

A The patient does not have diabetes but is overweight and at risk due to a family history of diabetes. The best way to prevent diabetes is to keep the BMI in the optimal range (<25). Beginning an exercise program with walking and progressing as tolerated increases muscle mass, improves depression, and strengthens the heart.

Trevor knows that receiving an immunization is included in which hierarchy of need according to Maslow? A. Physiological B. Safety and security C. Love and belonging needs D. Self-esteem E. Self-actualization

Answer: B Rationale: Receiving an immunization falls into the "physical safety" subdivision of Maslow's "safety and security" hierarchy.

A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preoperative care regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.

A, B A. CORRECT: It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that he understands the information the surgeon gave him. B. CORRECT: It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that he is consenting voluntarily and appears to be competent to do so. The nurse also should verify that he understands the information the surgeon gave him. C. INCORRECT: It is the surgeon's responsibility, not the nurse's, to explain the risks and benefits of the procedure. D. INCORRECT: It is the surgeon's responsibility, not the nurse's, to describe the consequences of choosing not to have the surgery. E. INCORRECT: It is the surgeon's responsibility to tell the client about any available alternatives to having the surgery

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A, B, C A: correct: the nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation B. correct: having another nurse listen to the telephone prescription is a safety precaution that helps prevents medication errors due to miscommunication C: correct: the provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr). D. unrelieved pain can become an emergency situation without the appropriate pain management interventions E. there is no need to inform the charge nurse every time a nurse receives a medication prescription, whether by telephone, verbally, or in the medical record

A nurse is discussing essential nutrients for normal functioning of the nervous system with a client. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Calcium B. Thiamin C. Vitamin B6 D. Sodium E. Phosphorus

A, B, C, D A. correct: Calcium is an important regulator of nerve responses. B.correct: Normal functioning of the nervous system depends on adequate levels of the B‑complex vitamins, especially thiamin, niacin, and vitamins B6 and B12. C. correct: Normal functioning of the nervous system depends on adequate levels of the B‑complex vitamins, especially thiamin, niacin, and vitamins B6 and B12. D. correct: Sodium is an important regulator of nerve responses E. maintains acid-base balance and formation of bones + teeth but not directly the nervous system

Whom should the school nurse engage in discussion when conducting a needs assessment related to the high incidence of obesity in the school system? (Select all that apply.) a. Parents b. Students c. School staff d. Community members e. Firefighters and police

A, B, C, D To address the concern regarding obesity, the nurse will need to engage each of these groups, as well as school administrators and teachers, to gain insight into the needs and identify resources. The nurse could form a task force with representatives of each group to work on necessary interventions to address the high incidence of obesity. It would not be necessary for the nurse to speak with firefighters or police, in this case.

Social determinants of health are the condition in which people are born, grow, live, work and age, including the health care system. These determinants are affected by which of the following? (Select all that apply). A. Government B. Resources C. Distribution of wealth and power D. Social groups E. Organizational policies

A, B, C, E

A school nurse is teaching a group of students how to read food labels. Which of the following is a required component of food labels that the nurse should include in the teaching? (Select all that apply.) A. Total carbohydrates B. Total fat C. Calories D. Magnesium E. Dietary fiber

A, B, C, E A. correct: FDA requires total carbs on food labels B. correct: single serving size, number of servings in package, percent of daily values, + amount of each nutrients in one serving. total fat included C. correct: calories included D. magnesium not included E. correct: dietary fiber included

Which items are supported by point-of-care use of information technology? (Select all that apply.) a. More accurate documentation b. Direct access to diagnostic results c. Confidentiality d. Direct access to records by patients e. Access to medication profiles

A, B, C, E Point-of-care use of information technology provides more accurate documentation because the nurse documents patient information in real time. Diagnostic results are immediately available to the nurse. Confidentiality is protected when the nurse documents at the bedside using a secure log-in and password. Medication profiles are available to the nurse at bedside. Patients do not have direct access to their medical records because these records are secured by log-ins and passwords accessible to only health care providers caring for each patient.

Progressive relaxation and guided imagery have been shown to significantly ________. (Select all that apply). A. Improve scores on anxiety and stress scales B. Promote sleep C. Increase activity D. Reduce pain as reported by the patient

A, B, D

A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.

A, B, D A. CORRECT: It is preferred that two or more personnel assist with any positioning in order to reduce the risk of injury. B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the nurse's risk for injury. C. when sitting for long periods of time it is essential to keep the knees slightly higher than the hips to decrease strain on the back D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements is recommended to prevent injury E. it is important to take a break every 15-20 minutes from repetitive movements to flex and stretch joints and muscles

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (select all) A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Complaint from a client's family member

A, B, D A: correct: complete an incident report regarding a medication error B: correct: complete an incident report regarding a needlestick C: report a conflict with a provider and nursing staff to the charge or nurse manager D: correct: complete an incident report following an omission of a prescription E: documentation should be current. waiting until the end of the shift can result in data omission

The registered nurse on an inpatient medical unit delegates vital signs and morning care to the UAP for five stable patients. The nurse asks the UAP to document the vital signs and report any abnormal results immediately. Which rights of delegation is the nurse demonstrating? (Select all that apply.) a. Right person b. Right circumstance c. Right time d. Right supervision e. Right patient

A, B, D The nurse is demonstrating all of the rights of delegation. Right time and right patient are not part of the Five Rights of Delegation. They are a part of the Rights of Medication Administration. The Five Rights of Delegation are 1. Right task 2. Right person 3. Right circumstance 4. Right communication 5. Right supervision

The general adaptation syndrome GAS is the physical response to stress. Which of the following of the three stages on GAS? (Select all that apply). A. Alarm B. Distress C. Resistance D. Exhaustion

A, C, D

A nurse is providing teaching to a client who follows vegan dietary practices. The nurse should instruct the client to ensure he is consuming enough of which of the following nutrients? (Select all that apply.) A. Vitamin D B. Fiber C. Calcium D. Vitamin B12 E. Whole grains

A, C, D A. correct: most vitamin D comes from fortified milk products B. fiber is found primarily in plants C. correct: few good sources of calcium come from plants D. correct: all reliable sources of vitamin B are in animal products E. grains are included in the vegan diet

A nurse is planning care for an older adult client who is receiving treatment for malnutrition. The client is scheduled for discharge to his home where he lives alone. Which of the following actions are appropriate to include in the plan of care? (Select all that apply.) A. Consult social services to arrange home meal delivery. B. Encourage the client to purchase nonperishable boxed meals. C. Advise the client to purchase frozen fruits and vegetables. D. Recommend drinking a supplement between meals. E. Educate the client on how to read nutrition labels.

A, C, D, E A. correct: promotes adequate nutrition B. usually high in calories and salt and are not recommended to promote adequate nutrition C. correct: promotes adequate nutrition D. correct: promotes adequate nutrition E. correct: promotes adequate nutrition

Which intrinsic factor(s) would be of major concern to the nurse about when the community has an outbreak of pertussis? (Select all that apply.) a. Age b. Gender c. Ethnic group d. Cultural background e. Immunization status

A, E Age and immunization status would be of most concern because people who have not had a pertussis vaccine could be a source of potentially fatal infection in infants. In the case of pertussis vaccination, gender ethnicity and cultural background are not of particular concern.

Jay delegates the task of taking vital signs to a new nursing assistant on the unit with whom Jay has never worked before. Which of the following questions asked of the new nursing assistant will help Jay determine that it is safe to delegate the task of taking vital signs? (Select all that apply.) A. "How long should you keep the thermometer in the patient's mouth?" B. "How do you apply a blood pressure cuff to an obese patient?" C. "How do you take a patient's pulse?" D. "Do you know how to take vital signs?"

A,B,C Rationale: Open-ended questions elicit a conversation and details to help the nurse assess the knowledge and skills on the nursing assessment. The question "Do you know how to take vital signs?" is a closed-ended question that does require further exploration.

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include (select all that apply) A. help the client see the benefits of their actions B. identify the client's support systems C. suggest and recommend community resources D. devise and set goals for the client E. teach stress management strategies

A,B,C,E A. correct: while also overcoming barriers B: correct: suggest steps to have friends and family become involved C. correct: help the client progress to meet goals D. the nurse and client should work together to devise and set mutually agreeable goals that are also realistic and achievable E. correct: risk for cardiovascular disease + other systemic diseases

At the end of the shift, the registered nurse assigned to Mr. Brown asks Cody if he would give the hand-off report to the nurse coming on who is assigned to Mr. Brown. Which of the following statements are true regarding hand-off reports? Select all that apply. A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient C. Must be given face to face between the nurses D. Must include an opportunity for the receiver to ask questions of the person giving the report

A,B,D Rationale: One of the National Patient Safety Goals provides for standardized communication so there is continuity of care when handing care of a patient over to another caregiver.

