Block 4, Assessment 2 PrepU
An elderly male client was in an automobile accident 2 weeks ago and incurred a spinal cord injury with resulting paralysis. The nurse assesses this disability as A. Acquired B. Permanent C. Age-related D. Developmental
A. Acquired Explanation: An acquired disability results from an acute and sudden injury, such as trauma to the spinal cord. The paralysis may be temporary. It may not be known to be permanent until swelling in the spinal cord has decreased. This may take weeks to months. A developmental disability is one that occurs prior to age 22 years. An age-related disability occurs in the elderly population as a result of the aging process.
Personal space and distance is a cultural perspective that can impact nurse-client interactions. What is the best way for the nurse to interact with a client who has a different cultural perspective on space and distance? A. Allow the client to adopt a position that is comfortable for him or her. B. Adopt a cultural preference similar to that of the client. C. Remember not to intrude into the personal space of the elderly. D. Realize that sitting close to the client is an indication of warmth and caring.
A. Allow the client to adopt a position that is comfortable for him or her. Explanation: If the client appears to position himself or herself too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, the client should be permitted to assume a position that is comfortable to him or her in terms of personal space and distance. "Realizing" and "remembering" are not interactions. It is also incorrect to attempt to adopt someone else's cultural preference as this can be very uncomfortable for the nurse, which adds a barrier to nurse-client interactions.
When the nurse attempts to obtain vital signs, the client pulls away, gathers the bed covers to their chin, and speaks in a language unfamiliar to the nurse. What is the best action for the nurse to take? A. Attempt to find an interpreter. B. Talk slowly and explain current actions. C. Use gesturing and pictures to explain current actions. D. Smile and take the vital signs anyway.
A. Attempt to find an interpreter. Explanation: Ideally, obtaining an interpreter will increase the communication between client and nurse. Talking slower or gesturing may not provide a clear understanding for client or nurse. Proceeding without the approval of client could violate the client's cultural beliefs.
How may a nurse demonstrate cultural competence when responding to clients in pain? A. Avoid stereotypical responses to pain in clients. B. Be knowledgeable and skilled in medication administration. C. Know the action and side effects of all pain medications. D. Treat every client exactly the same, regardless of culture.
A. Avoid stereotypical responses to pain in clients. Explanation: Culture influences an individual's response to pain. It is particularly important for nurses to avoid stereotypical responses to pain because they frequently encounter clients who are in pain or who anticipate that it will develop. A form of pain expression that is frowned upon in one culture may be desirable in another cultural group. Nurses should treat every client exactly the same but be aware of cultural influence in providing care. Medication knowledge is essential, but nurses should understand the cultural influence of pain and use of medication.
In terms of Maslow's hierarchy of need, families living in poverty may be focused more on which type of needs rather than self-actualization? A. Esteem B. Survival C. Security D. Safety
B. Survival Explanation: In terms of Maslow's need hierarchy, families living in poverty may be more focused on survival needs than self-actualization needs.
A client believes that the illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating? A. Ethnocentrism B. Cultural blindness C. Stereotyping D. Cultural diversity
D. Cultural blindness Explanation: The nurse is demonstrating cultural blindness, which occurs when one ignores differences and proceeds as though they do not exist.
The first method of choice for obtaining a urine specimen from a 3-year-old child with a possible urinary tract infection is: A. placing a cotton ball in the underwear to catch urine. B. obtaining a clean catch voided urine. C. performing a suprapubic aspiration. D. placing an indwelling urinary catheter.
B. obtaining a clean catch voided urine. Explanation: In the cooperative, toilet-trained child, a clean midstream urine may be used successfully to obtain a "clean catch" voided urine. If a culture is needed, the child may be catheterized, but this is usually avoided if possible. A suprapubic aspiration also may be done to obtain a sterile specimen. In the toilet-trained child, using a cotton ball to collect the urine would not be appropriate.
A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following would be the priority? A. Have the child sit up straight in a chair. B. Provide sedation as ordered. C. Administer 100% oxygen by mask. D. Check his capillary refill time.
C. Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing the ABCs and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume his own most comfortable position. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.
Native Americans who are wearing their tribal dress are demonstrating their native dance to a community group. This is an example of which of the following? A. Ethnocentrism B. Race C. Acculturation D. Ethnic expression
D. Ethnic expression Explanation: Ethnicity is the bond or kinship people feel with their country of birth or place of ancestral origin. Race refers to biologic differences in physical features, such as skin color and eye shape. Ethnocentrism is the belief that one's ethnic heritage is the "correct" one and superior to others. Acculturation involves the process of adapting to or taking on the behaviors of another group.
A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client? A. Assessing if the client speaks and understands English B. Requesting a professional translator fluent in the woman's language C. Directing assessment questions only to the client's partner or family members D. Realizing that some women are not allowed an education in their home country
A. Assessing if the client speaks and understands English Explanation: To best address individualization during a transcultural assessment with this client, the nurse must determine the degree to which the client effectively speaks and understands English. The nurse would need this information prior to asking for a translator, assuming the client was not allowed an education, or talking only with the partner or family members.
The nurse is caring for a 7-year-old boy and his family, who are immigrants. Which intervention will most significantly affect the success of the care provided? A. Communicating with sensitivity using understandable terms B. Asking about transportation to the appointment C. Referring them to state and local aid programs D. Inquiring about common health problems in their home country
A. Communicating with sensitivity using understandable terms Explanation: Being understood is essential to the provision of all nursing care. An interpreter may be needed. Speaking slowly and using simple terms is also useful. Inquiring about common health problems in their home country, asking about transportation, and helping them access aid programs are all secondary to and dependent upon effective communication.
A family recently immigrated to a new country. The parent reports that the adolescent is showing signs of fear, has vague reports of stomach pain, and feels humiliated by peers because of their culture. What is the priority assessment for the nurse? A. Culture shock B. Cultural assimilation C. Cultural blindness D. Cultural imposition
A. Culture shock Explanation: The client is experiencing symptoms associated with culture shock. Culture shock occurs when a person is immersed in a different culture that is perceived as strange. The person may feel foolish, fearful, incompetent, or humiliated, and these feelings can lead to frustration and anxiety. Cultural assimilation is when one begins to assume some characteristics of a culture outside of one's own. Cultural blindness occurs when cultural differences are ignored. Cultural imposition occurs when one pushes his or her beliefs onto another person.
Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report? A. Inspect for dependent edema. B. Assess for thrills. C. Palpate the carotid pulse. D. Ensure that the client lies flat for the examination.
A. Inspect for dependent edema. Explanation: Dependent edema results from sodium and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of nocturia results from the redistribution of fluid at night, forcing the client to get up to void more frequently. The client should only be told to lie flat for the physical examination if the client is hypovolemic and the neck veins need to be visualized. Palpation of the carotid pulse is useful for determining whether a murmur is systolic or diastolic. Thrills are formed by the turbulence of underlying murmurs and are associated with other cardiac conditions.
