chapter 4 - Chapter 13-
The nurse is planning interventions to promote the health of a family struggling with loss of energy and privacy for the parents. In which family stage is the family? A) Family with young children B) Family with adolescents and young adults C) Family with middle-aged adults D) Family with older adults
A) Family with young children
A nurse assigned to a client's care schedules a family assessment of the client. Which of the following should the nurse use for basic family assessment? A) Interview B) Physical assessment C) Survey D) Poll
A) Interview
Which of the following individuals would the nurse assess as being most at risk for altered family health? A) An unmarried adolescent with a newborn B) A newly married couple who ask about birth control C) A middle-aged man and woman with no children D) An older adult, living in an assisted-living community
A) An unmarried adolescent with a newborn
A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A) Assessing B) Diagnosing C) Planning D) Implementing
A) Assessing
The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? A) Cognitive skill B) Technical skill C) Interpersonal skill D) Ethical/legal skill
A) Cognitive skill
What name is given to standardized plans of care? A) Critical pathways B) Computer databases C) Nursing problems D) Care plan templates
A) Critical pathways
What is a systematic way to form and shape one's thinking? A) Critical thinking B) Intuitive thinking C) Trial-and-error D) Interpersonal value
A) Critical thinking
What is one method by which a nurse can be a role model to promote health in the community? A) Demonstrating a healthy lifestyle B) Becoming a member of a family C) Meeting own basic needs D) Exhibiting self-actualization
A) Demonstrating a healthy lifestyle
A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? A) Ethical/legal skills B) Technical skills C) Interpersonal skills D) Cognitive skills
A) Ethical/legal skills
Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.
A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. E) It calls for strategies that make the most of human potential.
Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.
A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. It calls for strategies that make the most of human potential.
Which of the following groups developed standard language to increase the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses? A) NANDA B) NIC C) NOC D) HHCC (now CCC)
A) NANDA
An unmarried couple in a committed relationship live together with their adopted twin boys. Which of the following best describes this type of family? A) Nuclear family B) Extended family C) Blended family D) Adoptive family
A) Nuclear family
Which of the following statements accurately describes how Maslow's theory can be applied to nursing practice? A) Nurses can apply this theory to the nursing process. B) Nurses can identify met needs as health care needs. C) Nurses cannot use the theory on infants or children. D) Nurses use the theory for ill, as opposed to healthy, patients.
A) Nurses can apply this theory to the nursing process.
The nursing student is assessing a community in regard to safety and security. Which of the following would be inappropriate for the nursing student to include under this basic need category? A) Parks and swimming pools B) Police and fire departments C) Sanitation facilities D) Housing and zoning codes
A) Parks and swimming pools
A nurse caring for a client in a long-term health care facility measures his intake and output and weighs him to assess water balance. These actions help to meet which of Maslow's hierarchy of needs? A) Physiologic B) Safety and security C) Love and belonging D) Self-actualization
A) Physiologic
According to Maslow's basic human needs hierarchy, which needs are the most basic? A) Physiologic B) Safety and security C) Love and belonging D) Self-esteem
A) Physiologic
The nurse is assessing the functions of a family. Which items are functions of the family? Select all that apply. A) Provide a safe, comfortable home in which to reside. B) Communicate cultural values and beliefs to family members. C) Provide emotional support to family members. D) Secure adequate income to meet the needs of the family. E) Make referrals to community-based healthcare resources
A) Provide a safe, comfortable home in which to reside. B) Communicate cultural values and beliefs to family members. C) Provide emotional support to family members. D) Secure adequate income to meet the needs of the family.
