CE3

A man has roles of father, husband, professional businessman, son, and community leader. What may he be at risk of experiencing?

B. Internal role conflict

When a nurse assesses a family, which family task has the highest priority for healthy family functioning?

B. Physical maintenance and safety

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection?

B. Removing the gown without rolling it from inside out

A licensed practice nurse is reporting observations to the Registered Nurse (RN). Based on the report, which client should the RN assess immediately?

B. The client with a crush injury to the arm who has given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

B. Three sputum cultures are negative.

A client is receiving care for dissociative identity disorder as a result of extreme childhood trauma. Which nursing intervention would be most appropriate when caring for this client

B. Focus on the client's strengths and skills

The registered nurse (RN) is caring for an older patient who has been admitted to the hospital. The RN allocates several tasks to the unlicensed nursing personnel (UNP). To evaluate the understanding of the UNP, the RN asks the UNP to describe which tasks have been allocated. Which responses by the UNP indicate effective understanding of the tasks? Select all that apply. One, some, or all responses may be correct

A. "I must assist the patient with oral care D. "I must give a sponge bath to the patient every morning. E. "I must record the blood pressure of the patient at regular intervals

The registered nurse (R) has delegated a task to an unlicensed nursing personnel (UNP). After performing the task, the UNP reports to the RN for appraisal. Which statements by the UNP are related to individual accountability? Select all that apply. One, some, or all responses may be correct.

A. "I take full responsibility for the action performed' B. "I have ensured that the action has achieved the desired outcome'

The nurse cares for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget. Which nursing statement is most appropriate in this situation?

A. "I've noticed that you seem to be pacing and fidgeting."

The patient reports to the nurse that they're afraid to speak up regarding a desire to end care for fear of upsetting their spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause?

A. Advocacy

The parent of an adolescent diagnosed with mental illness asks the nurse, "Why do you want to do a family assessment? My teenager is the client, not the rest of us." What is the nurse's best response

C. "Every family member's perception of events is different and adds to the total picture."

Which technique will best communicate to a client that the nurse is interested in listening?

A. Restating a feeling or thought the client has expressed

A 70-year-old immobile client, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take? answers.

A. Summon at least one other person to assist. D. Obtain a lift sheet. E. Place the client flat on their back.

While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a client. Which is the important information for the nurses to remember when talking about the client?

A. Talking about clients in public places is a violation of the client's confidentiality

Which teaching method is most effective when providing instruction to members of special populations?

A. Teach-back

A registered nurse (RN) cares for a client with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching? Select all that apply. One, some, or all may be correct.

A. The RN orders the patient eggs, toast, and coffee for breakfast B. The RN encourages the patient to ambulate around the unit. D. The RN raises the thermostat to increase the temperature in the room

During a home visit to a client who has just been diagnosed with hepatitis A, a nurse is providing education to prevent the spread of the disease to the client's wife and children. Which information should the nurse provide to the family? Select all that apply. One, some, or all may be correct

A. The client should use strict handwashing after bowel movements. C. Clean the common toilet seat with bleach after each use by the client.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing question

B. "Are you currently in any danger?"

A client diagnosed with schizophrenia tells the nurse, "The Central Intelligence Agency is monitoring us through the fluorescent lights in this room. The CIA is everywhere, so be careful what you say." Which response by the nurse is most therapeutic?

B. "It sounds like you're concerned about your privacy."

Which notations indicate accurate nursing documentation by the nurse? Select all that apply. One, some, or all may be correct.

B. Abdominal wound dressing is dry and intact without drainage. E. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The charge nurse is supervising a new nurse graduate who is caring for a client on the mental health unit. The client was involuntarily hospitalized and is scheduled for electroconvulsive therapy. The charge nurse notes that an informed consent has not been obtained for the procedure. What action by the new nurse graduate would indicate a need for further education

B. Arranging for the family to sign the consent form for the client

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. One, some, or all may be correct.

B. Ask the client to state the consequences for their behavior. C. Communicate expected behaviors to the client. E. Assist the client in setting limits on their current behavior

The nurse is reviewing an elderly client's AIC result of 8. The last office visit demonstrated AIC of 5.5. What question should the nurse ask the client to confirm a possible cause of increased blood glucose levels?

B. Can you demonstrate to me how to pull up 6 units of insulin?

A client is being discharged after having a cholecystectomy. What statement by the client indicates they understand discharge teaching instructions?

