Adaptive Quizzing
How can a nurse best evaluate the effectiveness of communication with a client?
Client feedback *Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.
A 4-year-old child who weighs 44 lb (20 kg) is prescribed prednisone. The recommended dosage for children is 2 mg/kg/day given in four divided doses. What will the child receive in each dose? Express your answer as a whole number
10 mg *The child's weight is 44 lb; divide by 2.2 to yield 20 kg. A dosage of 2 mg × 20 kg yields a 40-mg daily dose that should be divided by four: 40/4 = 10 mg.
A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for?
Decrease in the level of consciousness *Decreasing level of consciousness occurs because of the brain's acute sensitivity to hypoxia. The respirations usually are depressed because of brainstem compression. The systolic pressure increases, and the diastolic pressure decreases, resulting in a widening, not narrowing, pulse pressure. The peripheral vascular resistance is decreased when hypoxia occurs, thereby decreasing, not increasing, the diastolic blood pressure.
While managing the aftermath of a massive fire in a rural area, a physician is quickly examining clients and shifting them to urban health centers if required. What are the other duties of the physician in this role?
Determining the resource needs of the clients Deciding the number and acuity of the clients *The medical command physician serves to determine the resource needs of the client and decide the acuity and number of the clients. In addition to these responsibilities, they are also expected to determine which clients need to be moved to larger medical centers and who can be retained for treatment. This occurs especially in the small hospitals with limited facilities. Prioritizing treatment is the duty of the triage officer. Leadership and implementation of the emergency plan is the duty of the hospital incident commander. The community relations officer serves as a liaison between the health care facility and the media.
To help establish a therapeutic nurse-client relationship, the mental health nurse uses various communication techniques to convey a willingness to listen and a genuine desire to view the client and his or her needs in a respectful manner. What is the primary underlying principle guiding this process?
Caring is the underlying component of nursing that promotes client care. *Caring is the essential component of nursing that promotes the therapeutic relationship and ultimate growth of the nurse-client relationship and the development of client care that is respectful and genuine in its caring. Although understanding the psychosocial effects of a specific mental illness, directing appropriate care toward the client's strengths and weaknesses, and initiating and maintaining the nurse-client relationship contribute to the nurse-client relationship, they are not statements of the primary principle that serves as the basis of this process.
The nurse manager asks the staff nurse to participate in creating new guidelines for providing services to the client. Which management strategy is utilized by the nurse manager?
Empowerment of staff *Empowerment of staff enables participation in making practice decisions in the workplace environment, along with communication and teamwork. Insubordination is the refusal of a staff nurse to obey the order of nurse manager. Making the staff nurse participate in creating new guidelines involves the use of expert opinion but not the power or authority. Management by exception is the transaction leadership behavior in which the nurse manager monitors the performance and takes action to correct.
At 22 weeks' gestation a client visits the prenatal clinic for the first time. As part of the prenatal workup, the client has blood work performed. The nurse concludes that further assessment is indicated when the laboratory findings show what?
Hemoglobin of 10 g/dL (100 mmol/L) *A hemoglobin reading below 11 g/dL (110 mmol/L) suggests true anemia rather than physiologic anemia; this occurs because the plasma volume increases more than the red blood cell count during pregnancy, especially during the second trimester. The normal sedimentation rate in women is up to 20 mm/hr; no further assessment is necessary because this is an expected value. The normal blood glucose level ranges from 70 to 105 mg/dL (4.0-6.0 mmol/L); a slightly increased level is common during pregnancy. A WBC count of 5000 to 10,000/mm 3 is within expected limits; no further assessment is necessary.
The nurse is providing education to a client with systemic lupus erythematosus. Which education will the nurse consider as high priority?
Instructing about ways to protect the skin *A client with systemic lupus erythematosus is first taught to protect the skin to prevent infections. Helping the client with identifying coping strategies is given low priority. Different methods are taught to monitor body temperature because fever is a major sign of exacerbation. Teaching about the effects of the disease on lifestyle occurs after teaching ways to protect the skin.
Where should the nurse place a pillow or sandbag to prevent external rotation of a lower extremity?
Lateral to the client's affected hip *Because external rotation involves the hip joint, support is necessary at that point to promote functional alignment. Placing it under the client's lower affected leg, at the ankle of the client's affected leg, or on the side of the client's affected knee will not prevent external rotation of the hip.
A client in a debilitated state is admitted for palliative treatment of cancer of the liver. Which objective information collected by the nurse is most helpful for future monitoring of the client's condition?
Present weight *Weight is helpful in determining the extent of ascites; 1 L of retained fluid equals approximately 2.2 lb (1 kg). Ascites can develop in late stages of liver cancer, and the effects of cancer and dying cause weight loss. Diet history is subjective information and is not as helpful as weight. Bowel sounds are objective data but do not help monitor the liver. Pain is subjective.
