EAQ 2 Nurs 101
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client?1 It relieves bronchial spasms. 2 It increases the depth of respirations. 3 It loosens pulmonary secretions. 4 It expels carbon dioxide from the lungs
-it loosens pulmonary secretions
The registered nurse (RN) is teaching the nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 1 "I should serve food that is easy to eat." 2 "I should assist the client with eating." 3 "I should monitor weight and food intake once a month." 4 "I should offer food supplements that are tasty and easy to swallow."
"I should monitor weight and food intake once a month."
The nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage these people from bringing all that alternative medicine stuff to their family members. Which response by the nurse is correct? 1 "Hospital policies should put a stop to this." 2 "Everyone should conform to the prevailing culture." 3 "Nontraditional approaches to health care can be beneficial." 4 "You are right because they may have a negative effect on people's health."
"Nontraditional approaches to health care can be beneficial."
An 80-year-old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct? 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."
"The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."
A client with dementia is confused about what day it is. Which statement made by the nurse is an example of validation therapy? 1 "No, try to be in your sense of reality." 2 "Yes, today is the day that you just mentioned." 3 "You should try improving your awareness level." 4 "Try to recall your past memories associated with the day."
"Yes, today is the day that you just mentioned."
client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the correct response by the nurse? 1 "You must keep up a strong appearance for him." 2 "I think he'd have difficulty dealing with that now." 3 "Don't you think he knows that without you telling him?" 4 "You should share your feelings with him while you can."
"You should share your feelings with him while you can."
The nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include?
"You will need to apply them in the morning before you lower your legs from the bed to the floor."
Which is the most therapeutic response by the nurse to a client who is joking about dying? 1 "Why are you always laughing?" 2 "Your laughter is a cover for your fear." 3 "Does it help to joke about your illness?" 4 "The person who laughs on the outside cries on the inside."
"Your laughter is a cover for your fear."-is a nonjudgmental way to point out the client's behavior.
To prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care? -increase fluid intake restrict fluids encourage early mobility elevate the knee gatch of the bed
-Encourage early mobility- In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis.
Which disease process places a client at increased risk for infection? Select all that apply. One, some, or all responses may be corre -Leukemia -Lymphoma -Emphysema -Schizophrenia -Osteoarthritis
-Leukemia -Lymphoma -Emphysema
Which action relates with the relevance strategy of the motivational learning model proposed by Keller? 1 Extrinsic and intrinsic reinforcements for any learning effort 2 Linking the person's needs, interests, and motives for learning 3 Arousing and sustaining a person's curiosity and interest in learning 4 Having positive hope for successful achievements as a result of learning
-Linking the person's needs, interests, and motives for learning
When monitoring a client 24 to 48 hours after abdominal surgery, the nurse would assess for which problem associated with anesthetic agents?
-Paralytic ileus
Which stage of Piaget's theory of cognitive development would the nurse observe in a preschooler? -sensorimotor -preoperationsl -formal operations -concrete operations
-Preoperational-The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images.
The nurse is reviewing the procedure for intervention if a fire occurs. Which interventions would the nurse include in the procedure if a fire occurs that relate to the acronym RACE? Select all that apply. One, some, or all responses may be correct.
-activate the alarm -remove all clients from the area -confine the fire by closing doors and windows
When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction? -circulating nurse -surgical assistant -registered nurse first assistant -certified registered nurse anesthetist
-circulating nurse
Which principal components are associated with the nurse's time management skills? Select all that apply. One, some, or all responses may be correct. -autonomy -goal setting -priority setting -interruption control -right communication
-goal setting -priority setting -interruption control
Which of these is an ethical issue related to the long-term care setting? Select all that apply. One, some, or all responses may be correct. -guardianship -power of attorney -advanced directives -responsible party designation -DNR orders -Adherence to a patients bill of rights.
-guardianship -power of attorney -advanced directives -responsible party designation -DNR orders -Adherence to a patients bill of rights. -Resident rights are a universal priority in all long-term care settings. Guardianship, power of attorney, advance directives, responsible party designation, do-not-resuscitate orders, and adherence to a patient's bill of rights are all ethical issues related to the long-term care setting.
