Ch. 16, 19, 20 & 21

When the preoperative client tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is: a) "Sounds as if your surgery is a pretty scary procedure." b) "You shouldn't be nervous. We perform this procedure every day." c) "The thought of having surgery is keeping you awake." d) "You have a great surgeon. You have nothing to worry about."

c) "The thought of having surgery is keeping you awake."

It is acceptable for the nurse to accept a verbal order from the physician in which of these situations?

during a medical emergency

A nurse working in a community clinic assists middle adult patients to follow guidelines for health-related screenings and immunizations. What preventive measures would the nurse recommend for this population?

• A physical exam every year from age 40 on • Breast self-examination every month for women • Pelvic examination and Pap exam at least every 3 years for women • Prostate-specific antigen (PSA) test every year for men

SBAR-R

Situation Background Assessment Recommendation Read back Used for hand-off communication and or conversations with physicians.

What is the primary purpose of the client record?

communication

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:

have the right to copy their health records.

A nurse is caring for a 46-year-old male client who is being treated for depression following the death of his spouse. Which action best facilitates the accomplishment of a developmental task of this middle adult?

helping him to see the value of guiding his children to become responsible adults

When assessing a client during the middle adult years, the nurse recognizes which of the following as a normal physical change?

increased loss of calcium from the bones

Role modeling

involves a nurse's behaviors and the client observing and learning from these behaviors.

Which of the nurse's following actions is most likely to promote a patient's compliance with her antiretroviral drug regimen for the treatment of HIV?

use interactive and learner appropriate teaching techniques.

Clarifying question

used to prevent possible misconceptions that could lead to inappropriate nursing diagnosis. Pt: I have never needed to take medicine before in my life. Nurse: Is this the first health problem you have had?

A nurse is screening for Alzheimer's disease (AD) in patients in a long-term care facility. Which facts regarding AD are accurate?

* Scientists estimate that more than 5 million people have AD. • Nearly half of 85-year-old adults have A • AD affects brain cells and is characterized by patchy areas of the brain that degenerate.

The nurse understands that when caring for the older adult it is important to assist in maintaining independence and self-esteem. Assisting the client to adjust to a walker or wheelchair is an example of supporting which of Erikson's developmental tasks of the older adult?

Ego integrity and coping with reality of limitations

A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?

Graphic sheets Explanation: The graphic record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics. Flow sheets are documentation tools used to efficiently record routine aspects of nursing care, not data as asked in the question.

Which of the following is typically found in the client care summary or kardex?

Information commonly found in a the client care summary or kardex include demographic data, code status, safety precautions, basic care needs (such as activity status or diet), and treatment (such as vital sign schedule, IV therapy, and diagnostic or laboratory tests).

A school nurse is discussing bike and outdoor safety measures with a group of Boy Scouts. What type of health education and counseling is the nurse providing to this group of children? a) Facilitating coping b) Preventing illness c) Restoring health d) Promoting health

Preventing illness Explanation: Preventing illness includes first aid, safety, immunizations, screening, and identification and management of risk factors. Promoting health focuses on developmental and maturation issues, hygiene, nutrition, exercise, mental health, and spiritual health.

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client? a) Return demonstration b) Oral test c) Simulation d) Written test

Return demonstration Explanation: The nurse is evaluating psychomotor skills; thus, a return demonstration is a method of testing skill performance.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

When encouraging activity in older adults, it is important to consider which of the following?

The physical strength and health of the older adult declines and requires lifestyle modifications. Older adults have more chronic illness and have the potential for sleep disruptions and the increased risk of falls, thus the need for a cane/walker for assistance.

What are factors that affect learning in patients?

age, culture, finances

Sequencing question

placing events in a chronological order

Open-ended question

prevents yes no answers

Reflective question

repeating what the person has said or describing the person's feelings. Pt: I've been really upset about my BP and have to take these pills. Nurse: You've been upset...

Why are quality assurance programs important in nursing

they enable nursing to be accountable for the quality of care.

Validating question

used to validate what the nurse believes she has heard

A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

A nurse is providing teaching to patients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? (Select all that apply.) A The nurse fails to accept that patients have the right to change their minds. B The nurse negotiates goals with the patient. C The nurse uses medical jargon frequently when discussing the teaching plan. D The nurse ignores the restrictions of the patient's environment. E The nurse evaluates what the patient has learned. F The nurse reviews educational media when planning learner objectives.

A The nurse fails to accept that patients have the right to change their minds. C The nurse uses medical jargon frequently when discussing the teaching plan. D The nurse ignores the restrictions of the patient's environment.

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment? a) A 36-year-old male; uses public transportation, unable to read, wants to confer with pastor. b) A 28-year-old female; works nights, willing to try, asking about insurance coverage of appointment. c) A 45-year-old female; unsure of the benefit of psychiatric care, on a fixed income, good family support. d) A 51-year-old male; walks to most places because of no transportation, low income, works days.

