Fundamentals Final Exam
The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment? "Do you dribble urine throughout the day?" "Do you lose control of your urine all day?" "Do you have the sensation to urinate?" "Do you leak urine with strain or coughing?"
"Do you have the sensation to urinate?"
A client admitted to the hospital asks the nurse whether it would be acceptable for the client to bring food from home to eat that better meets the client's cultural preferences. What is the nurse's best response? "I'm sorry, but you are not permitted to bring food from home." "Food from home has too much fat and salt and should be avoided." "Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet." "No, you must learn to adjust to the food that is provided."
"Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet."
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? 10 L/min oxygen via Venturi mask 8 L/min oxygen via partial rebreather mask 8 L/min oxygen via nasal cannula 12 L/min oxygen via nonrebreather mask
10 L/min oxygen via Venturi mask
The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?
A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs
Nursing students need to learn to care for themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of client care? Time management, communication, and establishing a support system Establishing a support system, a sense of humor, and self-awareness Self-awareness, preparation for crisis, and stress management A sense of humor, anticipation of loss, and developing negative body image
A sense of humor, anticipation of loss, and developing negative body image
A nurse is caring for a 55-year-old male on an orthopedic unit. When the nurse hands the client his morning medication, he grabs her breast and squeezes it. How should the nurse best respond to this situation? *Ask another nurse to switch assignments and care for this patient *Seek legal advice to bring charges against the client *Assertively tell the client that this behavior is not acceptable *Withhold the client's pain medication
Assertively tell the client that this behavior is not acceptable
A nurse is providing care to a client with end-stage cancer. After weighing the alternatives, the client decides not to participate in a clinical trial offered and is requesting no further treatment. The nurse advocates for the client's decision based on the understanding that the client has the right to self-determination, interpreting the client's decision as reflecting which ethical principle? *Autonomy *Beneficence *Justice *Fidelity
Autonomy
The nurse is caring for a client with frequent UTIs. What does the nurse include in the client's teaching plan to decrease the incidence of UTIs? Be sure to urinate after sexual intercourse. Try soaking in bubble baths in the evenings. Wipe the perineal area from back to front. Decrease fluid intake to decrease urination.
Be sure to urinate after sexual intercourse
A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply. *Clostridium difficile *Norovirus *Staphylococcus aureas *Candida albicans *E. coli
Clostridium difficile, Norovirus
A client responds to an approaching diagnostic test with a rapidly beating heart and hands that are shaking. This is the result of what type of response? *Coping responses *Stress adaptation *Defense mechanism *Withdrawal behavior
Coping responses
Which example most accurately depicts the ethical principle of autonomy? *Describing a surgery to a client before the consent is signed *Changing a dressing on a wound as needed *Administering a morning dose of insulin before breakfast *Transporting a client to a scheduled physical therapy appointment
Describing a surgery to a client before the consent is signed
The nurse is caring for an older adult with influenza. Which precautions will the nurse begin? *Airborne *Droplet *Contact *None
Droplet
Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement? *Encourage fluid intake. *Restrict fluid intake. *No action is required. *Alert the health care provider of possible infection.
Encourage fluid intake.
Which nursing action demonstrates the principle of fidelity? *Filing an incident report after making a medication error *Administering a vaccination *Treating an uninsured client in the emergency department *Witnessing a client signature on an informed consent
Filing an incident report after making a medication error
The nurse has inserted a client's urinary catheter as ordered, but there has been no immediate flow of urine. What is the nurse's most appropriate action? Have the client take a deep breath to relax the perineal and abdominal muscles. Advance the catheter slightly, because a drainage hole may be resting against the bladder wall. Lower the head of the client's bed to increase pressure in the bladder area. Leave the catheter in place and reassess in 30 minutes.
Have the client take a deep breath to relax the perineal and abdominal muscles.
The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections? *Advise taking prophylactic antibiotics for the prevention of pneumonia *Immunize the client with the pneumococcal vaccination once in a lifetime *Discuss starting corticosteroids at low doses to prevent pulmonary infections *Instruct client to limit fluids when coughing and congestion occurs
Immunize the client with the pneumococcal vaccination once in a lifetime
a client diagnosed with hypothyroidism is suffering from fatigue, lethargy, depression and difficulty executing the tasks of everyday living. What type of sleep deprivation would the nurse suspect is affecting this client? REM deprivation NREM deprivation Total sleep deprivation Insomnia
NREM deprivation
A nurse is collecting a routine urinalysis on a client presenting to the ED with abdominal pain. What nursing action is important in the collection of this specimen? Obtain a nonsterile specimen and send it to the lab. Obtain a sterile specimen and send it to the lab. Obtain a sterile specimen and allow it to settle at room temperature for 2 hours. Obtain a nonsterile specimen, allow it to settle at room temperature for 2 hours, and then send it to the lab.