Which information would the nurse provide in a presentation to a group of women about ways to decrease their risk for becoming victims of crime? Select all that apply. One, some, or all responses may be correct. 1 Use night-lights. 2 Carry a weapon. 3 Install exterior lighting. 4 Attach whistle to key ring. 5 Park far from the building
-use night-lights -install exterior lighting -attach a whistle to a key ring
Arrange the steps involved in the evidence-based practice process in the correct order. 1. Evaluate the practice decision or change. 2. Ask a clinical question. 3. Collect the most relevant and best evidence. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Critically appraise the evidence you gather. 6. Share the outcomes of evidence-based practice.
.1 Ask a clinical question 2. Collect the most relevant and best evidence 3. Critically appraise the evidence you gather 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change.6. Share the outcomes of evidence-based practice.
A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing? 1 Lactated Ringer solution 2 5% dextrose and water 3 0.9% normal saline 4 0.45% normal saline
0.9% normal saline
Which critical thinking skill refers to the use of knowledge and experience to choose effective strategies for client care?
1 Evaluation Correct2 Explanation 3 Interpretation 4 Self-regulation
Which nursing intervention is classified under complex physiological domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. One, some, or all responses may be correct. 1 Interventions to restore tissue integrity 2 Interventions to optimize neurological functions 3 Interventions to manage restricted body movements 4 Interventions to promote comfort using psychosocial techniques 5 Interventions to provide care before, during, and immediately after surgery
1 Interventions to restore tissue integrity 2 Interventions to optimize neurological functions 5 Interventions to provide care before, during, and immediately after surgery
Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct. 1 Using pincer grasp well 2 Picking up small objects 3 Showing hand preference 4 Crawling on the hands and knees 5 Pulling oneself to standing or sitting
1 Using pincer grasp well 2 Picking up small objects 3 Showing hand preference
Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply.
Dry Cleaners Dye workers
Arrange the order of critical thinking for an existing problem.- Making a conclusion Evaluating the information Recognizing the existing issue Analyzing information about the issue
1.Recognizing the existing issue 2.Analyzing information about the issue 3.Evaluating the information 4.Making a conclusion
Which description of family-centered care is correct? 1 The nursing care is focused on the client as an individual. 2 A collaborative plan of care is developed to achieve optimal health. 3 The health care provider is the expert in developing a plan of care. 4 The nursing care is based solely on standards of practice.
2 A collaborative plan of care is developed to achieve optimal health.
Which are extrinsic factors responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. 1 Impaired vision 2 Cognitive impairment 3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices
3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices
Arrange the stages of Freud's psychoanalytical model of personality development in the correct order.
Oral Anal Phallic Latent Genital
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often? 1 Every 4 to 8 hours 2 Every 12 to 24 hours 3 Every 24 to 48 hours 4 Every 72 to 96 hours
4 Every 72 to 96 hours
Which theories are relevant only to development in adults? Select all that apply. One, some, or all responses may be correct. 1 Piaget's theory 2 Erikson's theory 3 Kohlberg's theory 4 Stage-Crisis theory 5 Life Span approach
4 Stage-Crisis theory 5 Life Span approach
Why would the nurse establish "moderately hard" client-centered goals? Select all that apply. One, some, or all responses may be correct. 1 To decrease the cost of treatment during therapy 2 To decrease the number of follow-up visits by the client 3 To achieve the goal in a shorter period of time with less effort 4 To prevent the client from quitting before the goal is achieved 5 To prevent the client from losing motivation toward achieving the goal
4 To prevent the client from quitting before the goal is achieved 5 To prevent the client from losing motivation toward achieving the goal
Which documentation is most informative for an assessment of drainage on a surgical dressing? 1 "Moderate amount of drainage." 2 "No change in drainage since yesterday." 3 "A 10 mm-diameter area of drainage at 1900 hours." 4 "Drainage is doubled in size since last dressing change."