Immunizations are not an objective as defined by Healthy People 2010 because immunizations are largely for children and children are not included in the Healthy People 2010 initiative. A. True B. False

Answer: B Rationale: Immunizations and infection control are a priority component of the Healthy People 2010 initiative for improving the health of all people in the United States.

Trevor is assigned to the immunization station at the health drive where he is responsible for administering vaccines to the children. Immunizations are an example of _________________ and _____________ prevention.

Answer: primary and illness Rationale: Primary prevention precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. It includes health education programs, immunizations, and physical and nutritional fitness activities. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health.

HIV testing and counseling would be considered: A. Primary B. Secondary C. Tertiary D. Quaternary

B

Healthy People 2020 is an initiative to track risk factors and personal behaviors related to health. The next time it will be written will be for: A. 2025 B. 2030 C. 2035 D. 2040

B

The process by which individuals from one cultural group merge with, or blend into a second group is called _____________. A. Socialization B. Assimilation C. Acculturation D. Biculturalism E. Ethnocentrism

B

You are working as a as school nurse and decide to initiate a program to address childhood obesity by assessing individual students body mass index, encouraging less consumption of processed foods and promoting extended periods of physical activity. Which level of prevention? A. Primary B. Secondary C. Tertiary

B

What is the best method for the public health nurse to determine if community members are involved in outdoor physical activity? a. Meet with the parents of high school children. b. Complete a windshield survey of the community. c. Evaluate the number of community health club members. d. Check the local health statistics for the incidence of obesity.

B A windshield survey will allow the nurse to observe whether people are walking or engaged in physical activity. It also will help the nurse identify single- or multiple-family private and public housing units; health, safety, and social services agency availability; and other essential community attributes. Meeting with parents, evaluating health club membership, or obesity statistics will not assess the concern of the prevalence of outside physical activity.

A nurse manager of a medical‑surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)

B A. Although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs. B. CORRECT: A client returning from surgery requires an RN's assessment and establishment of a plan of care, especially if the client is potentially unstable. C. Although PNs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time. D. Although APs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time, particularly assessment.

An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

B A. INCORRECT: Assault is an action that threatens harmful contact without the client's consent. The nurse has made no threats in this situation. B. CORRECT: The nurse gave the medication as a chemical restraint to keep the client from leaving the facility against medical advice. This is false imprisonment because the client neither requested nor consented to receiving the sedative. C. INCORRECT: Negligence is a breach of duty that results in harm to the client. It is unlikely that the medication the nurse administered without his consent actually harmed the client. D. INCORRECT: The nurse has not disclosed any protected health information, so there is no breach of confidentiality involved in this situation

A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? A. A client who has decreased vision B. A client who has Parkinson's disease C. A client who has poor dentition D. A client who has anorexia

B A. necessary for assistance, but not highest priority B. correct: at high risk for aspiration so highest priority C. necessary to evaluate needs for assistance/modified diet, but not highest priority D. necessary to evaluate intake but not highest priority

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. which of the following client statements indicates that the client understands how to proceed? A. " so i don't need the colon cancer procedure for another 2 or 3 years B. "for now, I should continue to have a mammogram each year C. because the doctor just did a pap smear, i'll come back next year for another one D. I had my blood glucose test last year, so I won't need it again for 4 years

B A. no history can begin screening procedure at 50 B. correct: mammogram annually C. 30-65 years old pap smear and human papillomavirus test every 5 years or pap test every 3 years D. every 3 years

A nurse at a health department is planning strategies related to heart disease. which of the following activities should the nurse include as part of primary prevention a. providing cholesterol screening b. teaching about a healthy diet c. providing information about hypertensive medications d. developing a list of cardiac rehabilitation programs

B A. secondary B. correct: primary prevention includes teaching strategies to prevent illness/injury. includes health info about nutrition, exercise, stress management, and protection from injuries/illness C. secondary D. tertiary

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Nonmaleficence

B A.INCORRECT:Fidelity is an agreement to keep promises. The nurse has not made any promises; this is the client's decision. B.CORRECT:In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy. C. INCORRECT:Justice is fairness in care delivery and in the use of resources. Because the client has chosen not to use them, this principle does not apply. D. INCORRECT: Nonmaleficence is the avoidance of harm or injury. In this situation, harm can occur whether or not the client has surgery. However, because he chooses not to, this principle does not apply

In using the PLISSIT model, what is the first action initiated by the nurse? a. Present basic information about sexual functioning. b. Ask permission to begin the sexual assessment. c. Inquire about any medications the patient is taking. d. Ask the patient about sexual activity and practices.

B Before initiating discussion via the PLISSIT model, the nurse should first seek permission to have the conversation with the patient. All of the other listed steps occur, but only after permission is obtained. Permission-gain and give permission Limited Information- answer questions with facts Specific Suggestions-effects of treatment Intensive Therapies- usually involve referral

Which description is an example of data? a. A printout of a patient's history and physical examination b. A patient's blood pressure and pulse rate c. The nurse's knowledge of a disease d. A nurse's interpretation of a change in the patient's condition

B Data are facts, observations, and measurements such as blood pressure and pulse rate. A printout of the patient's history and physical is organized information that is meaningful. Knowledge is organized and processed information such as a nurse's knowledge of a disease. When nurses interpret a change in the patient's condition, they are using wisdom or the use of knowledge and experience to manage and solve problems.

For which reason are patients unlikely to introduce the topic of sex with health care providers? a. Most patients have few, if any, questions or problems relating to this topic. b. They are too embarrassed to discuss the topic of sex with a health care provider. c. Female patients prefer to discuss problems with female health care providers. d. They assume that health care professionals know little about sexual functioning.

B Embarrassment to discuss a personal subject can cause the patient to avoid introduction of the topic. Gender is not a consideration in this question, and it cannot be generalized that patients have few questions or problems on any topics. Health care professionals generally are considered to be knowledgeable in subject matters associated with health and illness.

A patient is seeking information about leading indicators that show the importance of health promotion and illness prevention in the United States. To which government-sponsored program would the nurse refer the patient for the best source of information? a. American Cancer Society website b. Healthy People 2020 website c. Centers for Disease Control and Prevention (CDC) morbidity and mortality reports d. American Association of Hospitals home page

B Healthy People 2020 is the most up-to-date site for health indicators in the United States, and it is presented in a client-friendly format. The CDC Morbidity and Mortality Weekly Report does not cover all of the indicators, and it may be overly technical for the client. The same holds true for the American Cancer Society website and the American Association of Hospitals home page.

A client with metastatic cancer shares with the clinic nurse that he has only days or weeks to live. What type of community service would be most appropriate for the nurse to suggest to this client? a. Home health care b. Hospice care c. Forensic care d. Acute care

B Hospice care provides specialized care for people who are dying. It may take place in a person's home or community facility. Home care is less specialized. Forensic and acute care would not be appropriate for this client.

What action would be most appropriate for the home care nurse to take if an intrinsic factor appears to be contributing to a client's illness? a. Report the presence of multiple insects in the home to the health department. b. Document the intrinsic factor in the client's electronic health record. c. Explore the possible impact of changing jobs for stress reduction. d. Discuss the danger of having multiple throw rugs with the client.

B Intrinsic factors include variables such as genetics, age, gender, and ethnic group. These should be documented in the client's electronic health record so that their impact can be taken into consideration in assessing the client's health status. The presence of insects and throw rugs in a client's home and where the client works are extrinsic factors.

Ms. Ruiz tells Michelle that she left home at age 14 and was homeless until she met Roberto, who found her a job and provided shelter. When Ms. Ruiz was a homeless teenager, she was at an increased risk for which of the following because of her immaturity and lack of a nuclear family? A. Illness B. Risky behaviors C. Compromised self-esteem D. Malnutrition

B Rationale: Homeless teenagers are at an increased risk for risky behaviors because of immaturity and lack of a nuclear family.

Jay begins to plan Ms. Osborne's care and decides to delegate Ms. Osborne's assessment to the nursing assistant because he is behind on his patient rounds. It is acceptable for Jay to delegate the task of assessment according to the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). A. True B. False

B Rationale: The nurse does not delegate the steps of the nursing process of assessment, planning, and evaluation because these steps require nursing judgment according to the ANA and NCSBN.

When a patient is beginning a regimen of an antidepressant medication, which information should the nurse include in the medication teaching as it pertains to sexuality? a. "Your partner will be pleased because your sexual functioning is going to improve." b. "You may find that your desire for sex will decrease while on this medication." c. "Your skin will probably become supersensitive to touch, so you may need to change your activity during sex." d. "You will be unable to have an erection while taking your antidepressants."

