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The nurse is helping in discharge planning of a client who needs extensive rehabilitation and is on a complicated medication schedule. Which individual should the nurse include in this clients plan? 1. Clients spouse 2. Physician 3. Pharmacist 4. Social worker

The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness tells the nurse, This cannot be happening. There must be some mistake in the testing. What should be the nurses first step in assisting this family? 1. Provide structure and continuity to promote feelings of security. 2. Examine the nurses own feelings to ensure denial is not shared. 3. Offer spiritual support.

The nurse holds a clients hand during a painful procedure. This action shows a positive act towards the client that is referred to as: 1 Veracity 2 Fidelity 3 Beneficence 4 Nonmaleficence

Thenurseisfunctioningasapatientadvocate.Whatwordbestdescribesthisnursingrole? 1. Provider 2. Nurturer 3. Protector 4. Evaluator

A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslows human needs theory, at which level should the nurse recognize that the client is struggling? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem

The nurse is working in a busy intensive care unit. A client is admitted with extensive medical problems and requires a ventilator. Because the nurse already has two other clients assigned to his care, he requests that the nurse manager change assignments so that appropriate attention can be given to this new admission. According to Roachs six Cs of caring, which one is the nurse emulating? 1. Compassion 2. Confidence 3. Commitment 4. Conscience

Before helping a client with smoking cessation, the nurse reviews the steps of the change process. In which order should the nurse expect the client to progress through the stages of health change behavior? Arrange the following stages in the correct order: Standard Text: Click and drag the options below to move them up or down. Choice 1. Preparation stage Choice 2. Contemplation stage Choice 3. Maintenance stage Choice 4. Precontemplation stage Choice 5. Termination stage Choice 6. Action Stage

4, 2, 1, 6, 3, 5

A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering and for malpractice. Which key point will the prosecution attempt to prove against the nurse? a. The CPR procedure was done incorrectly. b. The patient would have died if nothing was done. c. The patient was resuscitated according to the policy. d. The older patient with brittle bones might sustain fractures when chest compressions are done.

During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing? a. Denial b. Anger c. Bargaining d. Depression

The actions people take to understand their health state, maintain their health, or prevent illness and injury are called: A) Health status B) Health beliefs C) Health behaviors (K & E pp.285) D) Health values

The nurse concludes that a young adult client is completing developmental tasks within Havighursts early adulthood age period. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Taking on civic responsibility 2. Developing adult leisure-time activities 3. Getting started in an occupation 4. Relating oneself to ones spouse as a person 5. Managing a home

اجابات خرابيط ما اقتنعت فيها لكن مكتوب 1-3 واحس خمسة وياهم

. In the emergency department a client feels that she has been waiting longer than the other individuals due to the fact that she has no insurance. The ethical principle that is involved in this exact situation is: 1-Justice 2-Autonomy 3-Beneficence 4-Nonmalefince

76-year-old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the clients spiritual needs and responds best by saying: 1 I notice you have a Bible; is that a source of spiritual strength to you? 2 What do you believe will happen to your personal spirit when you die? 3 We would allow members of your church to visit you whenever you desire. 4 Has hearing about your terminal condition made you lose your faith or beliefs?

A client is diagnosed with a terminal illness and is demonstrating anxiety. What intervention can the nurse use to help the client at this time? 1. Explore the clients history with other stressful life events and how successful coping was at that time. 2. Teach the family that while talking with the client about death and dying is permissible, they should not allow the client to dwell on death. 3. Supply information about the clients disease process and the expected trajectory of death only on a need-to- know basis. 4. Encourage early pharmaceutical intervention with antianxiety and sedative medications.

A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior? 1. Competing preferences 2. Competing demands 3. Situational influences 4. Interpersonal influences

A client recovering from back surgery is seen crying softly in bed. Upon assessment, the nurse learns that the client has been told of the future inability to perform certain sports, activities, and employment types because of the surgery. The nurse interprets this clients reaction as a response to which type of loss? 1. Situational loss 2. Anticipatory loss 3. Psychological loss 4. Developmental loss

A client who has AIDS tells the nurse, I dont know why I should even keep trying. This disease is so horrible and so many people die from it. It will get me, too. The nurse recognizes this statement as being 1. an indication of hopelessness that should be further evaluated for treatment. 2. a simple statement of the facts regarding AIDS. 3. common and expected in those facing the end of life. 4. proof that the client is accepting the facts of the illness and impending death.