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? A. Listen at each site for at least one complete respiratory cycle B. Instruct the client to breathe in and out rapidly through the mouth C. Move from anterior to posterior on the same side D. Use the diaphragm then the bell in each location
A. Listen at each site for at least one complete respiratory cycle Explanation: The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.
A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings? A. cleft palate B. esophageal atresia C. cleft lip D. coarctation of the aorta
B. esophageal atresia Explanation: Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens, no feedings should be given until the newborn has been examined.
In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse explains that this is due to: A. pressure of the presenting fetal part on the diaphragm. B. pressure of the gravid uterus on the vena cava. C. a 50% increase in blood volume. D. physiologic anemia due to hemoglobin decrease.
B. pressure of the gravid uterus on the vena cava. Explanation: The client is describing symptoms of supine hypotension syndrome, which occurs when the heavy gravid uterus falls back against the superior vena cava in the supine position. The vena cava is compressed, reducing venous return, cardiac output, and blood pressure, with increased orthostasis. The increased blood volume and physiologic anemia are unrelated to the client's symptoms. Pressure on the diaphragm would lead to dyspnea.
Which nursing plan is a good example of how to incorporate cultural diversity preferences into the labor and delivery unit? A. administering pain medication to a laboring woman, even though she requests a "natural" birth B. supplying long-sleeved gowns and head scarves for a woman who requests them C. encouraging the spouse to attend the birth rather than allowing the elder women to participate D. assisting a woman in showering, even though she is stating it is against her belief
B. supplying long-sleeved gowns and head scarves for a woman who requests them Explanation: Agencies may need to change a policy to accommodate a family's cultural preferences, such as the length of visiting hours, types of food served, or type of hospital clothing provided (e.g., women from certain cultures may only feel comfortable in long-sleeved gowns and with head scarves). Different cultures have different preferences; for example, women do not shower or wash up following birth or elder women attend the birth rather than the spouse. If a woman requests a "natural" birth, this should be respected.
A nurse's personal reflection reveals that the nurse tends to see their own culture as the "gold standard" to which all other cultures should aspire. This nurse should create learning goals to address what phenomenon? A. Unconscious incompetence B. Stereotyping C. Acculturation D. Ethnocentrism
D. Ethnocentrism Explanation: The perception that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called ethnocentrism. Unconscious incompetence involves being unaware that one lacks cultural knowledge and unaware that cultural differences exist. Acculturation involves the modification of cultural values to align with those of the predominant culture. Stereotyping is expecting all members of a particular culture to hold the same beliefs and behave in the same way.
The nurse performing a focused genitourinary and renal assessment of a client would focus on what anatomical location when assessing for pain at the costovertebral angle? A. At the umbilicus and the right lower quadrant of the abdomen B. At the lower border of the 12th rib and the spine C. At the 7th rib and the xiphoid process D. At the suprapubic region and the umbilicus
B. At the lower border of the 12th rib and the spine Explanation: The costovertebral angle is the angle formed by the lower border of the 12th rib and the spine. Renal dysfunction may produce tenderness over the costovertebral angle.
A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time? A. Position her right arm below heart level. B. Encourage her to turn, cough, and deep breathe at frequent intervals. C. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. D. Ask the client how she feels about having her breast removed.
B. Encourage her to turn, cough, and deep breathe at frequent intervals. Explanation: Upon return from surgery, the nurse should encourage the client to turn, cough, and deep breathe at frequent intervals, at least every 2 hours, to help expand collapsed alveoli, clear inhalation anesthetic agents from the body, and prevent postoperative atelectasis and pneumonia. Asking the client how she feels about her breast removal should be done at a later time, when she is more alert and oriented and has had time to think about what has happened. The sign should state that no BP, IV lines, and lab work should be done on the client's right arm. The right arm should be elevated on a pillow to promote lymph drainage.
A nurse is teaching nursing assistants in an extended-care facility measures to protect the skin of elderly clients. Which of the following measures is the nurse likely to recommend? A. Assisting clients to soak in the bathtub several times each week B. Encouraging clients to avoid cigarette smoking C. Taking the clients outside for sun exposure daily D. Instructing clients to use perfumed skin creams
B. Encouraging clients to avoid cigarette smoking Explanation: Measures to promote healthy skin function in elderly clients include not smoking. Other measures include avoiding exposure to the sun, using emollient skin cream containing petrolatum or mineral oil, and avoiding hot soaks in the bathtub.
A nurse is caring for an elderly client who is unable to walk without a support due to knee pain. During his initial assessment, however, the client does not mention pain. Which of the following beliefs common in elderly clients may cause them to underreport their pain? A. Pain is harmless B. Pain is a normal part of aging C. Pain can be eliminated with medication D. Pain will draw their families closer to them
B. Pain is a normal part of aging Explanation: When assessing elderly clients, the nurse should remember that they often underreport pain. Many elderly people believe that pain is a normal part of aging, may be a punishment for past actions, may result in a loss of independence, and may indicate that death is near. Elderly clients usually do not believe that pain is harmless, that medicine will eliminate pain, or that pain will draw the family closer to the elderly client.
A client with a recent history of nephrolithiasis has presented to the ED. After determining that the client's cardiopulmonary status is stable, what aspect of care should the nurse prioritize? A. Insertion of an indwelling urinary catheter B. Pain management C. Assisting with aspiration of the stone D. IV fluid administration
B. Pain management Explanation: The client with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the client's need for IV fluids or for catheterization. Kidney stones cannot be aspirated.
A client believes that restoring optimal health takes more than treating the body; the client believes that the mind and spirit must be addressed as well. What is this perspective of health? A. Wellness B. Balance of body C. Holism D. Equilibrium
C. Holism Explanation: Holism means viewing a person's health as a balance of body, mind, and spirit. Treating only the body will not necessarily restore optimal health. Wellness is a state of being involving a constant effort to stay healthy and achieve the highest potential for total well-being. Equilibrium is the condition in which competing forces are balanced. The balance of body aligns with the mind and the spirit to complete the view of holism.
A group of students are reviewing the mechanics of oxygen and carbon dioxide exchange in the alveoli. The students demonstrate understanding when they identify which mechanism as being responsible? A. Osmosis B. Facilitated diffusion C. Active transport D. Diffusion
D. Diffusion Explanation: The exchange of oxygen and carbon dioxide in the alveoli occurs via diffusion
The nurse working on a pediatric floor understands the importance of diagnosing inborn errors of metabolism early. A child with a suspected problem must have blood urea nitrogen (BUN) and creatinine testing done. Which is the purpose of these two tests? A. Detect changes in amino acid patterns. B. Evaluate metabolism. C. Evaluate liver function. D. Evaluate renal function.