Obtain a nonsterile specimen and send it to the lab.
An older adult client is experiencing urinary retention. What age-related physiologic change does the nurse discuss with the client that may be a contributing factor? Older adults can have a decrease in bladder muscle tone. Older adults may have a decrease in contraction of the bladder. Older adults have a decreased ability to concentrate urine. Older adults who have limited support can feel powerless.
Older adults may have a decrease in contraction of the bladder.
The nurse is collecting a clean-catch specimen from a client. Which nursing action is performed correctly in this procedure? Don sterile gloves Collect the first 10 mL of urine voided in the sterile specimen container. Position the container near the meatus, and collect at least 10 mL of urine. Continue collecting the urine in the container until the bladder is empty.
Position the container near the meatus and collect at least 10 mL of urine.
The nurse is providing care for a client whose diagnosis requires the nurse to use personal protective equipment (PPE). Place the steps in the order in which the nurse will perform the actions.
Provide instruction about precautions to client, family members, and visitors. Perform hand hygiene. Put on the gown, with the opening in the back. Tie gown securely at neck and waist. Put on the mask or respirator over your nose, mouth, and chin. Put on goggles and place over eyes and adjust to fit. Put on clean, disposable gloves and extend gloves to cover the cuffs of the gown.
The nurse performs a respiratory assessment on a healthy client. While listening to the client's lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds? "Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%." "Respiratory rate 22, regular; lungs sounds clear bilaterally; spontaneous, nonproductive cough, yellow drainage from nostrils." "Client sitting upright in bed, respirations 24 and shallow, lungs clear bilaterally, oxygen at 2 liters per nasal cannula, productive cough." "Client breathing without difficulty; respiratory rate 22 and regular on 2 liters of oxygen per nasal cannula; dry, hacky, intermittent cough; reports slight shortness of breath with exertion."
Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%
The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position? *dorsal recumbent *Sims *Semi-Fowler *supine
Sims
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/min. Which assessment finding will demonstrate that oxygen therapy is effective? clubbing of fingers respirations 26 breaths/minute heart rate 110 beats/minute SpO2 96%
SpO2 96%
An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate? *Standard *Droplet *Airborne *Contact
Standard
When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: *Droplet precautions *Standard precautions *Contact precautions *Airborne precautions
Standard precautions
A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? *The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention. *The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. *The nurses have given multiple opportunities for potential participants to ask questions, and have been following the informed consent process systematically. *The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.
The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention.
The nurse working on a medical unit always performs hand hygiene between contact with each client. In addition to being understood as an infection control measure, this practice can be understood as: a custom. an obsession. a coping strategy. a ritual.
a ritual
Which stressor collected during the assessment process for an adult client requires priority intervention by the nurse? *being laid off from a job *experiencing the death of a friend *taking early retirement *downsizing of a business venture
being laid off from a job
A nurse is caring for four adult clients. Which client would the nurse assess first? *client with a blood pressure of 120/60 mmHg *client with a temperature 98.6°F (37°C) *client with a respiratory rate 32 breaths/min *client with a heart rate of 88 bpm
client with a respiratory rate 32 breaths/min
What term is used to describe various disorders that progressively affect cognitive function? Dementia Ageism Reminiscence Delirium
dementia
The nurse is preparing to provide hygiene for a client who has Clostridium difficile-associated diarrhea. Which is most appropriate? *gown *face shield/goggles *mask *gloves
gown and gloves
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? nasal cannula tracheostomy collar simple mask face tent
nasal cannula
Which area of nursing experiences the highest levels of stress in the work setting? Obstetric nurses Pediatric nurses New graduate nurses Aging nurses
new graduate nurses
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
A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client? *public embarrassment *skin breakdown and UTI *inability to control urine *odor and leakage
skin breakdown and UTI
The nurse reviews principles of infection prevention during yearly safety training. Which action(s) would the nurse use as an example of safe practice? Select all that apply. *Recapping of needles immediately after use *Donning gloves and gowns as a substitute for handwashing in some circumstances *Applying alcohol-based products to reduce risk of contracting Clostridium difficile *Sterilizing any item entering the vascular system *Wearing artificial nails at an acceptable length in most areas of the clinic
sterilizing any item entering the vascular system
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? *condom catheter *urinary bag *straight catheter *retention catheter
straight catheter
The health care provider prescribes a long-term continuous drainage system to monitor a chronically ill client. What type of catheter would best suit the client's needs? indwelling urethral catheter intermittent urethral catheter suprapubic catheter external catheter
suprapubic catheter
A client is brought to the ED after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced? urge total reflex stress
total
The school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced? total urge reflex stress
total
When collecting data on a client, the nurse implements which nonverbal communication form as one of the most effective to express feelings? *eye contact *touch *gait *body posture
touch
A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. Which statement by the nurse would help reduce the client's anxiety? "We do these procedures every day, so you don't need to worry." "I have had this done to me, and it only hurt for a little while." "Why are you so worried? Do you think you have a tumor?" "Let me explain to you what they do during this procedure."
