Final 110

The client is a male who states his wife complains that his snoring awakens her at night. The spouse is present. To obtain further data, the nurse asks the spouse: "How loud is his snoring?" "Is there silence after snoring which then is followed with a snort?" "How long does he snore each night?" "How often are you awakened at night due to his loud snoring?"

"Is there silence after snoring which then is followed with a snort?"

A nurse is teaching a client how to care for her dentures. Which is a recommended teaching guideline? "Remove your dentures whenever possible in order to rest your gums." "Wrap your dentures in a clean napkin or facecloth when not using them." "Rinse your dentures in a dilute bleach solution at least once per week." "Store your dentures in cold water whenever they're not in use."

"Store your dentures in cold water whenever they're not in use."

Which statement indicates that a plan to assist a client in developing and following an exercise program has been effective? -"I have just been too busy to do my daily exercises." -"I guess I will begin the activity we discussed next week." -"I know I should exercise, but my health is not very good." -"I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day."

-"I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day."

Who was the first nurse to develop a nursing theory? -Virginia Henderson -Dorothea Dix -Clara Barton -Florence Nightingale

-Florence Nightingale

An older adult client is scheduled to receive passive range-of-motion (ROM) exercises. The family is present to learn how to do the exercises for the client at home. What interventions would the nurse include? Select all that apply. -Ask the unlicensed assistive personnel (UAP) to perform the exercises and teach the family. -Provide slow and gentle movements while supporting the extremity. -Massage the client's leg if the client reports sudden and sharp pain in the leg during exercise. -Perform the range-of-motion exercises once a day. -Perform the exercise to the point of resistance.

-Provide slow and gentle movements while supporting the extremity. -Perform the exercise to the point of resistance.

Which client outcomes are physiologic outcomes? Select all that apply. -The client's HbA1c is 7.4%. -The client's blood pressure is 118/74 mm Hg. -The client rates his or her pain rating as 6. -The client self-administers insulin subcutaneously. -The client describes manifestations of wound infection.

-The client's HbA1c is 7.4%. -The client's blood pressure is 118/74 mm Hg. -The client rates his or her pain rating as 6.

What is the rationale for conducting discharge planning? -to provide a means of documenting nursing care -to enlist family members in providing home care -to ensure client and family needs are met consistently -to ensure the best possible care in the acute care setting

-to ensure client and family needs are met consistently

What is the primary purpose of standards of nursing practice? -to provide a method by which nurses perform skills safely -to establish nursing as a profession and a discipline -to enable nurses to have a voice in health care policy -to ensure knowledgeable, safe, comprehensive nursing care

-to ensure knowledgeable, safe, comprehensive nursing care

On which client would a figure-eight bandage be appropriate? A client with a leg cast A client with pitting edema to his or her thighs A client with a toe fracture A client with a sprained ankle

A client with a sprained ankle

What nursing organization first legitimized the use of the nursing process? National League for Nursing American Nurses Association International Council of Nursing State Board of Nursing

American Nurses Association

A nurse is reviewing complementary and alternative therapies with aa group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (Select all that apply) Art therapy Acupressure Yoga Therapeutic touch biofeedback

Art therapy yoga biofeedback

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which is the best nursing intervention for this client? Briefly leave the client in order to call the primary health care provider to assess the client's condition. Assist the client back to bed and teach her about falls-prevention measures. Assess the client and document the incident and interventions in the client's medical record. Perform a head-to-toe assessment to determine whether an incident report is necessary.

Assess the client and document the incident and interventions in the client's medical record.

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action? Roll back the stocking partially and apply padding over the tender region. Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider. Stop applying the stocking and reattempt in 30 minutes. Apply the stocking, administer analgesia to the client, and then inform the primary care provider.

Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider.

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? Administer pain medications on a p.r.n. and regular basis. Assist in moving to prevent strain on the suture line. Tell the client that a mild fever is a normal response. If a scar forms over a joint, it may limit movement.

Assist in moving to prevent strain on the suture line.

A client who is bedridden and dependent has been ordered to resume an oral diet. When feeding the client, the nurse should perform what action? -Assist the client into a high-Fowler's position. -Feed the client carbohydrate-rich foods at the beginning of the meal. -Suction the client's upper airway before feeding. -Ensure that the client's food is at room temperature.

Assist the client into a high-Fowler's position.

A nurse is teaching a group of student nurses about recommended practices for providing skin care to their clients. Which practice should the nurse teach to the students? Assess the client's skin at least twice weekly. Avoid using soap and hot water, if possible. Do not use skin barrier products. Avoid using skin emollients whenever possible.

Avoid using soap and hot water, if possible.

According to Erikson, the stage of development of the middle adult is generativity versus stagnation. What happens to the middle adult if developmental tasks are not achieved? Has an increased awareness of own mortality Denies changes in the body that are related to aging Is more motivated to learn new material Becomes more concerned about own health needs

Becomes more concerned about own health needs

After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice? -Enrolling in an advanced degree program -Being licensed by the State Board of Nursing -Having a signed letter confirming graduation -Filing NCLEX results in the county of residence

Being licensed by the State Board of Nursing

The nurse administers an insulin injection to a client with diabetes and informs the client what is being done and demonstrates each step of preparing and giving the injection. What is the nurse promoting with the client? Client self-care Dependence of the client on the nurse Client competence Discipline of the client

Client self-care

A nurse working the night shift assesses a client's vital signs at 4 a.m. (0400). What would be the expected findings, based on knowledge of NREM sleep? Decreased TPR and BP Increased TPR and BP No change from daytime readings Highly individualized, cannot predict

Decreased TPR and BP

A child gains weight and becomes taller each year. What is this process called? Progression Orderly change Development Growth

Growth

Nurses who assist clients to deal holistically with their health care needs at the end of their lives work primarily in which health care delivery system? -Acute care -Hospice -Primary care -Rehabilitation

Hospice

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? Prolonged fasting Infection Advanced age Long periods of sleep

Infection

A nurse asks a client to rate his pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. What characteristic of pain is the nurse assessing? Duration Location Chronology Intensity

Intensity

A client who has a leg cast tells the nurse that he has pain inside his cast. Which type of stimulus is most likely causing this pain? Thermal Chemical Electrical Mechanical

Mechanical

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? Document the assessments and intervention. Reinforce the dressing with additional layers. Administer pain medications intramuscularly. Notify the physician and prepare for surgery.

Notify the physician and prepare for surgery.

A nurse calculates the BMI of a client during a general survey as 26. Under which category would this client fall? -Underweight -Overweight -Obesity Class I -Normal

Overweight

What is the most common method for ordering sleep medications? Stat p.r.n. Single order Daily dose

PRN

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? Physiologic Safety Love and belonging Self-actualization

Physiologic

What function of the skeletal system is essential to proper function of all other cells and tissues? Supporting soft tissues of the body Protecting delicate body structures Providing storage area for fats Producing blood cells

Producing blood cells

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? Self-care Deficit Risk for Imbalanced Nutrition Anxiety Risk for Infection

Risk for Infection

Two nurses are preparing to use a powered full-body sling lift to transfer a client from his bed to a chair. Which nursing diagnosis should the nurse use? Risk for Injury Risk for Powerlessness Risk for Disuse Syndrome Risk for Activity Intolerance

Risk for Injury

What is required of a client who leaves the hospital against medical advice (AMA)? -Full reimbursement of any medical expenses -Nothing. The hospital has no legal concerns. -Signing a form releasing legal responsibility -Providing contact phone numbers if needed

Signing a form releasing legal responsibility

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound? Stage II pressure ulcer Stage I pressure ulcer Stage III pressure ulcer Stage IV pressure ulcer

Stage II pressure ulcer

A client's bed partner reports the client often has irregular snoring and silence followed by a snort. Does this warrant further assessment? No, snoring has varied patterns. No, this is a description of normal snoring. Yes, this is an indicator of obstructive apnea. Yes, the bed partner is unable to sleep at night.

Yes, this is an indicator of obstructive apnea.

A nurse working in long-term care is assessing residents at risk for the development of a pressure injury. Which one would be most at risk? a client 83 years of age who is mobile a client 92 years of age who uses a walker a client 75 years of age who uses a cane a client 86 years of age who is bedfast

a client 86 years of age who is bedfast

Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep? a client who receives IV antibiotics every 3 hours a client whose opioid analgesics result in central nervous system depression a client who requires blood glucose checks 4 times daily a client whose physical therapy has been scheduled for 4:30 p.m.

a client who receives IV antibiotics every 3 hours

trade name

brand name copyrighted by the company that sells the drug

generic name

name assigned by the manufacturer who first develops a drug; it is often derived from the chemical name

official name (monograph)

name by which the drug is identified in official publications United States Pharmacopeia (USP) and National Formulary (NF) (typically generic name)

Of the following information collected during a patient assessment, which are subjective data? vomiting, pulse 96 respirations 22, blood pressure 130/80 nausea, abdominal pain pale skin, thick toenails

nausea, abdominal pain

A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain? cutaneous referred allodynia nociceptive

referred

Why is it important for the nurse to teach and role model proper body mechanics? to ensure knowledgeable client care to promote health and prevent illness to prevent unnecessary insurance claims to demonstrate knowledge and skills

to promote health and prevent illness

The nurse is providing care for an older adult client who is recovering from pneumonia on the hospital's medical unit. The nurse sets up the client's dinner tray on his overbed table. The client then states, "I won't be having any of this." What is the nurse's most appropriate response? -"Did the dietitian meet with you to discuss your nutritional needs?" -"Can you tell me why you don't want to have dinner tonight?" -"I'll set your tray aside and warm it up for you later this evening." -"Nutrition will play a big part in how quickly your recover."

"Can you tell me why you don't want to have dinner tonight?"

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? "I will drink a lot of orange juice and drink milk, too." "I will take the zinc supplement the doctor recommended." "I will restrict my diet to fats and carbohydrates." "I will drink 8 to 10 glasses of water every day."

"I will restrict my diet to fats and carbohydrates."