D. Evaluate renal function. Explanation: Tests of BUN and creatinine evaluate renal function. These tests are done to rule out chronic renal failure and to monitor the effects of treatments on the renal system. Tests of ammonia and lactic acid evaluate metabolism. Tests of plasma amino acids detect changes in amino acid pattern, while a liver function panel would help evaluate hepatic function.
Postoperatively, a client with a radical neck dissection should be placed in which position? A. Supine B. Side-lying C. Prone D. Fowler
D. Fowler Explanation: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position also promotes expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.
Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions? A. Northern and Central Europe. B. Central and South America. C. Australia and New Zealand. D. Mediterranean and Africa.
D. Mediterranean and Africa. Explanation: Drug metabolism differences, lactose intolerance, and malaria-related conditions—such as sickle cell disease, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and Duffy blood group—are considered biochemical variations. The malaria-related conditions would obviously occur in populations living in or originating from mosquito-infested locales such as the Mediterranean and Africa.
While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? A. Reddened perineal skin B. Presence of smegma C. Moist perineal skin D. Absence of discharge
A. Reddened perineal skin Explanation: The presence of reddened perineal skin is an abnormal finding. The healthy skin should be moist and noninflamed with no discharge present. Smegma (an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men) is considered a normal finding.
A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? A. Filgrastim B. Sargramostim C. Epoetin alfa D. Eltrombopag
C. Epoetin alfa Explanation: Erythropoietin (epoetin alfa) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis. Filgratism ( Neupogen) and Sargramostim stimulate granulocytosis( increasing WBC count) , Eltrombopag (Promacta) is used to treat aplastic anemia and thrombocytopenia.
A clinical nurse specialist is conducting a review class for a group of nurses about cultural competence and cultural diversity. Which term reflects the view of the world and set of traditions of a specific social group passed down through generations? A. race B. ethnicity C. culture D. values
C. culture Explanation: Culture consists of the world view and group of traditions shared by a social group and passed down through generations.
A group of students are reviewing the function of the kidneys and demonstrate understanding when they identify that the kidneys receive what portion of the cardiac output? A. 1/10 B. ½ C. ¼ D. 1/5
C. ¼ Explanation: The kidneys receive approximately 25% or ¼ of the cardiac output.
A client with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The client weighs 60 kg. The nurse is monitoring the client's urine output hourly and notifies the health care provider when the hourly output is less than what amount? A. 30 mL B. 125 mL C. 100 mL D. 50 mL
A. 30 mL Explanation: A urine output below 0.5 mL/kg/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.
Persistent gaps between the health status of minorities and non-minorities are defined as: A. health disparities. B. ethnocentrism. C. cultural relativity. D. racism.
A. health disparities. Explanation: Despite continued advances in health care and technology, racial and ethnic minorities continue to have higher rates of disease, disability, and premature death than non-minorities. These differences are known as health disparities. Racism is the belief that one's race is superior to another. Ethnocentrism is the belief that one's culture is superior to another. Cultural relativity is the belief that an understanding of a person's behavior depends, at least in part, on an understanding of that person's cultural context.
A client believes that the illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating? A. Cultural diversity B. Cultural blindness C. Ethnocentrism D. Stereotyping
B. Cultural blindness Explanation: The nurse is demonstrating cultural blindness, which occurs when one ignores differences and proceeds as though they do not exist.
A nurse is conducting a health assessment for a client. To assess the findings appropriately, which should the nurse consider? A. All individuals, regardless of culture, have the same anatomy and physiology. B. Cultural risk factors for alterations in health and normal racial variations C. Asking specific questions about race during the health history D. Differences in basic human needs
B. Cultural risk factors for alterations in health and normal racial variations Explanation: The person's culture does not affect how a health assessment is conducted, but it is an integral component of nurse-client interactions. Nurses should know risk factors for alterations in health based on racial inheritance, as well as normal variations that occur among races.
The nurse is caring for a client with lung metastases who just underwent a mediastinotomy. What is the nurse's priority postprocedure care? A. Performing chest physiotherapy B. Maintaining the client's chest tube C. Administering oral suction as needed D. Assisting with pulmonary function testing (PFT)
B. Maintaining the client's chest tube Explanation: Chest tube drainage is required after mediastinotomy. PFT may be needed, but it would be a lower priority than maintaining the chest tube. The client would need chest tube drainage after a mediastinotomy, not oral suctioning. Given that the client is healing from the incision made during the procedure, chest physiotherapy would be inappropriate at this time.
When assessing a client with suspected pertussis, which of the following would the nurse most likely find? A. High fever B. Paroxysmal cough C. Diarrhea D. Chest pain
B. Paroxysmal cough Explanation: A client with pertussis usual presents with a sudden paroxysmal cough that is accompanied by a characteristic whoop. A high fever, chest pain, and diarrhea are associated findings of Legionnaire's disease.
A nurse is caring for a client who is diagnosed with a breech presentation and in the transition stage of labor. The nurse is aware that which is common at birth? A. fetal tachycardia B. a thick meconium C. uterine rupture D. green-tinged amniotic fluid
B. a thick meconium Explanation: During a vaginal delivery of a breech presentation, the nurse expects to see a thick meconium as the buttocks are squeezed during labor. The presence of meconium does not necessarily indicate fetal distress and the meconium is not mixed with amniotic fluid. Although a difficult delivery for the mother, uterine rupture is not common. Fetal tachycardia is not commonly related to a breech presentation.
The nurse is caring for a child. The nurse is trying to ensure that the family's cultural practices are supported. Which statement by the nurse indicates a lack of understanding regarding cultural competence? A. "Are there any dietary practices related to your culture that we should know about?" B. "Is there a particular religion that we should note in your chart that may impact your care?" C. "Since your child is only 8, I doubt that your child has any cultural practices we need to be aware of." D. "Most cultures have certain practices that are important to them. We want to honor any that we can.
C. "Since your child is only 8, I doubt that your child has any cultural practices we need to be aware of." Explanation: Typically, a child begins to understand his or her culture at approximately 5 years of age, so stating that the child does not have any cultural practices at the age of 8 is inaccurate. Diet, cultural practices, and religious practices related to culture are important for the nurse to know so that the nursing staff can support as many of these practices as possible.
A client suffering from decreased muscle strength has been diagnosed with a low vitamin D level. The nurse should recommend that the client increase which vitamin source? A. Intake of dark green, leafy vegetables B. Intake of beans and peas C. Exposure to sunshine D. Intake of liver
C. Exposure to sunshine Explanation: Vitamin D can be obtained through exposure to sunlight. Food sources of vitamin D include fortified milk, orange juice, and cereals; certain fish; egg yolk; and mushrooms. Some people who are not exposed to enough sun and who don't get enough vitamin D through their diets may require dietary supplements. Liver, dried and cooked beans and peas, and dark green, leafy vegetables are all sources of folate, among other vitamins.
