3515: test 4

The nurse is providing care for a client that is terminally ill with cancer. The client states to the nurse, "Am I going to die?" What is the most therapeutic response by the nurse?

"what have you been told?"

The nurse admits a new client to the unit for elective surgery. What would be the best way for the nurse to facilitate the practice of religion for this client? Choose all that apply.

- Arrange for the client's pastor to visit if desired. - Attempt to meet religious dietary restrictions. - Respect the need for privacy during periods of prayer.

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

- Communication ability - Developmental level - Mobility

The nursing instructor is teaching about spirituality and asks a nursing student about the factors that can influence a client's spirituality. Which responses by the student are accurate? Select all that apply.

- Developmental considerations - Family - Ethnic background - Formal religion

A nurse is paying particular attention to the spiritual needs of a client today. The nurse identifies that spiritual beliefs can have a positive effect on general health of a client in which ways? Select all that apply.

- Diet - Support system - Endurance of extreme stress - Positive emotions

The nurse is massaging an older adult client's back and notices a reddened area on the client's sacrum. What actions would the nurse perform in response? Select all that apply.

- Document the reddened area on the client's medical record. - Report the finding to the primary care provider. - Institute a turning schedule.

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.)

- Encourage deep breathing. - Play the client's favorite music. - Promote a restful environment.

Which Knowledge, Skills, and Attitudes (KSAs) are nursing actions based on the QSEN competency of quality improvement? Select all that apply.

- The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward. - The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions. - The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes.

The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse identifies that the education has been effective when the family says they will know that death is imminent when they see which related symptoms? Select all that apply.

- irregular respiratory rate - Restlessness - Bowel incontinence - Cyanosis of dependent areas

When preparing for the death of a client, the nurse should provide the client's family with which interventions? Select all that apply.

- listen to concerns, fears, and worries. - Encourage rest and proper nutrition. - Explain the dying process and allow grieving. - Utilize therapeutic communication techniques.

Which factors affect the grieving process? Select all that apply.

- meaning of loss - circumstances of loss - personal stressors - sociocultural resources

A recently graduated nurse is working with a client who is suffering from excruciating pain with no relief. The client tells the nurse that religion and spirituality are a big part of her life. The nurse wants to help nurture this client's spirituality and can do so in which of the following ways? Select all that apply.

- promoting meaning and purpose - promoting love and relatedness - promoting forgiveness

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply.

-Check agency policy for the application of restraints and secure a physician's order. -Pad bony prominences. - Remove the restraint at least every 2 hours or according to agency policy and client need.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

-The client is wearing the oxygen around the neck. - There is spilled water on the floor. - The IV is not infusing at the correct rate. - The skin is a bluish-color

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

-takes furosemide daily - Admits to drinking wine through the evening - Has history of diabetic neuropathy

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?

1

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?

Administration of 0.4 mg of naloxone

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

Assess for medication prescription for breakthrough pain.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate.

The school nurse is concerned about the week-long absence of Jerry, a third grader. The nurse visits the home and learns that Jerry has been diagnosed with appendicitis by a local clinic doctor. The parents, who are Christian Science church members, have had several church groups in to pray over Jerry. He is not improving and is getting worse. The nurse should do which of the following?

Contact Child Protection Services

A client is brought to the emergency department after inhaling a substance suspected to be anthrax from the contents of an envelope. What symptoms experienced by the client would the nurse correlate with this substance?

Cough, dyspnea, and fatigue

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

When planning care for a 55-year-old male client with newly diagnosed terminal pancreatic cancer, which nursing diagnosis would be most appropriate?

Death Anxiety

The nurse is on the third day of caring for a client who recently underwent a colectomy. During the physical assessment, a discussion about spirituality develops. The client reports feeling some guilt about being in the hospital because her religion opposes modern science, including medicine. The nurse recognizes this as a belief of which of the following groups?

Jehovah's Witnesses

A nurse is caring for a post surgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation?

Separation from spiritual ties

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

A client recently diagnosed with cancer informs the nurse that they value faith and finds comfort in their faith. The nurse is aware that faith is best defined as:

a belief in something for which there is no proof or material evidence.

A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep?

a snack containing carbohydrates and protein

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention?

assisting the client to put on slippers prior to ambulation

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model?

bargaining

The nurse is talking with the son of a client with end-stage renal failure and late-stage dementia. The client can no longer live at home, and the son states, "I live 500 miles away. I don't know what to do." Which type of living arrangement will the nurse teach the son about?

residential care

Which care environment would the nurse suggest to a client with no family nearby who is diagnosed with end-stage lung disease?

residential care

When the nurse attempts to wake a client who has just closed his eyes and appears asleep, the client states he is not asleep. What stage of sleep is this client in?

stage 1

A client begins snoring and is sleeping lightly. The stage of sleep is:

stage 2

A client comes to the hospital because of complications related to newly diagnosed terminal cancer. The client is concerned about how his wife is coping with the diagnosis. Which information is important for the nurse to obtain to assess factors that may affect the family member's grief? Select all that apply.