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? "My husband has been ill and I don't have anyone to help me care for him." "I have learned to prepare foods differently so they are low in fat." "My neighbor walks with me around the neighborhood every morning." "I have been taking my hydrochlorothiazide every day."

"My husband has been ill and I don't have anyone to help me care for him."

chemical name of drug

- scientific name that precisely describes drug's atomic & molecular structure

A nurse asks a young adult questions about family, friends, and support systems based on Erikson's stages of psychosocial development. What is the reason this information is important during assessments of young adults? -Restrictions on new experiences may lead to feelings of guilt. -Without peer acceptance, the young adult will revert back to previous behaviors. -Overprotection by parents may result in feelings of shame and doubt. -Fear of commitments may lead to loneliness and isolation.

-Fear of commitments may lead to loneliness and isolation.

Which client care concern is clearly a nursing responsibility? -Prescribing medications -Monitoring health status changes -Ordering diagnostic examinations -Performing surgical procedures

-Monitoring health status changes

Which statement is true for nursing care of older adults? -Most older adults are unable to care for themselves independently. -Interventions for older adults are no different from those for young adults. -Fewer older adults will require nursing care during the 21st century. -Most older adults are functional, benefiting from health-oriented interventions.

-Most older adults are functional, benefiting from health-oriented interventions.

The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply. Stages of pressure injuries Nutritional status Mental status Skin moisture Sensory perception

-Nutritional status -Mental status -Skin moisture -Sensory perception

Which group of terms best describes the nursing process? -Nursing goals, medical terminology, linear -Nurse-centered, single focus, blended skills -Patient-centered, systematic, outcome-oriented -Family-centered, single point in time, intuitive

-Patient-centered, systematic, outcome-oriented

The nurse would recognize which of these devices as an open drainage system? -Penrose drain -Jackson-Pratt drain -Hemovac -Negative pressure dressing

-Penrose drain

What technique should the nurse use to implement infection control in the home? -Take prescribed antibiotics on a regular basis on working days. -Wear gloves at all times when in the home or traveling in the car. -Practice hand hygiene when beginning and ending the home visit. -Avoid touching any object in the home, including door knobs.

-Practice hand hygiene when beginning and ending the home visit.

What are functions of the skin? Select all that apply. -Protection -Temperature regulation -Sensation -Vitamin C production -Immunologic

-Protection -Temperature regulation -Sensation -Immunologic

A gerontologic nurse is assessing an older adult client's risk for falls. Which aspects of the client's current health status should the nurse identify as increasing the client's risk for falls? Select all that apply. -Recent changes have been made to the client's medication regimen. -The client has recently moved to a new assisted living facility. -The client has recently been diagnosed with hypertension. -The client had knee replacement surgery 6 weeks ago. -An occupational therapist has begun working with the client.

-Recent changes have been made to the client's medication regimen. -The client has recently moved to a new assisted living facility. -The client had knee replacement surgery 6 weeks ago.

A vocational nurse is overseeing the care of numerous residents in a care facility. Which tasks can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. Assessing a new resident's risk for falls Assessing the circulation of a resident in extremity restraints Removing items that have been deemed a risk for falls from a resident's room Helping a resident safely ambulate to the bathroom from her bed Applying a waist restraint that has been ordered for a resident

-Removing items that have been deemed a risk for falls from a resident's room -Helping a resident safely ambulate to the bathroom from her bed

On a previous clinic visit a month ago, the overweight client reported shortness of breath with activity and constipation. The client was diagnosed as having osteoporosis and noted to have an elevated triglyceride level. The primary care provider prescribed an exercise program. The nurse is assessing for the effects of exercise. What are the expected outcomes for this client? Select all that apply. -The client reports no shortness of breath with activity. -the client's blood triglyceride level is increased. -The client reports regular and formed bowel movements. -The client's weight is maintained or lessened. -The client reports joint pain with movement.

-The client reports no shortness of breath with activity. -The client reports regular and formed bowel movements. -The client's weight is maintained or lessened.

While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude? -These are normal physiologic changes of aging. -The observations are not typically found in older adults. -These are abnormal observations and must be reported. -Extra education will be necessary to prevent complications.

-These are normal physiologic changes of aging.

A nurse is caring for a client with a history of cardiac and vascular disease. Which fats should the nurse allow in the client's diet for his condition? -Saturated fats -Trans fats -Hydrogenated fats -Unsaturated fats

-Unsaturated fats

What is the goal of the nurse in a helping relationship with a client? -to provide hands-on physical care -to facilitate the client's interactions with others -to assist the client to identify and achieve goals -to ensure safety while caring for the client

-to assist the client to identify and achieve goals

The physician's admitting orders indicate that the client is to be placed in Fowler position. Upon positioning this client, how much will the nurse elevate the head of the bed? 45 to 60 degrees 15 to 20 degrees 30 degrees 90 degrees

45 to 60 degrees

For which client might skeletal traction be indicated? A client with a fractured arm A client with a dislocated shoulder A client with a skull fracture A client with a fractured cervical spine

A client with a fractured cervical spine

Which of the following nurses is most likely to care for clients who are trying to resolve identity versus role confusion? -A nurse who works in a long-term care facility -An occupation health nurse based at a lumber mill -A pediatric nurse -A nurse who provides care in a large junior high school

A nurse who provides care in a large junior high school

A nurse at a long-term care facility is planning to provide nail care to several of the residents. The nurse should be particularly cautious when providing this care to which resident? A resident who is obese and who has decreased level of consciousness A resident who wanders frequently due to Alzheimer's disease A resident who has decreased mobility and type 1 diabetes A resident who has recently completed chemotherapy

A resident who has decreased mobility and type 1 diabetes

Which client would be the most appropriate candidate to move by using a powered stand-assist device? A comatose client who is being taken for x-rays An alert client after knee replacement surgery who is being assisted to ambulate An obese client who has Alzheimer's disease and is being escorted to the shower room A car accident victim with fractures in both legs who is being moved to another room

An alert client after knee replacement surgery who is being assisted to ambulate

Which statement accurately describes a developmental consideration when assessing skin integrity of clients? In children younger than 2 years, the skin is thicker and stronger than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. A child's skin becomes increasingly at risk for injury and infection. In the older adult, circulation and collagen formation are increased.

An infant's skin and mucous membranes are injured easily and are subject to infection.

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? -Assessing -Diagnosing -Planning -Implementing

Assessing

A college student 20 years of age is preparing for a career as a teacher. What need initially influences the decision to establish a career? -Establishing one's own moral philosophy -Demonstrating industry and spirituality -Overcoming low self-esteem -Becoming independent of one's family

Becoming independent of one's family

What are the two major processes involved in the inflammatory phase of wound healing? Bleeding is stimulated, epithelial cells are deposited. Granulation tissue is formed, collagen is deposited. Collagen is remodeled, avascular scar forms. Blood clotting is initiated, WBCs move into the wound.

Blood clotting is initiated, WBCs move into the wound.

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information? -Continue with care; this is a normal fluid intake. -Ask the client to drink more water during the day. -Post a sign limiting fluids to 1,000 mL every 24 hours. -Change the plan of care to include forcing fluids.

Continue with care; this is a normal fluid intake.

A nurse and a client are discussing managed care. The nurse explains that the managed care model was designed for which of the following reasons? -Providing a distinct area of care -Controlling costs while maintaining quality of care -Increasing client satisfaction -Providing an all-RN staff

Controlling costs while maintaining quality of care

In providing nursing care, it is most important to perform which action? -Implementation of physician's orders -Coordination of care with the health care team -Evaluation of client's responses -Administration of prescribed medications

Coordination of care with the health care team

A boy age 4 years is constantly seeking out and exploring new experiences, and repeatedly asking his parents why-type questions. The boy's behavior suggests that he is successfully navigating an important developmental task within the developmental theory of: Erikson Freud Fowler Kohlberg

Erikson

A nurse uses the SBAR method to hand off the communication to the health care team. Which of the following might be listed under the "B" of the acronym? -Mental status -Vital signs -Further testing -Client request

Mental status

A nurse is educating an older woman on how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan? Minimize stress on the wife's joints. Provide exercise for the husband. Increase socialization with neighbors. Maintain self-esteem of the wife.

Minimize stress on the wife's joints.

A nurse is providing oral care to an unconscious client. When planning this intervention, the nurse should prioritize which nursing diagnosis? -Risk for Aspiration -Adult Failure to Thrive -Nausea -Risk for Trauma

Risk for Aspiration

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client? Back of the skull Elbows Sacrum Heels

Sacrum

The parents of a boy 10 years of age are worried about his sleepwalking (somnambulism). What topic should the nurse discuss with the parents? Sleep deprivation Privacy Schoolwork Safety

Safety

A nurse is shaving the facial hair of a client confined to bed. What is a recommended guideline for this procedure? Fill bath basin with cool water. Apply shaving cream approximately 1 inch thick. Shave with the direction of hair growth in downward, short strokes. Do not use aftershave or lotion on area shaved.

Shave with the direction of hair growth in downward, short strokes.

A nurse inspecting a client's pressure injury documents the following: full-thickness tissue loss; visible subcutaneous fat; no bone, tendon, or muscle visible. The nurse should recognize what stage of pressure injury? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3

An individual awakens from a sound sleep in the middle of the night because of abdominal pain. Why does this happen? Stimuli from peripheral organs to the RAS Stimuli to the wake center in the cerebral cortex Messages from chemoreceptors to the brain Messages from baroreceptors to the spinal cord

Stimuli from peripheral organs to the RAS

What is one way in which nurses can help shape health care reform? -Support legislation to improve care. -Refuse to participate in organizations. -Do their job and do it well. -Become a member of a support group.

Support legislation to improve care.

What type of non-pharmacologic pain relief measure uses electrical stimulation to inhibit transmission of painful impulses? TENS acupressure acupuncture hypnosis

TENS

Pet therapy is commonly used in long-term facilities for distraction. If a client is experiencing pain and the pain is temporarily decreased while petting a visiting dog or cat, this is an example of which type of distraction technique? Tactile kinesthetic distraction Visual distraction Auditory distraction Project distraction

Tactile kinesthetic distraction

Nurses evaluate many aspects of the health care delivery system. What is always the primary concern when performing the evaluating step of the nursing process? The nurse The Client The health care system The efficiency of the nursing process

The Client

A client is being transferred from the hospital to a long-term care facility. What will happen to the client's medical record? -Parts of the chart are deleted for confidentiality reasons. -The chart goes with the client to the long-term care facility. -A complete copy of the chart is provided to the client. -The chart remains in the hospital records.

