FOUNDATIONS review EAQ for HESI

Which theories are relevant only to development in adults? Select all that apply. One, some, or all responses may be correct. 1. Piaget's theory 2. Erikson's theory 3. Kohlberg's theory 4. Stage-Crisis theory 5. Life Span approach

4. Stage-Crisis theory 5. Life Span approach The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.

The advanced practice registered nurse (APRN) is caring for a pregnant woman ready to deliver. Which type of APRN would care for this client? 1. Clinical nurse specialist (CNS) 2. Certified nurse midwife (CNM) 3. Certified nurse practitioner (CNP) 4. Certified registered nurse anesthetist (CRNA)

2. Certified nurse midwife (CNM) The CNM is qualified and has the skills to care for a pregnant woman. The CNS is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. The CNP is an APRN who provides health care to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. The CRNA is an APRN with an advanced education in the nurse anesthesia accredited program.

Which critical thinking skill is being used when the nurse applies knowledge and experience to client care? 1. Analysis 2. Evaluation 3. Explanation 4. Interpretation

3. Explanation When the nurse is using experience to care for clients, the critical thinking skill of explanation is being applied. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

Which documentation is most informative for an assessment of drainage on a surgical dressing? 1. "Moderate amount of drainage." 2. "No change in drainage since yesterday." 3. "A 10 mm-diameter area of drainage at 1900 hours." 4. "Drainage is doubled in size since last dressing change."

3. "A 10 mm-diameter area of drainage at 1900 hours." A 10 mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.

Which is the most therapeutic response by the nurse to a client who is joking about dying? 1. "Why are you always laughing?" 2. "Your laughter is a cover for your fear." 3. "Does it help to joke about your illness?" 4. "The person who laughs on the outside cries on the inside."

3. "Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse would assess for which problem associated with anesthetic agents? 1. Colitis 2. Stomatitis 3. Paralytic ileus 4. Gastrocolic reflux

3. Paralytic ileus After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

Which is the most important skill of the nurse leader? 1. Priority setting 2. Time management 3. Clinical decision-making 4. Clinical care coordination

4. Clinical care coordination The most important leadership skill for the nurse leader is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.

The nurse is reviewing the procedure for intervention if a fire occurs. Which interventions would the nurse include in the procedure if a fire occurs that relate to the acronym RACE? Select all that apply. One, some, or all responses may be correct. 1. Activate the alarm. 2. Alert the local fire department. 3. Remove all clients from the area. 4. Evaluate all interventions provided. 5. Release the pin in the fire extinguisher. 6. Confine the fire by closing doors and windows.

1. Activate the alarm. 3. Remove all clients from the area. 6. Confine the fire by closing doors and windows. The acronym RACE stands for Remove all clients from immediate danger, Activate the alarm, Confine the fire by closing doors and windows, and Extinguish the fire with an appropriate fire extinguisher. The acronym does not include alerting the local fire department or releasing the pin from the fire extinguisher.

Which worker(s) would the nurse consider to be at high risk of developing dermatitis? Select all that apply. One, some, or all responses may be correct. 1. Dry cleaners 2. Dye workers 3. Lathe operators 4. Hospital workers 5. Agricultural workers

1. Dry cleaners 2. Dye workers Dry cleaners and dye workers are at high risk of developing dermatitis due to exposure to substances such as solvents and dye stuffs. Lathe operators are at high risk of developing cancer. Hospital workers are at greater risk of latex allergies. Agricultural workers are at high risk of skin cancer.

Which disease process places a client at increased risk for infection? Select all that apply. One, some, or all responses may be correct. 1. Leukemia 2. Lymphoma 3. Emphysema 4. Schizophrenia 5. Osteoarthritis

1. Leukemia 2. Lymphoma 3. Emphysema Disease processes that increase the client's risk for infection include leukemia, lymphoma, and emphysema, which lead to a diminished immune system. Schizophrenia and osteoarthritis do not impair a person's immune system.

Which factor(s) increase(s) the risk of nurses making medication errors in the health care setting? Select all that apply. One, some, or all responses may be correct. 1. Stress 2. Fatigue 3. Overwork 4. Equipment malfunction 5. Increased documentation

1. Stress 2. Fatigue 3. Overwork Factors that can lead to nurses making medication errors include stress, overwork, and fatigue. Equipment malfunction can lead to injury. Increased documentation can lead to decreased time for the nurse to spend with the client, but this does not cause medication errors.