- Financial concerns - Cultural practices - Religious beliefs - Social support

A nurse working in a facility that cares for clients with Alzheimer's includes spirituality in client care. A family caregiver tells the nurse that faith has been broken and asks about help in getting through the day. What approaches can the nurse use to help the family member? Select all that apply.

- Help the family member get relief so church services can be attended - Contact the family church group members for assistance - Give the family member some spiritual reading materials

A nurse is providing care to a 9 1/2-year old child who is terminally ill. When talking with the child, the nurse would need to understand that the child most likely views death as which type of event? Select all that apply.

- Irreversible - Universal - Inevitable

A nurse is conducting grief resolution for a client who lost his wife in a motor vehicle accident in which he was the driver. Which interventions best accomplish this goal? Select all that apply

- Listen to expressions of grief. - Include significant others in discussions and decisions as appropriate. - Communicate acceptance of discussing the loss.

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

Assessment of vital signs and respiratory status

A nursing student is studying spirituality and completing a report on the Mormon faith. Which fact about Mormonism should the student include in the report?

Mormons are not allowed to use tobacco or alcohol.

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs

A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain?

Placebos involve the use of deception and are considered unethical in most circumstances.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation?

Rescue anyone who is in immediate danger.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying.

The nurse caring for a bedridden hospitalized client who states that this will be the first time that he has missed a Methodist church service in 50 years plans care based on which of the following NANDA-I diagnoses?

Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt

A middle-age client tells the nurse that the client's neck pain reduced considerably after the client underwent a treatment in which thin needles were inserted into the skin. What kind of pain relief treatment did the client undergo?

acupuncture

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

administering medications to the client

A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process, a strong social support network was able to assist the client. What developmental stage of life does the nurse identify the client is in

adult

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?

aggressive management of symptoms

The nurse should obtain a sleep history on which clients as a protocol?

all clients admitted to a health care agency

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?

apple slices

The nurse is taking care of a client recently involved in a motor vehicle accident during which a pet was thrown from the vehicle and died. The client states, "My heart aches and I can't eat or sleep." According to Kübler-Ross, what stage of grief is the client experiencing?

depression

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

endorphines

A client diagnosed with liver failure in hospice care died 10 hours ago. The client's spouse is having difficulty leaving the room and is crying uncontrollably. What situation does the nurse identify is happening with this client's spouse?

grief reaction

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

guarding of the chest area

While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying:

his faith

Individuals who are Christian Scientists may not approve of:

immunizations

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

increased blood pressure

A nurse is conducting online research for information related to spiritual needs and religious traditions. The nurse demonstrates understanding of the information by identifying which need as common to all? Select all that apply.

love, meaning, and forgiveness

A couple has sent their youngest child to college in another state and both are experiencing "empty nest syndrome." This is an example of:

maturational loss.

A nurse is caring for Mr. Glanden, who recently underwent a lung resection. As the nurse is completing the physical assessment, he asks to have the elders from his church perform a "laying on of hands". The nurse interprets this as a healing process associated which of the following religions?

morman

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

naloxone

Mrs. Dupree is a 55-year-old patient with end-stage renal failure who has asked to be taken off dialysis. She now shares with the nurse that she has mistreated her only daughter in the past and would like to reconcile this before she dies. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people?

need for forgiveness

In the Parkes model, a person uses denial as a psychological defense in the stage of:

numbness

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep?

taking a diuretic at 9 a.m. and 5 p.m. daily

A nursing instructor has finished presenting information to a group of nursing students on the factors that influence the grieving process. Which statement by a student would indicate a need for further education?

"A death that occurs as a result of natural causes is just as stressful as a death from homicide or suicide."

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

The nurse is administering medications to a client with neuropathic pain. The client asks why he is getting an antidepressant medication since he is not depressed. What is the best response by the nurse?

"Antidepressants have been shown to have pain-relieving qualities in clients with neuropathic pain."

Which question would be appropriate for the F in the FICA spiritual assessment tool?

"Do you consider yourself a spiritual person?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body."

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis?

"I feel like I have absolutely no idea what to do next."

A client who has suffered a debilitating stroke asks the nurse, "Why did God allow this to happen to me?" What question would the nurse ask to promote a conversation with the client about the client's spiritual needs?