The chart remains in the hospital records.

Which is a correctly written client goal? -The client will eliminate a soft, formed stool. -The client understands what foods are low in sodium. -The client will ambulate 10 ft (3 m) with a walker by October 12. -The client correctly self-administers the morning dose of insulin.

The client will ambulate 10 ft (3 m) with a walker by October 12

An unconscious client is brought to the emergency department. Which assessment should be implemented first? The client's airway should be assessed. The nurse should determine the reason for admission. The nurse should review the client's medications. The client's past medical history is assessed.

The client's airway should be assessed.

A client who has breast cancer is said to be in remission. What does this term signify? The client is experiencing symptoms of the disease. The client has end-stage cancer. The client is experiencing unremitting pain. The disease is present but the client is not experiencing symptoms.

The disease is present but the client is not experiencing symptoms.

A nurse is sitting near a client while conducting a health history. The client keeps edging away from the nurse. What might this mean in terms of personal space? -The nurse is in the client's personal space. -The client has concerns about the questions. -The nurse is outside the client's personal space. -The client does not like the nurse.

The nurse is in the client's personal space.

According to Erikson, normal adolescent behavior includes trying on new roles and possibly even rebelling. What is the purpose of this behavior in adolescents? To gain autonomy To avoid inferiority To establish a sense of identity To establish a sense of security

To establish a sense of identity

A nurse tells a client, "Aren't you going to get out of bed or are you just going to sleep all day and night?" This is an example of which barrier to communication? -Using probing questions -Using comments that give advice -Using judgmental or belittling language -Using leading questions

Using judgmental or belittling language

A client has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain will predominate? Psychogenic pain Neuropathic pain Cutaneous pain Visceral pain

Visceral pain

Which client would be classified as having chronic pain? a client with rheumatoid arthritis a client with pneumonia a client with controlled hypertension a client with the flu

a client with rheumatoid arthritis

What is the most accurate definition of a wound? a disruption in normal skin and tissue integrity a change in the function of internal organs any injury that results in changes in nervous tissue any trauma resulting in serious damage and pain

a disruption in normal skin and tissue integrity

Which individual is likely to require more hours of sleep? a person 75 years of age a person 43 years of age a person 25 years of age a person 15 years of age

a person 15 years of age

What is the term used to describe a pharmaceutical agent that relieves pain? antacid antihistamine analgesic antibiotic

analgesic

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy? -lipids, vitamins, and minerals -vitamins, minerals, and water -carbohydrates, protein, and lipids -carbohydrates, protein, and water

carbohydrates, protein, and lipids

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? -complete -focused -general -time-lapsed

focused

What is the goal of nurses who provide home health care? -minimizing the manifestations of disease processes -helping clients achieve maximum independence and health -encouraging clients' dependence on family members -collaborating with other health care providers and services

helping clients achieve maximum independence and health

Which expected outcome demonstrates the effectiveness of a plan of care to promote rest and sleep? verbalizes inability to sleep without medications continues to read in bed for hours each night identifies factors that interfere with normal sleep pattern reports minimal improvement in quality of rest and sleep

identifies factors that interfere with normal sleep pattern

Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as: assessment of oneself. learning from mistakes. promoting the nurse's self-esteem. reflective practice.

reflective practice.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? friction necrosis of tissue ischemia shearing force

shearing force

A student nurse studying anatomy and physiology learns that the largest organ of the body is the: heart. lungs. skin. intestines.

skin

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides . The nurse informs the group that back stress and injury can be prevented by: spreading the feet shoulder-width apart to broaden the base of support. using the strength of the back muscles during strenuous activities. holding the object that you are lifting/moving away from the body. pulling equipment, rather than pushing it, when possible.

spreading the feet shoulder-width apart to broaden the base of support.

The nurse is preparing to move a client up in bed with the assistance of another nurse. In what position would the nurse place the client, if tolerated? reverse Trendelenburg supine sitting semi-folwers

supine

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will: terminate the plan of care. modify the plan of care. continue the plan of care. reevaluate the plan of care.

terminate the plan of care.

Before a long-term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? none; they should be placed in saline to increase comfort when replaced in the mouth to prevent drying and warping of plastic to ensure the dentures are not thrown away

to prevent drying and warping of plastic

A nurse tells a client that she will come back in 10 minutes to reassess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing? -Empathy -Closure -Trust -Sympathy

trust

When documenting subjective data, the nurse should: use the client's own words placed in quotation marks. paraphrase the information stated by the client. validate the information with the client's family prior to documentation. record the information using nonspecific words

use the client's own words placed in quotation marks.

Why is communication important to the "assessment" step of the nursing process? -Written information is rarely used in assessment. -Assessing is primarily focused on physical findings. -Assessing involves only nonverbal cues. -The major focus of assessing is to gather information.

-The major focus of assessing is to gather information.

Which phrase best describes continuity of care? -facilitating transition between settings -focusing on acute care in the hospital -providing single-episode care services -serving the needs of children

-facilitating transition between settings

The nurse working in the hospital understands the changes that have resulted in shorter hospital stays, with a focus on acute care needs of the client. Which factors influence shorter hospital stays? Select all that apply. -federal regulations for health care reimbursement policies -Clients realize that longer stays result in infections and other problems. -increased emphasis on preventive care -improvement in treatment of illness

-federal regulations for health care reimbursement policies -increased emphasis on preventive care -improvement in treatment of illness

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? the client's ability to assist the client's body weight the client's cognitive status the client's age

the client's ability to assist

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made? the pubic area for growth of hair the head for nits on hair shafts the nails for evidence of cleanliness the body for evidence of abuse

the head for nits on hair shafts

Of the following individuals, who can best determine the experience of pain? the person who has the pain the person's immediate family the nurse caring for the client the physician diagnosing the cause

the person who has the pain

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? taking medications as prescribed proper intake of food and fluids thorough hand hygiene adequate sleep and rest

thorough hand hygiene

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? to gather data about a specific and current health problem to identify life-threatening problems that require immediate attention to compare and contrast current health status to baseline data to establish a database to identify problems and strengths

to establish a database to identify problems and strengths

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? to identify a life-threatening problem to establish a database for medical care to practice respiratory assessment skills to facilitate the resident's ability to breathe

to identify a life-threatening problem

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? "Do you have a family history of chest problems?" "Why don't you use a laxative every night?" "Do you take anything to help your constipation?" "Everyone who ages has bowel problems."

"Do you take anything to help your constipation?"

A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the client's difficult sleeping? (Select all that apply). "Does your lack of sleep interfere with your ability to function during the day?" "Do you feel confused in the late afternoon?" "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" "Tell me about any personal stress you aware experiencing."

"Does your lack of sleep interfere with your ability to function during the day?" "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" "Tell me about any personal stress you aware experiencing."

A middle-age client is reporting acute joint pain to a nurse who is assessing the client's pain in a clinic. Which question related to pain assessment should the nurse ask the client? "Does your diet include red meat and poultry products?" "Does your pain level change after taking medications?" "Are your family members aware of your pain?" "Have you thought of the effects of your condition on your family?"

"Does your pain level change after taking medications?"

Which misconception is common in clients in pain? "I will get addicted to pain medications." "I need to ask for pain medications." "The nurses are here to help relieve the pain." "I do not have to fight the pain without help."

"I will get addicted to pain medications."

A client is scheduled to be fitted with a prosthesis following the loss of the nondominant hand after a traumatic injury. Nurses have documented an outcome which states "After attending multiple educational sessions, the client will demonstrate correct technique for applying the prosthesis." Which statement by the client would indicate a need to revise the plan of care? -"I'm not interested in wearing an artificial hand." -"People are going to look at me when I wear this thing." -"This doesn't look like my other hand." -"I don't understand the technology that's used in this artificial hand."

"I'm not interested in wearing an artificial hand."

A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client? "Only take morphine when you have the most severe pain." "Increase fluids and high-fiber foods, and use a mild laxative." "Administer an enema to yourself every third day." "Constipation is nothing to worry about; take your medicine."

"Increase fluids and high-fiber foods, and use a mild laxative."

A staff nurse asks a student, "Why in the world are you studying nursing theory?" How would the student best respond? -"It helps explain how nursing knowledge and practice improves patient care." -"I think it explains how we should collaborate with others." -"We do it so we know more than your generation did." -"Our school requires we take it before we can graduate."

"It helps explain how nursing knowledge and practice improves patient care."

A client in his 40s has asked the nurse how much sleep he should be getting in order to maximize his health and well-being. How should the nurse respond? "Most adults need between 7 and 9 hours, but everyone is different." "It's important to get a minimum of 8 hours sleep each night." "More sleep equals better health, so the more sleep you can fit into your schedule, the better." "Sleep needs depend a lot on age, and at your age, 6 to 7 hours usually suffice."

"Most adults need between 7 and 9 hours, but everyone is different."

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which statement by the nurse would recognize the client's value as an individual? "Can you tell me how long your father has been this way?" "Sarah, I have to go and read your father's old charts before we talk." "Mr. Koeppe, tell me what you do to take care of yourself." Mr. Koeppe, I know you can't answer my questions, but it's okay.

"Mr. Koeppe, tell me what you do to take care of yourself."

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in obtaining information about personal hygiene? "Perhaps you don't recognize your bad body odor." "You must eat a lot of greasy foods to have this acne." "Tell me about what you do to take care of your skin." "Why do you only take a bath once a week?"

"Tell me about what you do to take care of your skin."

A client who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return? "Oh, that is all in your mind. Just forget it." "That is called phantom pain, and it is not unusual." "Well, that is really strange. I will notify the doctor." "I think it might be good to refer you to a psychiatrist."

"That is called phantom pain, and it is not unusual."

