1163 NRSG Review P&P
The nurse is teaching a patient how to perform a testicular self-examination. What does the nurse tell the patient? "The testes are normally round, movable, and have a lumpy consistency." "Contact your health care provider if you feel a painless, pea-sized nodule." "The best time to do a testicular self-examination is after your bath or shower." "Perform a testicular self-examination weekly to detect signs of testicular cancer.
"Contact your health care provider if you feel a painless, pea-sized nodule."
A nursing instructor is helping a student nurse with discharge planning for a patient. The instructor realizes that further education is needed when the student nurse says which of the following? A: "I need to go over the patient's medications with him in terms he will understand." B: "I really can't start discharge planning until the physician writes the discharge orders." C: "I will give the patient's wife the appointment time I scheduled for follow-up and a list of agencies that provide medical supplies." D: "I will review signs and symptoms of infection with the patient so he will know what to watch for and will realize he should seek medical treatment if these occur."
"I really can't start discharge planning until the physician writes the discharge orders."
The nurse suspects that the patient is at risk for falling. Which of the following statements made by the patient would most alert the nurse to this risk? "My cancer has been in remission for five years." "I have lost 9 kg during the past six months." "I recently began taking medication for high blood pressure." "I no longer have pain in my knee after physiotherapy."
"I recently began taking medication for high blood pressure."
A patient's family member wipes her eyes as she cries at the loss of a loved one and says, "It's no big deal. I mean, we all have to die sometime, right?" The nurse is engaging in metacommunication when he responds with which following statement? "You are taking this really well." "You are exactly right. Dying is inevitable." "Losing a loved one can be really difficult. It looks like you're pretty upset. I'd like to help." "Let's not talk about it. That will help you feel better. After all, God won't give you more than you can handle."
"Losing a loved one can be really difficult. It looks like you're pretty upset. I'd like to help."
Family members make the following comments about the nursing care being received. Which one should be investigated further? "The nurses showed us how to keep Mother's arm propped on a pillow." "Our nurses don't seem too optimistic about the outcome of Dad's stroke." "The night nurse tells us to wait and ask the doctor the questions we have." "The nurses have written down the turn schedule and taped it above the bed."
"The night nurse tells us to wait and ask the doctor the questions we have."
Which of the following is an open-ended question the nurse might use when interviewing a client? "Do you have any concerns right now?" "Is your family worried about your being in the hospital?" "What do you mean when you say, 'I don't feel quite right'?" "How many times do you get up to go to the bathroom at night?"
"What do you mean when you say, 'I don't feel quite right'?" allows the client to respond completely and with more than a one-word answer.
Which of the following statements by the nurse would be nontherapeutic and tend to block communication? (Select all that apply.) "You look sad today." "Why are you so nervous?" "If I were you, I'd have the surgery." "I'm sure the test results will come out fine." "Tell me what it's like to live with dizziness."
"Why are you so nervous?" "If I were you, I'd have the surgery." "I'm sure the test results will come out fine."
When assessing the rectal temperature of an adult patient, how far should the nurse insert the temperature probe into the anus? 2 cm 3.5 cm 5 cm 1.5 cm
3.5 cm
A woman with which of the following waist circumferences is at significant risk for heart disease and stroke? 30 cm 45 cm 60 cm 90 cm
90 cm A waist circumference above 88 cm puts women at greater health risk.
Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following patients would it be most appropriate for unregulated care providers to measure the patient's vital signs? A patient who recently started taking an antiarrhythmic medication A patient with a history of transfusion reactions who is receiving a blood transfusion A patient who has frequently been admitted to the unit with asthma attacks A patient who is being admitted for elective surgery who has a history of stable hypertension
A patient who is being admitted for elective surgery who has a history of stable hypertension
A nurse who normally uses touch when caring for patients might consider this inappropriate for which of the following patients? A patient of the opposite sex A patient from a culture different from that of the nurse A psychiatric patient who is displaying suspicion and fear A patient who has many family members present in the room
A psychiatric patient who is displaying suspicion and fear
A home health nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A 55-year-old obese man recently diagnosed with diabetes mellitus A recently widowed 76-year-old woman recovering from a mild stroke A 22-year-old mother with a 3-year-old toddler who underwent tonsillectomy A 46-year-old man recovering at home following coronary artery bypass surgery
A recently widowed 76-year-old woman recovering from a mild stroke
Pair the following sentences with working phase, termination phase, and orientation phase A: "Mrs. Jones, tell me what brought you to see the nurse practitioner today." B: "As your nurse, I am pleased to see that you are going home to be with your family over the holidays." C: "Mr. Smith, my name is Jane, and I will be asking you some questions to obtain information that is important for us to care for you properly."
A: Orientation Phase B: Termination Phase C: Working Phase
Visual acuity declines with age. Presbyopia is a progressive decline in which of the following? Ability to see in darkness Adaptation to abrupt changes from dark to light Ability of the eyes to accommodate for close, detailed work Ability to distinguish between blues and greens and among pastel shades
Ability of the eyes to accommodate for close, detailed work
When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? (Select all that apply.) Ability to cook meals Ability to feed oneself Ability to write cheques Ability to bathe oneself Ability to take medications
Ability to cook meals Ability to write cheques Ability to take medications
When the nurse is performing surgical hand hygiene, what is the appropriate position for the hands?
Above the elbows
To meet the psychosocial needs of the older adult, the nurse may do which of the following? Acknowledge the older adult's role transitions and changes. Provide large-print reading material and a bright light. Use blue, green, and pastel shades to help create landmarks. Use music therapy, choosing music from the older adult's era.
Acknowledge the older adult's role transitions and changes.
The patients most in need of perineal care are those at the greatest risk for which of the following? Continence Falling Acquiring an infection Needing to be hospitalized
Acquiring an infection
Cultural competence is the process of which of the following? Learning about the large number of cultures Developing motivation and commitment to caring Using the dominant culture to influence care Acquiring specific knowledge, skills, and attitudes
Acquiring specific knowledge, skills, and attitudes
To determine the precise amount of a specific nutrient that Jane, an overweight 20-year-old, requires, the nurse considers which of the following aspects of dietary reference intakes? Estimated average requirement Recommended dietary allowance (RDA) Upper intake level Adequate intake
Adequate intake
Which two factors contribute to the projected increase in the number of older adults? Financial success and improved environment Greater acceptance of older adults and medical problems Improvements in health care programs for older adults Aging of the baby boom generation and the growth of the population segment over age 85
Aging of the baby boom generation and the growth of the population segment over age 85
As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route? Airborne Ingestion Absorption Bloodborne
Airborne
As sexuality is recognized as a factor in the care of older adults, which of the following is true? The need to touch and be touched is decreased. A decrease in an older adult's libido does occur. Any expression of sexuality should be discouraged. All older adults, whether healthy or frail, need to express sexual feelings.
All older adults, whether healthy or frail, need to express sexual feelings.
If the nurse is working with a patient who has expressive aphasia, it would be most helpful for the nurse to do which of the following? A: Ask open-ended questions. B: Speak loudly, and use simple sentences. C: Allow extra time for the patient to respond. D: Encourage a family member to answer for the patient.