"Let me explain to you what they do during this procedure."
Which clients does the nurse identify that are at the greatest risk for situational stress? Select all that apply. *a toddler learning to control elimination *a school-age child attending her first party *a man getting married to his high school sweetheart *a woman recovering from a car accident *a teenager being offered a cigarette by a friend *a high school graduate enrolling in the armed services
*a man getting married to his high school sweetheart *a woman recovering from a car accident *a high school graduate enrolling in the armed services
An older adult who identifies herself as a devout Catholix has recently relocated to an assisted living facility. The client is pleased with most aspects of the living situation but laments the fact that the church is not nearby, so attending daily mass is not an option. She is quite upset by this restriction and states, "Going to daily mass was my life." The nurse recognizes that this client is suffering: depression. spiritual distress. spiritual pain. hopelessness.
spiritual distress
The nurse is with a young client who has just been informed of terminal illness. The client's heart rate increases, pupils dilate, and blood pressure increases. The nurse recognizes this response as: part of the limbic system response. the sympathetic nervous response. the hypothalamic-pituitary response. local adaptation syndrome.
the sympathetic nervous response
The nurse is caring for a client diagnosed with asthma. The client reports drinking herbal tea to treat illnesses. Which question(s) will the nurse ask to obtain more information about the client's use of herbal tea? Select all that apply. "Do you take any other supplements along with your tea?" "Is there a specific brand of tea that you prefer?" "If you prefer to drink herbal tea, can your family bring some to the hospital for you?" "How many cups of herbal tea do you drink in a day?" "Have you previously discussed alternative therapies with your provider?"
"Do you take any other supplements along with your tea?" "How many cups of herbal tea do you drink in a day?"
A client strongly refuses to be admitted to a long-term facility despite having no family to assist with needs at home. The client states, "If I go to that facility, I will not be able to go to church every Sunday!" Which question will the nurse ask to explore the client's spiritual beliefs at the end of life? *"How does faith help you cope with this situation?" *"Are you actively involved in your church community?" *"Would you like to see the chaplain?" *"Have you had previous experience with attending church while in a health care facility?"
"How does faith help you cope with this situation?"
A client has just been diagnosed with a brain tumor after recurring headaches prompted the health care provider to prescribe a computed tomography (CT) scan. Which statement by the client indicates to the nurse that the client is not coping well with the diagnosis? *"I really need to get back to my job because I am falling behind on a lot of tasks." *"With medical advances, I am sure there are really promising treatments out there." *"I had a coworker whose spouse had a brain tumor and the spouse managed to recover." *"I am going to do everything I can to beat this thing."
"I really need to get back to my job because I am falling behind on a lot of tasks."
While performing the initial assessment of an infant, the nurse notes a soiled string of yarn around the infant's neck. Which response from the nurse would facilitate culturally competent care? "I see you have a string tied to your child's neck. Can you explain why you do this?" "I noticed the string around your child's neck. Why do you include this practice in your child's health care?" "I see the sacred string is dirty. In your culture, is it okay that I clean it?" "I noticed a ritual string on your child. Is this a cultural practice to protect the child's
"I see you have a string tied to your child's neck. Can you explain why you do this?"
The nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care? "I am a Christian and believe in Jesus. What does your religion believe?" "Do you have any dietary restrictions that we should know about?" "Will your religion allow us to give you blood if you need it?" "What can we do to help you meet any religious needs you may have?"
"What can we do to help you meet any religious needs you may have?"
