Fundamentals Custom Adaptive
Which of these is a part of health belief model? Multiple choice question Behavioral outcomes Behavior-specific knowledge Perception of susceptibility to an illness Individual characteristics and experience
Perception of susceptibility to an illness
While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? Multiple choice question Heroin Atropine Morphine Pilocarpine
Atropine The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.
While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this? Multiple choice question Provide comfort to the client Minimize trauma to rectal mucosa Reduce transmission of microorganisms Ensure adequate exposure to the blood vessels
Ensure adequate exposure to the blood vessels The nurse should place the thermometer probe into the anus in the direction of umbilicus to ensure adequate exposure to the blood vessels. Wiping the client's anal area with a soft tissue and helping the client get into the Sims' position provides comfort. Using a lubricant will help to minimize trauma to the rectal mucosa. The nurse should wash his or her hands before and after assessing the temperature to reduce the transmission of microorganisms.
A registered nurse is educating a nursing student about issues related to short staffing. What information should the nurse provide? Multiple selection question "Nurses should refrain from walking out when faced with a short staffing problem." "Written protests relieve the nurses of responsibility if a client is injured due to inattention." "There is no likelihood of legal problems if enough nurses are not available to provide competent care." "Nurses should inform their supervisors when they are assigned to care for more clients than is reasonable." "Written protests should be submitted to nursing administrators if unreasonable assignments are given to nurses."
"Nurses should refrain from walking out when faced with a short staffing problem." "Nurses should inform their supervisors when they are assigned to care for more clients than is reasonable." "Written protests should be submitted to nursing administrators if unreasonable assignments are given to nurses Nurses should never walk out when there is a short staffing problem as they may be charged with client abandonment. If nurses are assigned to care for an unreasonable number of clients due to inadequate staffing, they should notify the nursing supervisor regarding the problem. Nurses should submit written protests to nursing administrators if unreasonable assignments are given to them. If administrators have knowledge regarding the problem, some of the responsibility shifts to the institution. Submitting written protests does not relieve the nurses of the responsibility if a client is injured or harmed due to inattention. Legal problems occur if enough nurses are not available to provide competent care or if nurses have to work excessive overtime.
A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result? Multiple choice question "The result indicates that you have active tuberculosis." "The result indicates that you are infected with the tuberculosis organism." "The result indicates that there are no tuberculin antibodies in your system." "The result indicates that you have a secondary infection related to the tuberculin organism."
"The result indicates that you are infected with the tuberculosis organism." An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis. The other choices are incorrect.
An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? Multiple choice question 36.0ºC 36.8ºC 37.2ºC 38.5ºC
38.5ºC In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.
A registered nurse notices that the insertion site of a client receiving intravenous medication is swollen. The nurse takes appropriate measures to treat the area and takes a photo of the insertion site and saves it in the client's electronic health record. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse following? Multiple choice question Safety Informatics Client-centered care Teamwork and collaboration
According to the Quality and Safety Education for Nurses (QSEN) competency, informatics is the use of information and technology to communicate, manage knowledge, reduce errors, and support decision-making. In the given scenario, the nurse takes appropriate measures to treat a swollen insertion site, takes a photo, and saves the photo in the client's electronic health record for future reference. This scenario qualifies for the informatics competency. The safety competency is used to reduce the risk of harm to clients and providers through both system effectiveness and individual performance. Client-centered care competency is used to provide compassionate and coordinated care based on respect to the client's preferences, values, and needs. The teamwork and collaboration competency is used to effectively function within the nursing and interprofessional teams to achieve quality client care.
The nurse decides to teach deep-breathing exercises to a client recovering from a surgery. Which professional responsibility does the nurse display? Multiple choice question Advisory Advocacy Autonomy Caregiving
Autonomy The nurse practices autonomy by initiating independent nursing interventions without medical orders. Autonomy is an essential element of professional responsibility. The nurse explains concepts and facts related to health, but does not advise the client. The nurse acts as a client's advocate by speaking for the client and protecting the client's health care rights. As a caregiver, the nurse helps the client to improve physical, emotional, spiritual, and social well-being.