A mother calls the nurse practitioner to say, "I don't know what is wrong with my baby. He cried all night and kept pulling at his ear." How would the nurse respond? "Oh, he probably was just hungry and wet. Did you feed him?" "Babies at that age cry at night. Think nothing of it." "That means his ear hurt. Bring him in to be checked." "That probably means he had a tummy ache. How is he now?"

"That means his ear hurt. Bring him in to be checked."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? "My leg hurts so bad. I can't stand it." "Appears anxious and frightened." "I am so sick; I am about to throw up." "Unable to palpate femoral pulse in left leg."

"Unable to palpate femoral pulse in left leg."

A man is scheduled for hospital outpatient surgery. He tells the nurse, "I don't know what that word, outpatient, means." How would the nurse respond? -"You will have surgery and go home that same day." -"It means the surgeon will come to your home to do the surgery." -"It means you will have surgery in the hospital and stay for 2 days." -"Why would you ask such a question? Don't worry about it."

"You will have surgery and go home that same day."

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct? "needs nasal oxygen to improve breathing" "cough related to ineffective airway clearance" "ineffective airway clearance related to thick mucus" "refuses to cough and expectorate thick mucus"

"ineffective airway clearance related to thick mucus"

The home health nurse is providing care to a number of clients. Which client assessed by the nurse will require hospitalization related to complications associated with the feet? Select all that apply. - The client with peripheral vascular disease -The client who has osteoporosis -The client who has asthma -The client experiencing diabetes mellitus

- The client with peripheral vascular disease -The client experiencing diabetes mellitus

Which is an example of a closed-ended question or statement? -"How did that make you feel?" -"Did you take those drugs?" -"What medications do you take at home?" -"Describe the type of pain you have."

-"Did you take those drugs?"

Which question or statement would be appropriate in eliciting further information when conducting a health history interview? -"Why didn't you go to the doctor when you began to have this pain?" -"Are you feeling better now than you did during the night?" -"Tell me more about what caused your pain." -"If I were you, I would not wait to get help next time."

-"Tell me more about what caused your pain."

The staff at a long-term care facility have made minimal effort to secure a shared room for a couple in their late 80s, who have been married for several decades. The manager states, "I'm sure that bedroom activity is the last thing on their mind these days." How should the nurse best respond to the manager's characterization of sexuality in older adults? -"They might not be as active as in years past, but sexuality is still important for older people." -"Their sexual activity has probably stopped by now, but they still need companionship." -"It's actually a myth that older adults have sex less often than younger adults." -"There's no reason that we should assume they're less interested than when they first got married."

-"They might not be as active as in years past, but sexuality is still important for older people."

The nurse is visiting with the mother of a child age 20 months. The mother reports concern about the frequency of the toddler's loud outbursts of temper and saying "no." The nurse recalls Erikson's theory about negativism and tells the mother which of the following? -"This is normal and has to do with learning right from wrong." -"This has to do with regression and is a response to stress." -"This is unacceptable and you must provide appropriate discipline." -"This is normal, and this is how your child tries to exert control over his environment."

-"This is normal, and this is how your child tries to exert control over his environment."

A registered nurse is overseeing the care of numerous clients. Which health care needs can the nurse safely delegate to unlicensed assistive personnel (UAP)? -A teenager has suffered a soft tissue injury to his shoulder in a football game and requires a sling. -A postsurgical client needs to be taught range-of-motion (ROM) exercises prior to being discharged. -A client must be transferred from a chair back to her bed using a powered full-body lift. -A client with skeletal traction requires pin-site care.

-A client must be transferred from a chair back to her bed using a powered full-body lift.

What is an example of nonverbal communication? -A client asks the nurse for a pain shot. -A nurse presents information to a group of clients. -A client's face is contorted with pain. -A nurse says "I am going to help you walk now."

-A client's face is contorted with pain.

For which of the following clients should the nurse anticipate the need for a pureed diet? -A man with dementia who is unable to follow instructions -A man whose stroke has resulted in difficulty swallowing -An obese woman after bariatric surgery -A woman who has required gallbladder surgery

-A man whose stroke has resulted in difficulty swallowing

What is the result of increasing health care costs on hospital admissions? -The length of hospital stay has decreased. -There is an increase in hospital admissions. -Fewer surgeries are being performed at ambulatory centers. -The number of surgeries have decreased.

-The length of hospital stay has decreased.

After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner program. This nurse has been attracted to the program by the potential to provide primary care for clients after graduation, an opportunity that is most likely to exist in which of the following settings? -A long-term care facility -A rural health center -A community hospital -A university hospital

-A rural health center

The nurse is providing education on childhood safety to a group of parents. The nurse responds to a question from one of the parents asking about the major causes of death in toddlers. What would the nurse say are the major causes of death in toddlers? Select all that apply. -Accidents -Motor vehicle crashes -Drowning -Childhood diseases -Infections

-Accidents -Motor vehicle crashes -Drowning

A nurse applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply. -Apply a bath blanket over the aquathermia pad. -Use tap water, filling it to the fill mark. -Leave aquathermia pad in place for as long as the client wants it. -Assess skin and pain level at baseline and ongoing. -Check the water level in the aquathermia unit periodically.

-Apply a bath blanket over the aquathermia pad. -Assess skin and pain level at baseline and ongoing. -Check the water level in the aquathermia unit periodically.

Which of the following should the nurse first consider when attempting to become culturally competent? -Avoid labeling any clients -Listen and understand the client's response -Assess own personal cultural beliefs and prejudices -Treat the client with respect and dignity

-Assess own personal cultural beliefs and prejudices

The older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What actions will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply. -Assess the client's skin prior to application of heat. -Ensure the aquathermia unit contains water to the appropriate level. -Apply the heating pad to the client's back for intervals of 1 hour. -Instruct the client to lie on the pad to keep the pad in its proper position. -Set the temperature on the unit to the maximum heat setting.

-Assess the client's skin prior to application of heat. -Ensure the aquathermia unit contains water to the appropriate level.

The client is an older adult with osteoporosis. The client fractured a hip following a fall and had surgery. The nurse identified interventions based on the client's needs and outcomes. Which actions are nurse-initiated interventions? Select all that apply. -Assess vital signs and oxygen saturation every 4 hours. -Instruct the client about foods high in calcium. -Administer morphine 2 mg IV for pain reported as 6 to 10 on 10-point scale. -Assess surgical wound daily for redness, inflammation, and drainage.

-Assess vital signs and oxygen saturation every 4 hours. -Instruct the client about foods high in calcium. -Assess surgical wound daily for redness, inflammation, and drainage.

The nurse is working in a practice that sees clients of all age groups and developmental levels. What principles about growth and development does the nurse include in assessments of clients and planned interventions? Select all that apply. -Behaviors of previous developmental stages may be present. -Regression occurs when clients are ill. -Clients may exhibit behaviors of the next developmental stage. -Each client develops exactly to a set pattern. -There are definite beginning and ending points in each developmental stage. -Environmental and cultural influences affect psychosocial development.

-Behaviors of previous developmental stages may be present. -Regression occurs when clients are ill. -Clients may exhibit behaviors of the next developmental stage. -Environmental and cultural influences affect psychosocial development.

What is the primary focus of communication during the nurse-client relationship? -Nursing activity to be performed -Client and client needs -Time available to the nurse -Environment of the client

-Client and client needs

The client who has an immobilizer on the arm reports shortness of breath following ambulation to the bathroom. The nurse notes the client's pulse increased from 82 to 124 beats per minute, respirations increased from 16 to 24 breaths per minute, and blood pressure is 90/50 mm Hg. The nurse makes the nursing diagnosis of Activity Intolerance. What are the client's defining characteristics for this diagnosis? Select all that apply. -Client reports of shortness of breath -Increase in pulse rate -Increase in respiratory rate -Decrease in blood pressure -Limited range of motion

-Client reports of shortness of breath -Increase in pulse rate -Increase in respiratory rate -Decrease in blood pressure

Which activities does the nurse engage in during the evaluation phase? Select all that apply. -Collects data to determine whether desired outcomes are met -Assesses the effectiveness of planned strategies -Adjusts the time frame to achieve the desired outcomes -Involves the client and family in formulating desired outcomes -Initiates activities to achieve the desired outcomes

-Collects data to determine whether desired outcomes are met -Assesses the effectiveness of planned strategies -Adjusts the time frame to achieve the desired outcomes

Which statement is true of factors that influence communication? -Nurses provide the same information to all clients, regardless of age. -Distance from a client has little effect on a nurse's message. -Men and women have similar communication styles. -Culture and lifestyle influence the communication process.

-Culture and lifestyle influence the communication process.

Middle adults tend to gain weight. What is a reason for the middle adult to gain weight? -Decreased physical activity -Changes in hormones -Loss of satisfactory roles -Satisfaction with one's life

-Decreased physical activity

The nurse is discharging a client from the hospital following orthopedic surgery with a referral for home health. What action by the nurse would be performed during the entry phase of the home visit for this client? Select all that apply. -Determine the treatment prescribed for the client -Negotiate time for the next home visit -Make an initial and thorough assessment -Develop rapport with the client and family -Collect client information

-Negotiate time for the next home visit -Make an initial and thorough assessment -Develop rapport with the client and family

Medicare will no longer reimburse the hospital for certain adverse events, including in-hospital falls. Fall prevention is a major part of nursing and risk management. In order to reduce the risk of falling, the nurse must do which of the following? Select all that apply. -Ensure that the client wears his prescription glasses when up. -Always assist every client with ambulation. -Post signs to alert staff to the client at high risk for falls. -Assess the client's fatigue level. -Monitor gait and balance.