B Reduced sexual desire can be a side effect of antidepressant use. Skin sensitivity and erectile dysfunction are not side effects. Improved sexual function is not a specific effect of antidepressant administration.

A normally active, older patient has been frequently evaluated for minor problems at the clinic since the death of her husband 3 months earlier. During one of her visits she states that she has no energy to get through the day and no desire to keep up with her Tuesday night bridge club. Which type of holistic health model intervention should the nurse use to help the patient cope with the loss of her husband? a. Encouraging use as needed of a drug for anxiety ordered by her provider b. Teaching the value of music therapy to address anxiety about her loss c. Explaining that she will be over the loss of her husband in a few months d. Encouraging a gradual reentry into social interaction and activities with friends

B Teaching the patient to use music therapy when she feels anxious about her loss is the most appropriate intervention listed. This type of distraction is a holistic technique that works well in the form of music, painting, and expressive dance. Instructing the patient to use drugs is not part of the holistic approach. The patient may not be ready to re-engage in a full activity schedule, and it is unlikely that her feelings of loss will ever totally resolve.

What is the best way for a nurse to avoid crossing professional practice boundaries with patients? a. Spend extensive time with a patient without visitors. b. Focus on the needs of patients and their families. c. Intervene in problematic patient relationships. d. Discuss personal information excessively.

B The best way to avoid breaching professional practice boundaries is to focus on the patient's needs and those of the patient's family. Nurses should consistently avoid excessive self-disclosure of personal information, intervening in patient relationships, and spending excessive amounts of time with one patient. In addition to keeping patients' secrets, gaining personally from a relationship with a patient, and engaging in sexual overtures or behavior with a patient, these actions are considered violations of professional boundaries.

When teaching female reproduction to a group of high school students, the nurse uses what term to indicate the cessation of a woman's menstrual activity? a. Menarche b. Menopause c. Premenstrual syndrome d. Menstrual dysfunction

B The definition of menopause is the cessation of a female's menstrual activity. Menarche is the onset of menstruation. Premenstrual syndrome is a set of specific symptoms that occur before the monthly menstrual cycle. Menstrual dysfunction refers to altered patterns of menstruation associated with various disorders.

The hospital has implemented a new electronic medication administration record (MAR). What is true about the use of this new tool? a. Verifies medication dosages b. Reduces medication administration errors c. Eliminates the need to count narcotics d. Requires a hard copy of the MAR to be printed

B The electronic MAR reduces medication errors by requiring the nurse to scan the patient's identification band and the medication. Although the electronic MAR alerts the nurse to potential errors such as the wrong dose, it is the nurse's responsibility to verify all information before administration of a medication. Narcotic counts are still kept in the electronic system. A hard copy of the MAR is not necessary.

A nurse manager is trying to improve patient satisfaction ratings for her area of responsibility. The manager meets with the staff and forms an ad hoc committee to address the issues around the problem. This is an example of what style of leadership? a. Bureaucratic b. Democratic c. Laissez-faire d. Autocratic

B The nurse manager fits the description of the democratic style because the staff members have input into the solution of the problem. A bureaucratic manager develops policies and procedures to follow or reinforces existing policies and procedures. A laissez-faire manager presents the problem to the employees, but rather than offering a plan for addressing it, he or she asks employees to solve the problem on their own. An autocratic manager uses the threat of punishment or promise of rewards to solve the problem.

A nurse is volunteering in the community to educate parents to increase the number of children in the school district who are immunized. The nurse oversees the activities of a group of volunteers. Which role best describes the nurse's activity in this situation? a. Management b. Leadership c. Volunteerism d. Activism

B The nurse meets the criteria for leadership because the nurse is acting in an informal role, not as part of a managerial structure in an organization. Volunteerism and activism are not defined as management or leadership functions.

The nurse enters a patient's room to deliver a dinner tray and notices that the patient has not been out of bed since the previous day. The patient states that his condition has made him bedridden, although the nurse knows that he is capable of independent ambulation. Which type of reaction is the patient exhibiting? a. Ambivalence to symptoms b. Illness behavior c. Diminished functional ability d. Overreaction to illness

B The patient is defining and interpreting his disease symptoms according to his beliefs about illness and how to respond to it. The patient's ability to ambulate is intact. Overreaction to illness is a subjective anomaly, and the patient is not ambivalent about his diagnosis.

A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization.The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements is an appropriate response by the nurse? A."Sounds like something you should discuss with her when you get home." B."It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C."Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D."Just make sure you take your medication as directed, and you should be fine."

B CORRECT: The nurse is acknowledging and allowing the client to discuss his concerns regarding sexual functioning.

A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A."I was having difficulty with attaching the appliance at first, but my wife was able to help." B."I'll never be able to care for this at home. Can't you just send a nurse to the house?" C."I met a neighbor who also has a colostomy, and he taught me a few things." D."It may take me a while to get the hang of this. I have to admit, I am pretty nervous."

B CORRECT: This client is displaying a lack of interest in learning how to care for the colostomy and dependence on others to care for him. The nurse should suspect issues with self-concept with this client.

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record (select all that apply) A. Cover errors with correction fluid, and write in the correct info. B. Put the date and time on all the entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of shift to document.

B, C A. correction fluid implies that the nurse might have tried to hide the previous documentation or deface the medical record B. correct: the day and time confirm the recording of the correct sequence of events C. correct: documentation must be factual, descriptive, and objective, without opinions for criticism D. too many abbreviations can make the entry difficult to understand. nurses should minimize use of abbreviations, and use only those the facility approves E. documentation should be current. waiting until the end of the shift can result in data omission.

Which descriptions are advantages of health care information technology (IT)? (Select all that apply.) a. Increases health care delivery costs b. Improves communication among providers c. Improves administration functions d. Increases time necessary to document care e. Decreases the safety of providing care

B, C Health care IT improves communication among providers by providing immediate access that is legible and standardized to patient data by all providers. IT improves administrative functions by addressing the issues of quality, cost-effectiveness, and outcomes of care. Although there are initial costs to purchase hardware and software, these systems are cost-effective in the long run. Systems that support data collection at the point of care can directly enhance patient care by decreasing the time spent on documentation, reducing the potential for errors, and supporting improved assessment and data communication

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) A.Open doors to client rooms. B.Place blankets over clients who are confined to beds. C.Move beds away from the windows. D.Draw shades and close drapes. E.Relocate ambulatory clients in the hallways back into their rooms.

B, C, D A. INCORRECT: In the event of a tornado, the nurse should close all client doors to minimize the threat of flying glass and debris, not open them. B. CORRECT: In the event of a tornado, placing blankets over clients protects them from shattering glass or flying debris. C. CORRECT: In the event of a tornado, the nurse should move all beds away from windows to protect clients from shattering glass or flying debris. D. CORRECT: In the event of a tornado, the nurse should draw shades and close drapes to protect clients against shattering glass. E. INCORRECT: In the event of a tornado, the nurse should relocate ambulatory clients to the hallways, away from windows.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front‑wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this morning.

B, C, D A. The AP does not need to know the status of the client's roommate to complete this assignment. B. CORRECT: To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. CORRECT: To complete this assignment safely, the AP should make sure the client uses a front‑wheeled walker. D. CORRECT: To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication. E. The AP does not need to know the client's allergy status to complete this assignment. F. The AP does not need to know the client's food intake to complete this assignment.

Which factor(s) should be considered by the public health nurse before scheduling community infant immunization clinics? (Select all that apply.) a. Individual infant allergies b. Transportation availability c. Cost of immunization services d. Local attitudes toward immunization e. Personal feelings about immunization effectiveness

B, C, D Transportation availability and the cost of immunizations as well as the attitude of the target population toward immunization should be considered before scheduling clinics. These factors should guide the choice of location at which services are provided and help identify possible funding sources that can be tapped and education resources that need to be incorporated into the plan. Individual infant allergies need not be addressed beforehand—they will be considered at the actual clinics just before vaccination. Research evidence, not a nurse's personal feelings about immunization effectiveness, should guide practice.