A nurse is relying heavily on gestures and simplified language during the assessment of a client from another culture who speaks minimal English. During the lengthy assessment, the nurse asks the client if she is "okay" by making a circle with his thumb and forefinger. The nurse should be aware of which of the following? A. In some cultures, this gesture denotes confusion. B. In some cultures, this gesture denotes pain. C. In some cultures, this gesture is offensive. D. This gesture has meaning only in American cultures.
C. In some cultures, this gesture is offensive. Explanation: The way Americans sign "OK" by making a circle with the thumb and forefinger is a definite and serious insult in many cultures around the world.
Which of the following best reflects nursing's view of clients as holistic beings? A. Id, ego, superego B. Physical, psychosocial, religious C. Mind, body, spirit D. Spiritual, egocentric, naive
C. Mind, body, spirit Explanation: Nursing has a long history of incorporating spirituality into client care. References to spirituality underlie a primary idea in nursing, that clients are viewed as holistic beings in body, mind, and spirit. Id, ego, and superego are concepts associated with psychoanalytic theory. A holistic view is more than physical, psychosocial, and religious or spiritual, egocentric, and naà¯ve.
The nurse is preparing a presentation to a local parent group about pediatric health supervision. Which would the nurse emphasize as the focus? A. health maintenance B. developmental surveillance C. wellness D. injury prevention
C. wellness Explanation: The focus of pediatric health supervision is wellness. Injury and disease prevention, health maintenance and promotion, and developmental surveillance are all critical components of wellness.
A nurse is conducting a spiritual assessment on a client. The nurse determines normal spiritual findings when the client makes which of the following statements? A. "I should have attended church more often." B. "I am glad I took care of myself all these years." C. "I have prayed every day, but I am still ill." D. "I have faith that my health will improve."
D. "I have faith that my health will improve." Explanation: The client is expressing positive spiritual coping skills when they state, "I have faith that my health will improve." The client expressing regret about not attending church more and that they have prayed every day but are still ill are signs of spiritual distress. The fact that they client took care of themselves is not spiritually related.
Which of the following are signs of a healthy educational system in a community? Select all that apply. A. Preschool and early intervention programs are provided B. Up-to-date facilities and equipment are available C. The tax base is low D. General equivalency diploma (GED) classes are available E. Public libraries are scarce
A, B, D Explanation: Resources needed to meet community educational needs include preschool and early intervention programs. An adequate supply of qualified educators, up-to-date facilities and equipment, and programs for those with special needs are keys to a successful educational system. Adult education, including general equivalency diploma (GED) classes, should be available. Public libraries are an important community supplement to the school system. A low tax base would indicate a lack of funding for education.
A client is scheduled to have a Papanicolaou test. After the nurse teaches the client about the Pap test, which statement by the client indicates successful teaching? A. "I will get a clean urine specimen when I first wake up the morning of the test." B. "I will not engage in sexual intercourse for 48 hours before the test." C. "I need to douche the night before with a mild vinegar solution." D. "I will take a bath first thing that morning to make sure I'm clean."
B. "I will not engage in sexual intercourse for 48 hours before the test." Explanation: The woman should refrain from sexual intercourse for 48 hours before the test because sperm can obscure the specimen. Douching should be avoided for 48 hours before the test to prevent washing away cervical cells, which might be abnormal. Although a bath is an appropriate hygiene measure, it is not required before a Pap test. Collecting a urine specimen also is not necessary.
The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation? A. Apply barrier powder B. Dry skin thoroughly after washing C. Apply triamcinolone acetonide spray D. Dust with nystatin powder
B. Dry skin thoroughly after washing Explanation: The nurse should teach the client without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, triamcinolone acetonide spray, and nystatin powder are used when the client has peristomal skin irritation and/or fungal infection.
A pregnant client visits the clinic for the first time. The client tells the nurse that this is her first pregnancy and that she and her husband are Ashkenazi Jews and immigrated to the United States from Israel. The nurse should encourage the client to be tested for A. sickle cell anemia. B. cystic fibrosis. C. cerebral palsy. D. Tay-Sachs disease.
D. Tay-Sachs disease. Explanation: Certain inherited disorders occur more often in particular ethnic groups such as Tay-Sachs disease in the Ashkenazi Jewish population.
A nurse working with older adult clients recognizes a common report contributing to multiple pelvic organ issues. This common report would most likely be: A. diarrhea. B. pelvic pain. C. urinary incontinence. D. constipation.
D. constipation. Explanation: Constipation can be a contributing factor to several pelvic disorders. In an effort to control or prevent other conditions, such as urinary incontinence, the client may decrease her fluid intake, which leads to constipation; this in turn can result in excessive straining, resulting in conditions such as pelvic organ prolapse or urinary incontinence.
A nurse assists with immediate interventions when a newborn is unable to initiate and maintain adequate respiratory function based on the understanding that these interventions are important to prevent which event(s)? Select all that apply. A. hypoxemia B. acidosis C. hypoxia D. hyperglycemia E. hyperkalemia F. hypercarbia
A, B, E Explanation: The inability to initiate and establish respirations leads to hypoxemia and ultimately hypoxia (decreased oxygen), acidosis (decreased pH), and hypercarbia (increased carbon dioxide). Hyperglycemia and hyperkalemia are not involved.
A premature neonate born at 36 weeks' gestation is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment finding(s) will the neonate demonstrate? Select all that apply. A. increased serum bilirubin levels B. cyanosis C. tea-colored urine D. clay-colored stools E. congenital dermal melanocytosis (slate gray nevi)
A, D, C Explanation: Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots) are not associated with newborn jaundice.
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? A. A puncture at the radial artery B. The trachea and bronchi C. A catheter in the arm vein D. The pleural surfaces
A. A puncture at the radial artery Explanation: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
What is a consequence of hypothermia in a newborn? A. respirations of 46 B. heart rate of 126 C. holds breath 25 seconds D. skin pink and warm
C. holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.
After teaching the parents of an 8-year-old girl with asthma about common allergens their child should avoid, the nurse determines that the parents need additional teaching when they identify what as a common allergen for asthma? A. shellfish B. dust mites C. pet dander D. indoor molds
A. shellfish Explanation: Eating shellfish is not a typical asthma trigger. Allergic reactions can occur with shellfish, but usually not an exacerbation of asthma. Indoor molds, pet dander, and dust mites are common asthma triggers.