What is the priority outcome in the planning of care for a client in crisis?
Restoring the client's psychological equilibrium *Crisis intervention is short-term therapy with the major outcome of restoring the client to the precrisis state. Referring the client for occupational therapy is not an outcome, but an action to help achieve an outcome; it is not part of crisis intervention. Scheduling the client for follow-up counseling is not an outcome, but rather an intervention that may be necessary if psychological equilibrium cannot be restored. Having the client gain insight into the problem is not always necessary for a client to be able to function effectively.
An emergency department nurse is admitting a client after an automobile collision. The primary healthcare provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit?
Apical heart rate of 142 beats/min *In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. Urine output would fall to less than 30 mL/hr, because a decreased blood volume causes a decreased glomerular filtration rate. The blood pressure is decreased because of the decreased blood volume. Respiratory rate of 16 breaths/min is within the accepted range of 12 to 20 breaths/min; the respiratory rate is rapid with hypovolemic shock.
The nurse manager found that the nursing assistant (NA) shows unwillingness and is not motivated to go beyond the job description to take care of a client during the night. Which strategy by the nurse leader would motivate the NA and create job satisfaction?
Ask the nursing assistant (NA) to participate in decision making *According to the two-factor theory of leadership, motivating factors such as recognition and satisfaction of work promote job enrichment and create job satisfaction. Hygiene factors such as recruiting more staff to balance the work for nursing assistants (NAs), increasing the NA's salary, and increasing the security needs at night only avoid job dissatisfaction; these factors do not necessarily motivate the NA.
The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication?
Bronchodilator *airway and relieves bronchospasms. This in turn improves air exchange. An antibiotic is used to treat a bacterial infection. An antihistamine blocks the action of histamine. An expectorant is used to loosen mucus in the lungs. An antibiotic, an antihistamine, or an expectorant will not relax the smooth muscles in the bronchial airway for clients experiencing an acute episode.
What is discussed in Hersey's 2006 model related to delegation?
Core competencies of a situational leader *Hersey's model describes situational leadership, which include the core competencies of a situational leader. Anthony and Vidal described the five rights of delegation. Hersey's model does not include the legal authorities for delegation. Anthony and Vidal described characteristics of communication, such as information decay and information salience.
What is the priority nursing intervention for a 6-month-old infant with bronchiolitis?
Monitoring skin color, anterior fontanel, and vital signs *Continuous assessments are vital in determining the infant's oxygenation and hydration status and responses to the disease process. The infant needs the parents' presence to fulfill the developmental goal of infancy, the establishment of trust. Respiratory syncytial virus is the most common cause of bronchiolitis in an infant. Contact precautions are recommended for an infant with bronchiolitis; airborne precautions are not necessary. The infant is too ill to be involved in stimulating activities; energy should be conserved and oxygen demands kept to a minimum.
The nursing staff of a unit is frustrated and uncomfortable with the newly appointed nurse leader. Which role transition process is involved?
Role discrepancy *Role discrepancy is the development of gaps between role expectations and the role performances that may lead to discomfort and frustration of the team. In role exploration, the new nurse leader will be happy, excited, and is confident in exploring the new roles involved in the leadership position. Role negotiation is a strategy that is helpful during conflicting role expectations. When nurse leaders have been in their positions for several years and have internalized their roles, it is referred to as role internalization.
Which action of the leader signifies the implementation phase of the nursing process to teaching?
Sequencing different tasks The application of the nursing process involves four phases which are assessment, planning, implementation, and evaluation. The implementation phase involves sequencing of different tasks. Establishment of expectations indicates the planning phase. In the evaluation phase, the progress is compared to the plan. Assessing the needed performance level is part of the assessment phase.
The nurse is an active participant on human resource committees. What does this indicate?
The nurse is staying clear on group outcomes. *When a nurse participates as a leader in any leadership opportunities such as on human resource committees, it indicates that he or she is staying clear on group outcomes. Participating on human resource committees does not indicate any involvement in malpractice. Active participation on human resource committees does not indicate pursuing a higher degree. Participating on human resource committees indicates that the nurse is thinking beyond his or her personal needs.
When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship?
Assisting the client in acquiring more effective behavior *The therapeutic nurse-client relationship provides an opportunity for the client to try out different behaviors in an accepting atmosphere and ultimately to replace pathologic responses with more effective responses. Verbal communication, not nonverbal communication, is the objective of the therapeutic relationship. The nurse, although accepting of the client's hostile feelings, uses the therapeutic relationship to redirect hostile feelings into more acceptable behaviors. The nurse provides the support and acceptance that encourage clients to make their own decisions.
The nurse as a leader in the healthcare setting is studying how the communities and cultures that make up society relate to healthcare delivery. Which aspect of systems thinking theory of leadership is the nurse applying in this situation?