-Ensure that the client wears his prescription glasses when up. -Post signs to alert staff to the client at high risk for falls. -Assess the client's fatigue level. -Monitor gait and balance

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside, where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? -Environment -Personnel -Equipment -Client and visitors

-Environment

Before developing a procedure, a nurse reviews all current research-based literature on insertion of a nasogastric tube. What type of nursing will be practiced based on this review? -Institutional practice -Evidence-based practice -Factual-based nursing -Authoritative nursing

-Evidence-based practice

Which of the following phrases best describes hospitals today? -Primary care centers -Focus on chronic illnesses -Focus on acute care needs -Voluntary agencies

-Focus on acute care needs

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? -Full-thickness skin loss -Skin pallor -Blister formation -Eschar formation

-Full-thickness skin loss

Which factors increase basal metabolic rate (BMR)? Select all that apply. -Growth -Aging -Prolonged fasting -Fever -Infections

-Growth -Fever -Infections

A nurse explains to a client that following her knee surgery, a continuous passive motion machine will be used to promote healing. What benefits of using this machine should the nurse teach the client? Select all that apply. -Improved healing of a fracture -Increased rate of joint healing -Healing a hematoma -Improving circulation -Improving range of motion -Stabilizing respiratory rate

-Increased rate of joint healing -Improving circulation -Improving range of motion

The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle baby powder in the perineal area. Which of the following actions is correct? -Inform the client that baby powder is not used because it may become a medium for bacterial growth. -Carefully apply baby powder to skin folds only. -Pour a small amount of powder into the hand and gently pat the perineal area while avoiding aerosolization of the powder. -Apply a generous amount of baby powder to all areas where skin touches skin.

-Inform the client that baby powder is not used because it may become a medium for bacterial growth.

A nurse assists a client to clean his dentures. Which action should the nurse perform? -Apply force with a 4 × 4 gauze to grasp upper denture plate to remove it. -Pull the bottom denture straight up to remove it from the client's mouth. -Place both dentures in a clean sink to clean them thoroughly. -Insert the upper denture in the client's mouth and press firmly, then insert the lower denture.

-Insert the upper denture in the client's mouth and press firmly, then insert the lower denture

An experienced ICU nurse is mentoring a student. The nurse tells the student, "I think something is going wrong with your client." What type of clinical decision making is the experienced nurse demonstrating? -Trial-and-error problem solving -Intuitive thinking -Scientific problem solving -Methodical reasoning

-Intuitive thinking

A client has been prescribed a clear liquid diet. What food or fluids will be served? -Jell-O, carbonated beverages, apple juice. -Hot cereals, ice cream, chocolate milk -Milk, frozen dessert, egg substitutes -High-calorie, high-protein supplements

-Jell-O, carbonated beverages, apple juice

A nurse touches a client's hand to indicate caring and support. What channel of communication is the nurse using? -Auditory -Visual -Olfactory -Kinesthetic

-Kinesthetic

The nurse is visiting an older adult client in the home. The nurse assesses the client has been losing weight over the past several weeks. What additional assessments would the nurse make? Select all that apply. -Weight when the client was 25 years of age -Kitchen cupboards and refrigerator -Eating patterns and food choices -Mouth for properly fitting dentures -Ability to swallow food and fluids

-Kitchen cupboards and refrigerator -Eating patterns and food choices -Mouth for properly fitting dentures -Ability to swallow food and fluids

What is the ultimate goal of expanding nursing knowledge through nursing research? -Become full-fledged partners with other care providers -Learn improved ways to promote and maintain health -Apply knowledge to become independent practitioners -Develop technology to provide hands-on nursing care

-Learn improved ways to promote and maintain health

The client states to the nurse, "I don't know what they're doing for me. I see so many doctors. One says one thing, another says something else." What are appropriate actions by the nurse to assist the client in understanding the plan of care? Select all that apply. -Make rounds with health care professionals when visiting the client. -Restate recommendations in simple terms that the client will understand. -Read the consultation and progress notes written by health care professionals. -Ask visiting friends of the client to explain the plan of care to the client. -Assist the client to identify and write questions for the health care professionals.

-Make rounds with health care professionals when visiting the client. -Restate recommendations in simple terms that the client will understand. -Read the consultation and progress notes written by health care professionals. -Assist the client to identify and write questions for the health care professionals.

What role will the nurse play in transferring a client to a long-term care facility? -Inform the client that transferring should be a stress-free situation. -Arrange for the client's belongings to remain at the hospital until discharge from the long-term care facility. -Provide a verbal report to the nurse at the long-term care facility on the client, the hospital care, and the client's current condition. -Assure that the client's original chart accompanies the client.

-Provide a verbal report to the nurse at the long-term care facility on the client, the hospital care, and the client's current condition.

While providing hygiene care to a confused older adult client diagnosed with Alzheimer's disease, you are called to the nursing station. To ensure patient safety you must do what? -Cover him with a blanket for warmth. -Put side rails up before leaving the client. -Ask a family member to stay with him. -Reattach the restraints.

-Put side rails up before leaving the client.

A student nurse reading a client's chart notes that the physician has documented an adolescent as prepubescent. What does the term prepubescent mean? -Reproductive organs do not yet produce ova and sperm -Adult secondary sex characteristics are present -Ova and sperm are produced by the reproductive organs -Active sexual behavior has been initiated

-Reproductive organs do not yet produce ova and sperm

The nurse had a back injury on the job and is being evaluated. What activities placed the nurse at risk for the injury? Select all that apply. -Standing most of the shift. -Lifting a client after a recent and previous back injury. -Spreading the legs to provide a wide base of support. -Raising the bed to a comfortable height when changing a client's dressing. -Assisting a confused client from the bed to the wheelchair for discharge.

-Standing most of the shift. - Lifting a client after a recent and previous back injury. -Assisting a confused client from the bed to the wheelchair for discharge.

The nurse has completed as assessment of a client who has had difficulty sleeping for more than 3 months. The nurse has diagnosed the client as having the nursing diagnosis Insomnia. What data supports this diagnosis? Select all that apply. -Swelling of the client's eyelids -10 lb (4.5 kg) overweight; an increase of weight noted in the past 3 months -Report of increased energy in the afternoon -Yawning during the assessment interview -Rapid speech when asked questions about sleep history

-Swelling of the client's eyelids -10 lb (4.5 kg) overweight; an increase of weight noted in the past 3 months -Yawning during the assessment interview

The nurse uses the nursing process to provide care to clients. What are the benefits for the clients? Select all that apply. -The client receives care that is evidence based. -Care is individualized for the client. -The nurse collaborates only with other nurses to provide care. -The nurse provides care that is consistent for the client. -Care is specialized and focuses on one main problem of the client.

-The client receives care that is evidence based. -Care is individualized for the client. -The nurse provides care that is consistent for the client.

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply. -The client who has a body mass index (BMI) of 34 -The client who is emaciated -The client who has a temperature of 40° C and is perspiring -The ambulatory client who is recovering from an endoscopic procedure for abdominal pain -The client who is experiencing an allergic reaction and is scratching the skin

-The client who has a body mass index (BMI) of 34 The client who is emaciated -The client who has a temperature of 40° C and is perspiring -The client who is experiencing an allergic reaction and is scratching the skin

The nurse is working with a group of clients. Which of the following clients are at risk for a skin alteration? Select all that apply. -The client who is a roofer and spends a lot of time outdoors participating in sports -The client who has experienced vomiting and diarrhea for several days with a loss of 12 pounds in weight -The client who experienced numbness in the right arm that has resolved after several hours -The client who has paralysis and is unable to move in bed, and the nurse provides turning every 2 hours The client who is newly diagnosed as having diabetes and requires management education of the disease

-The client who is a roofer and spends a lot of time outdoors participating in sports -The client who has experienced vomiting and diarrhea for several days with a loss of 12 pounds in weight -The client who has paralysis and is unable to move in bed, and the nurse provides turning every 2 hours -The client who is newly diagnosed as having diabetes and requires management education of the disease

The nurse is providing care to a group of clients on a medical-surgical unit. Which clients are at an increased risk for problems with the oral cavity? Select all that apply. -The client who is in a coma -An elderly client who is confused -A client who has depression -The client undergoing chemotherapy -The client who is hypertensive

-The client who is in a coma -An elderly client who is confused -A client who has depression -The client undergoing chemotherapy

Which are correctly written client goals? Select all that apply. -The client will identify five low-sodium foods by October 9. -The client will rate pain as a 3 or less on a 10-point scale by 1700 today. -The client will understand the side effects of digoxin. -The client will eat at least 75% of all meals by May 5.

-The client will identify five low-sodium foods by October 9. -The client will rate pain as a 3 or less on a 10-point scale by 1700 today. -The client will eat at least 75% of all meals by May 5.

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply. Restraints may be used to prevent a client from falling if the facility is short-staffed. The client's family must be involved in the decision and care plan. Alternatives to restraints and less restrictive interventions must have been implemented and failed. -The benefit gained from using a restraint must outweigh the known risks for that client. -A physician or licensed independent practitioner must reevaluate and assess the client every 48 hours. -The client's vital signs must be assessed and the medical client must be visually observed every 4 hours.

-The client's family must be involved in the decision and care plan. -Alternatives to restraints and less restrictive interventions must have been implemented and failed. -The benefit gained from using a restraint must outweigh the known risks for that client.

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which action clearly demonstrates assessing? -The nurse bathing the client. -The nurse documenting the incident. -The nurse asking if the client is having pain. -The nurse removing the wash basin.

-The nurse asking if the client is having pain.

What are violations of the nurse's responsibility when using electronic communication? Select all that apply. -When a visitor inquired about a hospitalized client, the nurse, prior to answering, closed the computer monitor screen that was open to client data and could be seen by the visitor. -The nurse posted on a social media site, "Psychotic mean patient in Room 502 hit me," and, within 5 minutes, deleted the post. -The nurse accidentally texted a message about a new prescription for HIV medications to the wrong phone number. -The nurse sent an email message to a client informing the client how to access a secured website to view the lab report. -The nurse wrote on a social media site, "Had a bad day at work. Need some support. Call me."

-The nurse posted on a social media site, "Psychotic mean patient in Room 502 hit me," and, within 5 minutes, deleted the post. -The nurse accidentally texted a message about a new prescription for HIV medications to the wrong phone number.

A client has suddenly become very ill and needs to be transferred in the intensive care unit (ICU). What action by the nurse would ensure continuity of care? -The nurse would ask the family to provide additional information. -The nurse ensures the client's chart and his belongings are moved with the client. -The nurse writes the information for the nursing assistant to give to the ICU nurse. -The nurse provides an SBAR report to the nurse in the ICU.