Allow extra time for the patient to respond. For patients with aphasia, the nurse should be sure to allow extra time for the patient to respond. Asking open-ended questions is important, but these questions have to be developed based on the patient's personal communication ability. S peaking loudly is not necessary for a patient with a diagnosis of aphasia. The patient should be encouraged to answer questions himself or herself and not expect others to answer for the patient, even if it takes longer for the patient to do so.
The nursing diagnosis "hypothermia" is an example of what kind of diagnosis?
An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, a family, or a community.
While auscultating heart sounds, the nurse documents that S2 is best heard at the base. This sound (S2) correlates with closure of which of the following? Aortic and mitral valves Mitral and tricuspid valves Aortic and pulmonic valves Tricuspid and pulmonic valves
Aortic and pulmonic valves
The nurse's documentation indicates that a patient has a pulse deficit of 14 beats. How is the pulse deficit measured?
Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference
It is essential that nurses provide care based on transcultural principles. Which of the following examples best illustrates this principle? Gender-congruent care includes caring touch by the nurse for all genders. Part of caring is working with patients in the end-of-life stage. The caring aspect includes telling the patient directly that he or she is in the dying phase. Assessment of the patient's culture and family background by the nurse is important to determine if the nurse should provide or other individuals should be providing the caring and touch that communicates presence. Caring touch by the nurse transcends all cultures and ethnic backgrounds.
Assessment of the patient's culture and family background by the nurse is important to determine if the nurse should provide or other individuals should be providing the caring and touch that communicates presence.
The nurse demonstrates active listening by doing which of the following? Approving the patient's decision Repeating everything the patient says to clarify Assuming a relaxed posture and leaning toward the patient Smiling and nodding continuously throughout the interview
Assuming a relaxed posture and leaning toward the patient
Which of the following is subjective information to be entered in the client's medical record? A: Skin warm and dry. B: Pain intensity 8 out of 10. C: Breath sounds clear to auscultation. D: Amber urine in sufficient quantities.
B Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it depends on the client's report. The other options are objective data.
In addition to bathing, which of the following may best promote patient comfort? Snack Back rub Quiet music Many visitors
Back rub
For a nursing student to enhance cultural awareness, the student will need to make an in-depth self-examination of which of the following? The effect on others of his or her cultural background Social, cultural, and biophysical factors Engagement in cross-cultural interactions Background, including recognition of biases and prejudices
Background, including recognition of biases and prejudices
Depending on the patient's age and physical condition, the room temperature should be maintained at which of the following levels?
Between 20°C and 23.3°C
Ethnocentrism is the root of which of the following? Cultural beliefs Biases and prejudices Meanings by which people make sense of their experiences Individualism and self-reliance in achieving and maintaining health
Biases and prejudices
How does the nurse demonstrate listening skills? By blocking nonverbal communication so that the verbal communication is more defined By waiting until mealtimes so that the conversation can be more sociable By surrounding the patient with family and friends to make him or her comfortable By paying attention to the tone of voice in addition to the patient's words so the meaning is clear
By paying attention to the tone of voice in addition to the patient's words so the meaning is clear
When addressing cultural needs during the postpartum period, the nurse knows that which of the following statements is correct? A: Hindu mothers prefer bathing and sitz baths to feel clean after delivery and prefer liquid diets for several days after delivery. B: In Western medicine, it is common practice to perform religious rituals, such as a cleansing bath, before sexual relations are resumed after delivery. C: Members of non-Western cultures have fewer problems with postpartum depression because attention is given to the mother's recovery for a longer period of time. D: Eastern cultures, such as the Chinese, encourage activity and exercise by the mother soon after the delivery and a return to social involvement as soon as possible.
C: Members of non-Western cultures have fewer problems with postpartum depression because attention is given to the mother's recovery for a longer period of time.
Which of the following laboratory values would the nurse expect to see for a patient experiencing prolonged immobility? Calcium 11.5 mg/dL Sodium 142 mmol/L Potassium 4.2 mmol/L Hemoglobin 146 g/L
Calcium 11.5 mg/dL Immobility causes the release of calcium into the circulation, whereas under normal conditions, the kidneys excrete the excess calcium. However, if the kidneys is unable to respond appropriately, hypercalcemia results. Pathological fractures may occur if calcium reabsorption continues as the patient remains on bed rest or continues to be immobile.
A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner. Which of the following is the most important instruction the nurse can give to this parent? Give the child milk. Call the poison control centre. Try to make the child vomit. Take the child to the emergency department.
Call the poison control centre.
The nurse is working in a nursing home and decides to implement a stringent mouth care protocol. What is the most important reason to establish this protocol? Prevents the formation of caries Improves the patient's self-image Minimizes the occurrence of halitosis Can reduce the incidence of pneumonia in older adults
Can reduce the incidence of pneumonia in older adults
According to Watson's transpersonal caring theory, the nurse should understand which of the following concepts about caring? The act of caring is personal and cannot be shared. Caring can increase healing and promote well-being. Expressions of human caring are the same for all individuals. Nurses must use caring behaviours specific to their own cultures
Caring can increase healing and promote well-being
Which of the following characterizes kyphosis, a change in the musculoskeletal system? Decreased bone density in the vertebrae, hips, and wrists Increased risk for pathological stress fractures in the hip and wrist Changes in the configuration of the spine that affect the lungs and thorax Calcification of the bony tissues of the long bones, such as those in the legs and arm
Changes in the configuration of the spine that affect the lungs and thorax
The nurse conducts a general survey of an adult patient, which includes which of the following? Checking appearance and behaviour Measuring vital signs Asking about a review of systems Conducting a detailed health history
Checking appearance and behaviour
For which airborne disease(s) would the nurse be required to use gloves, respiratory devices, and a gown when in close contact with the patient? Scabies Viral pneumonia Chickenpox Pulmonary tuberculosis
Chickenpox
Jewish: hospitalized, the nurse should expect which special needs? Circumcision of all newborn boys Cremation of the body as soon as possible after death Burial of the placenta close to the home for newborn girls Dietary restrictions of no meat but only vegetables and herbs for the patient's diet
Circumcision of all newborn boys
The nurse tells the patient, "I'm not sure I understand what you mean by 'sicker than usual.' What is different now?" Which therapeutic technique is the nurse using? Focusing Clarifying Paraphrasing Providing information
Clarifying
Give an example of an outcome statement in measurable terms
Client will report pain intensity of less than 4 on a scale of 0 to 10
What type of interview technique are you using when you ask the question, "Do you have pain or cramping?"
Closed-ended questioning -one word reply
The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. What skill is the nurse demonstrating?
Cognitive Skill The nurse is using sound judgement and clinical decisions to provide individualization of care. A decision is made without direct interaction with the client but is based on knowledge about the client.
During the orientation phase of the helping relationship, the nurse might do which one of the following? Comment on the cards and flowers in the room. Work together with the patient to establish goals. Review the patient's history to identify possible health concerns. Use therapeutic communication to manage the patient's confusion.