A nurse is preparing an in‑service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply.) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances

B, C, E A. The right client is one of the rights of medication administration, not of delegation. B. CORRECT: The right supervision and evaluation is one of the five rights of delegation. They also include the right task and the right person. C. CORRECT: Right direction and communication is one of the five rights of delegation. They also include the right task and the right person. D. Although the delegatee needs to know whether there is a time frame or a specific time to perform the task, the right time is not one of the five rights of delegation. It is one of the rights of medication administration. E. CORRECT: The right circumstances is one of the five rights of delegation. They also include the right task and the right person Right task, right circumstance, right person, right direction and communication, right supervision and evaluation

During the meeting the committee discusses ethical theories such as deontology. Which of the following terms are associated and mean that the value of something is determined by its usefulness? (Select all that apply.) A. Accountability B. Consequentialism C. Advocacy D. Teleology E. Utilitarianism

B, D, E Rationale: Consequentialism means that the main emphasis is on the outcome or consequence of the action. Teleology is the study of the end or final causes. Utilitarianism means that the value of something is determined by its usefulness and embodies the concepts of consequentialism and teleology

Nursing students are held to which standard by the Code of Ethics for Nurses? (Select all that apply.) a. Clinical skills performance equal to that of an experienced nurse b. Demonstration of respect for all individuals with whom the student interacts c. Avoidance of behavior that shows disregard for the effect of those actions on others d. Accepting responsibility for resolving conflicts in a professional manner e. Incorporating families in patient care regardless of patient preference

B,C,D Nursing students are expected to demonstrate respect, avoid hurting others by their actions, and take responsibility for resolving conflicts in a professional manner, much the same as professional nurses. Student nurses are not required to perform clinical skills at the level of expertise exhibited by an experienced nurse. Involving a patient's family in care without the patient's approval indicates a lack of respect for patient autonomy.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at high risk for body image disturbances? (Select all that apply.) A.30-year-old male following laparoscopic appendectomy B.45-year-old female following mastectomy C.20-year-old female following left above-the-knee amputation D.65-year-old male following cardiac catheterization E.55-year-old male following stroke with right-sided hemiplegia

B,C,E B. CORRECT:Having a mastectomy involves a change in the physical appearance of a woman and can lead to body image disturbances related to femininity and sexuality. C. CORRECT:Having an above-the-knee amputation involves a change in physical appearance and can lead to body image disturbances related to function, health, and strength. E. CORRECT:Having right-sided hemiplegia involves a change in physical appearance and can lead to body image disturbances related to function, health, and strength.

A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg

B. CORRECT: In the semi-Fowler's position, the client lies supine with the head of the bed elevated approximately 30°. This position is frequently used to prevent regurgitation and aspiration in clients who have difficulty swallowing. This is the safest position for the client receiving a tube feeding.

A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A."Really, you look just fine to me. There's no need to feel undesirable. B."I'm interested in finding out more about how your body feels to you." C."Consider an afternoon at a spa. A facial will make you feel more attractive." D."It's still too soon to expect to feel normal. Give it a little more time."

B. CORRECT:Showing interest in the client is applying the therapeutic communication technique of offering self; asking more about how the client feels is applying the therapeutic communication technique of encouraging a description of perception.

A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C A. INCORRECT: The client may designate any competent adult to be his health care proxy. It does not have to be his spouse. B. INCORRECT: Although the hospital staff must ask the client whether he has prepared advance directives and provide written information about them if he hasn't, they may not refuse care based on the lack of advance directives. C. CORRECT: The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arises. D. INCORRECT: The client does not need his provider's approval to submit his advance directives. However, he should give his primary care provider a copy of the document for his records.

A nurse is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (select all that apply) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurse's station D. A client can request a copy of her medical record E. A nurse my photocopy a client's medical record for transfer to another facility.

BCDE A: The HIPAA Privacy Rule requires the protection of clients' electronic records. The rule states that electronic health records must be password-protected and each staff person should use an individual password to access information B: correct: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code C: correct: the HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location D:correct: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record E: correct: The HIPAA Privacy Rule states that nurses can only photocopy a client's medical record if it is to be used for transfer to another facility or provider

Who is responsible for coordination of care between multiple health care disciplines? A. Social worker B. Pastoral care C. Case manager D. Dietician

C

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit. B. Ask others on the team whether they have observed the same behavior. C. Report her observations to the nurse manager on the unit. D. Conclude that her coworker's fatigue is not her problem to solve.

C A. INCORRECT: Confronting the coworker might cause her to respond defensively and does nothing to resolve the problem. B. INCORRECT: Finding out whether others have noticed the problem is immaterial and should not affect the nurse's course of action. C. CORRECT: Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager. D. INCORRECT: The nurse may not be responsible for solving the problem, but she does have a duty to take action since she has observed the problem.

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A.Irrigate the affected area with running water. B.Wash the affected area with antibacterial soap. C.Brush the chemical off the skin and clothing. D.Apply a neutralizing agent.

C A. INCORRECT: In a dry chemical exposure, it is not recommended to wet the skin. B. INCORRECT: Washing the skin with antibacterial soap is not recommended in the event of a dry chemical exposure. C. CORRECT: In the event of a dry chemical exposure, the recommendation is to brush the chemical off the skin and clothing. D. INCORRECT: The nurse should not apply a neutralizing agent until after the chemical is identified.

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority? A. a client who received crush injuries to the chest and abdomen and is expected to die B. a client who has a 4-inch laceration to the head C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia

C A. INCORRECT: The nurse should give the lowest priority to a client who is not expected to live. The nurse should provide comfort measures for this client (Expectant Category - Class IV). B. INCORRECT: The nurse should give third priority to the client who has minor injury that is not life-threatening, such as a laceration to the head (Nonurgent Category - Class III). C. CORRECT: The nurse should give first priority to the client who has the greatest chance of survival with prompt intervention. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is still expected to live. Therefore, this client is the highest priority (Emergent Category - Class I). D. INCORRECT: The nurse should give second priority to the client who has major fractures(Urgent Category - Class II).

A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A. The client's input and output for the shift B. The client's blood pressure from the previous day C. A bone scan that is scheduled for today D. The medication routine from the medication administration record

C A. INCORRECT: Unless there is a significant change in the client's intake and output, the oncoming nurse can read that information in the chart. B. INCORRECT: Unless there is a significant change since the client's blood pressure measurements the previous day, the oncoming nurse can read that information in the chart. C. CORRECT: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit. D. INCORRECT: Unless there is a significant change in the client's medication routine, the oncoming nurse can read that information in the chart.

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A.A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B.A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C.A family has conflicting feelings about the initiation of enteral tube feedings for their father, whois terminally ill. D.A client who is terminally ill hesitates to name her spouse on her durable power of attorney form

C A. INCORRECT:Delivering client care while showing signs of a substance use disorder is a legal issue, not an ethical dilemma. B. INCORRECT:A nurse who threatens to restrain a client has committed assault. This is a legal issue, not an ethical dilemma. C. CORRECT:Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. D. INCORRECT:The selection of a person to make health care decisions on a client's behalf is a legal decision, not an ethical dilemma

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Nonmaleficence

C A. INCORRECT:Fidelity is an agreement to keep promises. Because donor organs are a scarce resource compared with the numbers of potential recipients who need them, no one can promise anyone an organ. Thus, this principle does not apply. B. INCORRECT:Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved with the qualifications for organ recipients. C. CORRECT:Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. D. INCORRECT: Nonmaleficence is the avoidance of harm or injury. In this situation, harm can occur to organ donors and to recipients. The requirements of the organ procurement organizations are standard procedures and do not address avoidance of harm or injury

A nurse on a medical‑surgical unit has received change‑of‑shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer

C A. It would be inappropriate to delegate the feeding of a client who has aspiration pneumonia to an AP because the client is at risk for further aspiration. B. Either an RN or an PN, not an AP, may reinforce teaching. C. CORRECT: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to an AP. D. Either an RN or an PN, not an AP, may apply a sterile dressing.

A charge nurse is assigning client care for four clients. which of the following tasks should the nurse assign to a PN A. creating a plan of care for a client who is recovering following a stroke B. assessing a pressure injury on a client who is on bed rest C. providing nasopharyngeal suctioning for a client who has penumonia D. teaching a client who has asthma to use a metered-dose inhaler

C A. creating a plan of care requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN B. assessing a pressure injury requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN C: correct: providing nasopharyngeal suctioning is within the scope of practice of the RN D. teaching requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN

A nurse is caring for a young adult at a college health clinic. which of the following actions should the nurse take first? A. give the client information about immunization against meningitis B. tell the client to have a TB test every 2 years C. determine the client's health risks D. Teach the client about exercise recommendations

C A. part of primary disease prevention, but there is another action the nurse should take first B. part of secondary disease prevention, but there is another action the nurse should take first C. correct: assessment is the first action a nurse should take. talk with the client to determine risk factors before initiating the health promotion and disease prevention measures D. part of health promotion but there is another action the nurse should take first

Processes used in management parallel the nursing process. Which sentence describes a nurse using a management principle paralleled with the nursing process? a. Planning is demonstrated when the nurse motivates others. b. Directing is demonstrated when the nurse plans care for the patient. c. Organizing is demonstrated when the nurse coordinates care for patients. d. Controlling is demonstrated when the nurse tells other staff members what to do.