Which potential health problem would the nurse include in the young adult's discharge teaching? 1. Kidney dysfunction 2. Cardiovascular diseases 3. Eye problems, such as glaucoma 4. Accidents, including their prevention

4. Accidents, including their prevention Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

Which nursing process involves delegation and verbal discussion with the health care team? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

4. Implementation The implementation process involves delegation and verbal discussion with the health care team. Planning involves interpersonal or small-group health care team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and talking with clients.

Which critical thinking skill will help a student nurse avoid making assumptions about clients? 1. Analysis 2. Inference 3. Evaluation 4. Explanation

1. Analysis Use of analysis allows the student nurse to be open-minded while looking at the client's information and to avoid making assumptions. Inference skills focus on the meaning of the findings and its significance. Evaluation involves looking at all situations objectively and using criteria to determine the results of nursing actions. Explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.

Which intervention would the nurse expect to implement to alleviate anxiety for a preoperative client? 1. Attempt to identify the client's concerns. 2. Reassure the client that the surgery is routine. 3. Report the client's anxiety to the health care provider. 4. Provide privacy by pulling the curtain around the client.

1. Attempt to identify the client's concerns. The nurse would assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the health care provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction? 1. Circulating nurse 2. Surgical assistant 3. Registered nurse first assistant 4. Certified registered nurse anesthetist

1. Circulating nurse The circulating, or nonsterile, nurse would sit with the client to provide comfort during induction. The surgical assistant and registered nurse first assistant will be assisting the surgeon during the procedure and will be scrubbed and sterile. The certified registered nurse anesthetist will be focused on providing medications to the client and cannot sit with the client during induction.

A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? 1. Contact an interpreter provided by the hospital. 2. Contact the client's family member to translate for the client. 3. Communicate with the client using Spanish phrases the nurse learned in a college course. 4. Communicate with the client with the use of a hospital-approved Spanish dictionary.

1. Contact an interpreter provided by the hospital. Interpreters provided by the health care organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate health care information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? 1. Their gag reflex has returned. 2. They are confused due to anesthesia. 3. They are nauseated and want to vomit. 4. Their airway is becoming obstructed.

1. Their gag reflex has returned. The ability to spit out the oral airway indicates that the normal gag reflex has returned and the client can protect her or his airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit out the airway does not mean that the client is nauseated. An oral airway is meant to keep the airway patent; it may not obstruct the airway.

Which type of functional health pattern describes values and goals? 1. Value-belief pattern 2. Role-relationship pattern 3. Self-perception-self-concept pattern 4. Health perception-health management pattern

1. Value-belief pattern The value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client in making choices or decisions. The role-relationship pattern includes the description of the client's patterns in role engagements and relationships. In the self-perception-self-concept pattern, the nurse may describe the client's self-concept pattern and perceptions of self. It involves self-concept/worth, emotional patterns, and body image. The health perception-health management pattern is associated with the description of the client's self-report of health and well-being.

The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct? 1. "Let me get my preceptor." 2. "Wash your hands before and after any client care." 3. "Clean all instruments and work surfaces with an approved disinfectant." 4. "Ensure proper disposal of all items contaminated with blood or body fluids."

2. "Wash your hands before and after any client care." The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

Which psychophysiological factors influence communication between the nurse and a client? Select all that apply. One, some, or all responses may be correct. 1. Privacy level 2. Emotional status 3. Information exchange 4. Level of caring expressed 5. Growth and development

2. Emotional status 5. Growth and development Growth and development and emotional status are two psychophysiological factors that influence communication between the nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

The nurse should expect to take which action to help alleviate anxiety for a client scheduled for a colostomy? 1. Administer the prescribed as-needed (PRN) sedative. 2. Encourage the client to express feelings. 3. Explain the post-procedure course of treatment. 4. Reassure the client that there are others with this problem.

2. Encourage the client to express feelings Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus would be on the client, not others. Reassurance may cut off communication and deny emotions.