A client woke in the middle of the night, confused and unaware of the surroundings. Although the call light was within reach, the client got out of bed unassisted, tripped on the bedside chair, and fell. Which element of malpractice should the clients attorney realize is missing in this case? 1. Foreseeability 2. Damages 3. Injury 4. Duty

A college-age client shares that he is struggling with feelings of both independence and dependence regarding his family. The nurse recognizes this as which stage of development, according to Roger Gould? 1. Stage 2 2. Stage 3 3. Stage 4 4. Stage 5

A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic

A home health-care nurse is functioning as a Case Manager for a patient recently dis- charged from the hospital. What is the primary role of the nurse when functioning as a Case Manager? 1. Coordinator 2. Counselor 3. Provider 4. Teacher

A nurse has been working a 12-hour shift in a labor and delivery unit. A client was admitted early in the shift and is now ready to deliver. The client had a difficult labor experience, was worried and anxious throughout, and had physiological problems with blood pressure as well as pain management. The nurse decides to stay until the delivery is over, after having it approved by her manager. What is this nurse demonstrating? 1. Compassion 2. Competence 3. Confidence 4. Conscience

A nurse is presenting an educational session regarding psychosocial development to a group of middle-aged adults. According to Eriksons theory, what activity should the nurse select to best meet the needs of this stage? 1. Providing opportunities to mentor school-age children 2. Giving the group handouts regarding peer socialization 3. Helping the members of this group find appropriate civic responsibility 4. Assisting the group members to look at their life accomplishments

A nurse who is working with a client who has been diagnosed with AIDS reveals the clients name and diagnosis with a co-worker on the way downstairs in an elevator. Unknowingly, a friend of the client that happens to be sharing the elevator and hears the entire story. The nurse who shared the information may be r 1 Slander 2 Assault 3 Malpractice 4 Invasion of privacy

A primary care provider prescribes one tablet, but the nurse accidently administers two. After notifying the primary care pro- vider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for professional negligence? 1. No, the client was not harmed. 2. No, the nurse notified the primary care provider. 3. Yes, a breach of duty exists. 4. Yes, foreseeability is present.

An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the emergency department, the client was given sedation for pain before a surgical permit was signed. What should be done to obtain consent? 1. The physician should have the clients wife sign the consent form. 2. The physician should wait until the effects of the medication wear off and have the client sign the form. 3. Because the client has been medicated, the nurse should thoroughly explain the consent form to the client. 4. This would be considered an emergency situation and consent would be implied.

Following a motor vehicle crash, the parents of a child with no apparent brain function refuse to permit withdrawal of life support from the child. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the basis for the nurse's actions? 1. Respect for autonomy 2. Nonmaleficence 3. Beneficence 4. Justice

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention? 1. Establish a trusting nurse-client relationship. 2. Have the client describe the basic problem. 3. Ask the client what religion is practiced in the home. 4. Identify the client's belief in a Supreme Being.

The nurse case manager is concerned about a particular client being discharged from the hospital. Which factors should alert the nurse to possible problems with this clients adherence to treatment? 1. The prescribed therapy is costly and of unknown duration. 2. The therapy will require no lifestyle changes of the client. 3. The client has not had difficulty understanding the regimen. 4. The clients culture is supportive of Western medicine.

The nurse has identified that many of the clients in the long-term care facility have spiritual concerns and distress. What is the nurse's first step in becoming a competent provider for these clients? 1. The nurse must possess a healthy spiritual self-awareness. 2. The nurse must learn about diverse spiritual beliefs and practices. 3. The nurse should start going to church more often. 4. The nurse should establish regular religious services in the facility.

The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis problem statement for this family? 1. Anticipatory Grieving 2. Dysfunctional Grieving 3. Hopelessness 4. Caregiver Role Strain

The nurse is preparing a patient for discharge from the hospital. Which is designed primarily to provide for a continuum of comprehensive health care after discharge? 1. Home care agencies 2. Urgent visit centers 3. Physicians' offices 4. Respite programs

The nurse is showing respect for a clients right to autonomy regarding an invasive procedure by: 1 Obtaining consent for the procedure 2 Performing the procedure appropriately 3 Providing client education regarding the procedure 4 Being frank when discussing the pros and cons of the procedure

The nurse needs to insert an intravenous access device into a toddler who is crying and scared. The parent asks if the procedure is painful. When practicing veracity, what should the nurse respond to the parent? 1. I wont lie to you. It may be easier for you if you step out until we get the line in. 2. Well take every care not to hurt your child. 3. It shouldnt be too bad and Ill be quick. 4. We do this all the time, so dont worry.

The nurse says, "If you do not let me do this dressing change, I will not let you eat dinner with the other residents in the dining room." This is an example of: 1. Assault 2. Battery 3. Negligence 4. Malpractice

The nurse who is assisting a client in the action stage of change would use which strategy? 1. Reinforce the importance of providing rewards for positive behavior. 2. Ask the client if he or she would like information. 3. Guide the client to create a plan of action. 4. Remind the client of previous successes.

What standard of care applies to the student nurses conduct when providing care normally performed by a registered nurse (RN)? lOMoARcPSD|6064164 1 The same standard of care as an RN 2 A standard of care of an unlicensed person 3 No special standard of care because her faculty member is responsible for her conduct 4 A standard similar to but not the same as the staff nurse with whom she is assigned to work

When a client who is in need of a lung transplant is placed on the organ donor registry according to his current health needs, this is an example of ethical: 1 Justice 2 Fidelity 3 Beneficence 4 Nonmaleficence

Which of the following statements made by a nurse regarding spiritual support provided displays an inappropriate intervention or attitude? lOMoARcPSD|6064164 1 I offer to pray with my clients as I prepare them for transport to surgery. 2 I always try to tell my Catholic clients when Mass is being held in the chapel. 3 When caring for a client for the first time, I always check to see their religious affiliation. 4 Im not very comfortable interviewing a client concerning their religious beliefs or practices.