A nurse is conducting a health history. The client's spouse is answering the interview questions. What question would be appropriate to ask the client before proceeding with the remainder of the interview? A. "Do you have a hearing impairment preventing you from hearing the questions?" B. "Who manages health care-related issues in your family?" C. "Can you ask your spouse to leave the room?" D. "Why is your spouse answering the questions?"
B. "Who manages health care-related issues in your family?" Explanation: In some cultures, the male is considered the head of the family and makes health care decisions and takes the role of answering questions related to health and medical care. It is important to establish who makes those decisions and to be respectful of the client's culture. It is best to take cues from the client. A client that is allowing another family member to answer questions may be doing so based upon the culture and roles in the family; it is important to clarify. Asking the spouse to leave the room or asking why the spouse is answering the questions can be insensitive and unprofessional. While asking about a hearing impairment may be appropriate, determining who makes the decisions is priority.
The nurse is teaching the parents of a child with conduct disorder about methods to deal with their child's detention from school for breaking science equipment. What advice should the nurse give the parents to deal with the situation? A. "You should punish your child so that the child never repeats the same mistake at school." B. "You should be supportive of the school for taking this step regarding your child's inappropriate behavior." C. "You should file a case against the school for punishing your child so severely." D. "You should be supportive of your child as your child might be very depressed after receiving detention."
B. "You should be supportive of the school for taking this step regarding your child's inappropriate behavior." Explanation: The nurse should explain to the parents that the child has received detention for behaving inappropriately in school and that they should support the school for this instead of blaming it. Using severe punishment is not a recommended treatment strategy for conduct disorder. The child with conduct disorder is unlikely to be depressed or feel guilty for receiving detention from school.
A parent informs the nurse that immunizations are contrary to her religious beliefs, and she does not want her child to receive them. The nurse proceeds to inform the parent that the child will be in grave danger of illness all her life and will not be allowed to start school unless she is immunized. The nurse also informs the parent that she had all of her own children vaccinated with no adverse effects. The nurse's behavior is an example of what? A. Acculturation B. Cultural taboos C. Cultural imposition D. Cultural blindness
C. Cultural imposition Explanation: The nurse's behavior is an example of cultural imposition, defined as the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Acculturation is the process by which members of a cultural group adapt to or learn how to take on the behaviors of another group. Cultural blindness is the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Cultural taboos are activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group.
What client would be most likely to benefit from the administration of epoetin alfa? A. A client born with spina bifida B. A client diagnosed with iron deficient anemia C. A client with a severe folic acid deficiency D. A client with hemorrhage after abdominal surgery
D. A client with hemorrhage after abdominal surgery Explanation: ESAs such as epoetin alfa are used to treat anemia associated with chronic kidney disease, chemotherapy for cancer treatment, Zidovudine (AZT) therapy for human immunodeficiency virus (HIV) infection and postsurgical blood replacement in place of allogeneic transfusions. Iron deficiency anemia is treated with oral iron supplements. Severe folic acid deficiency or megaloblastic anemia is treated with folic acid supplementation. Spina bifida is a condition that results from folic acid deficiency in utero resulting in a defect of the spinal cord.
The nurse is assessing an Asian client who presents with pigmented birthmarks on the buttocks and sacral area. The nurse would document this assessment as: A. Mongolian spots B. Nevi C. Rosacea D. Hemangiomas
A. Mongolian spots Explanation: Mongolian spots are caused by selective pigmentation. They usually occur on the buttocks or sacral area and are seen commonly in Asian and black persons. Hemangiomas are small, red lesions; nevi are moles. Rosacea is a chronic skin disorder causing papules and pustules.
A nurse is speaking with a client who has just learned that she is pregnant with her first child. The nurse reads in the client's chart that she does not drink alcohol on a regular basis. However, the nurse decides to go ahead and warn the client about the dangers of drinking alcohol while pregnant. Which phase of health care would this action be classified as? A. health rehabilitation B. health promotion C. health maintenance D. health restoration
B. health promotion Explanation: This action is an example of health promotion, which may be defined as educating parents and children to follow sound health practices through teaching and role modeling. Health maintenance is intervening to maintain health when risk for illness is present. Health restoration is using conscientious assessment to be certain symptoms of illness are identified and interventions are begun to return the client to wellness most rapidly. Health rehabilitation is helping prevent complications from illness, helping a client with residual effects achieve an optimal state of wellness and independence, and helping a client to accept inevitable death.
The nurse working in a mental health facility experiences resistance from the community when attempting to discharge a client into the community. Which action by the nurse with regard to residents opposing plans to establish a group home in their neighborhood will the nurse provide? A. To ensure the security of persons in the group home B. To provide for the safety and security of the neighborhood C. To provide information to correct misinformation related to stereotypes of persons with mental illnesses D. To persuade neighborhood residents that mentally ill people need safe, affordable, and desirable housing
C. To provide information to correct misinformation related to stereotypes of persons with mental illnesses Explanation: Frequently, residents oppose plans to establish a group home or residential facility in their neighborhood. These people may have strongly ingrained stereotypes and a great deal of misinformation. Local residents must be given the facts, and nurses are in a position to advocate for clients by educating members of the community. The neighborhood residents who object to the establishment of a group home or residential setting may not be motivated to understand the needs of mentally ill people. It is not the responsibility for the nurse to provide for the safety and security of the neighborhood. Ensuring the safety and security of persons in the group home does not address the needs of neighborhood residents.
A nurse working at a child health clinic is involved in primary prevention activities. Which activity will the nurse perform in this role? A. assisting with physical therapy exercises after knee surgery B. reviewing laboratory test results C. performing hearing screenings D. teaching about healthy food choices
D. teaching about healthy food choices Explanation: Primary prevention involves health-promoting activities to prevent the development of illness or injury, such as teaching about healthy food choices. This level of prevention includes giving information regarding safety, diet, rest, exercise, and disease prevention through immunizations and emphasizes the nursing roles of the educator and client advocate. Secondary prevention focuses on health screening activities that aid in early diagnosis and encourage prompt treatment before long-term negative effects arise, such as hearing screenings and reviewing laboratory test results. Tertiary prevention involves health-promoting activities that focus on rehabilitation, such as physical therapy exercises after surgery, and providing information to prevent further injury or illness.
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction? A. "Weigh yourself daily and report a gain of 2 lb in 1 day." B. "Eat a high-sodium diet." C. "Maintain bed rest." D. "Limit yourself to smoking only 2 cigarettes per day."
A. "Weigh yourself daily and report a gain of 2 lb in 1 day." Explanation: The nurse should instruct the client to weigh himself daily and report a gain of 2 lb in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy. The client shouldn't smoke at all.
A nurse cares for a female client of childbearing age who will undergo bariatric surgery. When teaching the client about precautions after surgery, which teaching will the nurse include that is specific to this population? A. "You should avoid pregnancy for at least 18 months after surgery." B. "After surgery, your ability to conceive is decreased considerably." C. "You should avoid pregnancy for at least 9 months after surgery" D. "After surgery, contraceptives have much less efficacy."