C. "I will make an effort to eat fewer gas-forming foods."

A client tells the nurse, "I don't think I'll ever get out of here." What is the nurse's most therapeutic response?

C. "You don't think you're making progress?"

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

C. "You need to consult with the primary health care provider (PHCP) before receiving immunizations."

A nurse talks with a woman who recently learned that her husband died while jogging. What is the appropriate statement for the nurse to provide in response?

C. "Your husband's loss must be very painful for you."

In preparation for which test should the nurse teach the patient to minimize physical and emotional stress?

C. A 24-hour urine test for free cortisol

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

C. A client who requires urine specimen collections

To provide culturally competent care, the nurse should focus on what action

C. Identifying strategies that fit within the cultural context of the client.

The nurse is conducting discharge teaching for a client with a new diagnosis of hypertension. What should the nurse include in the teaching session? Select all that apply. One, some, or all may be correct

C. Keep a diary of regular BP readings D. Instruct client to bake, roast, or boil foods E. Avoid over-the-counter medications

A fire has started in a work area on the unit. Which of the following is the response which demonstrates correctly using a fire extinguisher?

C. Move the extinguisher in a sweeping, side-to-side motion.

A charge nurse on a medical unit is determining where on the unit to place a client who is being admitted with an exacerbation of Crohn's disease. The client is female, 20 years old, alert and oriented, and has been taking azathioprine for disease management. Which room is most appropriate for the client?

C. Private room with a private bathroom.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

C. Removing the client from any immediate danger

A hospice client tells the nurse, "Life has been good. I am proud of being self-educated. I overcame adversity and always gave my best. I intend to die as I lived." The nurse planning care for this client would recognize the priority of supporting which client need?

C. Supporting the patient's use of their own resources to meet challenges.

A client is diagnosed with Hepatitis C. Which suggestion by the nurse would aid in prevention of this condition

C. Utilize strict needle precautions

The new nurse cares for a client with Clostridium difficile, while the charge nurse observes. Which action by the new nurse would cause the charge nurse to intervene

C. Washing hands with alcohol-based solution after client care

The nurse is caring for a client who fractured her right hip after falling in her backyard and is awaiting surgery. What order would the nurse anticipate by the health care provider?

A. Apply 5 lbs. of skin traction

A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?

A. Assault

A nurse should provide the following discharge teaching instructions for a client who had a diagnostic arthroscopy? Select all that apply. One, some, or all may be correct.

A. Elevate the involved extremity for 24 to 48 hours. C. Report severe joint pain immediately to the physician. E. Treat pain with a mild analgesic such as acetaminophen.

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?

A. Identifying situations that trigger anxiety

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list?

A. Increase the humidity in the home B. Wear high-collared shirts to protect the stoma C. Avoid showers due to the stoma E. Avoid exposure to people with infections

The nurse is caring for a child who was admitted with chronic renal failure. What assessment findings would the nurse expect in this client? Select all that apply

A. Increased Blood Urea Nitrogen (BUN) B. Decreased glomerular filtration rate C. Azotemia E. Oliguria

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. One, some, or all may be correct.

A. Institute seizure precautions B. Monitor vital signs frequently D. Re-orient the client as needed

An experienced psychiatric nurse plans to begin a new job in a community-based medication clinic. The clinic sees culturally diverse clients. Which action should the nurse take first to prepare for this position?

A. Investigate cultural differences in clients' responses to psychotropic medications.

A nurse on an acute care unit focuses on the development of assertive and responsible conflict resolution skills with peers. Which characteristic should the nurse develop?

A. Listens empathetically to peers

A 9 year old child has recently experienced the death of their sibling. The child has begun to ask questions about what happens to the body after death. The parents ask if these types of questions are abnormal behavior linked to playing video games. Which is the best response by the nurse

D. "School-aged children are inquisitive and ask a lot of questions about death

A nurse receives a change-of-shift report at 0700 for an assigned caseload of clients. Which client should be seen first?

D. A client whose blood transfusion began at 0645

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem?

D. A sedentary 65-year-old woman who smokes cigarettes

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse?

D. A woman who has dementia

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

D. Observing care provided to the client without the client's permission

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take

D. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center

Which activity performed by the registered nurse (RN) indicates effective delegation?

D. Supervising and monitoring the licensed practical nurse (LPN) about the different activities

A child diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and conducts teaching with the child's parents. Which action by the parents indicate a need for additional education?

D. The parents watch TV in the child's room with the volume up