Comment on the cards and flowers in the room
Hygiene care requires close contact with the patient. The nurse initially uses which of the following to promote a caring therapeutic relationship? Assessment skills Therapeutic touch Fundamental skills Communication skills
Communication skills
When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following? Use a fluorescent lamp. Blanch the skin while observing the colour change. Compare one side of the body with the other. Use the back of a gloved hand to feel for skin temperature.
Compare one side of the body with the other.
Which of the following concepts represent the five concepts of Roach's "human act of caring" theory? (Select all that apply.) Competence Confidence Commitment Compatibility Conscience Compassion
Conscience Commitment Confidence Competence Compassion
A client is experiencing nausea and abdominal distension postoperatively. The nurse initiates the interventions listed below. Which of the interventions are examples of an independent intervention? (Select all that apply.) Provide frequent mouth care. Maintain IV infusion at 100 mL/hour. Administer prochlorperazine (Compazine) via rectal suppository. Consult with the dietitian on initial foods to offer the client. Control aversive odours and unpleasant visual stimulation that trigger nausea.
Control aversive odours and unpleasant visual stimulation that trigger nausea. Provide frequent mouth care.
The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is the nurse demonstrating?
Control of adverse reactions The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids.
A nurse-patient helping relationship is characterized by which of the following actions by the nurse? Solving problems for the patient Distorting the truth when the patient is to receive bad news to protect the patient Conveying acceptance by always agreeing with the patient or approving of the patient's decisions or actions Conveying nonjudgemental acceptance with a willingness to hear a message or to acknowledge feeling
Conveying nonjudgemental acceptance with a willingness to hear a message or to acknowledge feeling
When assessing the older adult, the nurse should review the patient's achievement of developmental tasks. For the older adult, these may include which of the following? (Select all that apply) Coping with the loss of the work role Accepting himself or herself as aging Redefining relationships with children Engaging in more introspective, self-focused activities
Coping with the loss of the work role Accepting himself or herself as aging Redefining relationships with children
Theorist Jean Watson has a number of "carative" processes. Which concept is included in her processes? Compassion is a way of living born out of an awareness of one's relationship to all living creatures. Conscience is a state of moral awareness. Cultivating sensitivity to oneself and others is important. Competence is a state of having the knowledge, judgement, and skills to meet professional responsibilities.
Cultivating sensitivity to oneself and others is important.
Which statement about cultural safety is correct? Cultural awareness and cultural sensitivity are concepts interchangeable with cultural safety. Cultural safety is a stepwise progression. Cultural safety is safe care defined by the person delivering the care to the patient. Cultural safety ensures that the nurse is aware of the patients' cultural practices..
Cultural safety is a stepwise progression.
Which of the following statements about culture is correct? Subcultures are cultures that are inferior to others. Culture is not inherited but is a result of socialization. Cultural needs are the same as racial needs because they originate from biological traits that are unique to that group. Cultural conflict is the inability of a person to decide which cultural pathway to follow when exposed to multiple cultures.
Culture is not inherited but is a result of socialization.
According to the guidelines, quality documentation and reporting should be which of the following? (Select all that apply) Current Factual Accurate Available
Current Factual Accurate
Which of the following is objective information to be recorded in the client's medical record? A: Anxious over upcoming test B: Increasing stress over past two months C: Performs breast self-examination monthly D: Voided 250 mL of clear yellow urine
D Objective data are measurable data, such as the amount and colour of urine. Options A, B, and C describe data that the nurse cannot measure but that depend on the client's reports; thus, they are subjective data.
Which of the following are nurse-provided indirect care activities? (Select all that apply.) Delegating Documenting Evaluating new products Administering medications Providing client counselling
Delegating Documenting Evaluating new products
When discussing the client's care with a nurse's aide, the nurse instructs the aide to report any coughing during meals of the client, who recently experienced a stroke and requires feeding. In this situation, the nurse is acting in which following nursing role?
Delegator
An older adult recently diagnosed with a urinary tract infection displays a sudden onset of confusion. Which of the following is she most likely experiencing? Delirium Dementia Depression Social isolation
Delirium
Which three common conditions affect cognitive function in older adults? A: Blindness, hearing loss, and stroke B: Delirium, depression, and dementia C: Cancer, Alzheimer's disease, and stroke D: Stroke, heart attack, and cancer of the brain
Delirium, depression, and dementia
Which of the following statements related to cultural conflicts is an accurate definition? Cultural imposition is using others' values as the absolute guides in providing services to patients and interpreting their behaviour. Ethnocentrism is a belief that one's own way of life is inferior to that of others. Stereotypes are generalizations about any particular group that allow further assessment of unique characteristics. Discrimination is treating people unfairly on the basis of their group membership
Discrimination is treating people unfairly on the basis of their group membership
The nurse is planning to measure vital signs as part of the preparation for a test. The patient is talking to a visiting pastor. How should the nurse handle measuring the rate of respiration? Count respirations during the time the patient is not talking to the visitor. Wait at the patient's bedside until the visit is over, and then count respirations. Tell the patient it is very important to end the conversation so the nurse can count respirations. Document the respiration rate as "deferred," and measure the rate later because the talking patient is obviously not in respiratory distress.
Document the respiration rate as "deferred," and measure the rate later because the talking patient is obviously not in respiratory distress.
Using an oral electronic thermometer, the nurse checks the early morning temperature of a patient. The patient's temperature is 36.7°C. The patient's remaining vital signs are in the normally acceptable range. What should the nurse do next? Check the patient's temperature history. Document the results; the temperature is normal. Recheck the temperature every 15 minutes until it is normal. Check the temperature using another method.
Document the results; the temperature is normal.
To correctly palpate the patient's skin for temperature, which part of the hands does the nurse use?
Dorsal surface of the hands
Which of the following is one purpose of the patient's medical record? Education and research Ensuring accurate change-of-shift reports Legal documentation and maintenance of incident reports Auditing-monitoring and ease in locating procedure guidelines
Education and research
Eating Well with Canada's Food Guide recommends which of the following daily intakes for adult men aged 19-50? Three servings of calcium Two litres of water Eight servings of grain products One to two servings of meat and alternatives
Eight servings of grain products
Socialization of a 6-year-old child from Mexico into the Mexican culture is best described as which one of the following terms? Assimilation Biculturalism Enculturation Acculturation
Enculturation Enculturation is socialization into one's own culture. Acculturation is the process of adopting a new culture. Assimilation results when an individual gradually adopts and incorporates the characteristics of the dominant culture. Biculturalism occurs when an individual identifies equally with two or more cultures.
A manager is reviewing the nurses' notes in a patient's medical record. She finds the following entry: "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions should the manager give to the staff nurse who entered the note?
Enter only objective and factual information about the patient.
The nurse discovers an electrical fire in a patient's room. What would the nurse's first action be? Activate the fire alarm. Confine the fire by closing all doors and windows. Evacuate any patients or visitors in immediate danger Extinguish the fire by using the nearest fire extinguisher.