Which professional standard is important for critical thinking? 1. Logical thinking 2. Evaluation criteria 3. Accurate knowledge 4. Relevant information

2. Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which principal components are associated with the nurse's time management skills? Select all that apply. One, some, or all responses may be correct. 1. Autonomy 2. Goal setting 3. Priority setting 4. Interruption control 5. Right communication

2. Goal setting 3. Priority setting 4. Interruption control Goal setting, priority setting, and interruption control are the principal components of time management. Autonomy is an important component of the decision-making process. Right communication is considered one of the rights of delegation.

During a home visit, the nurse finds that a healthy older adult person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. Which inference about the client would the nurse make from these findings? 1. Not motivated 2. Intrinsically motivated 3. Extrinsically motivated with self-determination 4. Extrinsically motivated without self-determination

2. Intrinsically motivated An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy on suggestion or pressure created by other individuals.

Which action relates with the relevance strategy of the motivational learning model proposed by Keller? 1. Extrinsic and intrinsic reinforcements for any learning effort 2. Linking the person's needs, interests, and motives for learning 3. Arousing and sustaining a person's curiosity and interest in learning 4. Having positive hope for successful achievements as a result of learning

2. Linking the person's needs, interests, and motives for learning Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? 1. Ambulation 2. Repositioning 3. Purse-lipped breathing 4. Deep breathing and coughing

2. Repositioning Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain. Ambulation is not specifically used to decrease postoperative pain. Purse-lipped breathing is primarily used to improve ventilation. Deep breathing and coughing are used to clear the respiratory tract.

A home health nurse checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. Which response by the nurse is correct? 1. "I would, but my back hurts today." 2. "Okay. It will be my good deed for the day." 3. "Of course. I want to do whatever I can for you." 4. "I would like to, but it is not in my job description."

3. "Of course. I want to do whatever I can for you." Helping the client meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse would not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. Straightening the blankets is within the nurse's job description.

A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing? 1. Lactated Ringer solution 2. 5% dextrose and water 3. 0.9% normal saline 4. 0.45% normal saline

3. 0.9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

The nurse is preparing an intraoperative care plan for a client. Which intervention would be excluded from the care plan? 1. Ensuring the client's skin integrity 2. Reviewing the preoperative instructions 3. Administering a general anesthetic to the client 4. Placing the client in the correct position on the operating table

3. Administering a general anesthetic to the client Only anesthesiologists who are specially trained can administer anesthesia. The nurse would exclude this intervention from the nursing care plan. In the operating room, the nurse would ensure the client's skin integrity to prevent complications such as pressure sores. The nurse would review the preoperative care plan to establish or amend the plan if changes are required. The nurse would place the client in the correct position to prevent the client from injury during the operation.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. 1. Impaired vision 2. Cognitive impairment 3. Environmental hazards. 4. Inappropriate footwear 5. Improper use of assistive devices

3. Environmental hazards. 4. Inappropriate footwear 5. Improper use of assistive devices Environmental hazards, inappropriate footwear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? 1. Analysis 2. Inference 3. Explanation 4. Interpretation

3. Explanation Explanation requires knowledge and experience for choosing strategies for care for clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with ordered data collection.

An 80-year-old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct? 1. "The body's fluid needs decrease with age because of tissue changes." 2. "Access to fluid may be insufficient to meet the daily needs of the older adult." 3. "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4. "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."

4. "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased." For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

After a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. Which approach would the nurse take when interacting with this client? 1. Explain why there is a need to increase activity. 2. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3. Appear cheerful and noncritical regardless of the client's response to attempts at intervention. 4. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

4. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and to integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

Which skill in critical thinking requires the nurse to be orderly in data collection? 1. Analysis 2. Inference 3. Evaluation 4. Interpretation

4. Interpretation Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. Which is it important for the nurse to inform the client of? 1. The client is acting irresponsibly. 2. This action violates the hospital policy. 3. The client must obtain a new primary health care provider for future medical needs. 4. The client must accept full responsibility for possible undesirable outcomes.

4. The client must accept full responsibility for possible undesirable outcomes. The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for the illness and possible injury or undesirable outcomes. Health care professionals have a responsibility to inform the client and, if possible, have the client sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current primary health care provider will refuse to provide care to the client in the future.