A. "You should avoid pregnancy for at least 18 months after surgery." Explanation: When teaching a female of childbearing age regarding precautions after bariatric surgery, the nurse should instruct the client to avoid pregnancy for at least 18 months after surgery. The ability to conceive after weight loss surgery may improve more often than worsen. Contraceptives are no less effective after surgery than before.
A woman in active labor begins to recite a lullaby to "call the baby outside." Which action by the nurse caring for this woman is most appropriate at this time? A. Allow the client to perform a ritual. B. Ask the woman the importance of this lullaby to her culture. C. Administer IV pain medication. D. Ask the family to join in with the singing of this lullaby.
A. Allow the client to perform a ritual. Explanation: The nurse can acknowledge and celebrate a client's culture without stereotyping by such actions as ensuring that the client has the opportunity to perform her cultural traditions during labor, such as reciting a lullaby to "call her child outside." There is no indication that pain medication is needed at this time. When one respects the culture, quizzing about the purpose or importance of reciting this lullaby is inappropriate.
An infant with congenital heart disease is to undergo surgery to correct the defect. The mother states, "I guess I'm going to have to stop breastfeeding her." Which response by the nurse would be most appropriate? A. "That's true, but we'll make sure she gets the best intravenous nutrition." B. "Unfortunately, your baby needs more nutrients than what breast milk can provide." C. "She won't be able to suck, so we have to give her fortified formula through a tube." D. "Breast milk may help to boost her immune system, so you can continue to use it."
D. "Breast milk may help to boost her immune system, so you can continue to use it." Explanation: Breastfeeding a child before and after cardiac surgery may boost the infant's immune system, which can help fight postoperative infection. If breastfeeding is not possible, mothers can pump milk and the breast milk may be given via bottle, dropper, or gavage feeding. In addition, breastfeeding is associated with decreased energy expenditure during the act of feeding.
A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? A. "I'll contact your primary care provider." B. "If you don't attempt to void, I'll need to catheterize you." C. "I'll check on you in a few hours." D. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."
D. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." Explanation: After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.
Which approach by the nurse best demonstrates the correct way to prepare a Hispanic child for a planned hospital admission? A. Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening. B. Discourage questions so as to not frighten the child. C. Tell the child that the procedure will not hurt because we have "magic medicine." D. Since the family is Hispanic, all preparation needs to be in Spanish.
A. Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening. Explanation: Allowing the child to put on surgical attire lets him or her see that hospital equipment is "not scary" and prepares the child for what will be seen on the day of surgery. Both the child and parents should be encouraged to ask questions. Honesty is the most important part of the program, so the nurse would never tell the child that the procedure will be painless because even the best care by the nurse may not eliminate all pain. Assuming that the family only speaks Spanish is inappropriate and could be considered profiling and rude. The nurse needs to determine the family's preference of language.
Urine specific gravity is a measurement of the kidney's ability to concentrate and excrete urine. Specific gravity compares the density of urine to the density of distilled water. Which is an example of how urine concentration is affected? A. On a hot day, a person who is perspiring profusely and taking little fluid has low urine output with a high specific gravity. B. A person who has a high fluid intake and who is not losing excessive water from perspiration, diarrhea, or vomiting has scant urine output with a high specific gravity. C. On a hot day, a person who is perspiring profusely and taking little fluid has high urine output with a low specific gravity. D. When the kidneys are diseased, the ability to concentrate urine may be impaired, and the specific gravity may vary widely.
A. On a hot day, a person who is perspiring profusely and taking little fluid has low urine output with a high specific gravity. Explanation: Specific gravity is altered by the presence of blood, protein, and casts in the urine and is normally influenced primarily by hydration status. On a hot day, a person who is perspiring profusely and taking little fluid has low urine output with a high specific gravity. A person who has a high fluid intake and who is not losing excessive water from perspiration, diarrhea, or vomiting has copious urine output with a low specific gravity. When the kidneys are diseased, the ability to concentrate urine may be impaired, and the specific gravity remains relatively constant.
The nurse is teaching a Black client about common health conditions. Which statement by the client most directly addresses a health problem with an increased incidence in this population group? A. "I need to watch the amount of high-density lipids I eat." B. "It is important to monitor my blood pressure." C. "Increasing dairy will improve my bones." D. "Getting a mammogram in my thirties is important."
B. "It is important to monitor my blood pressure." Explanation: Monitoring the blood pressure is important for identifying the risk for hypertension and stroke, which are common health conditions among the Black population. The other statements are correct for preventing diabetes, breast cancer, and osteoporosis, but these diseases are not disproportionately common health conditions for the population.
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs? A. Let the client remained fully dressed for the examination B. Have a nurse who is the same sex as the client examine him C. Avoid asking any questions regarding the client's lifestyle D. Allow the client to pray before the examination
B. Have a nurse who is the same sex as the client examine him Explanation: Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.
The nurse is caring for a client who perceives time differently. What action should the nurse take for this client? A. Set all interventions to be done at specific times. B. Maintain flexibility when the client requests interventions at specific times. C. Perform interventions at random times during shift. D. Have the client set all times for the interventions.
B. Maintain flexibility when the client requests interventions at specific times. Explanation: People view time differently. Social time can reflect attitudes regarding punctuality that vary among cultures. The nurse should maintain a flexible attitude and adapt the time of interventions to the client's needs and requests. It is not realistic to have the client set all the times for the interventions or to have the interventions at a specific time or interventions at random times during the shift.
The nurse is preparing to teach a drug education class at a local elementary school. The nurse is focused on providing which type of care to the community? A. Secondary prevention B. Primary prevention C. Tertiary prevention D. Preventive care
B. Primary prevention Explanation: Primary prevention is promotion of healthy activities and includes education concerning safety, diet, rest, exercise, and disease prevention. Secondary prevention focuses on health screening activities that aid in early diagnosis and encourage prompt treatment. Tertiary prevention focuses on rehabilitation and instruction on ways to prevent further injury or illness. "Preventive care" is not considered a specific category but is a general function that encompasses all three levels.
The school nurse is caring for a 12-year-old boy with a bloody nose. Which action would be most appropriate for the nurse to do? A. Seat the child with his head tipped back and apply ice or a cold cloth to the nose. B. Seat the child leaning forward and pinch the anterior portion of the nose closed. C. With the child lying on his back, pinch the anterior portion of the nose closed. D. With the child lying on his back, apply pressure to the bridge of the nose.
B. Seat the child leaning forward and pinch the anterior portion of the nose closed. Explanation: The child should sit up and lean forward. Apply continuous pressure to the anterior portion of the nose by pinching it closed. The bleeding usually stops within 10 to 15 minutes. Ice or a cold cloth on the bridge of the nose may help, but pressure will stop the bleeding. Lying down or tipping the head back may allow aspiration of the blood and should be avoided.