While assisting in a community health project for middle-aged adults, the nurse attempts to identify members of the community who have been successful in the tasks identified by Erikson. What characteristic should the nurse identify in the community members? 1. Ability to have satisfaction in their volunteer activities 2. Ability to find an acceptable social group 3. Satisfaction with rearing children 4. Ability to manage a home

Which of the following may be considered normal or "healthy" types of grief? Select all that apply. 1. Abbreviated grief 2. Anticipatory grief 3. Disenfranchised grief 4. Complicated grief 5. Unresolved grief 6. Inhibited grief

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The nurse determines that an older client is in the medical care contact stage of an illness. What did the client demonstrate to cause the nurse to make this decision? Standard Text: Select all that apply. 1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion. 5. The client stated that treatment is accepted and will be completed as identified.

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The nurse educator is reviewing internal variables that affect peoples health status. On which variables is this nurse focusing? Standard Text: Select all that aply. 1. Genetic makeup 2. Age 3. Developmental level 4. Environment 5. Spiritual and religious beliefs

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A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor? Standard Text: Select all that apply. 1. Time management 2. Healthy eating habits 3. Exercise after stroke 4. Bicycle safety for children 5. Performing self-examination of the breasts

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The nurse is confident that a young adult has successfully achieved psychosocial development. What observations about the client did the nurse make to come to this conclusion? Standard Text: Select all that apply. 1. Discusses plans to expand his exercise routine to include running 2. Is optimistic about finding a new job 3. Volunteers weekly at the local senior center 4. Recognizes that professional sports may be enjoyed but does not aspire to participating 5. May be too bald to play Santa Claus

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The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? Standard Text: Select all that apply. 1. Selecting a mate 2. Rearing children 3. Achieving civic responsibility 4. Finding a congenial social group 5. Developing adult leisure-time activities

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Although the American Nurses Associations (ANAs) code of ethics is reviewed and revised regularly to reflect changes in nursing practice, the basic principles that remain constant are: (Select all that apply) 1 Advocacy 2 Reliability 3 Responsibility 4 Accountability 5 Confidentiality 6 Professionalism

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A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This client is modeling which behavior? 1. Health promotion 2. Health protection 3. Tertiary prevention 4. Primary prevention

A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions? 1. Interpersonal influences 2. Perceived benefits of action 3. Situational influences 4. Perceived self-efficacy

A client is hospitalized with numerous acute health problems. According to Maslows basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client? 1. Risk for Injury related to unsteady gait 2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients 3. Self-Care Deficit related to weakness and debilitation 4. Powerlessness related to chronic disease state

A client who is 46 pounds overweight tells you, "I was just born to be fat. I don't have the willpower." Although weight loss occurred while attending two previous programs that "guaranteed" weight loss, the weight returned along with extra pounds after each program. According to the Health Promotion Model, the nurse is most likely to focus on which behavior- specific cognition and affect variable for this client? 1. Perceived barriers to action 2. Perceived self-efficacy 3. Interpersonal influences 4. Situational influences

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." The best nursing response would be to: 1. Tell the client that this is not true, that we all have a purpose in life. 2. Identify recent behaviors or accomplishments that demonstrate the client's skills. 3. Reassure the client that you know how the client is feeling and that things will get better. 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

A nurses knowledge about spirituality begins with him or her: 1 Researching all popular religions 2 Looking at his or her own beliefs 3 Sharing his or her faith with the clients 4 Providing prayers and religious articles for clients

A parish nurse is helping a group of new parents within the congregation find appropriate health care providers within the community who specialize in infant/child and family health care needs. In which role is the nurse functioning? 1. Health educator 2. Referral source 3. Facilitator 4. Integrator

A patient with terminal cancer is willing to try new therapies. The nurse identifies that the patient is in what stage of Kübler-Ross' Stages of Grieving? 1. Denial 2. Bargaining 3. Depression 4. Acceptance

Abandoning a client would be an example of a nurses failure to professionally display: 1 Justice 2 Fidelity 3 Beneficence 4 Nonmaleficence

An adult client who cannot read needs surgery and is competent to make his own decisions. What is the best action that the nurse should take? 1. Tell the client in the nurses own words what the surgical procedure involves. 2. Read the consent form to the client and have the client state understanding. 3. Make sure the physician explains the procedure to the client. 4. Have a family member who can read sign the consent form.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells a clinic nurse that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action? 1. Tell the client that herbal substances are not safe and should never be used. 2. Encourage the client to discuss the use of an herbal substance with the physician. 3. Teach the client how to take her blood pressure so that it can be monitored closely. 4. Tell the client that if she takes the herbal substance she will need to have her blood pressure checked frequently.