Evacuate any patients or visitors in immediate danger
General health promotion and illness prevention measures the nurse may recommend to older adults include which of the following? Exercising regularly Taking medications in the morning Receiving influenza vaccine every six to eight years Undergoing immunization for pneumococcal pneumonia annually
Exercising regularly
A patient is isolated because he has pulmonary tuberculosis. The nurse notes that the patient seems angry but knows this is a normal response to isolation. What is the best intervention? Provide a dark, quiet room to calm the patient. Explain the isolation procedures, and provide meaningful stimulation. Reduce the level of precautions to keep the patient from becoming angry. Limit family and other caregiver visits to reduce the risk of spreading the infection.
Explain the isolation procedures, and provide meaningful stimulation.
To facilitate communication with an older adult who is hard of hearing, the nurse should do which one of the following? Face the patient and maintain eye contact. Use lengthy explanations to ensure that the message is made clear. Cover several topics at one time to be most efficient in communication. Help the patient by anticipating what he or she is going to say and finishing the patient's sentences for him or her.
Face the patient and maintain eye contact.
The nursing assessment is which phase of the nursing process?
First -The nursing process cannot proceed unless you first conduct a client assessment.
The nurse says to the patient, "We've talked a lot about your surgery and the implications for you when you go home. Let's discuss some of the exercises you can do." This is an example of which following communication technique? Focusing Clarifying Summarizing Providing information
Focusing
A woman is considering becoming pregnant. The nurse practitioner recommends that the patient begin to consume which of the following before attempting pregnancy to prevent neural tube defects in the fetus? Calcium Folic acid Vitamin C Riboflavin
Folic acid
A patient receiving an anticoagulant questions the nurse about mouth care. Which of the following mouth care practices would the nurse recommend? Obtaining an electric toothbrush to use for teeth cleaning Gargling with an alcohol-based mouthwash after each meal Brushing the teeth two or three times a day using a hard-bristled brush Gently flossing between the teeth once a day or more using unwaxed floss
Gently flossing between the teeth once a day or more using unwaxed floss
To assess a patient's superficial lymph nodes, the nurse does what?
Gently palpates using the pads of the index and middle fingers
Before the nurse washes the hands when leaving an isolation room, what is the last clothing item that the nurse removes? Mask Gown Goggles Head cover
Goggles
To remove a glove that is contaminated what should the nurse do first?
Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers.
The nurse prepares a client for a lumbar puncture. Before the start of the procedure, the nurse makes sure to do which one of the following? Have the client void. Place the client in Sims' position. Premedicate the client with analgesics. Insert a peripheral IV catheter.
Have the client void. The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters are not required for this procedure.
The nurse is caring for a patient experiencing dysphagia. Which interventions will help decrease the risk of aspiration during feeding? (Select all that apply.) Have the patient sit upright in a chair. Give liquids at the end of the meal. Place food in the strong side of the mouth. Provide thin foods to make it easier to swallow. Feed the patient slowly, allowing time for the patient to chew and swallow. Encourage the patient to lie down to rest for 30 minutes after eating.
Have the patient sit upright in a chair. Place food in the strong side of the mouth. Feed the patient slowly, allowing time for the patient to chew and swallow.
The nurse teaches the patient to inspect all skin surfaces and to report pigmented skin lesions that can be described in which following way?
Having irregular borders
Besides high blood pressure (BP) values, what other signs and symptoms may the nurse observe if hypertension is present?
Headache, flushing of the face, and nosebleed
Why are patients' perceptions important? Health care organizations are required always to act in the best interests of the patient. Health care organizations are placing greater emphasis on patient satisfaction. Health care organizations are under investigation for misappropriation of funds. Health care organizations are carefully watched and regulated by the federal government.
Health care organizations are placing greater emphasis on patient satisfaction.
A patient had a left-sided cerebrovascular accident three days ago and is being given 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? Hematuria Unilateral neglect Limited range of motion in the right hip Coughing up of a moderate amount of clear, thin sputum
Hematuria Because of the patient's heparin injections, he is at risk for bleeding. Hematuria is a sign that the patient is possibly bleeding in the urinary tract as an adverse effect of the heparin injections. Limited range of motion, the coughing up of clear, thin sputum, and unilateral neglect are not medical emergencies.
What type of diet is most important for an immobilized patient? Low protein Low residue Restricted carbohydrate High protein, high calorie
High protein, high calorie
For which of the following conditions is an immobilized patient at risk? Hyponatremia Hypocalcemia Hypernatremia Hypercalcemia
Hypercalcemia Immobility leads to the release of calcium from bone into the bloodstream. Hypocalcemia is calcium deficiency and is not a result of immobility. Neither hypernatremia, which is an elevated sodium level, nor hyponatremia, which is a sodium deficiency, is caused by immobility
Which of the following is a guideline for legally sound documentation? Record all entries legibly and in blue ink. If an order is questioned, record that clarification was sought. To use time more efficiently, wait until the end of shift to record what happened throughout the shift. If an error is made, use correction fluid to maintain neatness. Then record the note correctly over dried correction fluid to make optimum use of space.
If an order is questioned, record that clarification was sought.
When should a gown be worn? If the patient's hygiene is poor. If the patient has acquired immune deficiency syndrome or hepatitis. If the nurse is assisting with medication administration. If blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.
If blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.
The nurse understands that providing a complete bed bath may have which of the following cardiovascular effects and thus plan for rest periods during the bath? Increase in oxygen supply Decrease in glucose demand Increase in oxygen consumption Decrease in blood supply to the skin
Increase in oxygen consumption Turning during a complete bed bath and receiving back care increases oxygen demand and consumption. Thus, it is important for the nurse to provide rest periods and monitor the patient's heart rate before, during, and after the bath. Blood flow to the skin should increase with gentle rubbing from the bath. Glucose demand should increase as a result of increased activity. Oxygen supply is not increased with a complete bed bath, but oxygen demand does increase.
The caring aspect of nursing may be negatively affected in clinical practice today primarily for which of the following possible reasons? Lack of time constraints in nursing care Increased emphasis on the nurse-patient relationship Prevalence of chronic conditions that slow the pace of nursing Increase in technology that takes nurses' attention away from patients
Increase in technology that takes nurses' attention away from patients
When assessing the older adult, the nurse should know which findings represent common physiological changes associated with aging and which are abnormal findings. Which of the following is a normal and common physiological change? Urinary incontinence Increased saliva production and small intestine motility Increase in the time required for the heart rate to return to baseline after exercise Cold feet caused by a decrease in muscle mass and a decrease in the number of neurons
Increase in the time required for the heart rate to return to baseline after exercise
The nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time frame?
Indicate when the client is expected to respond in the desired manner. The time limit sets measurable points to evaluate the client's response and movement toward meeting the outcome goals
A 34-year-old client had a surgical repair of an abdominal hernia in the morning. At 12:00 noon, the nurse records the client's vital signs on the recovery room flow sheet. This is an example of what? Psychomotor skill Indirect care measure Physical care technique Anticipating complications
Indirect care measure Recording vital signs is an example of indirect care. Taking vital signs is an example of a psychomotor skill. Anticipating complications is a cognitive skill that is an assessment skill. Recording vital signs is a direct care measure and not a physical care technique.