C According to Fayol, the functions of managers are planning, organizing, directing, and controlling. The nurse demonstrates organizing by coordinating the care delivered to patients. Planning involves goal setting, assessment, and setting the plan and acting on it. Direction involves the ability to motivate others toward a common goal and includes good communication skills. Controlling involves comparing expected results of the planned work with actual results.

Which nursing intervention is the best example of patient advocacy? a. Collecting blood samples according to the physician's order each morning b. Assessing the vital signs of a patient who is receiving a blood transfusion c. Seeking an additional analgesic medication order for a patient who is experiencing severe pain d. Accompanying an ambulating patient who is walking for the first time after undergoing surgery

C Advocacy requires a nurse to work on behalf of others who may be unable to speak for themselves. When a patient is in pain and the physician or primary care provider is not present, a nurse must advocate for the patient's needs by initiating contact with the person responsible for addressing an immediate need. In this case, an order for additional pain medication is needed, which requires collaboration with the patient's physician. Collecting blood samples, assessing vital signs, and assisting a patient with ambulation are primary responsibilities of the nurse that do not require advocacy to meet the patient's need.

Cody wants to plan his morning. To which documentation form would Cody refer to find out activity orders, or what treatments Mr. Brown will be receiving today? A. Standardized care plan B. Flow sheet C. Kardex D. Admission history form

C Answer: C Rationale: The Kardex is a summary of the current list of orders, treatments, and diagnostic testing. This form allows the nurse to have all of these together instead of having to go to various places in the medical record.

Which intervention should the college health clinic nurse implement as a secondary prevention strategy to identify students at risk for diabetes? a. Nutrition education about high-protein food availability b. Promotion of registration in fitness classes c. Blood glucose screening at the health fair d. Administration of prescribed insulin

C Blood glucose screening is the only secondary prevention strategy listed. Education and promotion of fitness classes are primary prevention strategies, and administering insulin is a tertiary prevention intervention.

Making prejudicial, untrue statements about another person during a conversation may expose a nurse to being charged with what offense? a. Libel b. Assault c. Slander d. Malpractice

C Conversation that includes prejudicial and false statements about another person is an example of oral defamation of character or slander. Libel is the written form of defamation of character. Assault is a threat of bodily harm accompanied by a sense of imminent danger. Malpractice is professional negligence caused by unsafe practice.

An 8-year-old girl is newly diagnosed with type 1 diabetes. The nurse may expect fear and crying when teaching the child how to self-administer insulin injections because of which influencing factor? a. Self-concept b. Self-esteem c. Developmental level d. Hierarchy of needs

C Even when the child understands about having the disease, she is less likely to understand the need for insulin therapy due to her emotional and comprehension level of development. A child's self-concept is not well established at this point, and self-esteem is not a major factor. Hierarchy of needs is not yet fully developed because the child depends on her parents for the basic level of needs.

A nurse states she believes in the dignity of each patient. At break, she is overheard talking about a patient in a persistent vegetative state as a "lump." This represents an inconsistency in which quality of an effective leader? a. Dedication b. Magnanimity c. Integrity d. Humility

C Integrity refers to the alignment of stated values and actions. Dedication is the ability to spend the time to accomplish the task. Magnanimity means giving credit where credit is due. Humility is the ability to recognize that no one person is superior to another.

Which statement most closely reflects the differences between nurse leaders and managers? a. Nurse leaders are always in formal positions of authority. b. Nurse managers use transactional principles to accomplish goals. c. Nurse leaders rely primarily on interpersonal skills to accomplish goals. d. Nurse managers rely on supervisors for accountability and responsibility.

C Leaders influence others to effect change. They rely on personal characteristics to convince others that what they envision is worthwhile. Managers get their power from formal positions. Leaders may or may not be in formal positions of authority. Transactional leadership employs reward and punishment to gain the cooperation. Nurse leaders use a variety of leadership and management styles. Nurse managers maintain accountability and responsibility for their decisions.

What nursing intervention is best when a patient is struggling with the decision to abort an abnormally developing fetus discovered during genetic testing in the first trimester of pregnancy? a. Recommend additional testing. b. Refer the patient to an abortion clinic. c. Listen to the patient's concerns. d. Discuss regional adoption agencies.

C Listening is the best option for the nurse when patients are considering ethical care decisions. Patients often need someone to listen to their verbalized concerns to sort out feelings about the situation and make decisions that are best for them. The patient's primary care provider is responsible for recommending further testing or making requested patient referrals.

When developing treatment plans, which assumption should the nurse make about individual clients in vulnerable populations? a. Educational levels are minimal. b. Economic resources are strong. c. Personal beliefs are important. d. Support systems are extensive.

C Personal beliefs of clients within a vulnerable population are always important. They are a key to how people will respond to care that is offered. Educational levels, economic resources, and support systems vary dramatically by individual client within vulnerable populations.

A patient diagnosed with an aggressive cancer is estimated to have 6 months to live. Two months later, the patient's wife calls the nurse's office because she is upset that her husband has taken up motorcycle racing and has already been injured twice. The nurse knows that the patient is experiencing a behavioral change in which factor because of the prognosis of his illness? a. Spirituality b. Physical attributes c. Self-concept d. Personal affect

C Self-concept is profoundly affected by the diagnosis of a terminal disease. The individual often tries to reinvent himself or herself and behaves in an uncharacteristic manner.

The nurse is assigned to administer medications to a patient on a unit that has just implemented bar-code medication administration (BCMA). Which step is proper for the nurse to follow? a. Open the medication packages at the nurses' station. b. Ask the patient to verify his or her address. c. Scan the nurse's ID, the patient's ID, and the code on the medication package. d. Ask the patient to name two patient identifiers.

C The BCMA system scans the nurse's ID, the patient's ID, and the medication package to ensure that the proper drug is given to the correct patient. Asking the patient's address or two random identifiers that the patient may not be aware of would be inappropriate. Proper protocol for administration is to open the medication packages at the bedside. Use of a scanning device requires the medication to still be in the package while scanning to ensure that it is the proper medication

Which description is true about the Nursing Minimum Data Set (NMDS)? a. An admission assessment tool b. A discharge summary c. The core nursing data for collection across all sites d. An organization of nursing diagnoses

C The NMDS is a standardized collection of essential nursing data used by nurses to promote consistent, understandable documentation. Although standard terminology may be used during admission, and discharge, these tools are not a description of NMDS. Nursing diagnoses are organized using NANDA-I.

While performing a physical assessment on a female patient, the nurse finds several bruises on the patient's inner thighs that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. What should be the nurse's first action? a. Refer the patient to a sexual counselor. b. Tell the patient about the safe house for women. c. Ask the patient to describe how she got the bruises. d. Report the abuse immediately to the proper authorities.

C The nurse's first action is to gather more data that can confirm or negate the suspicion of sexual abuse. The other actions also could be appropriate after additional information is obtained.

Which statement is correct concerning the implementation of computerized provider order entry (CPOE)? a. The unit secretary transcribes the physician's orders into the computer. b. The nurse must ensure that orders go to the appropriate departments. c. Physician orders go directly to the appropriate department. d. Handwriting legibility is a major problem.

C Use of CPOE enables orders to go directly to the appropriate department decreasing the potential for errors. There is no transcription of orders and no need for someone to transcribe the orders. Because the orders are typed into the computer, handwriting legibility is not an issue.

A nurse is caring for a client who is transitioning to an oral diet following a partial laryngectomy. Which of the following actions by the nurse is appropriate? A. Request to have the client's oral medications provided in liquid form. B. Instruct the client to follow each bite of food with a drink of water. C. Encourage the client to tuck the chin when swallowing. D. Consult the dietician about providing the client with a thin liquid diet.

C a. medications in liquid form do not decrease risk for aspiration b. drinking liquids increases risk for aspiration c. correct: tucking the chin closes off the trachea and reduces risk for aspiration d. thick liquids reduce risk for aspiration

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. Which of the following actions are appropriate to include in the plan of care? (Select all that apply.) A. Thicken the client's liquids to honey consistency. B. Educate the client about the use of a nasogastric tube. C. Assist the client to use a straw to drink liquids. D. Ensure that the client receives ground meats. E. Encourage the client's intake of fluids between meals.