A 28-year-old female; works nights, willing to try, asking about insurance coverage of appointment. Explanation: Cultural issues, poor family support, or lack of transportation may cause barriers to obtaining needed care. If a client must choose between work and keeping an appointment, scheduling is an important factor. The characteristics of a client who will keep appointments with specialists include those clients who have been well educated about the importance of the referral, understand the benefit to seeing a specialist, and those who will not have to struggle to keep the appointment. A client who agrees, who has input in scheduling, and shows curiosity or hope about the benefit of the referral is more likely to keep the appointment.

Nurses must take into considerations factors that influence communication when communicating with patients. Which examples accurately reflect communication that considers these variables? (Select all that apply.) taylor 20 A A female nurse communicates in the same manner to both male and female patients. B A nurse communicates in the same manner to patients of different cultures to avoid stereotyping patients. C A nurse uses simple language and demonstrations to explain a procedure to a preschooler. D A nurse uses the intimate zone when explaining painful procedures to young children. E A nurse checks a patient's occupation for clues on how this will affect communication but avoids stereotyping the person. F A nurse takes into consideration a patient's culture when planning how far away to sit when communicating.

C A nurse uses simple language and demonstrations to explain a procedure to a preschooler. E A nurse checks a patient's occupation for clues on how this will affect communication but avoids stereotyping the person. F A nurse takes into consideration a patient's culture when planning how far away to sit when communicating.

A 78-year-old woman is status post right hip fracture after a fall. She has stopped going to her church over the past few months. She has also asked her neighbor to help her and do her gardening, an activity she previously loved. The client tells the nurse "I just don't enjoy gardening like I used to. I am always worried about falling." What would most concern the nurse regarding the client?

Depression

Hello Kitty is a student nurse at San Jacinto College Central. She will sign her name as:

Hello Kitty, SN/SJCC

A nurse encourages residents of a long-term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure healthy aging. This intervention is based on which aging theory?

Identity-continuity theory

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings.

When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate? a) Long-term counseling b) Short-term counseling c) Professional counseling d) Motivational counseling

Motivational counseling Explanation: The most appropriate counseling for the situation at hand would be motivational counseling. With motivational counseling, the nurse would discuss feelings and incentives with the client.

A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

There is an 86-year-old female on the medical inpatient unit. She explains that the hospital is quite noisy and that she is having difficulty sleeping. Which is not true regarding sleep in the older adult?

Sleep medications are usually the first choice in treating sleep disturbance.

A 90-year-old woman is admitted to a nurse's unit status post CVA. The client is alert and oriented to person, place, and time but has limited mobility and hemiparesis of the left side of her body. She is experiencing urinary incontinence. What is the most appropriate nursing action?

Use the Braden scale to assess for pressure ulcers. Explanation: The Braden scale is an evidence-based tool used to assess for pressure ulcers. Pressure ulcers can result from urinary incontinence, particularly if the skin is moist and skin integrity is impaired. The client would likely require assistance every time she uses the toilet.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

In which of the following situations would the SBAR technique of communication be most appropriate? a) A nurse is calling a physician to report a client's new onset of chest pain. b) A nurse is facilitating a family meeting in order to coordinate a client's discharge planning. c) A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke. d) A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure.

a) A nurse is calling a physician to report a client's new onset of chest pain.

The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions? a) "Why did the health care provider prescribe this medication for you?" b) "When was the last time you had your prescription refilled?" c) "How often do you take this medication?" d) "How many tablets do you take at one time?"

a) Why did the health care provider prescribe this medication for you?

Which characteristic is part of a nurse-client relationship? a) an unequal sharing of communication b) occurs spontaneously c) similar to a social relationship d) based on the needs of the nurse

a) an unequal sharing of communication

a) Orientation Phase b) Working Phase c) Termination Phase

a) the tone and guidelines for the relationship are established. You and the patient meet and learn to identify each other by name. b) the nurse works together with the patient to meet the patient's physical and psycho-social needs. Providing patient with whatever assistance might be needed to perform ADLs. c) occurs when the conclusion of the initial agreement is acknowledged.

The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, "I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do?" Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching?

appropriate staffing

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which of the following as a characteristic of an adult learner? a) The material presented should focus on future application. b) Their readiness to learn is often related to a developmental task or social role. c) Peer group acceptance is a critical issue for this age group. d) Previous experiences have little impact on learning.

b) Their readiness to learn is often related to a developmental task or social role.

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be: a) passive. b) aggressive. c) assertive. d) nurturing.

b) aggressive

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: a) pick a team leader who is not the dominant member. b) have group members confront the dominant member to promote the needed team work. c) have group members issue a written warning to the dominant member. d) plan a meeting where the dominant person cannot attend.

b) have group members confront the dominant member to promote the needed team work.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should: a) inform the client that several nurses will be needed to care for this wound. b) tell herself to "remain calm" and remember that she was trained to perform this skill. c) tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. d) ask the charge nurse to change her assignment.

b) tell herself to "remain calm" and remember that she was trained to perform this skill.