What problems may a nurse come across when dealing with ethical issues related to end-of-life care? Multiple selection question Clients are unable to communicate effectively. All interventions for helping the clients seem futile. Clients are often unfamiliar with the concept of autonomy. Multiple medications affect the cognitive ability of the clients. Predictions regarding health outcomes are not always accurate.
Clients are unable to communicate effectively. All interventions for helping the clients seem futile. Predictions regarding health outcomes are not always accurate. Older adults who need end-of-life care may be unable to communicate effectively. The nurse should evaluate the ability of the client to make important decisions about his or her care. During end of life care, all interventions for helping the clients may seem to be futile. As such, the caregivers, the client, and the healthcare workers should focus on providing palliative care. Predictions regarding health outcomes may not always be. There may also be differences of opinion regarding the worth of an outcome. Older adults are often unfamiliar with the concept of autonomy. As such, they may find it difficult to contradict primary healthcare providers and nurses. This problem is not restricted to end-of-life care situations. Older adults may also face problems such as diminished cognitive ability due to the intake of multiple medications. This problem is also not limited to end-of-life care.
Which findings in the older client are associated with a urinary tract infection (UTI)? Multiple selection question Fever Urgency Confusion Incontinence Slight rise in temperature
Confusion Incontinence Slight rise in temperature An older client with a urinary tract infection (UTI) is likely to appear confused. An older client may experience incontinence while a younger client may experience urgency. The older client may develop a slight rise in temperature. The classic symptoms of a UTI in a younger client are fever, dysuria, and urgency.
A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect? Multiple choice question Eczema Hypersensitivity Contact dermatitis Anaphylactic shock
Contact dermatitis A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.
A nurse caring for a client post-surgery takes necessary steps to achieve quality client care. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called informatics? Multiple selection question Washing the hands before handling the client's incision site Implementing a new method of monitoring the client's incision site for infections Documenting in the electronic health record (EHR) after performing wound debridement Locking the electronic health record (EHR) after every entrance of necessary information Using computer-assisted instruction (CAI) program to provide better quality of care to the client
Documenting in the electronic health record (EHR) after performing wound debridement Locking the electronic health record (EHR) after every entrance of necessary information Using computer-assisted instruction (CAI) program to provide better quality of care to the client A nurse satisfies the informatics competency by using information and technology to communicate, manage knowledge, minimize errors, and support decision-making. Documenting in the client's electronic health record (EHR) after performing wound debridement enables the nurse to track the client's progress and store information for future reference. The nurse maintains confidentiality of the client's medical information by locking the electronic health record (EHR). This enables the nurse to manage knowledge appropriately and minimizing the possibility of legal issues. The nurse also satisfies the informatics competency by using computer-assisted instruction (CAI) programs to provide better quality of care to the client. To satisfy the safety competency, the nurse is required to reduce the risk of causing harm to the client by ensuring appropriate individual performances. In the given situation, the nurse washes his or her hands to minimize the risk of infections. The nurse satisfies the quality improvement competency by implementing a new method of monitoring the client for infections.
A client is receiving an intravenous infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? Multiple choice question Excessive carbohydrate intake Lack of protein supplementation Insufficient intake of water-soluble vitamins Increased concentration of electrolytes in cells
Lack of protein supplementation An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore tissue breakdown occurs to supply the essential amino acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.
Which finding is inferred from a grade 4 intensity of heart murmurs? Multiple choice question Thrill is easily palpable Quiet and clearly audible thrill Loud murmur associated with thrill Moderately loud murmur without thrill
Loud murmur associated with thrill Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.
A nursing student notes the characteristics of middle-range theories. Which points noted by the nursing student are accurate? Multiple selection question Middle-range theories are systematic and broad in scope and complexity. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Middle-range theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching. Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations.
Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Mishel's theory of uncertainty in illness is an example of a middle-range theory; it focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories are more limited in scope and less abstract than grand theories. Middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching.
A registered nurse is teaching a nursing student about Nightingale's theory of nursing. Which statements have been correctly stated by the nursing student as a result of the teaching? Multiple selection question Nightingale's theory states that the focus of nursing is caring through the environment. Nightingale's theory limits nursing to the administration of medications and treatment. Nightingale's theory suggests that every nurse should know all about the disease process. Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness.