C, E, A. doesn't cause dysphagia, not necessary to thicken liquids B. doesn't indicate need for nasogastric tube C. correct: help the client determine where to insert the straw through the space in the jaws D. indicates need for liquid diet not ground meats E. correct: jaws will be wired shut and need liquid diet. encourage supplemental and nutrient rich liquids to maintain

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B.A client who has a nasogastric tube to treat a small bowel obstruction C.A client who is scheduled for a transurethral resection of the prostate (TURP) D.A client who is 24 hr postoperative following a mastectomy E.A client who is scheduled for an appendectomy

C,D A. INCORRECT: A client who is dehydrated and receiving IV fluid and electrolytes is unstable for discharge. B. INCORRECT: A small bowel obstruction that is not treated could result in the death of the client. C. CORRECT: A client who is scheduled for a TURP could be safely discharged because a TURP is not an emergent surgery. D. CORRECT: A client who 24 hr postoperative following a mastectomy is stable and could be safely discharged. E. INCORRECT: A client who has appendicitis needs immediate surgery to prevent rupture of the appendix and subsequent peritonitis.

A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A. lie on my back with my head and shoulders elevated on a pillow." B. lie flat on my stomach with my head to one side." C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table." D. lie on my side with my weight on my hips and shoulder with my arms flexed in front of me."

C. CORRECT: The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial to clients who have COPD.

Using Maslow's hierarchy of needs, a nurse would know that needs that are at the base of the pyramid must be satisfied before needs at a higher level are addressed. Which of the following would be considered to be at the base of the pyramid? A. Confidence and achievement B. Security of employment and resources C. Acceptance of facts and problem solving D. Breathing and Excretion E. Friendship and Family

D

Which of the following is NOT part of the six cultural domains used for collecting data in Giger and Davidhizar's Transcultural Assessment Model? A. Social orientation B. Time C. Biologic variation D. Income

D

Which statement is the best resource for the nurse to use when determining appropriate nursing care for a transsexual patient? a. Gender identity is altered by acute psychosis. b. Sexual attraction is to people of both genders. c. Gonadal gender, internal organs, and external genitals are contradictory. d. Anatomy associated with sexual identity is not consistent with gender identity.

D A transsexual's sex organs do not match gender identity. Being a transsexual is not a psychosis. Transsexuals usually are attracted to persons of the gender opposite their own gender identity. Gonadal gender and internal and external organs are not in contradiction.

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?A."I will get the caller off the phone as soon as possible so I can alert the staff." B."I will use overhead paging to alert the entire facility." C."I will not ask any questions and just let the caller talk." D."I will listen for background noises."

D A. INCORRECT: In the event of a bomb threat, the nurse should keep the caller on the line in order to trace the call and to collect as much information as possible. B. INCORRECT: The nurse should avoid announcing that a bomb threat has occurred using the paging system because it could cause mass panic. C. INCORRECT: It is recommended to ask to caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible. D. CORRECT: In order to identify the location of the caller, the nurse should listen for background noises such as church bells, train whistles, or other distinguishing noises.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

D A. INCORRECT:Fidelity is an agreement to keep promises. The nurse is not addressing a specific promise when she determines the appropriateness of a prescription for the client. Thus, this principle does not apply. B. INCORRECT:Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved when the nurse questions the client's prescription. C. INCORRECT:Justice is fairness in care delivery and in the use of resources. In this situation, the nurse is delivering responsible client care and not assessing available resources. This principle does not apply. D. CORRECT: Nonmaleficence is the avoidance of harm or injury. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A.Fidelity B.Autonomy C.Justice D.Beneficence

D A.INCORRECT:Fidelity is an agreement to keep promises. Unless the nurse has specifically promised the client a pain-free recovery, which is unlikely, this principle does not apply to this action. B.INCORRECT:Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. In this situation, the nurse is delivering responsible client care. This principle does not apply. C. INCORRECT:Justice is fairness in care delivery and in the use of resources. Pain management is available for all clients who are postoperative, so this principle does not apply. D.CORRECT:Beneficence is taking positive actions to help others. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

A 65-year-old male patient has been a one-pack-a-day smoker for 40 years. He was recently diagnosed with early stage chronic obstructive pulmonary disease (COPD) and would like to attend a smoking cessation class. The nurse recognizes smoking cessation as which level of prevention for this patient? a. Primary prevention b. Secondary prevention c. Statutory prevention d. Tertiary prevention

D According to the stages for disease prevention, primary prevention is implemented for the absence of disease, secondary prevention applies to the early stages of disease or recently diagnosed risk factors, and tertiary preventive care is offered for permanent and irreversible disease.

What action should nurses who demonstrate accountability take if they forget to administer a patient's medication at the ordered time? a. Document the medication as refused by the patient. b. Administer the medication as soon as the error is discovered. c. Record the medication as given after making sure the patient is okay. d. Follow the administration and documentation procedures for medication errors.

D Agency procedures must be followed after every medication error. Care must be taken to adhere to medication administration recommendations and documentation requirements to legally record the incident and provide patient safety. Documenting that the patient refused or already took the medication, when that is not factual, is illegal and unethical, regardless of the patient's condition. Administering the medication as soon as the error is discovered may not be recommended, depending on the medication's potency and frequency of administration.

If a student nurse overhears a peer speaking disrespectfully about a patient, nurse, faculty member, or classmate, what is the most ethical first action for the student nurse to take? a. Discuss the peer's actions during group clinical conference. b. Ignore the initial occurrence and observe if it happens again. c. Report the actions of the classmate to the clinical instructor. d. Speak to the peer privately to prevent further occurrences.

D Alerting the peer who has acted disrespectfully in a private setting is the most professional way to approach this situation. It is never appropriate for a professional to belittle or reprimand a peer in front of others. Ignoring disrespectful behavior may only perpetuate its occurrence. Seeking help from a clinical instructor would be appropriate if the peer does not respond to the initial intervention from the fellow student.

Effective nurse managers focus on which area? a. Cost-effective operation of the unit b. Motivation of staff c. Accomplishing organizational goals d. The patients and their needs

D All of the options are considerations of an effective manager. However, at the core of all nursing management actions must be the benefit of the patient or patient population that is served.

A 75-year-old male patient reports decreased frequency of sexual intercourse, although he does not express dissatisfaction or difficulty. He seems a little embarrassed by the discussion, but is engaged and asks some questions. Which nursing diagnosis does the nurse determine is most appropriate for this patient? a. Sexual Dysfunction b. Disturbed Body Image c. Sedentary Lifestyle d. Readiness for Enhanced Knowledge

D Because the patient is able to discuss the topic of reduced sexual frequency without noting difficulty or dysfunction, manages any embarrassment, is engaged in the conversation, and is able to ask questions, the most appropriate nursing diagnosis is Readiness for Enhanced Knowledge. These collective behaviors do not describe Sexual Dysfunction or Disturbed Body Image, and "sedentary lifestyle" is not a NANDA-I nursing diagnosis.

Which of the listed basic needs identified by Maslow must be addressed first when providing nursing care? a. Self-esteem b. Love and belonging c. Self-actualization d. Nutrition and elimination

D Nutrition and elimination must be addressed first before concerns about self-esteem, love and belonging, and self-actualization, according to Maslow's hierarchy of needs. According to Maslow, the lower-level needs must be fulfilled and maintained before the higher-level needs can be met.

A patient who had a hysterectomy 3 days ago says to the nurse, "I no longer feel like a real woman." Which response by the nurse would be most appropriate? a. "Don't worry about that. The feeling will probably go away." b. "You should talk to your doctor about how you feel." c. "I don't blame you. I would feel like half a woman also." d. "I hear your concern. Tell me more about your feelings."

D Providing an opportunity for communication with an open-ended response encourages the patient to discuss concerns. Telling the patient not to worry is dismissing those concerns and will hamper discussion. Agreeing with the patient also is nontherapeutic and does not foster dialogue. Telling the patient to talk with the doctor stops the chance of conversation and reduces the nurse's role in helping the patient to express feelings.

The outpatient clinic nurse develops a plan of care focusing on diet, exercise, and glucose monitoring for a preteen recently diagnosed with early-onset type 2 diabetes. On what type of interventions has the nurse based the client's care plan? a. Primary b. Progressive c. Secondary d. Tertiary

D The nurse has incorporated tertiary interventions, because the client has already been diagnosed with an illness. Tertiary interventions are implemented once a disease occurs, to prevent further deterioration.

The nurse manager is monitoring overtime for the unit. She closely monitors staff hours and does not allow staff to come in for extra hours if they are over their allotted time per week. This is an example of which of Mintzberg's decisional roles of the manager? a. Entrepreneur b. Disturbance handler c. Negotiator d. Resource handler

D The resource handler function of the decisional role of the manager includes monitoring the budget and regulating the use of personnel time. In the entrepreneur role, the manager is the problem solver. The disturbance handler responds to unplanned change. The negotiator works within and outside of the organization to intercede for resources and help.