An older client has just relocated from home to an assisted living facility. The nurse is concerned because the client has been withdrawn and is crying periodically throughout the day. What type of loss is this client demonstrating? 1. External objects 2. Familiar environment 3. Loved ones 4. Psychological

As a part of care planning, the nurse considers the client's spiritual needs. What is the rationale for this concern? 1. Nurses are the only health professionals who provide this type of holistic care. 2. Meeting the client's spiritual needs can decrease suffering. 3. Until spiritual needs are met, physical needs cannot be healed. 4. It is important that the nurse's idea of spirituality matches the client's ideas.

Clint receiving chemotherapy on a medical unit due to a recent diagnosis of terminal cancer of the liver, has an in-depth conversation with the nurse. The client says, This cannot be happening to me. The nurse identifies that this stage is associated with, according to Kbler-Ross: 1 Anxiety 2 Denial 3 Confrontation

Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents decision? 1. Showing respect for the family 2. Respecting the parents decision 3. Referring the parents to social services 4. Asking to be assigned to a different client

The major role of the nurse in the community setting is: 1. Advisor 2. Educator 3. Surrogate 4. Counselor

The nurse critically evaluates various models of grief used for terminally ill clients and their families. What should the nurse recognize when applying these models to individual cases? 1. The Kbler-Ross model is primarily used to describe anticipatory grief. 2. No clear timetables exist, nor are there clear-cut stages of grief. 3. The models serve as clear and definitive predictors of grief behaviors. 4. There is strong research proving that these models are not useful for many dying clients.

The nurse has identified the following nursing diagnoses for his assigned clients. Of the following diagnoses, which one indicates the greatest potential need to plan for the clients spiritual needs? 1 Altered health maintenance 2 Ineffective individual coping 3 Impaired long-term memory 4 Decreased adaptive capacity

The nurse has successfully completed a distance learning class on ECG (electrocardiogram) interpretation. This is an example of the nurse exhibiting the professional principle of: 1 Advocacy 2 Responsibility 3 Accountability 4 Confidentiality

The nurse identifies and meets the health needs of a patient. Which word best describes this role of the nurse? 1. Teacher 2. Advocate 3. Surrogate 4. Counselor

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

Which behavior is an initial step in culturally responsive nursing practice? 1. Help the client recognize the need to adapt health practices to fit commonly accepted practices. 2. Discuss the meaning of the medical regimen with the client. 3. Inform the client that lack of adherence to the medical Regimen may be detrimental. 4. Ask a cultural broker to explain the relevance of the intervention.

Which individual appears to have "taken on" the sick role? An obese client states, "I deserve to have a heart attack." A mother is ill and says, "I won't be able to make your lunch today." A man with low back pain misses several physical therapy appointments. An elder states, "My horoscope says I will be well again."

client is told by his nurse that he has to take the medications, including an injection. The client refuses the medications, but continues to have them administered by the nurse. This action is an example of the intentional tort of: 1 Assault 2 Battery 3 Malpractice 4 Invasion of privacy

nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action? 1. Administer the medication. 2. Notify the prescriber. 3. Call the pharmacist. 4. Refuse to administer the medication.

Which nursing actions could result in professional negligence? Select all that apply. 1. Learns about a new piece of equipment. 2. Forgets to complete the assessment of a client. 3. Does not follow up on client's complaints. 4. Charts client's drug allergies. 5. Questions primary care provider about an illegible order.

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A nurse describes low-risk therapies to a client and includes which of the following in the discussion? Select all that apply. 1. Herbs 2. Prayer 3. Touch 4. Massage 5. Relaxation 6. Acupuncture

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A client is brought to the emergency department after being involved in a motor vehicle crash. Although the client is conscious, her condition is critical and will require emergency surgery. The client does not speak English. Which action should the nurse take? 1. Read the consent form and have the client sign it anyway. 2. Explain the form to the best of the nurses ability using pictures and gestures. 3. Have the hospital interpreter explain the procedure. 4. Proceed with surgery, as implied consent would be the case in this situation.

A client is getting ready to go home from an intermediate care facility following surgery and a lengthy recovery period. On which item should the home health nurse focus to determine effectiveness of discharge teaching? 1. Activity restrictions 2. Follow-up appointment dates Return demonstration of dressing change 4. Signs of complications

A client is getting ready to go home from an intermediate care facility following surgery and a lengthy recovery period. On which item should the home health nurse focus to determine effectiveness of discharge teaching? 1. Activity restrictions 2. Follow-up appointment dates 3. Return demonstration of dressing change 4. Signs of complications

A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with staff and reads the medical record. The nurse realizes that the attorney is performing which activity? 1. Burden of proof 2. Complaint 3. Discovery 4. Civil action

A client who is recently diagnosed with cancer is encouraged to consider sharing the information with her family so they can support her through the decisions she will need to make regarding her care. The nurse is using the principle of: 1 Confidentiality 2 Fidelity 3 Veracity 4 Justice