The adult children of a client diagnosed with brain death are trying to come to terms with this diagnosis. Which statement(s) by the children exhibits normal grieving to the nurse? Select all that apply. *"I just need to get out of here right now and go for a walk." *"I am so angry with mom for leaving all of us so suddenly." *"We should start thinking about the funeral arrangements." *"She would want us to donate her organs to others." *"We have to accept this is really happening right now."
*"I just need to get out of here right now and go for a walk." *"I am so angry with mom for leaving all of us so suddenly." *"We should start thinking about the funeral arrangements." *"She would want us to donate her organs to others." *"We have to accept this is really happening right now."
A nurse is educating a client about how the general adaptation syndrome (GAS) theory works in the human body. What statement(s) made by the client indicates to the nurse that further education is required? Select all that apply. *"The alarm reaction alerts my family that I need to slow down." *"I often get exhausted when I do too much yardwork." *"The fight-or-flight reaction is initiated by growth hormone released in my brain." *"Physical activity can help me cope with the challenges of my deadlines at work." *"The alarm reaction may last for days."
*"The alarm reaction alerts my family that I need to slow down." *"I often get exhausted when I do too much yardwork." *"The fight-or-flight reaction is initiated by growth hormone released in my brain."
The nurse suspects the older client may have difficulty with vision. What assessments would the nurse include to determine if the client has visual disturbances? Select all that apply. *Have the client identify an object that is located on the opposite side of the room. *Ask the client to read the hospital menu that is on the bedside table. *Observe the client for squinting of the eyes and rubbing of the eyes. *Inspect both eyes for cloudiness in the area of the pupil and iris *Question the client about corrective lenses and a history of glaucoma.
*Ask the client to read the hospital menu that is on the bedside table. *Inspect both eyes for cloudiness in the area of the pupil and iris. *Question the client about corrective lenses and a history of glaucoma. *Observe the client for squinting of the eyes and rubbing of the eyes.
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. *Insert the lubricated catheter into the urethra. *Inflate the balloon with the correct amount of sterile saline. *Clean each labial fold, then the area directly over the meatus. *Advance the catheter until there is a return of urine. *Discard used supplies.
*Clean each labial fold, then the area directly over the meatus. *Insert the lubricated catheter into the urethra. *Advance the catheter until there is a return of urine. *Inflate the balloon with the correct amount of sterile saline. *Discard used supplies.
A nurse is conducting a spiritual assessment of a 73-year-old client who is being admitted to an assisted living center. Which factor(s) should the nurse prioritize? Select all that apply. *Client's friends or support system *Best treatment to assist client in current situation *Available resources to assist client *How the family feels about the situation *Suggest ways of coping with the situation
*Client's friends or support system *Best treatment to assist client in current situation *Available resources to assist client
Assessment of a client reveals that the client is experiencing sensory deprivation. Which finding would the nurse identify as a perceptual response to this situation? Select all that apply. *Hallucinations *Daydreaming *Decreased attention span *Difficulty with problem solving *Belligerent behavior
*Hallucinations *Daydreaming
A nurse is reviewing the history of an older adult who is diagnosed with presbycusis. Which finding would the nurse identify as supporting this condition? Select all that apply. *Reports of difficulty hearing low-pitched sounds *Reports that hearing difficulties are worse in a noisy environment *Reports of the problem being localized to one ear *Reports that the difficulties are getting worse over time *Statements that indicate the problem came on suddenly
*Reports that hearing difficulties are worse in a noisy environment *Reports that the difficulties are getting worse over time
Which clients would the nurse identify that are at risk for the development or presence of sexual dysfunction? Select all that apply. *a 25-year-old male client in traction *a 52-year-old male with a history of hypertension *a 19-year-old male who is still a virgin *a postmenopausal female client *a 49-year-old male diagnosed with an enlarged prostate (BPH) *a 30-year-old female experiencing PMS
*a 52-year-old male with a history of hypertension *a postmenopausal female client *a 30-year-old female experiencing PMS
The nurse is assessing a group of assigned clients. Which client's does the nurse determine are more sensitive to sensory alterations? Select all that apply. *a 75-year-old male admitted to the hospital for urinary tract infection *a 65-year-old client staying in an assisted living community *a 75-year-old client taking narcotic pain medication for a fractured hip *a 50-year-old client who works in a baseball stadium *a 65-year-old client who serve in the Vietnam War and is living alone
*a 75-year-old male admitted to the hospital for urinary tract infection *a 75-year-old client taking narcotic pain medication for *a fractured hip *a 50-year-old client who works in a baseball stadium *a 65-year-old client who serve in the Vietnam War and is living alone
During measurement of a rectal temperature, the thermometer probe should be inserted about how many inches (centimeters) into the anus in an adult? *0.5 in (1.25 cm) *1 in (2.5 cm) *1.5 in (3.75 cm) *2 in (5 cm)
1.5 in (3.75 cm)
A client was at home alone when a tornado struck and damaged the structure. What type of crisis does the nurse address in the care of this client? *Adventitious *Developmental *Situational *Maturational
Adventitious
A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong-sized catheter to the bedside. What is the nurse's best action? *Place a sterile drape over the client's penis, obtain the right catheter, and proceed with insertion. *Teach the client the importance of not touching his penis or the sterile field and obtain the correct catheter. *Dismantle the sterile field, obtain a new dressing tray and the correct catheter, and then begin the procedure from the beginning. *Illuminate the client's call light and have a colleague bring the correct catheter to the bedside.