A nurse is planning care for an adult client with severe hearing impairment and a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care? a) Use text-telephone device (TTD) for daily communication. b) Consult the oncology nurse specialist. c) Arrange for an interpreter when discussing treatment. d) Talk with the client's children to determine needs.

c) Arrange for an interpreter when discussing treatment.

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which of the following is the most appropriate method the nurse should use to conduct new learning? a) Create small groups and facilitate group discussions. b) Talk to the client's relatives and get a detailed account of the client's history. c) Begin the session with a reference to the client's actual experience. d) Begin the session with identifying each learner by his/her name.

c) Begin the session with a reference to the client's actual experience.

Which of the following are examples of nonprofessional involvement? (Select all that apply.) a) Discussing your recent breakup with your boyfriend with a patient who is also going through a difficult breakup. b) Asking a patient if they would like to go out for dinner after they are discharged. c) Discussing today's weather forecast. d) Asking a patient in hospice care to describe their relationship with various family members.

c) Discussing today's weather forecast. d) Asking a patient in hospice care to describe their relationship with various family members.

older adults have completed moral development and many experience self transcendence, which may be defined as what

capability to reach beyond prior limits with more awareness of other people's values and beliefs.

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

charting by exception

A nurse touches the client's hand while discussing his diagnosis. This action is a

communication channel

A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an) a) therapeutic relationship. b) congruent relationship. c) functional focus. d) incongruent relationship.

d) incongruent relationship. Explanation: What the nurse is communicating verbally and nonverbally are incongruent with each other. Even though the nurse is verbally saying that he or she has time to talk, the nurse's nonverbal actions demonstrate that he or she is ready to perform the procedure. In addition, the back turned to the client while speaking demonstrates closed communication.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: a) softly humming a song near the neonate. b) staring into the neonate's eyes and smiling. c) offering the neonate infant formula. d) swaddling the child and gently stroking its head.

d) swaddling the child and gently stroking its head. Explanation: Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or long-term care facility care. Vision, taste, and hearing are not as fully developed as touch in the neonate.

A nurse enters the client's room and introduces himself stating, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and I will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." He then gives the client a printed card with this information. In the helping relationship, what does this represent? a) Working phase b) Intimate phase c) Termination phase d) Orientation phase

d. orientation phase

A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education?

help in teaching self-care

Programmed instruction

incorporates the use of books as the instructor, independent of study with a teacher.

panel discussion

involves a presentation of information by two or more people.

A client has come into the clinic for a postoperative visit. The outcome for the patient's pain level is less than equal to 3/10. The client states that the postoperative pain continues to be 6 on a 10-point rating scale. The nurse evaluates the patient and the current plan of care. Based on the information provided by the client, the nurse should do which of the following?

modify the plan of care

When a patient says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate?

motivational counseling

According to Havighurst, the major tasks of old age are primarily concerned with

the maintenance of social contacts and relationships. Successful aging depends on a person's ability to be flexible and adapt to new age-related roles. The person must find new and meaningful roles in old age while being reasonably comfortable with the social customs of the times.

A nurse gives a speech on nutrition to a group of pregnant women. What is the speech itself known as?

the message The message is the actual physiologic product of the source. It might be a speech, interview, conversation, chart, gesture, memorandum, or nursing note. This communication process is initiated based on a stimulus. The sender or source of the message is a person or group who initiates or begins the communication process. The channel of communication is the medium the sender has selected to send the message.

A nurse is caring for an older adult client who fell and sustained a hip fracture. Which intervention needs to be included in the nursing care plan?

• Cough and deep breathe every 2 hours. • Avoid massaging over bony prominences. • Auscultate breath sounds every 1-2 hours. Explanation: An older adult is more likely to develop complications after illness occurs. An older adult with a hip fracture is at high risk for pneumonia and skin breakdown because of immobility, a decreased ability to expel pulmonary secretions, and thinner, more fragile skin. Coughing, deep breathing, and auscultating breath sounds are interventions used in preventing and detecting impaired gas exchange (pneumonia). Maintaining skin integrity can be achieved by the avoidance of massage over bony prominences.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems?

• The content is not in accordance with professional standards. • There are lines between the entries. • Dates and times of entries are omitted.

Which of the following are high-risk errors made in documentation?

• inadequate admission assessment • failure to document completely • charting in advance • falsifying client records

A nurse is counseling the caregivers of an older adult male. The caregivers feel that they want to do everything to prevent hospitalization of their loved one. Which of the following can the nurse recommend?

• vitamin D supplementation • daily exercise • throw rugs with nonslip backing