-The nurse provides an SBAR report to the nurse in the ICU. When a client is transferred to another unit, the nurse in the original unit gives a verbal report about the client to the nurse in the new area. Continuity of care is not ensured by moving the chart and belongings, delegating responsibility to a nursing assistant, or asking the family to provide additional information.

Why are the developmental theories important to nursing practice? -They describe how parts work together as a system. -They define human adaptation to others and to the environment -They outline the process of human growth and development. -They explain the importance of legal and ethical care.

-They outline the process of human growth and development.

The emergency department nurse is caring for an infant age 2 months who was brought in by a hired caregiver. The infant is underweight and looks uncared for. The caregiver reports that the mother of the infant is unreliable and may be using drugs; the infant is often unclean and hungry when dropped off at the caregiver's home. The infant has diaper rash and a weak cry. If this situation is not remedied, what will this infant have difficulty achieving, according to Erikson's developmental theory? -Autonomy -Trust -Initiative -Identity

-Trust

The nurse is educating parents about actions that may increase safety for their 14-month-old child. What child safety information would the nurse include in the teaching of the parents? Select all that apply. -Use an approved car seat and install it correctly -Keep medications locked away. -Do not swing your child by his arms or legs. -Plastic bags should be kept out of reach. -Teach your child to chew small food well.

-Use an approved car seat and install it correctly -Keep medications locked away. -Do not swing your child by his arms or legs. -Plastic bags should be kept out of reach.

A nurse is providing oral care for a client who has been in a coma for 2 weeks. Which of the following problems (etiologies) should guide the nurse in developing a nursing care plan? -A client who is in a coma has an exaggerated gag reflex that creates a risk for aspiration. -White patches may be present that indicate a fungal infection called thrush. -Oral tissue and structure integrity are not generally affected by a client's cognitive level. -A client who is comatose is at high risk for developing bleeding gums.

-White patches may be present that indicate a fungal infection called thrush.

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record? -a clean separation of skin and tissue with a smooth, even edge -a separation of skin and tissue in which the edges are torn and irregular -a wound in which the surface layers of skin are scraped away -a shallow crater in which skin or mucous membrane is missing

-a separation of skin and tissue in which the edges are torn and irregular

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed? client restrictions client age client food preferences client restraints

-client restrictions

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is: -legal representation to care. -assisting in organization of care. -noting the client's response to interventions. -conveying information.

-conveying information.

What population do hospice nurses provide with care? -dying persons and their loved ones -children with chronic illnesses -older adults requiring long-term care -those requiring care to improve health

-dying persons and their loved ones

A nurse is repositioning a client who has physical limitations due to recent back surgery. The nurse should turn the client in bed every: -hour. -two hours. -four hours. -shift.

2

The nurse and an unlicensed assistive personnel (UAP) are preparing to move a client up in bed. What is the order of the steps for moving the client to the head of the bed? A. Adjust the head of the bed to a flat position. B. Remove all pillows from under the client. C. If not present, place a friction-reducing sheet under the client. D. Ask the client to bend legs and fold arms across the chest. E. Grasp the friction-reducing sheet close to the client's body. F. Move the client in the bed on the count of three.

A,B,C,D,E,F

When teaching range-of-motion exercises to a dependent client's caregiver, a nurse moves the arm of the client laterally to an upright position above the client's head, and then returns it to the original position. What anatomic movements has the nurse utilized during this exercise? Select all that apply. Abduction Rotation Extension Flexion Adduction

Abduction Adduction

A teenager states, "Old people are different. They don't need the same things that young people do." What is this statement an example of? Ageism Knowledge Racism Indifference

Ageism

A school nurse is concerned about the almost skeletal appearance of one of the high school students. Although all of the following nutritional problems can occur in adolescents, which one is most often associated with a negative self-concept? Anorexia nervosa Fad dieting Obesity Eating fast foods

Anorexia nervosa

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? Neither appendicitis nor acute pain Both appendicitis and acute pain Appendicitis Acute pain

Appendicitis

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would this outcome be evaluated? Ask the client to verbally repeat the steps of the injection. Ask the client to demonstrate self-injection of insulin. Ask family members how much trouble the client is having with injections. Ask the client how comfortable he is with injections.

Ask the client to demonstrate self-injection of insulin.

A nurse is planning to use a healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? Tell the client the goal of the therapy is to promote healing. Ask whether the client is comfortable with using prayer. Encourage the client to actively participate for best results. Instruct the client to relax during the therapy.

Ask whether the client is comfortable with using prayer.

An older adult lives in a facility that provides, housing, group meals, personal care and support, social activities, and minimal health care services. What type of facility does this describe? -Assisted living -Accessory apartment -Home modification -Nursing home

Assisted living

In general, what is the focus of care for nurses who work with older adults? -Referring clients for needed emotional support -Providing all necessary physical care -Assisting clients to function as independently as possible -Establishing goals and expected outcomes for the client

Assisting clients to function as independently as possible

How may a nurse demonstrate cultural competence when responding to clients in pain? Treat every client exactly the same, regardless of culture. Be knowledgeable and skilled in medication administration. Know the action and side effects of all pain medications. Avoid stereotypical responses to pain in clients.

Avoid stereotypical responses to pain in clients.

A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which are classes of nutrients that supply this energy? Select all that apply. Minerals Carbohydrates Vitamins Proteins Fats

Carbohydrates Proteins Fats

A nurse is caring for a client with excessive abdominal fat. The nurse should inform the client about a risk associated with excessive abdominal fat. What is that risk? -Cachexia -Emaciation -Anorexia -Cardiovascular disease

Cardiovascular disease

A nurse educates adults in preventive measures to avoid problems of middle adult years. Which of the following are the major health problems during the middle adult years? -Upper respiratory infections, fractures -Sexually transmitted diseases, drug abuse -Communicable diseases, dementia -Cardiovascular disease, cancer

Cardiovascular disease, cancer

A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress, The nurse should suspect the tea includes which of the following ingredients? Chamomile Ginseng Ginger Echinanea

Chamomile

A nurse is discussing sleep problems with a client. What type of foods should the nurse recommend to promote sleep? One cup of hot chocolate Three glasses of red wine Cheese and crackers One cup of peanuts

Cheese and crackers

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? Cleanse to remove secretions from less-soiled to more-soiled areas. Cleanse using a cotton cloth and warm water. Use tissue rolls to clean the client's perineal area. Provide the client with a bed pan or a jar to collect the urine.

Cleanse to remove secretions from less-soiled to more-soiled areas.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. What is an example of a long-term goal? Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. Within 1 hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.

Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? Cognitive skill Technical skill Interpersonal skill Ethical/legal skill

Cognitive skill

Nurses who are employed in home care have a variety of responsibilities. Which of the following is one of those responsibilities? -Provide all care and services. -Advise clients on financial matters. -Maintain a clean home environment. -Collaborate with other care providers.

Collaborate with other care providers.

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next? Interpret and summarize findings. Document his or her judgment. Collect data about patient responses. Formulate a new plan of care.

Collect data about patient responses.

Of the following data, what type would be collected during a physical assessment? Color, moisture, and temperature of the skin Type, amount, and duration of pain Foods eaten that cause nausea Specific allergies resulting in itching

Color, moisture, and temperature of the skin

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic, isometric, and isokinetic exercises into the class. Which activity is an isometric exercise? Sitting in a chair with a low weight on the ankle and lifting the knee to the seat level of the chair Walking single file at a rate of 3 miles (5 km) per hour around a race track two times Contracting the gluteal muscles while holding a simple yoga pose Carrying an air-filled ball while wading through the water across the width of a pool

Contracting the gluteal muscles while holding a simple yoga pose

The nurse and an unlicensed assistive personnel (UAP) are moving the client to the edge of the bed with a friction-reducing sheet to facilitate turning the client to his right side. Which positioning instruction would the nurse tell the client? Cross your arms over your chest and keep your legs straight. Cross your arms over your the chest, and place your left leg over your right leg. Keep your arms at your side, and cross your right leg over your left leg. Keep your arms folded loosely at the abdomen and your legs straight.

Cross your arms over your the chest, and place your left leg over your right leg.

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? Remove ingrown toenails. Cut the nail straight across. Protect the foot from blisters. Soak the foot in witch hazel.

Cut the nail straight across.

A nurse has developed a plan of care for a client that recently had a spouse die. A nursing diagnosis of: Risk for Loneliness was assigned. When evaluating the plan, the client tells the nurse new information about an active social life and there is satisfaction with social activities. What would the nurse do next? Continue with the plan. Delete the nursing diagnosis. Tell the client he is lonely. Adjust the time criteria.

Delete the nursing diagnosis.

A nurse is providing oral care to a client with dentures. What action would the nurse perform first? Assess the mouth and gums. Don gloves. Wash the client's face. Apply lubricant.

Don gloves.

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. Draw the shape of the wound with a description. Measure the wound's length and width. Use a dry sterile applicator at a 90-degree angle to measure depth. Document tunneling by estimating the extend of the tunneling. Assess color, drainage, presence of pain, or complications.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications.

What independent nursing intervention can be implemented to stimulate appetite? -Assess manifestations of malnutrition. -Recommend dietary supplements. -Administer prescribed medications. -Encourage or provide oral care.

Encourage or provide oral care.

A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain? Narcotics Sedatives A-delta fibers Endorphins

Endorphins

A nurse writing a postsurgical client's care plan has included ambulation several times daily. What is the best rationale for this intervention? Increased muscle mass Decreased blood pressure Improved psychological well-being Enhanced circulation

Enhanced circulation

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? Apply restraints to the hands or wrists, never to the ankles. Ensure that two fingers can be inserted between the restraint and the client's extremity. Use a quick-release knot to tie the restraint to the side rail. Remove the restraint at least every 4 hours, or according to facility policy.