Which of the following is the highest priority nursing diagnosis for an immobilized patient? Risk for disuse syndrome Risk for deficient fluid volume Ineffective airway clearance Ineffective peripheral tissue perfusion
Ineffective airway clearance
Place them in order of priority Constipation Anticipatory grieving Ineffective tissue perfusion Ineffective airway clearance
Ineffective tissue perfusion Ineffective airway clearance Anticipatory grieving Constipation
The family of your confused ambulatory patient insists that all four side rails be up when the patient is alone. Which is the best way to handle this situation? Ask them to stay with the patient at all times. Inform them of the risks associated with side rail use. Thank them for being conscientious, and raise all four rails. Provide the patient with a one-to-one sitter while the side rails are up.
Inform them of the risks associated with side rail use.
The techniques of physical assessment are inspection, palpation, percussion, and auscultation. The order in which these techniques are used is slightly different during abdominal examination than during examination of other body areas. The nurse should perform which procedures first? Palpation and inspection Inspection and percussion Palpation and auscultation Inspection and auscultation
Inspection and auscultation The nurse begins with inspection and then follows with auscultation. It is important to perform auscultation before palpation and percussion because palpation and percussion may alter the frequency and character of bowel sounds.
The older adult is at risk for falls for various reasons. What might the nurse do to help prevent falls? Ensure that someone is available to assist the older adult when walking. Use vest restraints when the older adult goes to bed. Instruct the older adult to use a night light in the bathroom. Instruct the older adult to place throw rugs on the floor to remove glare.
Instruct the older adult to use a night light in the bathroom.
A nursing student gives herself positive messages regarding her ability to do well on a test. This is an example of what level of communication?
Intrapersonal
The nurse demonstrates the concept of "knowing the patient" when he or she does which one of the following? Gathers pertinent data about the patient's condition Predicts the need for certain interventions based on the disease process Encourages the patient to depend on the nurse to make important decisions Is able to detect changes in the patient's condition based on shared information and bonding
Is able to detect changes in the patient's condition based on shared information and bonding
Culture strongly influences pain expression and the need for pain medication. Which one of the following statements is true about cultural pain? It is not expressed verbally or physically. It is expressed only to others of like culture. It is more intense, thus necessitating more remediation. It may be suffered by a patient whose valued way of life is disregarded by practitioners.
It may be suffered by a patient whose valued way of life is disregarded by practitioners.
Which of the following statements reflects the current trend in the directives from the Centers for Disease Control and Prevention for minimizing the risks of infection? Discard all dressings into red bags. Do not recap bottles of solutions to minimize the risk of contamination. Recap syringes or break needles off before discarding them into sharps containers. Keep all drainage tubing below the level of the waist or site of insertion.
Keep all drainage tubing below the level of the waist or site of insertion.
Based on knowledge of the benefits of choosing carbohydrates with a low glycemic index, the nurse recommends which of the following? Olive oil Orange juice Muffin Lentils
Lentils
In a review of systems, asking about the last time a client had a tuberculosis (TB) skin test is a question that would fit under which of the following categories? Laboratory data Immunizations Lower respiratory system Upper respiratory system
Lower respiratory system
Which of the following characteristics of a goal is missing from the statement, "Client will ambulate daily"? Observable Measurable Client-centred Singular goal or outcome
Measurable Goals must be measurable, such as, "Client will ambulate five metres daily." The other characteristics are met in this goal statement.
For patients who experience conditions that threaten the integrity of the oral mucosa, which of the following is true? No mouth care is needed. Less oral hygiene is needed. No anti-infective agents are needed. More frequent mouth care is needed
More frequent mouth care is needed
A patient with head and neck cancer has begun receiving radiation therapy to the right side of the neck. Because of the radiation treatments, the nurse includes which of the following interventions in the patient's plan of care? Brushing teeth and flossing twice daily Lemon glycerine swabs to the mouth every two hours Mouth care every four hours Nothing-by-mouth status during radiation therapy treatments
Mouth care every four hours
Which of the following types of restraint is commonly used with an infant or small child? Mummy restraint Wrist restraint No restraint Waist restraint
Mummy restraint
Which of the following is true about aging? Genetic changes are solely responsible. The patient's environment is the main factor. No single theory explains aging. The presence of disease is what causes a decline in function.
No single theory explains aging.
A patient's personal preferences for hygiene are influenced by a number of factors. What must the nurse recognize? The nurse is in charge of the care. Hygiene care is a routine procedure. Hygiene has no influence on patient outcomes. No two individuals perform hygiene in the same manner.
No two individuals perform hygiene in the same manner.
A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes
Nursing Diagnosis
The patient, who has been on bed rest for two days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? Give him some slippers, and tell him where the bathroom is located. Ask the nursing assistant to assist him to the bathroom. Obtain orthostatic BP measurements. Tell him it is not a good idea and provide a urinal.
Obtain orthostatic BP measurements.
The nurse is concerned about the fluid intake of an older adult who is reluctant to drink more water. Which intervention could the nurse try? Offer the older adult extra coffee with each meal. Offer extra intake in the morning and early afternoon. Offer two 250-mL glasses of fluid from beverage and food sources. Offer all vegetables as raw because of the higher fluid content.
Offer extra intake in the morning and early afternoon.
What techniques encourage a client to tell his or her full story? (Select all that apply.) Active listening Back-channelling Use of open-ended questions Use of closed-ended questions
Options A, B, and C encourage clients to tell their full stories. Active listening helps them feel that they, and their stories, are important. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story.
A patient has been on bed rest for several days. The patient stands, and the nurse notes that the patient's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record? Rebound hypotension Positional hypotension Orthostatic hypotension Central venous hypotension
Orthostatic hypotension
Which of the following is not a normal physiological change associated with aging? Osteoporosis Decreased cardiac output Reduced ability to see in darkness Smooth, brown, irregularly shaped spots on the backs of the hands and forearm
Osteoporosis
Turgor is the skin's elasticity, which can be diminished by edema or dehydration. Which is the best place for the nurse to assess skin turgor in the older adult? Side of the neck Back of the hand Top of the foot Over the sternal area
Over the sternal area
The nurse examines the laboratory data and observes a patient with many chronic health conditions currently hospitalized because of diarrhea. Which finding is consistent with poor nutrition? Nitrogen balance of 3 g Reddish pink oral membranes Presence of surface papillae on tongue Pale conjunctivae
Pale conjunctivae Eyes should have a bright appearance with eyelids and conjunctivae a healthy pink colour and no sores at the corners of membranes. Pale conjunctivae may indicate anemia. The other options are all indicators of health.
A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned patient? As shiny skin As bluish skin As yellowish skin As ashen grey skin
Pallor would appear as yellowish brown in brown-skinned people. Pallor would manifest as bluish skin in light-skinned people. Pallor would appear as ashen grey skin in black-skinned people. Shiny skin indicates edema.
The nurse demonstrates caring when he or she does which one of the following? Leaves the light off in the patient's room Pats the patient's arm when approaching the bed Asks the patient if he or she needs anything while exiting the room Provides the patient with a new blanket without the patient having to as
Pats the patient's arm when approaching the bed
A patient who has been admitted to your unit has been identified as being colonized by (is a carrier of) methicillin-resistant Staphylococcus aureus (MRSA). Which measure should be taken to prevent the spread of MRSA to other patients on the unit? Place the patient in a single or a private room, and place the patient on contact precautions. Standard precautions and routine practices only are indicated for the patient. Place the patient in a room with another patient on isolation for Clostridium difficile. Place the patient in a single room.