The nurse is discussing lifestyle changes and weight reduction with a female client with excessive abdominal fat. What is the method the nurse will use to measure the client's waist circumference? A. The tape measure is placed in a frontal plane from the rib cage to the iliac crest. B. A tape measure is placed in a horizontal plane around the abdomen at the level of the middle of the pelvis. C. A tape measure is placed in a horizontal plane around the abdomen at the level of the iliac crest. D. A tape measure is placed in a vertical plane around the abdomen at the level of the middle of the pelvis.
C. A tape measure is placed in a horizontal plane around the abdomen at the level of the iliac crest. Explanation: In addition to the calculation of BMI, waist circumference measurement is a useful assessment tool. To measure waist circumference, a tape measure is placed in a horizontal plane around the abdomen at the level of the iliac crest. A waist circumference greater than 40 inches (102 cm) for men or 35 inches (89 cm) for women indicates excess abdominal fat.
The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement? A. Dried beans B. Dried apples C. Orange juice D. Fortified grains
C. Orange juice Explanation: Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron. Dried fruit (such as apples), fortified grains, and dried beans are additional food choices that are rich in iron and should be included in her daily diet.
The younger nurses on a unit, who seem to adapt easily to the new technology presented, are perceived as threatening by two nurses who have worked on the unit for years. The older nurses begin to ridicule the younger nurses, saying, "You might be able to work a computer, but we know how to provide real care." How should the charge nurse respond? A. The charge nurse should recognize that this is cultural imposition and the younger nurses are forcing new technology on the older nurses. B. The charge nurse should demonstrate cultural blindness and pretend that the issue does not exist. C. The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit. D. The charge nurse should understand that this is stereotyping in the form of racism and intervene immediately.
C. The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit. Explanation: The scenario presents a classic example of cultural conflict. The older nurses feel threatened by those who are technologically savvy and try to prove their value so that they feel more secure. Both parties have value, and the charge nurse can use knowledge of diversity to help bring cohesion to the unit.
The community health nurse is assessing a home-bound client. The client expresses their own past-oriented ancestral heritage and family rituals. The nurse recognizes that the client is expressing: A. a subculture. B. assimilation. C. ethnic identity. D. ethnocentrism.
C. ethnic identity. Explanation: Ethnicity or ethnic identity refers to a self-conscious, past-oriented form of identity based on a notion of shared cultural (and perhaps ancestral) heritage and current position in larger society. Assimilation refers to new customs and attitudes that are acquired through contact and communication among persons of a particular culture and subculture refers to a group of people within a culture who have ideas and beliefs that are different from the rest of that society. Ethnocentrism is the practice of seeing one's own culture as the highest standard.
When the bladder contains 400 to 500 mL of urine, this is referred to as A. anuria. B. renal clearance. C. functional capacity. D. specific gravity.
C. functional capacity. Explanation: A marked sense of fullness and discomfort, with a strong desire to void, usually occurs when the bladder contains 400 to 500 mL of urine, referred to as the "functional capacity." Anuria is a total urine output less than 50 mL in 24 hours. Specific gravity reflects the weight of particles dissolved in the urine. Renal clearance refers to the ability of the kidneys to clear solutes from the plasma.
A nurse is working at a community women's health clinic. The nurse is involved in primary prevention activities. Which activity would the nurse be performing? A. cholesterol monitoring B. Papanicolaou (Pap) tests C. immunizations D. fecal occult blood testing
C. immunizations Explanation: Primary prevention encompasses a vast array of areas, including nutrition, good hygiene, sanitation, immunizations, protection from ultraviolet rays, genetic counseling, bicycle helmets, handrails on bathtubs, drug education for school children, adequate shelter, smoking cessation, family planning, and the use of seat belts. Papanicolaou (Pap) tests, cholesterol monitoring, and fecal occult blood testing are examples of secondary prevention activities.
A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care? A. Monitor temperature every 4 hours. B. Administer isotonic fluid therapy as ordered. C. Keep the drainage catheter below the level of insertion. D. Encourage use of incentive spirometer every 2 hours.
D. Encourage use of incentive spirometer every 2 hours. Explanation: To address the issue of ineffective breathing pattern, encouraging the use of incentive spirometer would be most appropriate to help increase alveolar ventilation. Administering isotonic fluid therapy would be appropriate for issues involving fluid loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of insertion would be appropriate to reduce the risk of obstruction leading to acute pain. Monitoring the temperature every 4 hours would be appropriate to reduce the client's risk for infection.
The nurse is admitting a client with uncontrolled hypertension and type 1 diabetes to the unit. During the initial assessment, the client reports seeking assistance and care from the shaman in the client's community. What is the nurse's best response to the client's indication that the care provider is a shaman? A. "It seems that the care provided by your shaman is not adequately managing your hypertension and diabetes, so we will try researched medical approaches." B. "Don't worry about insulting your shaman; the health care provider will explain to the shaman that the shaman's approach to your hypertension and diabetes was not working." C. "Thank you for providing the information about the shaman, but we will keep that information and approach separate from your current hospitalization." D. "I understand that you value the care provided by the shaman, but we would like you to consider medications and
D. "I understand that you value the care provided by the shaman, but we would like you to consider medications and dietary changes that may lower your blood pressure and blood sugar levels." Explanation: Some clients may seek assistance from a shaman or medicine man or woman. The nurse's best approach is not to disregard the client's belief in these healers or try to undermine trust in these healers. Nurses should make an effort to accommodate the client's beliefs while also advocating the treatment proposed by health science. The nurse's best response in incorporating these strategies is, "I understand that you value the care provided by the shaman, but we would like you to consider medications and dietary changes that may improve your blood pressure and blood sugar levels."
The unlicensed assistive personnel reports to the nurse that the client is refusing to eat the food on the meal tray. The nurse observes the client eating the food brought in by family members. How should the nurse respond? A. "You can only eat the food that we serve you." B. "I will need to get permission from your health care provider for you to eat the food your family brought in." C. "Do you understand that you are on a strict diet and any variation can cause you harm?" D. "What type of food did your family prepare for you, and does it have special meaning?"
D. "What type of food did your family prepare for you, and does it have special meaning?" Explanation: The culturally competent nurse should assess the type of food the client is eating and if the food has special meaning. Some cultures use food for healing and balance during times of illness. The client may have a restricted diet, but educating the client and family can allow the client to meet the cultural needs while still getting nutrition and meeting the dietary restrictions. The nurse does not need to ask permission from the health care provider regarding the food brought in from the family. Telling the client that he or she must only eat the food offered in the health care setting is not true or empathetic.