A hospital receives notice of being sued for an action performed by a nurse. The nurse realizesthat which doctrine is being implemented in this case? 1. Contractual relationship 2. Stare decisis 3. Respondeat superior 4. Res ipsa loquitur

A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after- hours clinic. Which professional value is the nurse demonstrating? 1. Human dignity 2. Altruism 3. Social justice 4. Integrity

A patient with impaired mobility is to be discharged within a week from the hospital. Which is the best example of a discharge goal for this patient? The patient will: 1. Understand range-of-motion exercises 2. Be taught range-of-motion exercises 3. Transfer independently to a chair 4. Be kept clean and dry

A young adult has never lived away from his parents and feels unable to make decisions on his own. According to Freuds theory of development, the nurse should suspect that this person would be fixated at which stage of development? 1. Phallic 2. Latency 3. Genital 4. Anal

An Asian-American client is experiencing a fever. A nurse recognizes that the client is likely to self treat the disorder with: 1. Magnetic therapy 2. Intercessory prayer 3. Foods considered to be yin 4. Foods considered to be yang

During the bath, the client suddenly says, I am not going to get well. I think I am going to die. What response given by the nurse is most appropriate? 1. Lets think of something more cheerful. 2. You are doing so well; dont talk like that. 3. What makes you think you are dying? 4. Whatever is meant to be will happen.

In initiating care for a client from a different culture than the nurse, which of the following would be an appropriate statement? 1. "Since, in your culture, people don't drink ice water, I will bring you hot tea." 2. "Do you have any books I could read about people of your culture?" 3. "Please let me know if I do anything that is not acceptable in your culture." 4. "You will need to set aside your usual customs and practices while you are in the hospital."

Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying? 1. Termination stage 2. Preparation stage 3. Contemplation stage 4. Action stage

The client presents her hand when the nurse makes this statement: I need to start an IV so you can get your antibiotics. Which behavior did the client demonstrate? 1. Informed consent 2. Express consent 3. Implied consent 4. Compliance

The client tells the nurse that she has been having problems sleeping since her boss died unexpectedly 3 weeks ago. She confides that she and the boss had been having a secret extramarital affair for years. The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief? 1. Abbreviated 2. Chronic 3. Disenfranchised 4. External

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response? 1. "It is a process of learning a different culture to adapt to a new or changing environment." 2. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." 3. "It is a group of individuals in a society who are culturally distinct and have a unique identity." 4. "It is a group that shares some of the characteristics of the larger population group of which it is a part."

The nurse forgets to put the call light within the clients reach and then leaves the room. The client reaches for it and falls out of bed. With what should the nurse expect to be charged? 1. Assault 2. Battery 3. Negligence 4. Criminal intent

The nurse identifies the major responsibilities of various health-care professionals and identifies that the person best prepared to track a patient's progress through the health- care system is the: 1. Home Care Nurse 2. Primary Nurse 3. Case Manager 4. Manager Nurse

The nurse is assigning support personnel to assist the families of clients who have died in dealing with the stress related to the loss of their family members. Which family would the nurse screen as at highest risk for complicated grief? The family of a client who 1. died after a long battle against cancer. 2. died after developing diabetes-induced renal failure. 3. was killed in the robbery of a bank. 4. died from chronic heart disease.

The nurse is caring for a patient recently diagnosed with advanced cancer. Which patient statement reflects stage of denial in the grief process? 1. "Why did this have to happen to me now?" 2. "My daughter will live with my sister after I am gone." 3. "Maybe they mixed up my records with someone else's." 4. "How could this happen when I quit smoking cigarettes?"

The nurse is explaining the rationale for seeking the familys permission to apply a physical restraint to a combative client. This is an example of the nurse exhibiting the professional principle of: 1 Advocacy 2 Responsibility 3 Accountability 4 Confidentiality

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify that which client is most typical of a victim of abuse? 1. A 75-year-old man who has moderate hypertension 2. A 68-year-old man who has newly diagnosed cataracts 3. A 90-year-old woman who has advanced Parkinson's disease 4. A 70-year-old woman who has early diagnosed Lyme disease

The nurse is providing assistance at a community health fair for middle-aged clients. Which information should the nurse use when working with this group of clients? 1. The middle-aged person has decreased intellectual and cognitive abilities as a result of the normal aging process. 2. Adults make the transition into this stage easily and without problems. 3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life. 4. Cognitive and intellectual abilities are somewhat decreased due to slower reaction time, loss of memory, and changes in perception and problem solving.