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A nurse recently attended a conference which focused on management of acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information from the conference. Which resource is the nurse utilizing to enhance practice? Evidence-based practice Clinical experience Current medical practice Ethical and legal guides to practice

Evidence-based practice

A middle-age adult man has just started an exercise program. What would the nurse teach him about timing of exercise and sleep? Exercising immediately before bedtime enhances ability to sleep. Exercising within 2 hours of bedtime can hinder ability to sleep. The time of day does not matter; exercise facilitates sleep. The fatigue from exercise may be a hindrance to sleep.

Exercising within 2 hours of bedtime can hinder ability to sleep.

A nurse is caring for a client who is visually impaired. Which of the following is a recommended guideline for communication with this client? -Keep communication simple and concrete -Explain reason for touching client before doing so. -Ease into the room without acknowledging presence until the client can be touched. -Speak in a louder tone of voice to make up for lack of visual cues.

Explain reason for touching client before doing so.

A nurse uses proper body mechanics to move a client up in bed. Which action is a guideline for using these techniques properly? -Face the direction of movement. -Twist body at the waist when lifting. -Keep body weight higher than center of gravity. -Keep feet together to provide a base of support.

Face the direction of movement.

A nurse is making a bed occupied by a client. What is a recommended step for this procedure? Nurse should lower side rail on the side opposite to her. Discard soiled linen onto the floor. Fan-fold soiled linens as close to client as possible. Place the drawsheet under the client's knees.

Fan-fold soiled linens as close to client as possible.

The client has a wound on the ankle that the nurse has cleansed and dressed The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage? Circular turn only Spiral turn Figure-of-eight turn Recurrent bandaging

Figure-of-eight turn

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? Fowler's low-Fowler's protective supine semi-Fowler's

Fowlers

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair? -Have the client sit on the side of the bed for several minutes before moving to the chair. -Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair. -Position a friction-reducing sheet under the client. -Obtain a quad cane for the client to use as a transfer aid.

Have the client sit on the side of the bed for several minutes before moving to the chair.

Which of the following statements accurately describes an aspect of home health care? -Home health care is provided for people of all ages in various settings. -Home health care is designed for people with chronic, not acute illness. -Home health care is setting up a hospital in the home. -Home health care is illness care provided at home.

Home health care is provided for people of all ages in various settings.

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? Human Needs (Maslow) model Functional Health Patterns model Human Response Patterns model Body System model

Human Needs (Maslow) model

A nurse is instructing a client who has a a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify was an indication that the client understands the instructions? "I'll add plenty of carbohydrates to my meals." I'll take a short nap whenever I feel a little sleepy." "I'll make sure I stay warm when I am at my desk at work." "It's okay to drink alcohol as long as I limit it to one drink per day."

I'll take a short nap whenever I feel a little sleepy."

The nursing student is visiting a middle school with an assignment to observe and visit with students while walking around with the school nurse. The nursing student is interested to learn that some students seem to be rebelling against authority figures like teachers and parents. The nursing student recalls that, according to Erikson's theory, this is not abnormal behavior. To which stage of Erikson's theory does this behavior belong? -Autonomy versus shame -Initiative versus guilt -Industry versus inferiority -Identity versus role confusion

Identity versus role confusion

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? To ensure safety, do not allow the client to assist with the transfer. Use assistive devices if either nurse will have to lift more than 60 lb. If the client is in pain, administer analgesics in advance of the transfer. Avoid using handling aids unless absolutely necessary.

If the client is in pain, administer analgesics in advance of the transfer.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? Apply the stockings at night when the client is going to bed. Apply the stockings after the client has been sitting up for an hour. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Avoid the use of powders on the legs before applying stockings.

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? Change position at least once each shift. Implement a turning schedule every 2 hours. Use ring cushions for heels and elbows. Do not turn; use pressure-relieving support surface.

Implement a turning schedule every 2 hours.

When the nurse is administering furosemide 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? Assessment Planning Implementation Evaluation

Implementation

Based on an established plan of care, a nurse turns a client every 2 hours. What part of the nursing process is the nurse using? Assessing Planning Implementing Evaluating

Implementing

Most nutritionists recommend having a proper amount of fiber in the diet. In addition to other benefits, how does fiber affect cholesterol? -Facilitates intake and use of trans fat -Raises blood cholesterol levels -Increases fecal excretion of cholesterol -Decreases fecal excretion of cholesterol

Increases fecal excretion of cholesterol

A nursing student is visiting a third-grade class to observe growth and development in action and does assessments on the children. The nursing student notes the third-grade children are learning to think logically and classify and relate objects and ideas. According to Erikson, what is the developmental stage the children are in? Concrete operational Latency Acceptance of deity Industry versus inferiority

Industry versus inferiority

Then nurse is caring for single, professional woman age 29 years, who was admitted with a severe gall bladder attack. The nurse visits with her and performs an assessment. The client is not married and fears a committed relationship because of a bad experience some years ago. The nurse knows that, according to Erikson's developmental theory, Judith is in danger of which of the following? Stagnation Isolation Inferiority Role confusion

Isolation

Why is acute pain said to be protective in nature? It warns an individual of tissue damage or disease. It enables the person to increase personal strength. As a subjective experience, it serves no purpose. As an objective experience, it aids diagnosis.

It warns an individual of tissue damage or disease.

A nurse has documented that a client has anorexia. What does this term mean? -Vitamin C deficiency -Eating more than daily requirements -Fluid deficit -Lack of appetite

Lack of appetite

A nurse is caring for a client who has been diagnosed with insomnia. Which nursing intervention would help the nurse relieve the client's condition? Maintain a calm and quiet environment free from noise. Administer sedatives as prescribed by the physician. Motivate the client to sleep because it may affect his health. Engage the client in some diversional activities.

Maintain a calm and quiet environment free from noise.

Which client would be at greatest risk for injury to the skin and mucous membranes? infant 10 days old with no health problems adolescent 17 years of age with asthma Man 44 years of age with hemorrhoids Man 77 years of age with diabetes

Man 77 years of age with diabetes

Based on the circadian cycle, the body prepares for sleep at night by decreasing the body temperature and releasing which chemical? Norepinephrine Seratonin Melatonin Dopamine

Melatonin

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? Perform hand hygiene. Insert a swab into the wound at 90 degrees. Measure the width of the wound with a disposable ruler. Assess the condition of the visible wound bed.

Perform hand hygiene.

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? Yes, this helps prevent vaginal odor. Yes, this decreases vaginal secretions. No, douching removes normal bacteria. No, douching may increase secretions

No, douching removes normal bacteria.

A child 2 years of age is hospitalized for a surgical procedure. Although previously all fluids were taken from a cup, the toddler wants a bottle to suck on. The nurse recognizes this behavior as what? Totally unacceptable Proof that the child is sick Abnormal behavior Normal regression

Normal regression

A nursing student is observing in a pediatric clinic. A grandmother brings an infant age 2 months to be seen. The infant has failed to gain the expected amount of weight and looks unwell. The nursing student wonders if this may be a "failure to thrive" baby. Which one of the following has been linked to "failure to thrive" babies? Working mothers Nutritional deprivation Use of day care centers Premature births

Nutritional deprivation

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? Ask the client what precipitates the pain. Question the client about the location of the pain. Offer the client a pain scale to measure his pain. Offer the client a pain scale to measure his pain

Offer the client a pain scale to measure his pain

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which condition is likely affecting the client? Thrombophlebitis Anemia Orthostatic hypotension Bradycardia

Orthostatic hypotension

A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which outcome decision option would the nurse document if the woman has not smoked for 7 months? Outcome partially met Outcome not met Outcome inappropriate Outcome met

Outcome met

Eight hours after spinal surgery a client has not voided. The client is restless and reports abdominal pain. What action would the nurse perform before administering pain medications? Check database for last bowel movement. Auscultate abdomen for bowel sounds. Assess dressing for drainage. Palpate abdomen for distended bladder.

Palpate abdomen for distended bladder.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following? -Paralysis of the legs -Weakness affecting one-half of the body -Paralysis affecting one-half of the body -Paralysis of the legs and arms

Paralysis of the legs

Which of the following research studies would be of most interest to a nurse manager? -Sister Callista Roy's theory on adaptation -Kleinpell and Ferrans' older intensive-care clients -Madeleine Leininger's transcultural nursing theory -Patricia Benner's From Novice to Expert

Patricia Benner's From Novice to Expert

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and yellow exudate can be expressed when the gums are palpated. What condition do these symptoms indicate? Periodontitis Plaque Halitosis Caries

Periodontitis

A nurse is providing care for a client who is in skin traction following multiple trauma. Which action should be included in the client's care plan? Ensure the traction apparatus is not attached to the bed. Check that all knots are tight and are positioned near the pulleys. Place the client in a supine position with the foot of the bed elevated slightly. Place the bed in the lowest position, allowing the weights to touch the floor.

Place the client in a supine position with the foot of the bed elevated slightly.

What activity is carried out during the implementing step of the nursing process? Assessments are made to identify human responses to health problems. Mutual goals are established and desired client outcomes are determined. Planned nursing actions (interventions) are carried out. Desired outcomes are evaluated and, if necessary, the plan is modified.

Planned nursing actions (interventions) are carried out.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? Stand at the top of the bed and have a colleague stand at the bottom of the bed. Place the bed in its lowest position to reduce the client's risk for falls. Position a friction-reducing sheet under the client to facilitate movement. Use back muscles to gently and gradually pull the client to the side.

Position a friction-reducing sheet under the client to facilitate movement.

What is the rationale for using CPAP to treat sleep apnea? Positive air pressure holds the airway open. Negative air pressure holds the airway closed. Delivery of oxygen facilitates respiratory effort. Alternating waves of air stimulate breathing.

Positive air pressure holds the airway open.

The nurse manager in an acute care facility has received client evaluations in which the clients have complained about excessive noise that interfered with their rest. The nurse manager and nursing staff plan to take the following actions. Which action will most assist clients in obtaining rest? Post signs for quiet and turn down hall lights during formal quiet times. Ensure clients are offered prescribed sleeping medications at bedtime. Provide a small carbohydrate snack or juice prior to hours of sleep. Adjust the temperature of the room to 74 °F (23.3 °C) and provide a blanket.