A 10 mm-diameter area of drainage at 1900 hours - this is objective data and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage,"
Which is the most important nursing action involved in caring for a client receiving medications? 1 Administering the medications 2 Teaching about the medications 3 Ensuring adherence to the medication regimen 4 Evaluating the client's ability to self-administer medications
Administering the medications
The family of an older adult reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter. Which rationale would the nurse manager consider before responding? 1 Procedures for a client's benefit do not require a signed consent. 2 Clients who are aphasic are incapable of signing an informed consent. 3 A separate signed informed consent for routine treatments is unnecessary. 4 A specific intervention without a client's signed consent is an invasion of rights.
A separate signed informed consent for routine treatments is unnecessary.
nWhen ammonia is excreted by healthy kidneys, which mechanism usually is maintained? 1 Osmotic pressure of the blood 2 Acid-base balance of the body 3 Low bacterial levels in the urine 4 Normal red blood cell productio
Acid-base balance of the body
Which intervention improves client satisfaction? 1 Recording the vital signs and leaving the room 2 Adjusting the bed and asking if the client is comfortable 3 Leaving the door of the room open while attending to the client 4 Telling the client that the primary health care provider will visit soon
Adjusting the bed and asking if the client is comfortable
Which professional standard is important for critical thinking? -logical thinking evaluation criteria accurate knowledge relevant information
An evaluation criterion is an important professional standard required for critical thinking.
Which critical thinking skill will help a student nurse avoid making assumptions about clients? 1 Analysis 2 Inference 3 Evaluation 4 Explanation
Analysis-allows the student nurse to be open-minded while looking at the client's information and to avoid making assumptions.
The nurse records the client's weight and body mass index (BMI) at a healthy range, but the client states, "I wish I were as thin as my coworkers." Which culturally bound condition is the client at risk for? 1 Neurasthenia 2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios
Anorexia nervosa
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin
Arterial blood gas
Which statement is true for attachment in the newborn? 1 Attachment occurs over the first 28 days. 2 Attachment begins in the first week of birth. 3 Attachment is the overlapping of soft skull bones. 4 Attachment is the interaction between parent and child.
Attachment is the interaction between parent and child.--The nurse promotes the parents' and newborn's need for physical contact by encouraging breast-feeding. Attachment is a process that evolves over the first 24 months.
Which intervention would the nurse expect to implement to alleviate anxiety for a preoperative client? 1 Attempt to identify the client's concerns. 2 Reassure the client that the surgery is routine. 3 Report the client's anxiety to the health care provider. 4 Provide privacy by pulling the curtain around the client
Attempt to identify the client's concerns.
Which intellectual factor would the nurse consider as a dimension when gathering data for a client's health history? 1 Attention span 2 Primary language 3 Coping mechanisms 4 Activity and coordination
Attention span-is an intellectual dimension used to gather data for a health history. The social dimension for gathering the health history includes primary language
While assessing the vital signs of an older adult, alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. Which other findings would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct. 1 Body temperature of 84.2°F/29°C 2 Body temperature of 100.6°F/38.1°C 3 Blood pressure of 100/62 mm Hg 4 Respiratory rate of 12 breaths/minute 5 Respiratory rate of 16 breaths/minute
Body temperature of 84.2°F/29°C Blood pressure of 100/62 mm Hg Respiratory rate of 12 breaths/minute
Which activity demonstrates fine motor skills in infants aged 2 to 4 months? 1 Turning from side to back 2 Sitting erect using support 3 Showing good head control 4 Bringing objects from hand to mouth
Bringing objects from hand to mouth
A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? 1 Sodium 2 Calcium 3 Potassium 4 Phosphorus
Calcium
The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? 1 Care that supports physical functioning 2 Care that supports homeostatic regulation 3 Care that supports psychosocial functioning 4 Care that provides immediate short-term help in physiological crises
Care that supports homeostatic regulation
The nurse is helping a client and her or his family to set and meet goals. Which professional role is the nurse displaying? 1 Educator 2 Advocate 3 Manager 4 Caregiver
Caregiver
The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? 1 Promoting analgesia and circulation 2 Numbing the nerves and dilating the blood vessels 3 Promoting circulation and reducing muscle spasms 4 Causing local vasoconstriction, preventing edema and muscle spasms
Causing local vasoconstriction, preventing edema and muscle spasms
The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? A-94.2F B-85.3F C-89.4F D-91.5F
Client B, with a body temperature of 29.6°C (85.3°F) is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 30°C (86°F).--Hypothermia is classified as mild hypothermia (body temperature of 34°C-36°C [93.2°F-96.8°F]), moderate hypothermia (body temperature of 30°C-34°C [86°F-93°F]), and severe hypothermia (body temperature below 30°C [86°F]).