"In the past, what has given you strength during a crisis?"

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

"Only certain members of the health care team can extinguish a fire."

The nurse is caring for a woman with terminal breast cancer. Which statement made by the client reflects the bargaining stage of grief?

"Please, let me live long enough to see my grandchild."

The new hospice nurse is reviewing the concepts of loss and grief with the preceptor. Which statement leads the preceptor to believe that the nurse has an understanding of grief and loss?

"The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief."

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed so that it's not possible for you to overdose on your pain medication."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear."

The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. Which question does the nurse ask to begin a conversation about the conflict that the client is experiencing?

"Would you like to talk to someone to help you make an informed decision?"

When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.

- expression of feelings - management of pain - use of coping strategies

Which client could be diagnosed with insomnia?

A 50-year-old woman who is reporting increased irritability for the past 2 months. She states that she goes to bed at 10 p.m. every night and tries to sleep in but, no matter what she does, she always wakes up around 4 a.m.

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle

Which medical client is most likely to be experiencing diffuse pain?

A client with shingles affecting her entire torso

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

An older adult client who identifies as a devout Catholic has recently relocated to an assisted living facility. The client is pleased with most aspects of the living situation but laments the fact that the church is not nearby, so attending daily mass is not an option. The client is quite upset by this restriction and states, "Going to daily mass was my life." Which action would the nurse take to address the client's spiritual distress?

Actively listen to the client to explore the client's feelings.

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

the nurse is caring for a client who has just expired. Which action will the nurse perform?

Allow the client's family to see the client's body before it is discharged.

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

When reviewing the history of a client admitted to the health care facility, the nurse notes that the client reported being an atheist. Which action will the nurse take to meet spiritual needs when planning nursing care for the client?

Ask the client how he or she expresses spirituality.

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action?

Avoid massaging this area and report the finding to the health care provider.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

CRIES Pain Scale

The son of a dying female client is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation?

Contact the chaplain to arrange a visit with the client.

The nurse is caring for a 6-year-old child who was in a motor vehicle accident and has lost a lot of blood through an open leg wound. The parents tell inform the nurse that the child cannot have blood transfusions due to their religious beliefs. What decision does the nurse determine that the court will support regarding the child's blood transfusion?

Did not support the parents' right to refuse treatment for the child

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?

Durable power of attorney form

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

The nurse is caring for a dying male client who practices Islam. What is the most appropriate action for the nurse after the client's death?

Ensure that a male washes the client's body.

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?

FLACC scale

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

A nurse is providing community education about the importance of getting enough sleep. Which information about REM sleep is most accurate?

It plays a role in memory.

The nurse is caring for a client on the acute care unit who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?

Keep the client safe by monitoring ambulation on the unit.

The nurse is caring for a client who asks that his special undergarments not be removed for an upcoming procedure. The nurse is aware that these undergarments are related to the client's religion. This religion is:

Mormon

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours for pain. What type of order is this considered?

PRN ordrer

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?

Reduce the temperature on the water heater.

The home care nurse visits a client with asthma and observes several lighted candles by the client's bedside. Which action should the nurse take?

Replace the lighted candles with battery operated candles.

Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take?

Reposition the client and gently massage the client's back.

The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion?

Roman Catholic

The nurse is caring for an older adult client admitted with a terminal illness. The client's chart indicates do not resuscitate (DNR) status. Which communication technique will facilitate a trusting nurse-client relationship?

Speak in a well-modulated voice and listen carefully to what the client says.

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

A nurse is developing a plan of care to meet a client's spiritual needs. When identifying appropriate interventions, which concept would the nurse need to integrate as the foundation for all the interventions?

Supportive presence

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia.

A client who was brought to the emergency room for gunshot wounds dies in intensive care 15 hours later. Which statement concerning the need for an autopsy would apply to this client?

The coroner must be notified to determine the need for an autopsy.

Which does not coincide with Kübler-Ross's stages related to a dying client?

The dying client usually exhibits anger first.

A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency?

The nurse researches best current practices for prevention of the spread of infection in physician offices.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

The nurse is performing a safety belt fit test for a young client at a well-child check-up. What criteria confirms that the child may sit in the back seat of a vehicle with a lap and shoulder belt in place?

The seat belt stays low on the hips and is not resting on the soft part of the stomach.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

A widow develops cancer within 6 months of her husband's death. This may be a result of:

bereavement

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback

Which food group would be appropriate to suggest to a client who practices tenets of the Islamic faith?

broiled chicken sandwich with skimmed milk

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

confused time and place

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

fifth

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the health care provider?

temazepam