Using Maslow's framework, which statement characterizes the highest level of need? 1. "Nurse, my pain is severe . . . is it time for my shot?" 2. "I felt welcomed when I first joined the group and I look forward to the monthly meetings." 3. "I'm very proud of receiving the Employee of the Month award." 4. "There have been home break-ins with burglary in our Suggested Readings

When asked about his or her religious affiliation, a client responds, Thats personal; why do you want to know? The most appropriate nursing response is: 1 You need not answer my question if you prefer not to share that information. 2 All information you provide will be kept in strict confidence. 3 By knowing your religious preferences, I can best meet your spiritual needs. 4 I did not mean to offend you; we ask that question of all our new admissions

Which statement by the client best represents the contemplation stage of the stages of behavior change? 1. "I currently do not need to exercise and do not intend to start in the next six months." 2. "I have tried several times to exercise 30 minutes three times a week but am seriously thinking of trying again in the next month." 3. "I currently do not exercise 30 minutes three times a week, but I am thinking about starting to do so within the next six months." 4. "I have exercised 30 minutes three times a week regularly for more than six months."

Although not every client progresses in order through each stage, what is the usual sequence in Suchman's stages of illness? 1. The client makes contact with medical care. 2. The client goes into rehabilitation/recovery. 3. Signs and symptoms appear. 4. The client takes on the dependent role. 5. The client takes on the sick role.

3. Signs and symptoms appear 5. The client takes on the sick role 1. The client makes contact with medical care 4. The client takes on the dependent role 2. The client goes into rehabilitation/recovery

A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make? 1. Just sign the form, and Ill make sure your physician talks to you before he begins the procedure. 2. Ill explain whatever you dont understand. 3. You should have asked your physician when he was in here. 4. Ill call your physician back in the room to answer your questions.

A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior- specific cognitions should the nurse focus to assist this client with success in the rehabilitation program? 1. Situational influences 2. Perceived benefits of action 3. Perceived barriers to action 4. Interpersonal influences

A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program? 1. Situational influences 2. Perceived benefits of action 3. Perceived barriers to action 4. Interpersonal influences

A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change? 1. Termination stage 2. Maintenance stage 3. Contemplation stage 4. Action stage

A community health nurse is planning adult health education classes. According to Eriksons stages of development, the nurse should address which task with this age group? 1. Industry versus inferiority 2. Identity versus role confusion 3. Intimacy versus isolation 4. Generativity versus stagnation

A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling? 1. Autonomy 2. Justice 3. Beneficence 4. Nonmaleficence

A middle-aged client is struggling with life changes, including menopause. What is the best response by the nurse to this client? 1. Dont worrymenopause cant last forever. 2. There are some very good antidepressants you can take. 3. What did your mother do to get through menopause? 4. There is a menopause support group that meets every 2 weeks.

A student nurse accidentally left the call light outside the reach of an older client. Another nurse discovered the situation and was able to rectify the matter before something happened. The student apologizes and states the need to double check for call light placement before leaving a clients room. What behavior did the student demonstrate? 1. Justice 2. Fidelity 3. Responsibility 4. Accountability

An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss? 1. "I told the doctor I would stop driving, but I am not going to yet." 2. "I always knew this day would come, but I hoped it wouldn't be now." 3. "What does he know? I'm a better driver than he will ever be." 4. "Well, at least I have friends and family who can take me places."

During a home visit, an older male client tells the nurse that his wife died 3 years ago. What did the nurse observe as an indication that this client is experiencing complicated grief? 1. The client has an album of photographs of his wife open on the living room table. 2. He tells the nurse that his wife was an awful cook and that he has eaten better meals since she died. 3. He indicates that he sends his laundry out to be done because he had never figured out how the washer works. 4. He shows the nurse his wifes craft room that remains just as she left it before she died.

The client has been diagnosed with malignant bone cancer and the treatment involves chemotherapy on an outpatient basis. While treating the cancer the client unfortunately becomes very ill, experiences significant side effects from the therapy, and has a severe reduction in the quality of life. The specific ethical principle that is in question in this situation is: 1 Veracity 2 Fidelity 3 Justice 4 Nonmaleficence

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive

The nurse carries out a medication order, incorrectly written by the physician and subsequently filled by the pharmacist. Who, in this situation, is legally liable for the action? 1. Physician 2. Pharmacist 3. Hospital 4. Nurse

The nurse concludes that effective discharge planning (hospital to home) has been conducted when the client states which of the following? 1. "As soon as I get home, the nurse will come out, look at where I live, and see what kind of care I will need." 2. "All I need are my medications and a ride home. Then I'm all ready for discharge." 3. "When I visit my doctor in 10 days, they will show me how to change my bandages." 4. "I have the phone numbers of the home care nurse and the therapist who will visit me at home tomorrow."