Illuminate the client's call light and have a colleague bring the correct catheter to the bedside.
A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean? *Nothing, the nurse's honesty will not be questioned. *The nurse can add the documentation after the client goes home. *The physician will verify that the nurse carried out the order. *In the eyes of the law, if it is not documented, it was not done.
In the eyes of the law, if it is not documented, it was not done.
The nurse has received an order to catheterize a female client. What action should the nurse perform? Lubricate 3 to 4 in of the catheter tip before insertion. Using both hands, hold the catheter near the tip and insert slowly into the urethra. Advance the catheter until slight resistance is felt. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm).
Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm).
A 7-year-old child is admitted to the emergency department with a tentative diagnosis of asthma. Which assessment requires a priority intervention by the nurse? *Intercostal retractions *Snoring sound on inspiration *Expiratory wheezing *Stridor
Stridor
A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep? a snack containing carbohydrates and protein a snack containing carbohydrates and fat a snack containing protein and fat it is best to avoid a snack prior to bedtime
a snack containing carbohydrates and protein
A client informs the nurse that headaches started when marital problems began. The client reports that each time they have a fight, a headache develops and loss of appetite occurs for several days. What does the nurse identify as the physiologic symptoms? *a somatic disorder *anxiety *fear *a coping mechanism
a somatic disorder
A nursing instructor is describing the difference between sleep and rest. Which characteristic would the instructor identify as distinguishing sleep from rest? decrease in motor response to stimuli involves all the body systems decrease in cognitive response to stimuli decrease in awareness of environment
decrease in awareness of environment
Which strategy can be used to help clients overcome powerlessness? Encourage clients to identify their weaknesses. Encourage clients to identify their strengths. Provide advice on how to handle problems. Set goals and make decisions for the client.
encourage clients to identify their strengths
A nurse working on a critical care unit was informed by a client with multiple sclerosis that the client did not wish to be resuscitated in the event of cardiac arrest. Now the client is no longer able to express wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may involve: *ethical distress. *paternalism. *deception. *confidentiality.
ethical distress
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation? high intake of fiber constant urges to defecate inadequate intake of liquid constant physical activity
inadequate intake of liquid
A nurse is explaining the process of infection to a nursing student. Place the process in the most appropriate order. *transmission mode *susceptible host *entry portal *infectious agent *an exit route *reservoir
infectious agent a reservoir an exit route transmission mode entry portal susceptible host
The nurse is assisting a colleague with wound care. The colleague has established the sterile field and is pouring out normal saline into a sterile container. What is the nurse's best action while observing the colleague perform the task? *observe the colleague and take no further action *remind the colleague that the container should be centered on the sterile field *obtain a new dressing tray for the colleague *encourage the colleague to hold the bottle closer to the sterile container
observe the colleague and take no further action
After failing a nursing exam, the nursing student states, "That exam was written terribly." What coping strategy would the nursing instructor identify?" rationalization denial repression suppression
rationalization
A new graduate is having difficulty coping with the role transition from student to registered nurse (RN). Which defense mechanism is being exhibited when the nurse states, "I hate going in to work on weekends. The aides are lazy, the clients are all complaining, and the families are all crazy!" *denial *projection *displacement *reaction formation
reaction formation
A client states, "I have successfully raised my family and had a good life." This statement illustrates meeting which basic human need? Safety and security Love and belonging Self-esteem Self-actualization
self-actualization
What term best describes a person's sense of his own adequacy and worth? Esteem Self-esteem Love Self-actualization
self-esteem