Post signs for quiet and turn down hall lights during formal quiet times.

A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? Presence of associated manifestations. Location of pain. Pain quality. Aggravating and relieving factors.

Presence of associated manifestations.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? -Proliferation phase -Hemostasis -Inflammatory phase -Maturation phase

Proliferation phase

A nurse educates a young couple on putting their newborn on his back to sleep. What is the rationale for this information? Prone position increases the risk for sudden infant death syndrome. Prone position decreases the risk for sudden infant death syndrome. Supine position may alter the size and shape of the infant's head. Supine position makes changing diapers and feeding difficult.

Prone position increases the risk for sudden infant death syndrome.

The vocational nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply. Assess the client's need to continue the waist restraint. Chart the skin findings during the 2-hour check. Provide a bedpan and pericare. Determine if the waist restraint is too tight. Obtain, record, and report vital signs.

Provide a bedpan and pericare. Obtain, record, and report vital signs.

A client has an order for a narcotic analgesic every 3 to 4 hours and he received his last dose 3 hours earlier. Which action is most appropriate for the nurse to take in response to the client's request for pain medication on his first postoperative day? -Provide the client with pain medication. -Tell the client that the pain cannot be severe. -Document and ask the client to wait 1 hour. -Contact the physician for a change in medication.

Provide the client with pain medication.

A client who recently had a cast applied to his fractured arm is experiencing pain and tightness in his hand and arm, along with sluggish capillary refill. What is the nurse's most appropriate action? Raise the arm above the client's head and monitor swelling every 15 minutes; call the physician if swelling continues over several hours. Immediately bivalve (split) the cast to relieve pressure. Reposition the arm so that it is no higher than the heart level, and call the physician immediately. Administer analgesia and assess vital signs every half hour for the next 4 hours.

Reposition the arm so that it is no higher than the heart level, and call the physician immediately.

During a health assessment, a woman age 49 years tells the nurse that she is "just so tired and has been having mood swings and hot flashes." Based on this information, the nurse would conduct a more thorough history and assessment of what body system? Cranial nerves Cardiovascular Reproductive Respiratory

Reproductive

Which nursing role is the nurse exhibiting when collecting data about the number of urinary tract infections on the nursing unit? - Researcher -Counselor -Leader -Advocate

Researcher

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct? -Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. -Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry; then, replace the foreskin in its original position. -Avoid retraction of the foreskin because injury and scarring could occur. -Soak the end of the penis in warm water before cleaning the shaft of the penis.

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? Allow the client to keep standing for several minutes until balance returns. Use the call bell to summon the assistance of another nurse. Return the client to the bed. Place the client into the wheelchair.

Return the client to the bed.

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? Number of rooms in the house Safety of the immediate environment Frequency of home visits to be made Friendliness of the client and family

Safety of the immediate environment

After completing an assessment of a client, which data would the nurse determine is the priority for care? -Severe bleeding from a wound -History of asthma -Diabetes -Lack of family support

Severe bleeding from a wound

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial action by the nurse is appropriate? -Support the client's body against yours and gently slide the client onto the floor. -Ask the client to lean against the wall while you obtain a wheelchair. -Apply oxygen and wait several minutes for the weakness to pass. -Ask the client, "When was the last time you ate?" -Firmly grasp the client's gait belt.

Support the client's body against yours and gently slide the client onto the floor.

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? evisceration infection dehiscence fistula

infection

A nurse is educating a home care client on how to administer a topical medication. The client is watching television while the nurse is talking. What might be the result of this interaction? -The stimulus for communication is unclear. -The message will likely be misunderstood -The communication will be reciprocal. -The receiver will accurately interpret the message.

The message will likely be misunderstood

The nurse formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made? The nurse expressed the client outcomes as a nursing intervention. The nurse wrote vague outcomes that will confuse other nurses. The nurse included more than one client behavior in the outcome. The nurse used verbs that are not observable and measurable.

The nurse included more than one client behavior in the outcome.

Which action by the nurse demonstrates respect for the client as an individual? -The nurse is administering medication to a client she addressed as "Mrs. Taylor." -The nurse is giving report to another nurse about "the gallbladder client." -The nurse asks the aide to provide a bath for "the motor vehicle accident (MVA) client." -The nurse is providing care to an older adult client and calls her "Mom."

The nurse is administering medication to a client she addressed as "Mrs. Taylor."

A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? The nurse should place his or her feet close together with one foot in front of the other. The nurse should rock his or her pelvis out on the opposite side of the client. The nurse should grasp the gait belt and pull the client's body backward away from his or her body. The nurse should gently slide the client down his or her body to the floor.

The nurse should gently slide the client down his or her body to the floor.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? Respond to the past history of the client (including previous falls) to determine the need for restraints. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. Individualize the use of restraints and choose the most easily used device. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position? -To prevent hyperextension of the neck -To prevent pressure on the arms -To lower the client's center of gravity -To decrease the effort needed to move the client

To prevent hyperextension of the neck

Which guideline does the nurse apply to discussion of sleep patterns with older adult clients? Circadian rhythms become more prominent as clients age. The amount of stage 4 sleep increases as clients age. Total sleep time decreases as the clients age. Older clients fall asleep more quickly than younger ones.

Total sleep time decreases as the clients age.

At what point during hospital-based care does planning for discharge begin? -After leaving the hospital -Upon admission to the hospital -Immediately before discharge . -After the client is settled in a room

Upon admission to the hospital

The nurse is educating a client who has a sleep disorder and suggests trying stimulus control to improve amount and quality of sleep. What would the nurse state to the client about stimulus control? Use the bedroom for sleep and sex only. Use the bedroom for reading and eating. Go to bed at varied times each night. Sleep alone with minimal coverings.

Use the bedroom for sleep and sex only.

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? Shaving the face of a resident who has worn a beard for several years Using a tool to remove a contact lens that has adhered to the resident's eye Providing a tub bath to a resident who is unable to mobilize independently Providing oral care to a client who has cognitive deficits and a decreased level of consciousness

Using a tool to remove a contact lens that has adhered to the resident's eye

Which client would be an appropriate candidate to move by using a powered stand-assist device? a comatose client who is being taken for x-rays an alert client after knee replacement surgery who is being assisted to ambulate an obese client who has Alzheimer's disease and is being escorted to the shower room a car accident victim with fractures in both legs who is being moved to another room

an alert client after knee replacement surgery who is being assisted to ambulate

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and: -covering the wound area with sterile towels moistened with sterile 0.9% saline. -closing the wound area with Steri-Strips. -pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze. -holding the wound together until the physician arrives.

covering the wound area with sterile towels moistened with sterile 0.9% saline.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? biofeedback cutaneous stimulation patient controlled analgesia percutaneous electrical nerve stimulation

cutaneous stimulation

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth? from the pubic area toward the anal area from the anal area to the pubic area from side to side within the labia the direction does not make any difference

from the pubic area toward the anal area

Dementia is a disorder that progresses over several years, with increasing confusion, forgetting family, and disorientation in familiar surroundings. A common problem with dementia patients is sundowning syndrome, which is described as ... -occasional onset of marked confusion, wandering and feeling lost during the afternoon, before sunset. -habitual agitation, restlessness, and confusion that occurs after dark. -a behavior change at sunset as the client becomes more fatigued, listless, and disoriented. -increasing sleeplessness at night because the patient cat-naps during the day.

habitual agitation, restlessness, and confusion that occurs after dark.

A nursing student caring for an unconscious client knows that communication is important even if the client does not respond. Which nonverbal action by the nursing student would communicate caring? -holding the client's hand while talking -sighing frequently while providing care -making constant eye contact with the client -waving to the client when entering the room

holding the client's hand while talking

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? saline-moistened dressing dressing secured with Montgomery straps hydrocolloid dressing foam dressing

hydrocolloid dressing

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action? Place the client in a prone position to apply the restraint. Remove the client's upper body clothing and reapply it over the restraint. Insert a fist between the restraint and the client to ensure that her breathing is not constricted. Assess the client at least every 2 hours or according to facility policy, as required.

insert a fist between the restraint and the client to ensure that her breathing is not constricted.

Which action by the nurse will facilitate the nurse-client relationship during the orientation phase? -designing a specific education plan of care -preparing for termination of the relationship -providing assistance to meet activities of daily living -introducing oneself to the client by name

introducing oneself to the client by name

Which client would be most likely to have decreased anxiety about, and response to, pain as a result of past experiences? one who had pain but got adequate relief one who had pain but did not get relief one who has had chronic pain for years one who has had multiple pain experiences

one who had pain but got adequate relief

A hospitalized client has been n.p.o. with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? -sleep disturbances, anger, increased output -weight gain, visual deficits, erythema of skin -poor wound healing, apathy, edema -fever, joint pain, dehydration

poor wound healing, apathy, edema

Using Erikson's theory, which of the following activities would the nurse use to provide a sense of fulfillment and purpose in later adulthood? -reminiscing about life events -trying on new and different roles -making a commitment to others -becoming involved within the community

reminiscing about life events

A woman aged 88 years who lives alone has deficits in vision and hearing, although these deficits are corrected by glasses and hearing aids. Her blood pressure medicine is making her dizzy. What response to these health problems would the home health nurse identify? risk for accidental injury risk for decreased social interaction risk for impaired judgment altered consciousness

risk for accidental injury

Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning? to be able to employ the nursing process in client care. The licensing examination requires nurses to be adept at critical thinking. Clients deserve experts who know how to care for them. to provide quality care with nursing ability and knowledge

to provide quality care with nursing ability and knowledge

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure? to lift the client off the bed to slide the board with the client onto the stretcher to reduce friction as the client is pulled laterally onto the stretcher to protect the client's head from hitting the headboard

to reduce friction as the client is pulled laterally onto the stretcher

A client is diagnosed with narcolepsy. What is a characteristic of this disorder? waking during sleep restless leg syndrome uncontrollable desire to sleep decrease in the amount or quality of sleep

uncontrollable desire to sleep

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? clear, watery blood large numbers of red blood cells mixture of serum and red blood cells white blood cells, debris, bacteria

white blood cells, debris, bacteria