What action should a nurse take if a patient who needs to sign an informed consent form for nonemergency surgery appears to be under the influence of drugs or alcohol? a. Contact the physician to see what should be done. b.Ask the patient's spouse to sign the form. c. Request permission to bypass the need for a signed consent form. d. Wait to have the informed consent form signed when the patient is alert and oriented.

D When a normally competent patient is assessed to be under the influence of alcohol or drugs, it is the nurse's responsibility to delay a nonemergency procedure until legal informed consent can be obtained from the patient. Only in the case of an emergency is it possible to obtain informed consent from a spouse or designated power of attorney for a temporarily impaired adult. It is not necessary to contact the physician for guidance on what should be done because there is an established legal procedure to follow. The nurse should contact the surgeon who is scheduled to perform the surgery and the operating room staff regarding the need to delay due to the patient's status.

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A."I'll be able to function exactly as I did before the accident." B."I just can't stop crying." C."I am so mad at that guy who hit us. I wish he lost a leg." D."I don't even want to look at my leg. You can check the dressing."

D CORRECT:Refusing to look at the leg or the dressing indicates that the client is having difficulty acknowledging the fact that the leg has been amputated. This would imply a distorted body image.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.

D. CORRECT: The first action the nurse should take using the nursing process is to assess/collect data from the client. The nurse should assess the client's ability to help with transfers (balance, muscle strength, endurance). Then the nurse can proceed with a safe transfer of the client.

Bringing the different points of view of the ethics committee members to agreement and harmony is referred to as collective ethics. A. True B. False

False Rationale: Building consensus brings different points of view to agreement and is an act of discovery in which "collective wisdom" guides a group to the best possible decision.

Michelle knows that infertility is the inability to conceive after 6 months of unprotected intercourse. A. True B. False

False, Infertility is the inability to conceive after 1 year of unprotected intercourse.

During the counseling session with Michelle, the nursing mentor, and the childless couple, sexual dysfunction is discussed. Sexual dysfunction is higher in men than in women. A. True B. False

False, The general incidence of sexual dysfunction in the general population is estimated to be as high as 40% in men and 45% in women.

The committee evaluates the impact of relationships on health care. _____________ ethics looks to the nature of relationships to guide participants in making difficult decisions.

Feminist Rationale: Feminist ethics looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible.

A nurse approached an overweight patient about lifestyle modifications to reduce the risk for heart disease. The patient demonstrates lack of perceived susceptibility by making which statement? a. "I'm only a little overweight; there is no way I can have a heart attack." b. "I should lose a few pounds and try to exercise more often." c. "I don't think a little weight loss is related to heart disease." d. "I will investigate the online Weight Watchers programs that helped me in the past."

a

A nurse is making assignments for the day. One of the nurses just returned from medical leave due to a back injury. Which patient would be most appropriate to assign to this nurse? a. Confused, ambulatory, and requires assistance with feeding b. Recent postoperative total knee replacement patient who has not gotten out of bed yet c. Elderly, requires one-person assistance for bed-to-chair transfers d. Cerebral palsy patient with pneumonia, uses a wheelchair

a

A patient recognizes that a family history of a terminal disease predisposes him to the same disease. The nurse recognizes this realization as which component of the Health Belief Model? a. Perception of susceptibility b. Likelihood of action c. Modification of factors d. Adherence to factors

a

A school nurse wants to participate in a primary prevention event related to obesity. What event would the nurse join? a. Education event about healthy eating habits and fun ways to exercise. b. Screen for BMI and send letters home to parents of identified at-risk children. c. Volunteer at a summer camp for obese children. d. Create a weight loss contest with weekly weigh-ins.

a

End-of-life care for terminally ill clients in their homes is described as which type of nursing? a. Hospice b. Public health c. Community based d. Home health care

a

If a nurse threatens to strike a patient while rushing toward the patient in an angry manner, which intentional tort has been committed? a. Assault b. Battery c. Negligence d. Invasion of privacy

a

The nurse determines that which question is the most appropriate way to begin a sexual assessment of an older adult? a. "How has your sexual function changed as you have become older?" b. "Do you find it embarrassing to talk about sexual activity?" c. "Do you ever feel pressured or unsatisfied during sexual activity?" d. "Would it be okay if I asked you some questions about your sexual health?"

a

The nurse is speaking to UAP about an immigrant for whom they are caring. Neither the nurse nor the UAP are familiar with the patient's culture. The UAP states, "I don't trust him. He never looks you in the eye. He must be lying about something." What must the nurse recognize in order to effectively manage the situation? a. The UAP is unaware of the cultural traditions of the patient and beliefs about eye contact. b. The UAP most likely has some good insight into this patient's behavior. c. The UAP comfort with closer social space is making the patient uncomfortable. d. The patient most likely does not feel well and just wants to rest.

a

The school nurse drives or walks through the community to observe if people are walking or engaged in physical activity. This is called a: a. windshield survey. b. health walk. c. walk through. d. community tour.

a

When a patient asks the nurse what forms of birth control options are over the counter, the nurse will respond at which level of the PLISSIT model? a. Limited information b. Specific suggestion c. Permission giving d. Intensive therapy

a

Which statement is true regarding codes of ethics and laws? a. Ethical codes hold professionals to a higher standard than the law. b. Laws limit the scope of codes of ethics in most professions. c. Breaking the law is not always an ethical code violation. d. Codes of ethics delineate punishments for breaking laws.

a

The nurse conducting community wellness events recognizes that which elements contribute to an individual's health and wellness? (Select all that apply.) a. Age b. Genetics c. Access to health care d. Culture e. Environmental f. Health policies

a, b, c, d, e, f

The nurse using the OASIS data set would assess clients for which of the following? (Select all that apply.) a. Vaccination status b. Living arrangements c. Understanding of medication regime d. Integumentary status e. Behavioral and neurological status f. Past medical and surgical history

a, b, c, d, e, f

Which actions describe the primary scope of practice of a public health nurse? (Select all that apply.) a. Assesses populations within the community b. Emphasizes health promotion and disease prevention using evidence-based strategies c. Focuses on individual, setting specific care. d. Collaborates with community stakeholders to assure that essential health services are available to the community. e. Promotes health policies to protect health

a, b, d, e

A nurse working in an early childhood home visitation program tells a class of nursing students that outcome provided by the service include which of the following? (Select all that apply.) a. Reduction in child maltreatment b. Improved spacing of pregnancies c. Improved social development of child d. Improved cognitive abilities of mom e. Better childhood health overall

a, c, e

When the nurse teaches sexually transmitted disease (STD) prevention, which unimmunized individual would be identified as being at the highest risk for contracting the human papilloma virus (HPV)? a. A prepubescent 11-year-old child b. A sexually active 21-year-old college student c. A 42-year-old celibate divorced person d. A 28-year-old monogamous married person

b

Which components must exist for nursing malpractice to be established? (Select all that apply.) a. Intent of harm to the patient b. Omitted or substandard care c. Injury resulting from care provided d. Responsibility to provide nursing care e. Emotional distress

b, c, d

Which of the following are examples of the planning function of management? (Select all that apply.) a. Taking action b. Goal setting c. Assessing the present situation d. Setting the plan e. Being creative

b, c, d

A hospitalized patient comments to the nurse, "Well, I guess my sex life is over." Which response from the nurse would be the most appropriate? a. "I am sorry to hear that." b. "Tell me why you say that." c. "Oh, you have a lot of good years left." d. "Have you asked your doctor about that?"

b

A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catherization. The client states, "I am concerned that things might be a little, you know, 'different' with my partner when I get home." Which of the following statements should the nurse make? a. "Sounds like something you should discuss with them when you get home." b. "It sounds like you are concerned about sexual function. Let's discuss your concerns." c. "Oh I wouldn't be too concerned. Things will be fine as soon as you get home." d. "Just make sure you take your medication as directed, and you will be fine."

b

A nursing student is fascinated by reading about the frequency and distribution of diseases and injuries. What specialty area is this student interested in? a. Public health b. Epidemiology c. Case management d. Population analyst

b

A staff nurse in the critical care unit routinely assists with calling staff to find coverage for the next shift and volunteers to coordinate policy and procedure revision and development on the unit. Which type of leadership is this nurse demonstrating? a. Formal b. Informal c. Laissez-faire d. Democratic

b

An adult patient is mentally incompetent to make personal health care decisions. Which advance directive should the nurse refer first prior to contacting a person to provide consent for the patient? a. Living will b. Health care proxy c. Do not resuscitate orders d. Durable power of attorney

b

What nursing intervention best demonstrates a commitment to patient autonomy? a. Encouraging a patient to ambulate independently following surgery b. Collaborating with a patient while developing the patient's care plan c. Establishing patient-centered goals for decreased chronic pain d. Assessing a patient for potential postprocedural complications

b

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply) a. A client who has had a laparoscopic appendectomy b. A client who had a mastectomy c. A client who had a left above-the-knee amputation d. A client who had a cardiac catherization e. A client who had a stroke with right-sided hemiplegia

b, c, e

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) a. Right place b. Right supervision and evaluation c. Right direction and communication d. Right documentation e. Right circumstances

b, c, e

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which of the following client statements indicate an understanding of the teaching? (Select all that apply) a. "I should select organic canned vegetables." b. "I need to read food labels when grocery shopping." c. "I will stop eating frozen dinners for lunch at work." d. "I know that deli meats are usually high in sodium." e. "I can refer to the American Heart Association's website for good dietary recommendations."