How can the nurse evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiological responses
Client Feedback
A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? 1 Contact an interpreter provided by the hospital. 2 Contact the client's family member to translate for the client. 3 Communicate with the client using Spanish phrases the nurse learned in a college course. 4 Communicate with the client with the use of a hospital-approved Spanish dictionary.
Contact an interpreter provided by the hospital.
Which is the action of an antidiuretic hormone (ADH)? 1 Reduces blood volume 2 Decreases water loss in urine 3 Increases urine output 4 Initiates the thirst mechanism
Decreases water loss in urine
After abdominal surgery, a client reports pain. Which action would the nurse take first? -reposition the pt -obtain their vitals -administer the prescribed analgesic -determine the characteristics of the pain
Determine the characteristics of the pain. -The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery.
The nurse is reviewing a client's plan of care. Which is the determining factor in the revision of the plan? 1 Time available for care 2 Validity of the problem 3 Method for providing care 4 Effectiveness of the interventions
Effectiveness of the interventions
Which nursing intervention is correct for a client with venous insufficiency? 1 Apply abdominal girdle as needed. 2 Remove compression stockings for client ambulation. 3 Elevate the client's legs above heart level. 4 Keep the upper extremities elevated.
Elevate the client's legs above heart level.
Which psychophysiological factors influence communication between the nurse and a client? Select all that apply. One, some, or all responses may be correct. 1 Privacy level 2 Emotional status 3 Information exchange 4 Level of caring expressed 5 Growth and development
Emotional status Growth and development -Growth and development and emotional status are two psychophysiological factors that influence communication between the nurse and a client.
Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events," according to Swanson's theory of caring? 1 Knowing 2 Enabling 3 Doing for 4 Being with
Enabling -The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death
The nurse should expect to take which action to help alleviate anxiety for a client scheduled for a colostomy? 1 Administer the prescribed as-needed (PRN) sedative. 2 Encourage the client to express feelings. 3 Explain the postprocedure course of treatment. 4 Reassure the client that there are others with this problem.
Encourage the client to express feelings.
Which physiological changes are expected during the first trimester of pregnancy? Select all that apply. One, some, or all responses may be correct. 1 Fatigue 2 Increased libido 3 Morning sickness 4 Breast enlargement 5 Braxton Hicks contractions
Fatigue Morning Sickness Breast Enlargement
Which would the nurse consider to be the center of decision-making when providing client care? 1 Ethics 2 Nursing skills 3 Analytical skills 4 Research-based practice
Ethics-A professional nurse always follows the ethics of care and considers caring to be the center of decision-making.
The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? Teaching how to make a room allergy-free Referring to a support group for individuals with asthma Arranging with the college to ensure a speedy return to classes Evaluating whether the necessary lifestyle changes are understood
Evaluating whether the necessary lifestyle changes are understood
The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle? 1 Every 3 days 2 Every 5 days 3 Every 7 days 4 Every 9 day
Every 7 Days
Which critical thinking skill is being used when the nurse applies knowledge and experience to client care? 1 Analysis 2 Evaluation 3 Explanation 4 Interpretation
Explanation
The nursing student is learning about the realms of family life. Which component would be included while learning about integrity processes? 1 Family rituals 2 Family relationships 3 Family life stressors and daily hassles 4 Family care takings and responsibilities
Family rituals
A client is discussing with the nurse concerns about their unhealthy family relationships. During the nurse-client interaction the client begins to talk also about a job problem. The nurse's response is, "Let's go back to what we were just talking about." Which therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting
Focusing
Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1 Activity theory 2 Continuity theory 3 Disengagement theory 4 Gerotranscendence theory
Gerotranscendence Theory --The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. T
arrange in order the items of personal protection equipment (PPE) removed after seeing a client in droplet precautions.