Which of the following is an essential feature of professional nursing? Select all that apply. A) Providing a caring relationship to facilitate health and healing B) Attention to a range of human experiences and responses to health and illness C) Use of objective data to negate the client's subjective experience D) Use of judgment and critical thinking to form a medical diagnosis E) Advancement of professional nursing knowledge through scholarly inquiry
A) Providing a caring relationship to facilitate health and healing B) Attention to a range of human experiences and responses to health and illness E) Advancement of professional nursing knowledge through scholarly inquiry
A student is asked to perform a skill for which he is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation? A) Purpose of thinking B) Adequacy of knowledge C) Potential problems D) Helpful resources
A) Purpose of thinking
After completing an assessment of a client, the nurse uses critical thinking and clinical reasoning to prioritize the client's problems. Which of the following would the nurse determine is the highest priority? A) Severe bleeding from a wound B) History of asthma C) Diabetes D) Lack of family support
A) Severe bleeding from a wound
A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion
A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing
28. When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive
A) Technical
Based on a community assessment, the nurse has set the following outcomes. Which outcome reflects Maslow's level of safety and security needs? A) The community will establish an effective wastewater disposal system by January 22. B) The community will demonstrate pride by posting a welcome sign and flowers at the edge of town by April 8. C) The community will open a senior citizens center by March 9. D) The community will identify a walking path through the community by February 2.
A) The community will establish an effective wastewater disposal system by January 22.
A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily.
A) The nurse cleans the wound and applies a dressing to it.
In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving? A) The nurse is attempting to landmark an obese client's apical pulse. B) The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain. D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.
A) The nurse is attempting to landmark an obese client's apical pulse.
The nurse is providing care for a pediatric client on night shift. At 0400, the nurse notes that the child has a high fever but does not have an order for an antipyretic. What nursing action represents a good example of teamwork and collaboration as defined by the Quality and Safety Education for Nurses (QSEN) competencies? The nurse: A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic. B) gives the child a common over-the-counter antipyretic based on dosing recommendations and reports this to the oncoming nurse. C) reports to the oncoming nurse at 0700 that the child has a fever so that when the healthcare provider comes in, she can obtain an order for an antipyretic. D) requests that the child 's mother give the child something for the fever that she brought from home.
A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic.
During the course of assessing the family structure and behaviors of a pediatric patient's family, the nurse has identified a number of highly significant risk factors. Which of the following actions should the nurse prioritize when addressing these risk factors? A) Engage in appropriate health promotion activities. B)Validate the family's unique way of being. C) Enlist the help of community and social support. D) Introduce the family to another family that possesses fewer risk factors.
A)Engage in appropriate health promotion activities.
Five functions have been identified as being essential to the growth of individuals and families. One of these functions is education and support. How is support manifested in the context of coping with crisis and illness situations? A) Making clear distinctions between the generations B) Actions that tell family members they are cared about and loved C) The promotion of exercise in the lifestyle D) Transmitting culture and acceptable behaviors
B) Actions that tell family members they are cared about and loved
Which of the following is an example of a community factor that may affect health? A) Rural setting B) Air and water quality C) Number of residents D) Educational level
B) Air and water quality
What nursing organization first legitimized the use of the nursing process? A) National League for Nursing B) American Nurses Association C) International Council of Nursing D) State Board of Nursing
B) American Nurses Association
A boy age 2 years arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. Which of the following would be the priority nursing intervention? A) Giving him his favorite stuffed animal to hold B) Assessing respirations and administering oxygen C) Raising the side rails and restraining his arms D) Asking his mother what are his favorite foods
B) Assessing respirations and administering oxygen
Nurses make decisions in their practice every day. Which of the following are potential errors in this decision-making process? Select all that apply. A) Placing emphasis on the last data received B) Avoiding information contrary to one's opinion C) Selecting alternatives to maintain status quo D) Being predisposed to multiple solutions E) Prioritizing problems in order of importance
B) Avoiding information contrary to one's opinion C) Selecting alternatives to maintain status quo
What is the major effect of a health crisis on family structure? A) Adaptation to stress B) Change in roles of family members C) Respect for family values D) Loss of individual identities
B) Change in roles of family members
Which of the following statements accurately describes a characteristic of a community? A) Communities do not exist in rural areas. B) Communities are formed by the characteristics of people and other factors. C) Communities are not limited by geographic boundaries. D) Communities have little or no effect of the health of residents.
B) Communities are formed by the characteristics of people and other factors.