Place the patient in a single or a private room, and place the patient on contact precautions.
Which of the following is an example of transpersonal communication? Prayer Negotiation Active listening Positive self-talk
Prayer
Which term is used for a common age-related change in auditory acuity?
Presbycusis
What is the priority when providing oral hygiene to an unconscious patient? Prevent aspiration. Prevent halitosis. Prevent dental caries. Prevent mouth ulcerations.
Prevent aspiration. When providing oral hygiene to an unconscious patient, the nurse should position the patient appropriately and use suction to eliminate the risk of aspiration. Good oral hygiene is still necessary to prevent halitosis, dental caries, and ulcerations.
The nurse teaches a patient who has had surgery to increase intake of which nutrient to help with tissue repair? Fat Protein Vitamins Carbohydrate
Protein
Which of the following best describes the nurse's role in planning care for a culturally diverse population? Focus only on the needs of the patient, ignoring your beliefs and practices. Include care that is culturally congruent with the nursing staff based on predetermined criteria. Provide care while remaining aware of your own bias and focusing on the patient's individual needs rather than the staff's practices. Blend your values that are for the good of the patient and minimize the patient's individual values and beliefs during care.
Provide care while remaining aware of your own bias and focusing on the patient's individual needs rather than the staff's practices.
During the night shift, a patient is found wandering the hospital halls looking for a bathroom. What would your initial intervention be? Insert a urinary catheter. Ask the physician to order a restraint. Assign a staff member to stay with the patient. Provide scheduled toileting during the night shift.
Provide scheduled toileting during the night shift.
During the nurse's assessment of a 56-year-old man, he reports increased alcohol consumption because of stress at work. Which of the following is one of the expected outcomes for this patient? Decrease stress in his life. Teach him ways to promote sleep. Decrease his alcohol intake during times of stress. Provide the patient with information about stress management classes.
Provide the patient with information about stress management classes.
The nurse finds that the systolic BP of an adult patient is 88 mm Hg. What are the appropriate nursing interventions? Check other vital signs. Recheck the BP, and give the patient orange juice. Recheck the BP after ambulating the patient safely. Recheck the BP, make sure the patient is safe, and report the findings.
Recheck the BP, make sure the patient is safe, and report the findings.
After establishing a nursing diagnosis of "acute pain," the nurse develops which following appropriate client-centred goal? A: Determine the effect of pain intensity on client function. B: Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay. C: Encourage the client to implement guided imagery when pain begins. D: Administer analgesic 30 minutes before physiotherapy treatment.
Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay. Option B is measurable and objective. "Encourage" is not specific enough. How does one "encourage"? Also, it is not measurable. Determining the effect of pain is part of the assessment or evaluation. Administering an analgesic is an intervention, not a goal.
A family is in spiritual distress because of the recent, but expected, death of a family member. The nurse who provides counselling to the family implements which of the following interventions? Praying with the family Reminiscing with the family Arranging for the chaplain to visit the family Obtaining a consultation with a psychiatric clinical nurse specialist
Reminiscing with the family Correct Reminiscing is an active intervention that allows family members to remember the deceased in a positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and arranging for a chaplain's visit may be appropriate interventions, but they are not counselling.
A patient is complaining of pain at 0400. The nurse telephones Dr. Rice and receives an order for oxycodone hydrochloride 5 mg one tablet every four hours as needed. It is wise for the nurse to do which one of the following? Repeat the prescribed order back to the physician. Document the following immediately on the physician's order sheet: "0415 oxycodone hydrochloride 5 mg q4h prn. T.O. Dr. Rice." Complete an incident report to assist the unit's quality improvement program so that awakening physicians during the night can be avoided. Wait until the physician makes rounds in the morning and remind him to write the order to cover the nurse for the oxycodone hydrochloride the nurse gave during the night
Repeat the prescribed order back to the physician
Lisa, a trained unregulated care provider, is working with you during your shift. One of your patients has upper limb restraints. In delegating care of this patient to Lisa, you would tell her to do which of the following? Secure the restraints to the side rails. Check to see if the patient can have a medication for sleep. Call the physician if the patient becomes more agitated with the restraint. Report any signs of redness, excoriation, or constriction of circulation under the restraint.
Report any signs of redness, excoriation, or constriction of circulation under the restraint.
The nurse observes that a patient's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? Respirations cease for several seconds. Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. Respirations are laboured, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
Which of the following statements are true? (Select all that apply.) An example of an environmental restraint is a locked nursing unit. Mechanical restraints should be applied when the nurse is busy. Chemical restraints are psychoactive medications. Restraints must not be considered punitive.
Restraints must not be considered punitive. Chemical restraints are psychoactive medications. An example of an environmental restraint is a locked nursing unit.
When a nurse follows the SOAP method of charting, the information the nurse would record under "O" would be which of the following? A: "My foot keeps throbbing." B: Right foot is red with +4 pitting edema and capillary refill less than three seconds. C: Patient has an alteration in comfort related to swelling in right foot and keeping foot in dependent position. D: Offer "as needed" pain medication every four hours as ordered. Instruct patient on nonpharmacological pain-relieving measures. Elevate foot on pillows.
Right foot is red with +4 pitting edema and capillary refill less than three seconds. In SOAP (subjective-objective-assessment-plan) charting, the "O" should be objective data (those that are measured and observed). Option A provides subjective data (verbalizations of the patient). Option C demonstrates assessment (a diagnosis based on the data). Option D provides a plan of care.
A patient who was in a car accident and broke his femur has been immobilized for five days. When the nurse gets this patient out of bed for the first time, a nursing diagnosis related to the safety of this patient would be which of the following? Pain Impaired skin integrity Altered tissue perfusion Risk for activity intolerance
Risk for activity intolerance
Environmental factors heavily affect a client's care. What should your first concern for the client be?
Safety
In the older adult, taste buds atrophy and lose sensitivity, and appetite may decrease. Which of the following is the older adult therefore less able to discern? Spicy and bland foods Salty, sour, sweet, and bitter tastes Hot and cold food temperatures Moist and dry food preparations
Salty, sour, sweet, and bitter tastes
Because patients and nurses may differ in their perceptions of caring, it is important that the nurse does which one of the following? Focuses on keeping the relationship on a business level Follows his or her own beliefs about what is appropriate Seeks information regarding what is important to the patient Allows a more experienced nurse to establish the nurse-patient relationship
Seeks information regarding what is important to the patient
When a patient is immobilized, which of the following positions is preferred to prevent skin breakdown? Semi-Fowler's Side-lying with knees flexed Prone with upper extremities flexed Supine with lower extremities extended
Semi-Fowler's
A 46-year-old woman from Bosnia came to Canada six years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of Canada for which of the following reasons? Assimilation was likely forced upon her. She adapted to and adopted the Canadian culture. She had an extremely negative experience with the Canadian culture. She gave up part of her ethnic identity in favour of the Canadian culture.