Gloves face shield gown mask
The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? 1 Hand washing before and after providing client care 2 Cleaning all equipment with an approved disinfectant after use 3 Wearing personal protective equipment (PPE) when providing client care
Hand washing before and after providing client care
When a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take?
Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.
Which statement is true about the nursing model of team nursing? 1 The registered nurse (RN) is responsible for all aspects of client care. 2 Client care can be delegated to other members of the health care team. 3 The registered nurse (RN) works directly with the client, family members, and health care team members. 4 Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.
Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.
A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention in this situation? 1 Immediately involve pastoral services while caring for the client. 2 Involve the family member in the client's care instead of pastoral support. 3 Listen to the client's request for support and then carry on with the clinical work. 4 Falsely promise that pastoral services has been contacted and plan to see the client.
Immediately involve pastoral services while caring for the client.
The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation
Implementation
Which nursing process involves delegation and verbal discussion with the health care team? 1 Planning 2 Evaluation 3 Assessment 4 Implementation
Implementation
Which goals of care are associated with the family health system model? Select all that apply. One, some, or all responses may be correct. 1 Improving family health or well-being 2 Preparing for family transitions later in life 3 Providing assistance in family management of illness conditions 4 Promoting positive family behaviors to achieve essential tasks 5 Achieving health outcomes related to the family's areas of concern
Improving family health or well-being Providing assistance in family management of illness conditions Achieving health outcomes related to the family's areas of concern
Which skill in critical thinking requires the nurse to be orderly in data collection? -analysis -inference -evaluation -interpretation
Interpretation
During a home visit, the nurse finds that a healthy older adult person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. Which inference about the client would the nurse make from these findings? 1 Not motivated 2 Intrinsically motivated 3 Extrinsically motivated with self-determination 4 Extrinsically motivated without self-determination
Intrinsically motivated-individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members
Which intrinsic factor is associated with the fall of an older adult? 1 Wet floors 2 Poor lighting 3 Lack of exercise 4 Inappropriate footwear
Lack of exercise- Intrinsic risk factors associated with the fall of an older adult may include a lack of exercise or deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.
Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be . 1 Lifestyle 2 Occupation 3 Chronic diseases 4 Frequent traveling 5 Diagnostic procedures
Lifestyle occupation frequent travel `
Which nursing action(s) reflect(s) the evaluation phase of the critical thinking process? Select all that apply. One, some, or all responses may be correct. 1 Collecting all the data in order 2 Looking at all the situations objectively 3 Supporting the findings and drawing conclusions 4 Being open-minded to information about a client 5 Using several criteria to determine the effectiveness of a nursing intervention
Looking at all the situations objectively Using several criteria to determine the effectiveness of a nursing intervention
Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)?
Move the client to a private room.
The nurse has provided discharge instructions to a client who received a prescription for a walker. The nurse determines that the teaching has been effective when the client does which? 1 Picks up the walker and carries it for short distances 2 Uses the walker only when someone else is present 3 Moves the walker no more than 12 inches (30.5 cm) during use 4 States that a walker will be purchased on the way home from the hospital
Moves the walker no more than 12 inches (30.5 cm) during use
Which behavioral characteristic, according to temperament theory, is demonstrated by a slow-to-warm up child? 1 Highly active 2 Irritable and irregular in habits 3 Negative reaction to new stimuli 4 A positive mild-to-moderately intense mood
Negative reaction to new stimuli
A new mother says to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." From this information, which culture would the nurse infer that the new mother belongs to? 1 Asian culture 2 African culture 3 North American culture 4 Latin American culture
North American culture People who belong to North American and Western European cultures generally possess individualistic characteristics
The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial
Nosocomial- a hospital-acquired infection
A client does not take his or her medication regularly and is depressed. Which inference can the nurse make about the client's motivational level? 1 Not motivated 2 Intrinsically motivated 3 Extrinsically motivated with self-determination 4 Extrinsically motivated without self-determination
Not Motivated
When teaching a health promotion class at a retirement home, which information would the nurse include about ways to decrease infection in older adults? 1 Use handkerchiefs. Correct2 Obtain flu vaccinations. 3 Decrease dietary protein. 4 Limit daily activity.