A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems? A) Assessing B) Diagnosing C) Planning D) Implementing
B) Diagnosing
The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process? A) Planning B) Diagnosis C) Implementation D) Outcome identification
B) Diagnosis
A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process? A) Systematic B) Dynamic C) Outcome oriented D) Universally applicable
B) Dynamic
The nurse conducting a community emergency preparedness education class includes which of the following as an example of a natural disaster? A) Toxic spill B) Earthquake C) War D) Terrorist event
B) Earthquake
Which of the following groups involves all parts of a person's life and is concerned with meeting basic human needs to promote health? A) Peers B) Family C) Community D) Health care providers
B) Family
A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using? A) Cognitive skills B) Interpersonal skills C) Technical skills D) Ethical/legal skills
B) Interpersonal skills
An experienced ICU nurse is mentoring a student. The nurse tells the student, "I think something is going wrong with your client." What type of clinical decision making is the experienced nurse demonstrating? A) Trial-and-error problem solving B) Intuitive thinking C) Scientific problem solving D) Methodical reasoning
B) Intuitive thinking
A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating? A) Diagnosing B) Planning C) Implementing D) Evaluatin
B) Planning
What step in the nursing process is most closely associated with cognitively skilled nurses? A) Assessing B) Planning C) Implementing D) Evaluating
B) Planning
Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what? A) Promoting the nurse's self-esteem. B) Reflective practice. C) Assessment of oneself. D) Learning from mistakes.
B) Reflective practice.
A couple recently married. Both the husband and the wife have previously been married and had two children. What name is given to this type of family? A) Extended family WWW.NURSINGTESTBANKSWORLD.COM B) Nuclear family C) Blended family D) Cohabiting family
C) Blended family
Which of the following is a tenant of Maslow's basic human needs hierarchy? A) A need that is unmet prompts a person to seek a higher level of wellness. B) A person feels ambivalence when a need is successfully met. C) Certain needs are more basic than others and must be met first. D) People have many needs and should strive to meet them simultaneously.
C) Certain needs are more basic than others and must be met first.
Which of the following is one example of a client benefit of using the nursing process? A) Greater personal satisfaction B) Decreased reliance on the nursing staff C) Continuity of care D) Decreased incidence of medical errors
C) Continuity of care
Legally speaking, how would the nurse ensure that care was not negligent? A) Verbally reporting assessments to the client's physician B) Keeping private notes about the care given to each assigned client C) Documenting the nursing actions in the client's record D) Tape recording complete information for each oncoming shift
C) Documenting the nursing actions in the client's record
When the nurse is administering Lasix 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? A) Assessment B) Planning C) Implementation D) Evaluation
C) Implementation
Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using? A) Assessing B) Planning C) Implementing D) Evaluating
C) Implementing
Which of the following factors may be a barrier to health care services for those living in rural areas? A) Inadequate health care insurance B) Lack of knowledge about needed care C) Living long distances from services D) Decreased interest in health promotion
C) Living long distances from services
A nurse provides health promotion and accident prevention programs for a family with adolescents and young adults. Which of the following is a task of a family at this stage? A) Establish a mutually satisfying marriage. B) Adjust to cost of family life. C) Maintain supportive home base. D) Maintain ties with younger and older generations.
C) Maintain supportive home base.
As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection? A) Read the steps of the procedure before clinical assignments. B) Even if you do not know how to give an injection, act as if you do. C) Practice giving injections in the learning laboratory until you feel comfortable. D) Tell your instructor that you don't think you can ever give an injection.
C) Practice giving injections in the learning laboratory until you feel comfortable.