b, c, e

When teaching a patient about surgical procedures for birth control, the nurse would include which methods? Select all that apply. a. Diaphragm b. Vasectomy c. Hormone injection d. Tubal ligation e. Oral contraceptives

b, d

For which reasons are patients unlikely to introduce the topic of sex with health care providers? Select all that apply. a. Most patients have few, if any, questions or problems relating to this topic. b. They are too embarrassed to discuss the topic of sex with a health care provider. c. Female patients prefer to discuss problems with female health care providers. d. They assume that health care professionals know little about sexual functioning. e. They are concerned that the health care professionals will be judgmental.

b, e

___________ is mental or physical exhaustion due to constant stress or activity.

burnout

A nurse has considered relevant patient factors such as isolation requirements, acuity, mobility, and other care needs when determining who can care for each patient. This is a demonstration of what right of delegation? a. Right task b. Right person c. Right circumstance d. Right supervision

c

A nurse is in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse, "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? a. "I'd rather have my brother made decisions for me, but I know it has to be my wife." b. "I know they won't go ahead with the surgery unless I prepare these forms." c. "I plan to write that I don't want them to keep me on a breathing machine." d. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

c

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? a. "Lie on your back with your head and shoulder supported by a pillow." b. "Have your head turned to the side while you lie on your stomach." c. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." d. "Lie on your side with your top arm resting on the bed and your weight on your hip."

c

A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today d. Medication routine from the medication administration record

c

A nurse manager receives two vacation requests from staff for the same days off. Unit policy states that only one person may be off at a time. The manager decides to allow the staff the time off anyway. What type of leadership is the manager demonstrating? a. Democratic b. Bureaucratic c. Laissez-faire d. Autocratic

c

A school nurse notes that several children in the facility have diabetes type 2. The nurse wants to have several hours during the week set aside for these children to check their blood glucose logs and food intake. This type of activity would be known as which of the following? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Progressive prevention

c

Decisions regarding the legality of licensed practical nurses administering intravenous therapy established in the Nurse Practice Act are determined by which type of law? a. Constitutional b. Statutory c. Regulatory d. Case

c

If a student nurse is asked by a staff nurse to complete a patient care procedure that the student has previously performed only in lab, what response by the student best exemplifies an ethical commitment to both safe practice and learning? a. Asking the staff nurse to perform the care procedure while the student observes b. Locating the clinical instructor to provide the patient care procedure with student oversight c. Reviewing the procedure prior to initiating the patient care with supervision of a registered nurse d. Requesting the help of another student who has previously performed the patient care procedure

c

Sexual health history questions would be most relevant for the nurse to include when admitting a patient who is taking what type of medication? a. Hypnotics (sleeping pills) b. Antihistimines (cold medications) c. Antihypertensives (blood pressure medication) d. Antiinflammatories (such as aspirin or ibuprofen)

c

Strategies introduced at the first detection that a health problem may be evident is called: a. tertiary intervention. b. primary intervention. c. early intervention. d. secondary intervention.

c

The nurse informs a group of men at the senior citizens' center about what age-related sexual change? a. Increased testosterone levels b. More frequent erections c. Weaker erections d. Sperm production increases

c

The outpatient surgical nurse is caring for a 35-year-old married male who has been admitted for a vasectomy. Though he is seeking this procedure of his own free will, the nurse's personal moral standards indicate this is wrong. What would be the most appropriate action by the nurse when caring for this patient? a. Have the hospital chaplain speak with this patient. b. Remind the patient that he has time to still change his mind. c. Provide the patient with appropriate care, realizing the decision is personal. d. Tell the patient about all the males in the infertility clinic who would be envious

c

Veracity mandates which action by the nurse if a cancer patient inquires about diagnostic test results that show further metastasis of the patient's cancer? a. Telling the patient that the diagnostic test results are not available yet from the laboratory b. Avoiding contact with the patient to prevent accidental disclosure of the information c. Encouraging the patient to discuss the results with the provider who ordered the tests d. Sharing that the test results do not appear to indicate any significant changes at this time

c

Which action by the nurse best illustrates the ethical concept of fidelity? a. Caring for an incarcerated patient without expressing disdain b. Weighing the benefits versus the risks of medical treatment c. Ensuring that patients receive care that is promised d. Endorsing equal access to health care for everyone

c

Which statement by a patient indicates an accurate understanding of contraceptive methods? a. "Hormonal injections are an effective defense against sexually transmitted infections." b. "Abstinence is never an effective method of contraception when used as a strategy." c. "Withdrawal of the penis before ejaculation is an ineffective method of birth control." d. "Emergency contraceptives will abort a fertilized egg."

c

A patient is preparing for discharge. In discussing one of the discharge medications ordered, the patient mentions that the medication is too expensive to purchase. What action by the nurse best displays advocacy? a. Explain to the patient that the medication must be taken as ordered to work. b. Get the names of local pharmacies that offer discounted prescriptions. c. Contact the provider to schedule a follow-up appointment to check adherence. d. Contact the social worker to investigate programs to help the patient.

d

A patient undergoing chemotherapy for bone cancer states that using guided imagery in conjunction with pain medications helps in tolerating bone marrow aspirations. The nurse recognizes guided imagery as a component of which health promotion model? a. The Health Function Model b. Lifestyle Fatality Model c. Model for Human Disease Progression d. Holistic Health Model

d

A young adult male patient tells the nurse he uses marijuana regularly to try to boost sexual performance. What statement does the nurse identify as true about the effects of marijuana on sexual performance? a. Marijuana has no effect on sexuality. b. Even a small amount of marijuana can cause ED. c. Marijuana can reduce sex hormone levels and sperm production. d. Chronic use results in loss of desire in men and women and ED in men.

d

According to Maslow's hierarchy of needs, the nurse understands that which element(s) must be maintained first before a patient can reach self-actualization? a. Self-esteem b. Safety c. Love and belonging d. Nutrition

d

According to Mintzberg's 1994 model, what are the three levels of management? a. Thinking, feeling, and doing b. Planning, directing, and controlling c. Autocratic, democratic, and laissez-faire d. Information, people, and action

d

In the United States, practicing nursing without a license is what type of offense? a. Misdemeanor b. Malpractice c. Battery d. Felony

d

The nurse has assessed that the patient has the confidence in the ability to take action. What is this concept is called? a. Perceived benefits b. Cues to action c. Perceived severity d. Self-efficacy

d

The nurse manager of a nursing unit monitors the actual number of missed medications on the unit each month and compares this number with the expected results. This is an example of which function of management? a. Planning b. Organizing c. Directing d. Controlling

d

To be effective, nurse managers should focus on which area? a. Cost-effective operation of the unit b. Motivation of staff c. Accomplishing organizational goals d. The patients and their needs

d

What action by the nurse at the site of a motor vehicle accident is critical in order for requirements of the Good Samaritan Act to be met? a. Accepting compensation for professional services b. Transferring rescue efforts to family members c. Providing all needed emergency intervention d. Performing within nursing standards of care

d

You are the nurse in charge of a care team consisting of a new graduate, a male UAP, and an LPN. You are caring for a patient with renal failure and congestive heart failure. The patient is bedridden and weighs 227 kilograms (500.1 lb) and must be turned every 2 hours. In making out assignments, what is your best approach? a. Assign the patient to the new nurse so she can get experience with a large patient. b. Assign the patient to the UAP because he is a male and is stronger. c. Assign the patient to the LPN and the new RN so the new RN can perform assessments. d. Take this patient as your own assignment and assign the other staff to assist with turns every 2 hours.

d

List complementary and alternative therapies.

music, exercise, sleep, meditation, yoga, biofeedback, relaxation therapy, mindfulness

Health as defined by the World Health Organization as "a state of complete __________, __________, and __________ well-being and not merely the ____________ of __________ or ____________."

physical, mental, social, absence, disease, infirmity

What are individual risk factors regarding stress?

sleep schedule, workload, socioeconomic status, cultural/language barriers