Recognizing the dynamic, complex, and interdependent nature of systems *According to the systems thinking theory of leadership, the nurse as a leader should identify and understand the communities and cultures of a society and how they relate to healthcare delivery. When the nurse envisions the context of their work beyond the immediate tasks, it indicates thinking of the "Big Picture" principle of systems thinking theory. Balancing short-term and long-term objectives indicates that the nurse recognizes the long-term consequences of actions taken today on the organization or client care. Using measurable versus non-measurable data systems triggers the tendency to see only what is measured
The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?
Skin integrity *Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.
A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." What is the best reply by the nurse?
"How do you feel about having a male nurse?" *Inquiring neutrally about the client's feelings about having a male nurse encourages the client to express and explore feelings in an open, nonjudgmental way. Asking the client whether having a male nurse is disturbing puts the client on the defensive. Stating that there aren't many male nurses does not encourage further conversation, and the client will not have the opportunity to express feelings; this response is focused on the nurse rather than on the client. Immediately volunteering to get a female nurse puts the client on the defensive rather than encouraging verbalization of feelings.
After observing a client waiting for food, the nurse leader instructs the nurse to make arrangements for food. Which statement used by the nurse to the client appropriately makes his or her positive intent explicit?
"I want to make you comfortable, here's your food." The nurse makes the client comfortable by providing the food, and verbally makes this known. Therefore this action is related to the nurse making his or her positive intent explicit. The act of ordering the food for the client clearly shows that the client is the focus for the nurse. However it may not relate to positive intent explication. The apology for the food delay is an example of a blameless apology. The expression of admiration of the client's patience is a way of expressing appreciation.
A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, "Can I have your phone number so I can call you for a date?" What is the best response by the nurse?
"Our relationship is professional; therefore I will not see you socially." *Stating "Our relationship is professional; therefore I will not see you socially" sets clear limits on the relationship and maintains a professional rather than a social role. Saying "We are not permitted to date clients" shifts responsibility from the issue at hand to the institution. Stating "It is against my professional ethics to date clients" avoids the real issue and shifts responsibility to the ethical code. Saying "I'm glad you like me, but I can't give out my phone number" does not clarify the nature of the relationship as professional.
A young client who has just lost her first job comes to the mental health clinic very upset and says, "I just start crying without any reason and without any warning." How should the nurse respond initially?
"Crying unexpectedly can be very upsetting." *The response "Crying unexpectedly can be very upsetting" identifies the client's feelings. Asking, "Do you know what makes you cry?" is an unrealistic question; the cause of anxiety may not be known. "Most of us need to cry from time to time" moves the focus away from the client. "Are you having any other problems at this time?" disregards the client's comment; it is a direct question that may impede communication.
Who functions as a liaison between team leaders and other healthcare providers?
Charge nurse *The charge nurse functions as a liaison between team leaders and other healthcare providers. Registered nurses function as accountable and responsible people for delegated tasks. Nursing managers are responsible for more than one unit and have other managerial responsibilities. Chief nursing officers are accountable for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation.
A 2-year-old child is admitted to the hospital with severe pain. Which factors should be considered when administering opioids to this child?
Dosing calculations Presence of other symptoms Appropriate dosage form *While administering opioids in children, the dose must be calculated and double-checked to avoid errors because excessive doses may be fatal in children. Opioids may cause side effects such as hallucinations and dizziness; therefore, the child should be monitored for signs and symptoms indicating side effects. Proper dosage forms such as oral, subcutaneous, and rectal administration of drugs should be chosen according to the client's condition. Diet modification and information on body mass index of the client is not required for the administration of opioids.
A client complains to the nurse that a staff member did not respond to the client's call. The nurse politely reassures the client, and makes the client comfortable. The nurse speaks to the staff member about the incident and solves the problem. Which critical thinking attitude has the nurse demonstrated in this situation?
Fairness *Listening to both sides of the story, in this situation, listening to the client and the staff member regarding the client's complaint indicates fairness. The nurse collects inputs from both parties involved before coming to a conclusion. Taking time to become thorough and managing time effectively reflects discipline in critical thinking. Encouraging the client to ask questions reflects confidence. Following the correct standard of practice in care reflects responsibility
Which school-age developmental characteristics increases the client's risk for poisoning?
Adhering to group rules Being easily influenced by peers Having a strong allegiance to friends *Developmental characteristics of the school-age client that increase the risk for poisoning include adhering to group rule, being easily influenced by peers, and having a strong allegiance to friends. Trying new things and increasing independence increase the risk for burn injury, not the risk for poisoning.
Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving warfarin therapy after a myocardial infarction?