A nurse is reviewing the medical record of a patient who has just learned that she is pregnant. Which of the following would the nurse identify as being least likely to indicate a need for a genetic evaluation referral? A. Sister with intellectual disability B. History of epilepsy C. Three previous unexplained miscarriages D. Age 33 years at expected delivery
D. Age 33 years at expected delivery Explanation: Indicators that suggest a need for a genetics referral include maternal age of 35 years or older at expected time of delivery, history of diabetes, family history of intellectual disability, positive alpha-fetoprotein screening test, and two or more unexplained miscarriages.
The nurse in a long-term care facility is caring for an older adult client who had a 7% weight loss over a two-year period. Which is an expected intervention based on the information? A. Place the client on fall risk precautions. B. Teach the client to choose food low in protein. C. Ask the client to eat in their room to avoid distractions at mealtime. D. Assess the client's dentures for proper fit.
D. Assess the client's dentures for proper fit. Explanation: Poor-fitting dentures can detract from the enjoyment of meals, and unless the situation is remedied there can be a further decrease in weight. Losing weight doesn't automatically cause an older adult to be at risk for falls. If the client is having difficulty with maintaining proper fluid status, they will be at risk for falls. Older adults need to consume diets high in protein. Mealtimes should be as enjoyable as possible.
Which scenario is an example of cultural competence in nursing? A. Attending one's own church B. Assuming the provider and the client share beliefs and values C. Assessing the rate at which an illness causes death in a culture D. Attending a conference for cultural diversity
D. Attending a conference for cultural diversity Explanation: Cultural competence can be shown by actively learning about culture through attending a conference. Assessing the rate at which an illness leads to death does not develop cultural competence. One's own church is a familiar culture, and attending it does not breed cultural expansion or competence. The provider should never assume that beliefs or values are shared.
With which condition are the bronchial epithelial cells replaced by a fibrous scar tissue? A. Bronchitis B. Asthma C. Pneumonia D. Bronchiectasis
D. Bronchiectasis Explanation: Bronchiectasis is a chronic disease characterized by dilation of the bronchial tree and chronic inflammation of the bronchial passages. The chronic inflammation leads to replacement of the bronchial epithelial cells by fibrous scar tissue. Asthma is an obstructive disorder characterized by reversible bronchospasm, inflammation, and hyperactive airways. Bronchitis is an acute inflammation of the bronchi. Pneumonia is an inflammation of the lungs.
The nurse observes unlicensed staff insisting that he will bathe a female client, including her perineum, even though the client's caregivers request that a female aide perform this task. The nurse realizes that the unlicensed caregiver is exhibiting which characteristic? A. Cultural taboos B. Cultural blindness C. Acculturation D. Cultural imposition
D. Cultural imposition Explanation: Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person or people from a different culture. Cultural blindness is the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Acculturation is the process by which members of cultural group adapt to or learn to take on the behaviors of another group. Cultural taboos are activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group.
The pediatric nurse is explaining to a new graduate nurse the differences in planning well-child maintenance for a child with cancer. Which statement by the new nurse demonstrates understanding of the teaching? A. Siblings and parents should not receive nonlive vaccines. B. Growth may be stunted due to chemotherapy. C. Eliminate second-hand smoke within the home. D. No routine live vaccines are administered while on chemotherapy.
D. No routine live vaccines are administered while on chemotherapy. Explanation: Children with cancer need much of the same well-child maintenance care that all children do, with one exception. While they are undergoing chemotherapy, which causes a decreased immune response, they should not receive "routine" vaccines, especially live vaccines. The siblings in the home can receive all nonlive vaccines, and the entire family (including the child undergoing treatment) is encouraged to receive a yearly flu vaccine. Growth and development are monitored during well-child visits, but it is not necessarily true that growth and development may be stunted. It is always a good idea to eliminate second-hand smoke for all children, not just for children with cancer. Childhood cancers do not seem to be related to environmental contaminants.
While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements? A. Spirituality is the behavioral manifestation of religious beliefs. B. Religion and spirituality are synonymous. C. Spirituality is a recently developed alternative to traditional religious belief. D. Religion is a collection of spiritual beliefs and practices.
D. Religion is a collection of spiritual beliefs and practices. Explanation: Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable, and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion; nor is it a recent development.
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding? A. Tympany B. Dullness C. Hyper-resonance D. Resonance
D. Resonance Explanation: Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A. Hypersensitivity to an immunization B. Psychosocial stress C. Menarche D. Streptococcal infection
D. Streptococcal infection Explanation: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.
A female client is a carrier for a gene mutation on one of her X chromosomes. Her spouse is unaffected. The nurse understands that which of the following is most likely? A. The risk of transmitting the disorder is negligible. B. Any daughters of the client would be carriers for the disorder. C. The client has signs and symptoms of the condition. D. The client's sons have a 50% chance of being affected.
D. The client's sons have a 50% chance of being affected. Explanation: A person who is a carrier for a gene mutation on one of her X chromosomes is a carrier of the condition. The client would not have any signs and symptoms of the condition but would be capable of transmitting the mutated gene to offspring. The most common pattern of inheritance would be X-linked recessive inheritance. Thus, any sons of the client would have a 50% chance of being affected and any daughters would have a 50% chance of being carriers.
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence? A. Overflow B. Functional C. Stress D. Urge
D. Urge Explanation: Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an over distended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.
A client who practices Judaism requests a clergy person. Which of the following people should the nurse contact? A. a priest B. an imam C. a Buddhist priest D. a rabbi
D. a rabbi Explanation: A member of the clergy for those practicing Judaism is a rabbi. A priest is an ordained minister of the Catholic faith. An imam is an Islamic priest. A Buddhist priest or pastor is an ordained monastic in Buddhism.
A surgical client develops nonobstructive postoperative urinary retention. What drug would the nurse expect to be ordered for this client? A. pyridostigmine B. neostigmine C. ambenonium D. bethanechol
D. bethanechol Explanation: The agent bethanechol, which has an affinity for the cholinergic receptors in the urinary bladder, is available for use orally and subcutaneously to treat nonobstructive postoperative and postpartum urinary retention and to treat neurogenic bladder atony. The other options are not indicated for this purpose.
A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A. increasing fluid intake to 3,000 mL/day B. stool-softening laxatives, such as docusate C. drinking fluids with a high sugar content D. eating fermented products, such as yogurt
D. eating fermented products, such as yogurt Explanation: Some medications, such as antibiotics, may destroy normal intestinal flora and cause diarrhea. To promote the return of normal flora, the nurse can recommend an intake of fermented dairy products, such as buttermilk or yogurt. Laxatives and high volume water intake will delay the return of normal flora within the GI tract. Sugar ingestion in a low normal flora state will promote the overgrowth of the fungus Candida Albicans.