Obtain flu vaccinations.
Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe? 1 Instruct the client to position one arm on each shoulder of the nurses. 2 Direct the client to extend the legs and remain still during the procedure. 3 Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. 4 Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.
Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.
Which nurse collaborates with the client to establish and implement a basic plan of care on admission? 1 Primary nurse 2 Nurse clinician 3 Nurse coordinator 4 Clinical nurse specialist
Primary nurse
Which cation regulates intracellular osmolarity? 1 Sodium 2 Potassium 3 Calcium 4 Calcitonin
Potassium-A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell
The nurse develops a goal that makes a client feel as if the client is engaging in a competition. Which type of motivation is the nurse using in this situation?
Power motivation
Which interventions would the nurse perform while caring for an actively dying client? Select all that apply. One, some, or all responses may be correct. 1 Admit the client in hospice care. 2 Perform aggressive laboratory tests. 3 Provide client and family reassurance. 4 Keep the client undisturbed for a long time. 5 Perform symptom management for the client.
Provide client and family reassurance. Perform symptom management for the client.
The nurse is caring for a client who had a hip replacement 2 days prior. Which nursing intervention would the nurse perform next? 1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement
Provide perineal care.
An older adult is experiencing emotional stress after a recent surgery. Which intervention would be most appropriate for the client? 1 Touch 2 Reminiscence 3 Reality orientation 4 Validation therapy
Reality orientation
Which nursing practice is associated with a self-regulation skill?
Reflecting on one's experience
Which action made by the client indicates that she or he is in the precontemplation stage of the transtheoretical model of change? 1 Refuses to think about changing 2 Intends to change in the next 60 days 3 Sustains the changed action for 6 months 4 Recognizes the advantages of the change
Refuses to think about change
Which caring intervention helps provide comfort, dignity, respect, and peace to a client? 1 Listening 2 Spiritual caring 3 Providing presence 4 Relieving pain and suffering
Relieving pain and suffering
Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? 1 Ambulation 2 Repositioning 3 Purse-lipped breathing 4 Deep breathing and coughing
Repositioning-Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain.
Which component of ethical decision-making refers to the duties and activities the nurse is employed to perform? 1 Authority 2 Autonomy 3 Responsibility 4 Accountability
Responsibility
Which risk of adolescent pregnancy would the community nurse teach? 1 Risk for premature birth 2 Risk for having a large baby 3 Risk for chromosomal defects 4 Risk for increased weight gain
Risk for premature birth-The nurse would teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity
The nurse is developing a plan of care for the client who has activity intolerance. Which intervention would the nurse do to obtain the desired client outcomes? 1 Prioritize psychosocial needs over physical needs. 2 Use the Nursing Outcomes Classification (NOC) only. 3 Use nursing knowledge to plan outcomes and disregard client and family desires. 4 Set priorities and outcomes using the client's and family input.
Set priorities and outcomes using the client's and family input.
Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? 1 Sharing hope 2 Sharing humor 3 Sharing empathy 4 Sharing observations
Sharing humor
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? 1 Shift of fluid into the interstitial spaces 2 Weakening of the cell wall 3 Increased intravascular compliance
Shift of fluid into the interstitial spaces
A client has terminal cancer after 7 years of chemotherapy and surgeries. The nurse enters the client's room and finds the client crying. Which is the correct intervention by the nurse? 1 Sit down quietly next to the bed and allow her or him to cry. 2 Pull the curtain and leave the room to provide privacy for the client. 3 Explain to the client that her or his feelings are expected and they will pass with time. 4 Observe the length of time the client cries and document her or his difficulty accepting her or his impending death.