She adapted to and adopted the Canadian culture.
When working with an older adult, what should the nurse remember to avoid? Touching the patient Shifting from subject to subject Allowing the patient to reminisce Asking the patient how he or she feels
Shifting from subject to subject because it can create confusion
How can the nurse best demonstrate caring to a patient who has recently suffered a loss through miscarriage? Sit with the patient in silence. Share a personal account of a similar loss. Offer some literature on the grieving process. Ask the hospital chaplain to visit the patient.
Sit with the patient in silence.
When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent which of the following? Food poisoning Spread of hepatitis A Bacterial food infections Salmonella contamination
Spread of hepatitis A
A review of systems is based on information obtained from the client during the interview. This information is an example of ______________ data.
Subjective
The immobilized patient should be instructed to do which of the following activities? Eat a restricted-calorie diet. Take in a minimum of 2000 mL of water per day. Breathe deeply and cough every four hours. Quickly resume walking exercises when able.
Take in a minimum of 2000 mL of water per day.
An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was prescribed an antibiotic for pneumonia. The patient indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? Respirations = 20 breaths per minute Oxygen saturation by pulse oximetry = 92% BP = 138/84 mm Hg Temp = 39°C, tympanic
Temp = 39°C, tympanic -fever
A school nurse is conducting nutrition teaching with an adolescent. Which of the following considerations guides the nurse's teaching? The chronological age of the adolescent The adolescent's increased daily need for iron The need to eliminate snacking The need to increase consumption of calories from all nutrient groups
The adolescent's increased daily need for iron
A client-centred goal is a specific and measurable behaviour or response that reflects which of the following? The agency's goal for a client with a similar problem The client's desire for specified health care interventions The client's response compared with that of another client with a similar problem The client's highest possible level of wellness and independence in function
The client's highest possible level of wellness and independence in function
The nurse is assigned to a client who has returned from the recovery room following surgery for a colorectal tumour. After an initial assessment, the nurse anticipates the need to monitor the client's abdominal dressing, intravenous (IV) infusion, and drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which of the following situations? The family comes to visit the client. The client expresses concern about pain control. The client's vital signs change, showing a drop in blood pressure. The charge nurse approaches the assigned nurse and requests a report at the end of the shift.
The client's vital signs change, showing a drop in blood pressure. A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site. Concern about pain control, including a thorough assessment focusing on the client's pain, would be the second priority. The end-of-shift report and the family's visit are lower priorities.
The nurse has gathered the following assessment data about a client. Which of these cues form a pattern? A:Client is restless B: Respirations are 24 breaths per minute and irregular C: Client reports feeling short of breath D: Fluid intake for eight hours is 800 mL. E: Client has drainage from surgical wound. F: Client reports loss of appetite for over two weeks.
The data in items A, B, and C—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia.
Which of the following are defining characteristics for the nursing diagnosis of "impaired urinary elimination" (select all that apply) Nocturia Frequency Urinary retention Inadequate urinary output Receipt of intravenous fluids Sensation of bladder fullness
The defining characteristics for "impaired urinary elimination" include nocturia, frequency, and urinary retention. The other options do not indicate issues with urinary elimination.
Which statement comparing a surgical scrub with a regular handwashing session is correct? Water and soap are turned on with the leg or foot pedal in both cases. A surgical scrub lasts the same length of time as a handwashing between patients. The hands are held in the same position after the scrub as after regular handwashing to prevent contamination from other sources of contact. The fingers are held down to rinse in routine handwashing but are held upright when performing a surgical scrub.
The fingers are held down to rinse in routine handwashing but are held upright when performing a surgical scrub.
Although the older adult's libido does not decrease, changes occur in sexual activity. Which of the following is correct with regard to these changes? The need to touch and be touched is decreased. The sexual preferences of older adults are not as diverse. Physical changes usually will not affect sexual functioning. The frequency of and opportunities for sexual activity may decline
The frequency of and opportunities for sexual activity may decline
Which of the following illustrates the focus of the nurse's interaction during the working phase of the nurse-patient helping relationship? That nurse says to the patient, "Hi, Mr. Owen. My name is Gwen, and I'll be your nurse today." The nurse asks the patient, "What do you think would help you recover more quickly from your surgery?" The nurse asks another nurse while receiving a report, "What did the laboratory report indicate for Mr. Owen?" The nurse tells the patient, "My shift will be over in about 30 minutes, but I'll see you again tomorrow. You did really well with physiotherapy today."
The nurse asks the patient, "What do you think would help you recover more quickly from your surgery?"
The nurse is caring for a 1-year-old girl with leukemia. When taking the child's temperature, the nurse notices that an older woman is standing at the back of the room with an anxious affect. Which action best describes a caring practice? The nurse greets the woman and explains that she is going to take the child's temperature. The nurse greets the woman and assumes that she is the grandmother and makes a mental note to ask parental permission later to give an update of the child's condition to her. The nurse greets the woman, engages her in a conversation, and finds out that she is the grandmother. The nurse makes eye contact and encourages her to come to the bedside to comfort the child. The nurse acknowledges the woman, takes the child's temperature, and leaves the room.
The nurse greets the woman, engages her in a conversation, and finds out that she is the grandmother. The nurse makes eye contact and encourages her to come to the bedside to comfort the child.
The nurse is meeting a 3-year-old for the first time. Communication with the child will be facilitated if the nurse does which of the following? The nurse directs questions to the parent. The nurse lifts the child onto her lap. The nurse distracts the child by clapping her hands. The nurse kneels down while holding and talking to a teddy bear.
The nurse kneels down while holding and talking to a teddy bear.
Which of the following is an example of a positive outcome of a nurse-health team relationship? The nurse becomes an effective change agent in the community. The nurse better understands the family dynamics that affect the patient. The nurse better appreciates what the patient perceives as meaningful from the patient's perspective. The nurse receives encouragement and support from co-workers to cope with the many stresses associated with the nursing role.
The nurse receives encouragement and support from co-workers to cope with the many stresses associated with the nursing role.
Give an example of a nurse acting to avoid a data collection error
The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her.
A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client's pain rating stayed the same (8 out of 10). What should the nurse recognize?
The pain plan needs changing.
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following patient conditions influenced the nurse's decision? The patient is in shock. The patient has an arrhythmia. The patient underwent surgery 18 hours earlier. The patient showed a response to orthostatic change
The patient has an arrhythmia.
As the nurse enters the patient's room, the nurse notices that he is anxious to say something. The patient quickly exclaims, "I don't know what's going on; I can't get an explanation from my doctor about the results of my test. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? The patient has a defiant attitude. The patient appears to be upset with his physician. The patient is demanding and complains frequently. The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests.
The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests.
A patient with diabetes is hospitalized with a sore on his foot that has failed to heal. The nurse is gathering a videotape and some printed material on diabetes to begin teaching the patient when he calls the nurse asking for something to decrease his pain. In terms of the elements of the communication process, which is the referent in this situation? The nurse The patient's pain The videotape and printed material on diabetes The patient's and the nurse's sociocultural background
The patient's pain A referent motivates one person to communicate with another. In this case, sensations and perceptions of pain initiated communication. The videotape and printed material are means of conveying and receiving messages, called channels. The nurse is the receiver, the person who receives and decodes the message. The nurse's sociocultural background and that of the patient are interpersonal variables that influence communication.