Blood-clotting function of vitamin K *A neonate lacks the ability to produce vitamin K because of a lack of bacteria in the intestine. After a cholecystectomy a client experiences interference with absorption of the fat-soluble vitamin K because of disruption in bile flow. A client who is receiving warfarin experiences inhibition of vitamin K-dependent activation of clotting factors. Neuromuscular function of vitamin B 1, calcium-absorbing function of vitamin D, and hemoglobin-forming function of vitamin B 12 are not common nutritional problems for these clients.
A nurse on the psychiatric unit is assigned to work with a male client who appears reclusive and distrustful of everyone. How can the nurse help the client develop trust?
By being prompt for their scheduled meetings *Being prompt for their scheduled meetings helps the client feel important because the nurse remembers their meetings and is on time. The client is distrustful of others and will probably not believe a sincere declaration of caring about the client's feelings; caring is best demonstrated through behavior. Handing the client medication and not watching to see whether it is swallowed is not only an unsafe practice, but could make the client feel that the nurse does not care enough to stay. Feelings should never be ignored; instead, they should be accepted as important to the client.
The nurse is caring for an assignment of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage?
Giving birth to a baby weighing 9 lb 8 oz (4309 g) *The chance of postpartum hemorrhage is five times greater with large infants because uterine contractions may be impaired after the birth. Early breastfeeding will stimulate uterine contractions and lessen the chance of hemorrhage. Having a pudendal block for the birth does not contribute to postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. Ten minutes is a short third stage; a prolonged third stage of labor, 30 minutes or more, may lead to postpartum hemorrhage.
After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?
Monitoring the client for increasing intracranial pressure *Limiting increasing intracranial pressure and resulting brain damage depends on frequent, systematic assessments to identify this complication early. There is no indication that movement should be restricted. Mannitol is administered to reduce cerebral edema; there is no indication at this time that this is needed. Stimulating the client to maintain responsiveness is unrealistic; the state of consciousness should be monitored, but otherwise rest is not contraindicated.
Which nurses should be reassigned to assist with acute care of trauma victims coming through the emergency department?
Nurse who works in intensive care Nurse who works in the post-anesthesia care unit Nurse who works on a general medical-surgical care area *Nurses who care for critically ill clients such as the intensive care nurse and the post-anesthesia care unit nurse are the most qualified to assist with acute care of trauma victims in the emergency department. The skin and wound care, general medical-surgical, and intravenous nurses are less qualified to provide care to trauma victims in the emergency department.
A community health nurse visits an infant who was born at home 24 hours ago. While assessing the infant the nurse identifies slight jaundice of the face and trunk. What should the nurse do next?
Obtain a stat order for a bilirubin level. *Jaundice that appears within 24 hours of birth may be indicative of a pathological process; if the bilirubin level is high, intervention is required. Jaundice is not an indication for admission unless accompanied by a very high serum bilirubin level. In this situation bilirubin levels may be within normal limits and feedings may need to be increased to reduce jaundice. Physiologic jaundice does not appear until 72 hours after birth; this observation in the 24 hours after birth indicates pathologic hyperbilirubinemia. While it is important to document the jaundice in the infant's record, further intervention is indicated. The infant may require phototherapy after further assessment, but this is not the first action.
A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water?
Prevents reflux of air back into the chest *Water acts as a seal, preventing air from entering the pleural space, which will interfere with expansion of the lung. Removal of air (drainage) is promoted by negative pressure, not gravity, in the closed chest drainage system. Water in the system does not facilitate measurement of pressures in the chest wall; this is not the purpose of a water-seal drainage system. Although air exiting the pleural space will cause bubbling in the water-seal chamber, water in the system does not ensure bubbling in the water-seal chamber; this is not the purpose of the water-seal chamber.
A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care?
Registered nurse (RN) *Bathing is often delegated to a patient care associate (PCA) on the healthcare team. The registered nurse (RN) is accountable for the client care, but is not delegated the task of basic hygiene care such as bathing. Though the nursing aide is responsible for client care, he or she is not accountable for the client care. Similarly, a PCA may be responsible but not accountable for client care. As bathing is not generally delegated to a licensed vocational nurse (LVN), the LVN is neither responsible nor accountable for client care.
Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel
Telescoping of a proximal loop of bowel into a distal loop *Intussusception is the telescoping or prolapse of a segment of the bowel into the lumen of an immediately connecting segment of the bowel. Volvulus is a twisting of the bowel onto itself. Adhesions are bands of scar tissue that can compress the bowel. Herniation describes protrusion of an organ through the wall that contains it.
The nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate?
Unusual uterine enlargement *The proliferation of trophoblastic tissue filled with fluid causes the uterus to enlarge more quickly than if a fetus were in the uterus. Hypertension, not hypotension, often occurs with a molar pregnancy. There is no fetus within a hydatidiform mole. There may be slight painless vaginal bleeding.