Sit down quietly next to the bed and allow her or him to cry.
Which developmental changes require the nurse's assessment in a 12-year-old female? -motor skills -visual acuity -skeletal growth -hormonal changes
Skeletal growth -Girls around the age of 12 years may develop scoliosis (a lateral curvature of the spine); therefore skeletal growth should be evaluated.
Which is the regulator of extracellular osmolarity? 1 Sodium 2 Potassium 3 Chloride 4 Calcium
Sodium
Which chemical buffers excessive acetoacetic acid? 1 Potassium 2 Sodium bicarbonate 3 Carbon dioxide 4 Sodium chloride
Sodium Bicarbonate-a base and one of the major buffers in the body.
How would the nurse prevent footdrop in a client with a leg cast? 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.
Support the foot with 90 degrees of flexion.
The nurse at the well-baby clinic is assessing the gross motor skills of a 5-month-old infant. Which finding is a cause for concern? 1 The baby has a head lag when pulled to sit. 2 The baby can turn from the side to the back. 3 The baby can turn from the abdomen to the back. 4 The baby supports much of her or his own weight when she or he is pulled to stand.
The baby has a head lag when pulled to sit.
A community health care nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? 1 The children are underimmunized and at risk for childhood illnesses. 2 The children are more likely to drop out of school and become unemployable. 3 The children have access to health care only through the emergency department. 4 The children do not have a physical shelter and may sleep outdoors or in vehicles.
The children do not have a physical shelter and may sleep outdoors or in vehicles.
Which assessment finding is associated with depression? 1 The client has islands of intact memory. 2 The client has impaired recent and remote memory. 3 The client has impaired recent and immediate memory. 4 The client needs step-by-step instructions for simple tasks.
The client has islands of intact memory.--A client with depression has selective or patchy memory loss with islands of intact memory
Which statement defines the term "family resiliency"? 1 Each family is unique. 2 The family has an ability to cope with stressors. 3 An interfamilial structure and support system exist. 4 The family has the ability to transcend lifestyle changes.
The family has an ability to cope with stressors.-Family resiliency is the ability of the family to cope with expected and unexpected stressors.
A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? 1 The local hazardous waste collection site 2 The regular household trash 3 The local health department for disposal 4 The Environmental Protection Agency (EPA) through the mail
The local hazardous waste collection site
The registered nurse (RN) instructs a nursing student to use knowledge and experience to choose proper strategies to use when caring for clients. Which critical-thinking skill would the RN refer to? analysis evaluation explanation interpretation
explanation-The critical-thinking skill of explanation involves using knowledge and experience to provide client care.
A client is likely to undergo reconstructive surgery for which purpose? 1 To restore function and/or appearance 2 To replace an organ or tissue 3 To relieve or reduce symptoms 4 To remove or excise an organ or tissue
To restore function and/or appearance.-The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury.
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? 1 Their gag reflex has returned. 2 They are confused due to anesthesia. 3 They are nauseated and want to vomit. 4. Their airway is becoming obstructed
Their gag reflex has returned
Which is the role of a case manager in a health care organization? 1 To delegate work on the unit suitably 2 To follow up with the client after discharge 3 To provide direct care for the client at the bedside 4 To unite the strategic direction of the organization
To follow up with the client after discharge
Which approach is a comforting approach that communicates concern and support? 1 Touch 2 Listening 3 Knowing the client 4 Providing a positive presence
Touch-Touch is a comforting approach that involves reaching out to clients to communicate concern and support.
Which intervention reflects the nurse's approach of "family as a context"? 1 Trying to meet the client's comfort 2 Evaluating the client family's coping skills 3 Determining the client family's energy level 4 Trying to meet the client family's nutritional needs
Trying to meet the client's comfort
At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? 1 Tubing injection port 2 Distal end of the tubing 3 Urinary drainage bag 4 Catheter insertion site
Tubing injection port