The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the clients life. What action is the nurse assisting the client to complete? 1. Lifestyle assessment 2. Social support systems review 3. Health beliefs review 4. Spiritual health assessment

When a nurse considers the possible positive effect a treatment will have against the pain it may cause the client, the nurse is displaying: 1 Justice 2 Fidelity 3 Beneficence 4 Nonmaleficence

Which of the following statements best reflects the nurses ethical concern for nonmaleficence regarding the clients treatment plan? 1 The radiation therapy has not substantially decreased the clients tumor related pain. 2 The client expressed the idea that this treatment was definitively going to cure her cancer: 3 The clients family requested that she not be informed of the seriousness of her cardiac condition. 4 The procedure is quite invasive, and there is little chance that it will improve the clients quality of life.

client is discharged following a heart attack. In using the Stages of Health Behavior Change as a guide, the nurse recognizes that the client is most likely to begin to accept information on diet changes and an exercise program during which stage? 1 Action 2 Preparation 3 Maintenance 4 Contemplation

parish health nurse is working with a particular congregation in setting up a support program for shut-ins within the congregation who are not able to come to regular prayer services. In which role is this nurse functioning? 1. Counselor 2. Educator 3. Referral source 4. Facilitator

tool that may be used effectively with clients who have terminal diseases is hope. Hope provides a: 1 Relationship with a divinity 2 System of organized beliefs 3 Cultural connectedness 4 Meaning and purpose

Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? 1. An unintentional tort 2. Assault 3. Invasion of Privacy 4. Battery

4. Battery

7. A nurse attempts to meet a patient's religious dietary restrictions. • 8. A nurse explores with a patient the importance of learning to accept himself, even with his faults. • 9. A nurse treats her patient with respect, empathy, and genuine caring. • 10. A nurse explores with a patient spiritual practices from which he might derive strength and hope. • 11. A nurse respects a patient's need for privacy during prayer. • 12. A nurse helps a patient explore his self-expectations and determine how realistic they are. • 13. A nurse encourages a patient to explore her relationship with her family and identify the origin of negative beliefs about people. A. Facilitating the practice of religion B. Promoting meaning and purpose C. Promoting love and relatedness D. Promoting forgiveness

7. a • 8. d • 9. c • 10. b • 11. a • 12. d • 13. c

Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle ismost compromised when only one nurse anesthetist is on call? a. Justice b. Fidelity . Beneficence d. Nonmaleficence

The mother of a child who died recently keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing? a. Normal b. End-of-life c. Abnormal d. Complicated

The nurse chooses to delay taking a break so that pain medication could be administered on time rather than making the client wait until the nurse's break is complete. Which of the following ethical principles is best described by the nurse's action? a. Beneficence b. Justice c. Nonmaleficence d. Autonomy

The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death? A) At about age 9, children begin to understand death is inevitable. B) Adolescents tend to have better outcomes than adults after a loss. C) Preschool children view death as a spiritual release. D) Toddlers perceive death as irreversible and unnatural

When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response? a. "Tell me what it means to you to have this surgery." b. "You must be very glad to be having this lesion removed." c. "I cry when I am happy or relieved sometimes, too." d. "Isn't it wonderful that the lesion is not cancer?"

You need to have an invasive procedure in radiology. You will have some dye injected into your vascular system to look for defects. The procedure is explained to you in detail (along with risks and benefits). You sign the consent form. What is this form of consent called? A. Express B. Implied

Your patient has CHF and needs to have a Foley catheter inserted to measure accurate fluid output after receiving potent diuretics. You explain the procedure to the patient and ask the patient if it is okay to proceed. The patient says yes. What kind of consent have you just received? A. Express B. Implied

The nurse hears a health care provider say to the charge nurse that a certain nurse cannot care for patients because the nurse is stupid and won't follow orders. The health care provider also writes in the patient's medical records that the same nurse, by name, is not to care for any of the patients because of incompetence. Which torts has the health care provider committed? (Select all that apply.) a. Libel b. Slander c. Assault

A-B

A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Blooms domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation

A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 pm when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? a.Gently explain the policy to the family and then implement it. b.Inquire of the nursing supervisor how an exception to the policy could be made. c.Call the client's primary care provider for advice. d.Move the deceased to an empty room and assign an aide to stay with the body.

A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. Which action is most appropriate for the nurse to take? Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and a. Accountability Act (HIPAA). b. Use the book as needed while keeping it away from individuals not involved in patient care. c. Move the book to the upper ledge of the nursing station for easier access. d. Ask the nurse manager to move the book to a more secluded area.

A nurse works full time on the oncology unit at the hospital and works part time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. How will the hospital's malpractice insurance provide coverage for this nurse? a. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly. b. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the ho As long as the nurse has never been sued before this incident, the hospital's malpractice insurance will co c. nurse. d. The hospital's malpractice insurance will provide approximately 50% of the coverage the nurse will need

A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? a. "You are practicing under the license of the hospital's insurance." b. "You are expected to perform at the level of a professional nurse." c. "You are expected to perform at the level of a prudent nursing student." d. "You are practicing under the license of the nurse assigned to the patient."

A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient? b. Situational loss c. Maturational loss d. Uncomplicated loss

Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. Which initial action should the nurse take? a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly. b. Tell the cameraman where the hospital's public relations department is located. c. Have the cameraman wait for permission from the health care provider. d. Ask the cameraman how the pictures are to be used in the newspaper.