A man 75 years of age is being discharged to his home following a fall in his kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need? A) Sleep and rest B) Support from family members C) Protection from potential harm D) Feeling a sense of accomplishment
C) Protection from potential harm
What is the purpose of the affective and coping function of the family? A) Providing a safe environment for growth and development B) Ensuring financial assistance for family members C) Providing emotional comfort and identity D) Transmitting values, attitudes, and beliefs
C) Providing emotional comfort and identity
Which of the following group of terms best describes the nursing process? A) nursing goals, medical terminology, linear B) nurse-centered, single focus, blended skills C) patient-centered, systematic, outcomes-oriented D) family-centered, single point in time, intuitive
C) patient-centered, systematic, outcomes-oriented
When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive
D) Adaptive
A nurse caring for a female client in isolation with tuberculosis is aware that the client's love and belonging needs may not be properly met. Which of the following nursing actions would help to meet these needs? A) Respecting the patient's values and beliefs B) Focusing on the client's strengths rather than problems C) Using hand hygiene and sterile technique to prevent infection D) Encouraging family to visit and help in the care of the client
D) Encouraging family to visit and help in the care of the client
When providing nursing care to a client, the nurse provides family-centered nursing care. What is one rationale for this nursing action? A) The nurse does not want the client to feel lonely. B) The client will be more compliant with medical instructions. C) The family will be more willing to listen to instructions. D) Illness in one family member affects all family members.
D) Illness in one family member affects all family members.
The nursing student asks the nurse about the difference between family-centered nursing and client-centered nursing. Which of the following would be inappropriate for the nurse to include when responding to the student? A) The family is composed of interdependent members who affect one another. B) The health of the family can be improved through health promotion activities. C) A strong relationship exists between the family and the health status of its members. D) Illness of one family member infrequently occurs in other members.
D) Illness of one family member infrequently occurs in other members
When a family visits the counseling clinic for the first time, which of following activities will the nurse complete as part of the initial family assessment? A) Discuss the roles of the parents. B) Outline the basic needs of the family. C) Resolve all family conflicts. D) Interview the family members.
D) Interview the family members.
Which of the following interpersonal skills is essential to the practice of nursing? A) Performing technical skills knowledgeably and safely B) Maintaining emotional distance from clients and families C) Keeping personal information among shared clients confidential D) Promoting the dignity and respect of patients as people
D) Promoting the dignity and respect of patients as people
What action by a nurse will help a client meet self-esteem needs? A) Verbally negate the client's negative self-perceptions B) Freely give compliments to increase positive self-regard C) Independently establish goals to improve self-esteem D) Respect the client's values and belief systems
D) Respect the client's values and belief systems
An woman 80 years of age states, "I have successfully raised my family and had a good life." This statement illustrates meeting which basic human need? A) Safety and security B) Love and belonging C) Self-esteem D) Self-actualization
D) Self-actualization
A mother teaches her son to respect his elders. This is an example of which of the following family functions? A) Physical B) Economic C) Affective and coping D) Socialization
D) Socialization
Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree,based on her care of the client and family. What critical thinking attitude is the student demonstrating? A) Being curious and persevering B) Being creative C) Demonstrating confidence D) Thinking independently
D) Thinking independently
Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning? A) To be able to employ the nursing process in client care. B) The licensing examination requires nurses to be adept at critical thinking. C) Because clients deserve experts who know how to care for them. D) To provide quality care with nursing ability and knowledge.
D) To provide quality care with nursing ability and knowledge.
Which of the following definitions best describes community-based nursing? A) A focus on populations within the community B) A focus on older adults living in nursing homes C) Care provided in the client's home for chronic illnesses D) care centered on individual and family health care needs
D) care centered on individual and family health care needs
The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs? A)Love and belonging B) Physiologic C) Self-esteem D) Self-actualization
Love and Belonging
The community health nurse is creating a plan of care for a client with Parkinson's disease. The client's spouse has provided care to the client for the past five years and the client's care needs are increasing. What is an appropriate nursing diagnosis for the client and family? A) Risk for Caregiver Role Strain. B) Health Seeking Behaviors. C) Parental Role Conflict. D) Readiness for Enhanced Family Processes.
Risk for Caregiver Role Strain.
The community health nurse is creating a plan of care for a client with Parkinson's disease. The client's spouse has provided care to the client for the past five years and the client's care needs are increasing. What is an appropriate nursing diagnosis for the client and family? A) Risk for Caregiver Role Strain. B) Health Seeking Behaviors. C) Parental Role Conflict. D) Readiness for Enhanced Family Processes.
Risk for Caregiver Role Strain.