Nightingale's theory states that the focus of nursing is caring through the environment. Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness Florence Nightingale's theory of nursing focuses on nursing by caring through the environment. Nightingale's theory is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Nightingale's theory does not limit nursing to the administration of medications and treatment. Nightingale's theory suggests that nurses do not need to know all about the disease process, which differentiates nursing from medicine.
The nurse is reviewing the website www.nursing.uiowa.edu/cncto gather information about standardized terminology. The website would provide the nurse with which standardized nursing terminologies? Multiple selection question Clinical Care Classification Perioperative Nursing Data Set Nursing Outcomes Classification Nursing Interventions Classification International Classification of Nursing Practice
Nursing Outcomes Classification Nursing Interventions Classification The website www.nursing.uiowa.edu/cnc provides information regarding Nursing Outcomes Classification and Nursing Interventions Classification terminology. The nurse should check www.sabacare.com/ for information about Clinical Care Classification terminology. The nurse should refer to www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord/PNDS Resources/ to gather information about Perioperative Nursing Data Set terminology. The nurse can gather information about International Classification of Nursing Practice from www.icn.ch/icnp.htm.
A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, and that everything is under control. What is the best interpretation of the nurse's statement? Multiple choice question Adequate, because the preparations are routine and need no explanation Effective, because the client's anxieties would increase if she knew the danger involved Questionable, because the client has the right to know what treatment is being given and why Incorrect, because only the primary healthcare provider should offer assurances about management of care
Questionable, because the client has the right to know what treatment is being given and why The client's rights have been violated. All clients have the right to a complete and accurate explanation of treatment based on cognitive ability. All interventions should be explained, because they are not routine to the client. When administering treatment, the nurse is responsible for explaining what the treatment is and why it is being given. The Patient Care Partnership (Canada: The Patient's Bill of Rights) states that the client should be informed.
A nurse needs to record a client's data from admission until discharge. Which record will the nurse use? Multiple choice question Acuity record Source record Hand-off records Problem-oriented medical record
Source record The nurse will use the source record for writing information from the client's admission until discharge. This record has a separate section for each discipline (such as the admission sheet, nursing records, and medication). Acuity records are not part of a client's medical record. They are useful for determining the hours of care and staff required for a given group of clients. A hand-off record is used when up-to-date information about a client's condition, required care, treatments, medications, services, and any recent or anticipated changes is to be communicated. The problem-oriented medical record (POMR) is a method of documentation that places emphasis on the client's problems. In this record, data is organized by problem or diagnosis.
Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves patient health outcomes? Multiple choice question Neuman's system theory Swanson's theory of caring Orem's self-care deficit theory Mishel's theory of uncertainty in illness
Swanson's theory of caring Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves patient health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.
A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? . Multiple selection question Taking on parental roles Adjusting to a reduction in family size Development of intimate peer relationships Adjusting the marital system to make space for children Realigning relationships to in-laws and grandchildren
Taking on parental roles Adjusting the marital system to make space for children A family with more young children undergoes an emotional transition of accepting a new generation of members. These changes include taking on parental roles and adjusting the marital system to make space for children to proceed developmentally. Adjusting to a reduction in family size is required for the family life-cycle stage of children leaving the family home. The development of intimate peer relationships is required for an unattached young adult. Realigning relationships to in-laws and grandchildren is required for the family life-cycle stage of children leaving the home to start their own lives.
The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Multiple selection question The client reports pain with movement. The client has pain over the surgical area. The client wants to know when he can go home. The client rates the pain as 8 on a scale of 0 to 10. The client has concerns about caring for the wound.
The client reports pain with movement. The client has pain over the surgical area. The client rates the pain as 8 on a scale of 0 to 10. The nurse groups all information that contains a defining characteristic such as pain. The nurse clusters all assessments related to pain. The client reports pain with movement. The clinical criteria are observable and verifiable. The nurse learns that the pain is over the surgical area and not an underlying pain. The nurse verifies and measures the data by rating the pain as 8 on a scale of 0 to 10. The client wants to know when he can go home, but this assessment is not related to the pain. The client is also worried about caring for the wound, but this assessment will belong to a different cluster.