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

The nurse gives a resident in a nursing home a choice about which color shirt to wear. What level need, according to Maslow's Hierarchy of Needs, has the nurse just met? a. Physiologic b. Self-esteem c. Safety and Security d. Love and Belongin

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice

Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding? a. Contemplation b. Maintenance c. Preparation d. Action

Which individual appears to have "taken on" the sick role? a.An obese client states, "I deserve to have a heart attack." b.A mother is ill and says, "I won't be able to make your lunch today." c.A man with low back pain misses several physical therapy appointments. d.An older adult states, "My horoscope says I will be well again."

Which of the following is the nurse's role in the health promotion? a. Health risk appraisal b. Teach client to be effective health consumer c. Worksite wellness d. None of the above

You need to start an IV on a patient. She really does not want the IV because she is afraid of 'needles.' However, when you approach the side of the bed, she extends her left hand to you to start the IV and mentions that she is right handed. What kind of consent has she just given to you? A. Express B. Implied

recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained? a. Ask a family member to translate what the nurse is saying. b. Request an official interpreter to explain the terms of consent. c. Notify the nursing manager that the patient doesn't speak English. d. Use hand gestures and medical equipment while explaining in English.

A client in the emergency department needs a transfusion of red blood cells. The client tells the nurse that, as a Jehovah's Witness, blood transfusions are not permitted. Which statement would most likely lead to a resolution for this conflict? a. You must accept the transfusion or else leave. b.Don't worry, you can ask for pardon after taking the blood. c. May I please call a representative of your religion so that I can understand your position better? d.I understand your position; I'll be here with you as you die.

A client reports, "Cancer was the best thing that happened to me! It is making me appreciate life so much more." This statement fits best with which NANDA diagnosis? a.Impaired Religiosity b.Risk for Spiritual Distress c.Readiness for Enhanced Spiritual Well-Being d.Cognitive Denial

A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that these lines should not be touched, but the patient continues. Which is the best action by the nurse at this time? a. Apply restraints loosely on the patient's dominant wrist. b. Notify the health care provider that restraints are needed immediately. c. Try other approaches to prevent the patient from touching these care items. d. Allow the patient to pull out lines to prove that the patient needs to be restrained.

A female nurse is called into the supervisor's office regarding her deteriorating work performance since the loss of her spouse 2 years ago. The woman begins sobbing and says that she is "falling apart" at home as well. Which type of grief is the female nurse experiencing? a. Normal grief b. Perceived grief c. Complicated grief d. Disenfranchised grief

A nurse in a long-term care facility is caring for several older adults with noticeable hearing losses. Which is the best way for the nurse to communicate with these clients? a. Speak slowly using the proper volume and as few words as possible. b.Write the information using large lettering. c. Speak in a low and distinct voice tone. d.Have the client increase the volume in the hearing aid.

Because a 45-year-old woman is worried that she still has regular menstrual periods, she asks about menopause. Which answer by the nurse is most appropriate? a. "Regular menses in a 45-year-old woman should be promptly evaluated by a gynecologist." b. "Although you continue to have menstrual periods, you are unlikely to become pregnant." c. "It is common for women to experience menopause in their late 40s." d. "Many women dread menopause because it is an unpleasant experience."

Crisis is a sudden event in one's life that disturbs a person's homeostasis. Which of the following is NOT TRUE in crisis? A. The person experiences heightened feeling of stress B. Inability to function in the usual organized manner C. Lasts for 4 months D. All of the above

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

A newly hired experienced nurse is preparing to change a patient's abdominal dressing and hasn't done it before at this hospital. Which action by the nurse is best? a. Have another nurse do it so the correct method can be viewed. b. Change the dressing using the method taught in nursing school. c. Ask the patient how the dressing change has been recently done. d. Check the policy and procedure manual for the facility's method.

A patient whose spouse recently died begins to cry. The nurse's best respons e is to: a. Arrange for gr ief co unseling b. Explain that being sad is normal c. Look aw ay when the patient cries d. S it down wh ile touc hing the patient's hand

A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus's outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence

After the physician explains the surgery to the client, the nurse provides the client with information about surgery, answers the client's questions, and allows the client to agree or refuse to have surgery. Which of the following ethical principles is best described by the nurse's actions? a. Nonmaleficence b. Beneficence c. Truth telling d. Autonomy

An older adult client tells the nurse that the client has human immunodeficiency virus (HIV). The nurse should: a. document this information in the client's chart. b. tell the client's physician. c. inform the health care team who will come in contact with the client. d. encourage the client to disclose this information to the client's physician.

The nursing student is planning care for an older adult who had a total knee replacement yesterday evening. Which nursing intervention would be most appropriate? a. Ask the client how much of his bath he can independently perform. b. Ask the client if he has any questions regarding discharge from the hospital. c. Tell the client that he needs to decide when he wants his medications. d. Tell the client that he needs to rest and will be given a complete bed bath.

Which is the best response by the nurse if a patient fails to follow information or teaching provided regarding health promotion measures? A) Give up, because the patient doesn't want to change B) Develop a tough approach C) Reteach the information, because the nurse is the expert D) Reassess the patient's importance given to the behavior and readiness to change it

EC

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