Which nurse is showing behaviour that indicates that the nurse is providing presence in a caring relationship? The clinic nurse who pats the patient on the back for reassurance The newly licensed nurse who braces the patient as he or she gets out of bed The home care nurse who focuses attention on the older adult patient sharing a story The staff nurse who stays with a patient who is undergoing an unfamiliar procedure
The staff nurse who stays with a patient who is undergoing an unfamiliar procedure
The nursing diagnosis, "readiness for enhanced communication," is an example of what kind of diagnosis?
The term readiness indicates a wellness nursing diagnosis.
Which of the following is true regarding the dominant values in Canadian society of individual autonomy and self-determination? These values do not have an effect on health care. These values rarely have an effect on those of other cultures. These values may be in direct conflict with the values of diverse groups. These values may hinder the ability to gain admission to hospice programs.
These values may be in direct conflict with the values of diverse groups.
Which of the following statements about water-soluble vitamins are true? (Select all that apply.) They cannot be stored. They often cause toxicity. They must be consumed daily. Supplements must be taken to reach the recommended daily allowance of these vitamins.
They cannot be stored. They must be consumed daily.
Which of the following is one advantage of standardized care plans? A: They are used independently by the nurse. B: They establish clinically sound standards of care for similar groups of patients C: They inhibit nurses' identification of unique, individualized therapy for patients. D: They make quality improvement audits unnecessary.
They establish clinically sound standards of care for similar groups of patients Standardized care plans are preprinted, established guidelines that are used in caring for patients who have similar health problems. The establishment of clinically sound standards of care is useful when quality improvement audits are conducted. Standardized care plans are also beneficial for education because nurses learn to recognize the accepted requirements of care for patients. Standardized care plans can also improve continuity of care. Inhibition of individualized therapy is a disadvantage of standardized care plans. Standardized care plans cannot replace the nurse's professional judgement and decision making. Quality improvement audits are still necessary. The use of standardized care plans can facilitate this process. Standardized care plans may at times be used independently, but they also include interprofessional care.
Nurses have the responsibility to dispel myths and replace stereotypes of older adults with accurate information. Which of the following does the nurse know is true about most older adults? They are confused. They are forgetful and rigid. They have a reduced ability to respond to stress. They are unable to understand and learn new information.
They have a reduced ability to respond to stress.
Why are critical pathways a valuable tool in patient care?
They provide members of the health care team with a way to document their contributions to the patient's total plan of care.
Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate
Transcultural nursing
What is it important to do when caring for the older adult? Repeat oneself often because older adults are forgetful. Be aware that older adults are no longer interested in sex. Treat the patient as an individual with a unique history of his or her own Speak in a louder voice, as older adults are often hard of hearin
Treat the patient as an individual with a unique history of his or her own
The nurse has just admitted a patient to rule out Alzheimer's disease. The patient is confused and spitting on everyone who enters the room. What should the nurse do? Wait an hour until the patient calms down, and then use gloves when touching the patient. Use gloves, a mask, a face shield, and a gown when entering the room to perform the initial assessment. Administer a sedative, and then perform the assessment after the patient is asleep; no precautions would be needed. Realize that isolation equipment might further confuse the patient and avoid using a face mask and shield, but use gown and gloves.
Use gloves, a mask, a face shield, and a gown when entering the room to perform the initial assessment.
Benner provides a holistic approach for nursing practice and caring. Which statement best describes one of the foundational concepts? A: Using analyzed nursing stories, this theorist describes the essence of nursing as primacy of caring. B: The nurse has a conscious intention to care and promotes healing and wholeness. C: Each of the five caring processes is important to make a positive difference: knowing, being with, doing for, enabling, and maintaining belief. D: The following concepts are crucial for this theorist: caring, competence, confidence, and commitment.
Using analyzed nursing stories, this theorist describes the essence of nursing as primacy of caring.
The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?" This is an example of __________________ of assessment data.
Validation
What is the single most effective method by which the nurse can break the chain of infection?
Wash hands between procedures and patients.
The nurse feels frustrated because she is behind in administering her patients' medications. The nurse comes to one patient's bedside hurriedly with a frown on her face and sighs while she is waiting for the patient to swallow the medication. The nurse then says brightly, "Isn't it a relaxing day?" The nurse should remember ...
When incongruity exists between verbal and nonverbal communication, the receiver usually "hears" the nonverbal message as the true message.
The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would probably occur during which phase of a client interview?
Working
The professional nurse can best be said to be engaging in collaboration with others to develop the patient's plan of care when the nurse does which of the following? Consults the physician for direction in establishing goals for patients Depends on the evidenced-informed practice to complete a plan of care for patients Works independently to plan and deliver care, and does not depend on other staff for assistance Works with colleagues and patients' families to take advantage of combined expertise in planning care
Works with colleagues and patients' families to take advantage of combined expertise in planning care Collaboration is teamwork in which individuals in multiple disciplines work together, each contributing his or her expertise to the patient's care. The physician will provide medical direction, but teamwork and collaboration require more than just medical direction. Consulting the latest literature can help in planning care, but this is not collaboration. The collaborative team works together to provide care for the patient.
In order to determine whether an intervention was successful, the nurse evaluates the success of attaining a goal. Which of the following is an example of an evaluation? Dressing is changed every eight hours using sterile technique. Client will ambulate 150 metres four times a day with minimal assistance. Client performed quadriceps-setting exercises to right leg every four hours. Wound is filling in with granulation tissue that is red to pink without signs of infection.
Wound is filling in with granulation tissue that is red to pink without signs of infection.
The nurse asks the patient to shrug the shoulders and turn the head side to side against the resistance of the examiner's hand. These actions allow the nurse to evaluate which cranial nerve? VII—Facial V—Trigeminal XII—Hypoglossal XI—Spinal accessory
XI—Spinal accessory
What is it called when an infectious disease is transmitted directly from one person to another
communicable disease
The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for acute pain with those for chronic pain. In the end, the nurse selects "acute pain" as the correct diagnosis. This is an example of avoiding which type of error?
error in clustering data
The nurse asks the client whether the client has any allergies. What is this an example of doing?
gathering health history data
Which is the term that describes the fibrous tissues that bind joints together and connect bone and cartilage? Tendons Ligaments Skeletal muscles Cartilaginous tissues
ligaments
The nurse should assist the patient to a sitting position to provide the best position to examine which following area? Heart Lungs Abdomen Pulse sites
lungs
To auscultate the patient's lung fields, the nurse uses a systematic pattern that compares which of the following? Side to side Top to bottom Anterior to posterior Interspace to interspace
side to side
A patient tells the nurse, "I have stomach cramps and feel nauseous." This is an example of which type of data?
subjective data
What is the purpose of assessment?
to establish a database concerning the client
What is the use of standard formal nursing diagnostic?
to facilitate understanding of client problems by different health care providers The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the client's needs.